Incidental chest findings on coronary CT angiography: a pictorial essay and management proposal / Achados torácicos incidentais na angiotomografia coronariana: ensaio pictórico e proposta de manejo

ABSTRACT Many health systems have been using coronary CT angiography (CCTA) as a first-line examination for ischaemic heart disease patients in various countries. The rising number of CCTA examinations has led to a significant increase in the number of reported incidental extracardiac findings, mainly in the chest. Pulmonary nodules are the most common incidental findings on CCTA scans, as there is a substantial overlap of risk factors between the population seeking to exclude ischaemic heart disease and those at risk of developing lung cancer (i.e., advanced age and smoking habits). However, most incidental findings are clinically insignificant and actively pursuing them could be cost-prohibitive and submit the patient to unnecessary and potentially harmful examinations. Furthermore, there is little consensus regarding when to report or actively exclude these findings and how to manage them, that is, when to trigger an alert or to immediately refer the patient to a pulmonologist, a thoracic surgeon or a multidisciplinary team. This pictorial essay discusses the current literature on this topic and is illustrated with a review of CCTA scans. We also propose a checklist organised by organ and system, recommending actions to raise awareness of pulmonologists, thoracic surgeons, cardiologists and radiologists regarding the most significant and actionable incidental findings on CCTA scans.

RESUMO Muitos sistemas de saúde têm utilizado a angiotomografia coronariana (ATC) como exame de primeira linha para pacientes com doença cardíaca isquêmica em diversos países. O crescente número de exames de ATC tem levado a um aumento significativo do número de relatos de achados extracardíacos incidentais, principalmente no tórax. Nódulos pulmonares são os achados incidentais mais comuns nas imagens de ATC, pois há uma substancial sobreposição de fatores de risco entre a população que busca a exclusão de doença cardíaca isquêmica e aqueles em risco de desenvolver câncer de pulmão (por exemplo, idade avançada e tabagismo). No entanto, a maioria dos achados incidentais é clinicamente insignificante e seu seguimento ativo pode ter um custo proibitivo e submeter o paciente a exames desnecessários e potencialmente prejudiciais. Além disso, há pouco consenso sobre quando relatar ou ativamente excluir esses achados e como manejá-los, ou seja, quando acionar um alerta ou imediatamente encaminhar o paciente para um pneumologista, um cirurgião torácico ou uma equipe multidisciplinar. Este ensaio pictórico discute a literatura atual sobre esse tópico e é ilustrado com uma revisão de imagens de ATC. Também propomos uma lista de verificação organizada por órgão e sistema, recomendando ações para a conscientização de pneumologistas, cirurgiões torácicos, cardiologistas e radiologistas sobre os achados incidentais mais significativos e acionáveis nas imagens de ATC.

Clinical value of coronary artery tracking freezing technique in improving the quality of CT coronary images / 中国基层医药

Objective@#To explore the clinical value of cardiac coronary artery tracking and freezing(SSF) in improving the quality of CT coronary images.@*Methods@#A total of 52 patients who underwent coronary angiography(CTA) scan from December 2015 to December 2017 in the Maternal and Child Health Care Hospital of Zhuhai were enrolled.The patients were divided into two groups according to the heart rate of the patients.The heart rate in high heart rate group (24 cases) was>75 beats/min.The heart rate in low heart rate group(28 cases) was ≤75 beats/min.The two groups used the standard algorithm(STD) and SSF technique to reconstruct the image separately.The obtained images were obtained by multiple names.The diagnostician performed the analysis and scored the quality of the coronary image using the LiKert 5-point scoring system.The score of <3 points required CTA examination again to evaluate the value of SSF in improving CT coronary image quality.@*Results@#The STD and SSF image quality scores of the high heart rate group were (2.33±0.87)points and (3.99±0.82)points, respectively, and the difference was statistically significant(t=-7.347, P<0.05). The STD and SSF image quality scores of the low heart rate group were (3.15±1.06)points and (4.23±0.65)points, respectively, and the difference was statistically significant(t=-4.596, P<0.05). The STD and SSF image quality scores between the two groups had statistically significant differences (t=5.723, 7.386, all P<0.05). In the high heart rate group, the image quality scores reconstructed using SSF technique was increased by 71%, which in the low heart rate group was increased by 34%, the difference between the two groups was statistically significant(χ2=9.668, P<0.05).@*Conclusion@#SSF algorithm can improve image quality of CTA, especially in patients with high heart rate.

Clinical value of coronary artery tracking freezing technique in improving the quality of CT coronary images / 中国基层医药

Objective To explore the clinical value of cardiac coronary artery tracking and freezing (SSF) in improving the quality of CT coronary images.Methods A total of 52 patients who underwent coronary angiography (CTA) scan from December 2015 to December 2017 in the Maternal and Child Health Care Hospital of Zhuhai were enrolled.The patients were divided into two groups according to the heart rate of the patients .The heart rate in high heart rate group (24 cases) was＞75 beats／min.The heart rate in low heart rate group (28 cases) was ≤75 beats／min.The two groups used the standard algorithm ( STD) and SSF technique to reconstruct the image separately.The obtained images were obtained by multiple names.The diagnostician performed the analysis and scored the quality of the coronary image using the LiKert 5-point scoring system.The score of ＜3 points required CTA examination again to evaluate the value of SSF in improving CT coronary image quality.Results The STD and SSF image quality scores of the high heart rate group were (2.33 ±0.87)points and (3.99 ±0.82)points,respectively,and the difference was statistically significant(t＝-7.347,P＜0.05).The STD and SSF image quality scores of the low heart rate group were (3.15 ±1.06)points and (4.23 ±0.65)points,respectively,and the difference was statistically significant (t＝-4.596,P＜0.05).The STD and SSF image quality scores between the two groups had statistically significant differ -ences (t＝5.723,7.386,all P＜0.05).In the high heart rate group,the image quality scores reconstructed using SSF technique was increased by 71%,which in the low heart rate group was increased by 34%,the difference between the two groups was statistically significant ( χ2 ＝9.668, P ＜0.05).Conclusion SSF algorithm can improve image quality of CTA,especially in patients with high heart rate.

Unscheduled Emergency Visits after Cardiac Devices Implantation: Comparison between Cardioverter Defibrillators and Cardiac Resynchronization Therapy Devices in less than one year of Follow Up / Consultas Não Programadas em Emergência após Implante de Dispositivos Cardíacos: Comparativo entre Cardiodesfibriladores e Ressincronizadores em Seguimento Inferior a 1 Ano

Abstract Background: The use of Cardiovascular Implantable Electronic Devices (CIED), such as the Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT), is increasing. The number of leads may vary according to the device. Lead placement in the left ventricle increases surgical time and may be associated with greater morbidity after hospital discharge, an event that is often confused with the underlying disease severity. Objective: To evaluate the rate of unscheduled emergency hospitalizations and death after implantable device surgery stratified by the type of device. Methods: Prospective cohort study of 199 patients submitted to cardiac device implantation. The groups were stratified according to the type of device: ICD group (n = 124) and CRT group (n = 75). Probability estimates were analyzed by the Kaplan-Meier method according to the outcome. A value of p < 0.05 was considered significant in the statistical analyses. Results: Most of the sample comprised male patients (71.9%), with a mean age of 61.1 ± 14.2. Left ventricular ejection fraction was similar between the groups (CRT 37.4 ± 18.1 vs. ICD 39.1 ± 17.0, p = 0.532). The rate of unscheduled visits to the emergency unit related to the device was 4.8% in the ICD group and 10.6% in the CRT group (p = 0.20). The probability of device-related survival of the variable "death" was different between the groups (p = 0.008). Conclusions: Patients after CRT implantation show a higher probability of mortality after surgery at a follow-up of less than 1 year. The rate of unscheduled hospital visits, related or not to the implant, does not differ between the groups.

Resumo Fundamento: O uso de dispositivos cardíacos eletrônicos implantáveis (DCEI) como o cardiodesfibrilador (CDI) e terapia de ressincronização cardíaca (TRC) - é cada vez maior. O número de eletrodos de estimulação e desfibrilação varia de acordo com o dispositivo. A colocação do eletrodo no ventrículo esquerdo aumenta o tempo cirúrgico podendo associar-se a maior morbidade no acompanhamento após alta hospitalar, evento muitas vezes confundível com a gravidade da patologia base. Objetivo: Avaliar a taxa de internação não programada na emergência e óbito após cirurgia de dispositivos implantáveis estratificados pelo tipo de aparelho. Métodos: Estudo de coorte prospectivo analisando 199 pacientes submetidos à implante de dispositivos cardíacos. Os grupos foram divididos de acordo com o tipo de dispositivo: CDI (n = 124) e TRC (n = 75). Estimativas de probabilidades foram analisadas pelo método de Kaplan-Meier de acordo com o desfecho. Valor de p < 0,05 foi considerado significativo nas análises estatísticas. Resultados: A maioria da amostra era do sexo masculino (71,9%) - idade média de 61,1 ± 14,2. A fração de ejeção do ventrículo esquerdo foi similar entre os grupos (TRC 37,4 ± 18,1 vs. CDI 39,1 ± 17,0; p = 0,532). A taxa de visita não programada na emergência relacionada ao dispositivo foi de 4,8% no grupo CDI e de 10,6% no grupo TRC (p = 0,20). A probabilidade de sobrevida relacionada ao dispositivo da variável "óbito" mostrou-se diferente entre os grupos (p = 0,008). Conclusões: Paciente após o implante de TRC apresenta maior probabilidade de mortalidade após o procedimento cirúrgico no seguimento menor que 1 ano. A taxa de visita hospitalar não programada, relacionadas ou não ao implante, não difere entre os grupos.

Angiotomografia computadorizada de coronárias com tomógrafo com 320 fileiras de detectores e utilizando o AIDR-3D: experiência inicial / Coronary computed tomography angiography with 320-row detector and using the AIDR-3D: initial experience

A angiotomografia computadorizada de coronárias (angioTC de coronárias) é um excelente método de imagem não invasivo para avaliar a doença arterial coronariana. Atualmente, a dose de radiação efetiva estimada da angioTC de coronárias pode ser reduzida em tomógrafos de última geração com múltiplos detectores, como o tomógrafo com 320 fileiras de detectores (320-CT), sem prejuízo na acurácia diagnóstica da angioTC de coronárias. Para reduzir ainda mais a dose de radiação, novos algoritmos de reconstrução iterativa foram recentemente introduzidos por vários fabricantes de tomógrafos, que atualmente são utilizados rotineiramente nesse exame. Neste trabalho, apresentamos nossa experiência inicial na angioTC de coronárias utilizando o 320-CT e o Adaptive Iterative Dose Reduction 3D (AIDR-3D). Apresentamos ainda as indicações mais comuns desse exame na rotina da instituição bem como os protocolos de aquisição da, angioTC de coronárias com as atualizações relacionadas a essa nova técnica para reduzir a dose de radiação. Concluímos que a dose de radiação da angioTC de coronárias pode ser reduzida seguindo o princípio as low as reasonable achievable (tão baixo quanto razoavelmente exequível), combinando a indicação de exame com técnicas bem documentadas para a diminuição da dose de radiação, como o uso de betabloqueadores e a redução do kV, com os mais recentes aplicativos de reconstrução iterativa para redução da dose de radiação, como o AIDR-3D.

Coronary computed tomography angiography (coronary CTA) is a powerful non-invasive imaging method to evaluate coronary artery disease. Nowadays, coronary CTA estimated effective radiation dose can be dramatically reduced using state-of-the-art scanners, such as 320-row detector CT (320-CT), without changing coronary CTA diagnostic accuracy. To optimize and further reduce the radiation dose, new iterative reconstruction algorithms were released recently by several CT manufacturers, and now they are used routinely in coronary CTA. This paper presents our first experience using coronary CTA with 320-CT and the Adaptive Iterative Dose Reduction 3D (AIDR-3D). In addition, we describe the current indications for coronary CTA in our practice as well as the acquisition standard protocols and protocols related to CT application for radiation dose reduction. In conclusion, coronary CTA radiation dose can be dramatically reduced following the "as low as reasonable achievable" principle by combination of exam indication and well-documented technics for radiation dose reduction, such as beta blockers, low-kV, and also the newest iterative dose reduction software as AIDR-3D.

The image quality and influencing factors of high-pitch dual-source CT coronary angiography in patients with different heart rates / 中华放射学杂志

Objectives To investigate the image quality,influencing factors and radiation doses of prospectively ECG-triggered spiral acquisition mode (Flash spiral mode)coronary computed tomography angiography (CCTA) using high-pitch dual-source CT in patients with different heart rates.Methods One hundred and thirty-four consecutive patients with mean heart rate (HR) ＞ 65 beats per minute (bpm) and ≤ 100 bpm were included in this study as group A using Flash spiral mode setting at 20％ -30％ of the R-R interval and 134 consecutive patients with mean HR ≤65 bpm were enrolled as group B using Flash spiral scan mode at 55％ of the R-R interval; 134 consecutive patients with mean HR ＞ 65 and≤100 bpm using spiral scan mode were included as group C. The image quality scores, effective radiation dose and influencing factors of image quality in three groups were assessed. All statistical analyses were performed using SPSS.Results (1)The non-diagnostic coronary artery segments in group A (28/1842,1.52％) were more than in group B (8/1819,0.44％ ) ( x2 =10.97,P =0.001 ) and there was no significant difference between group A and group C (32/1838,1.74％) ( x2 =0.280,P =0.345).The number of patients with non-diagnostic coronary segments in group A( 10/134,7.5 ％ )was more than in group B (2/134,1.5 ％,x2 =5.52,P =0.018 ),while there was no significant difference between group A and group C (9/134,6.7％,x2 =0.057,P =0.812).(2)The average heart rate variability (HRV) of patients with different image scores in the three groups wcrc significantly different. In group A,the HRV of score 1,2 and 3 were (2.29 ± 1.06),(5.17 ± 1.37),(8.88 ± 1.53) bpm,respectively (F =170.402,P =0.001 ).In group B were (2.26±1.01),(5.97 ±1.82),(12.00 ±9.64) bpm,respectively (F=95.843,P=0.001).In group C were (2.61 ±1.85),(7.90 ±3.97),(11.22 ±5.62) bpm,respectively (F=68.629,P=0.001 ). (3) The average effective radiation doses in groups A and B were significant lower than in group C [ A group was 1.04 ± 0.16,B group was 1.03 ± 0.16 and C group was 7.05 ± 1.05,t =65.5 ( A vs C),P ＜0.01 ( A vs C) ].Conclusions Flash spiral mode of high-pitch dual-source provides high image quality with significant reduction of radiation exposure in patients with HR ≤ 65 bpm. Patients with heart rates ＞65 bpm and ≤100 bpm without cardiac arrhythmia can perform CCTA using Flash spiral mode with image acquisition time setting at 20％-30％ of the R-R interval.

Análises morfológica e dinâmica da coronária baseadas no processamento tridimensional de exames de ultrassonografia intravascular / Morphological and dynamic analysis of the coronary based on tridimensional image processing of intravascular ultrasound examination

Na prática intervencionista, a ultrassonografia intravascular (USIV) é usada para se obter informações quantitativas e qualitativas do acometimento aterosclerótico, de forma complementar à angiografia. Esta tese teve como objetivos explorar a característica tomográfica do exame de USIV, bem como sua dinâmica dentro do ciclo cardíaco. Para isso, desenvolvemos técnicas de processamento de imagens médicas. Primeiramente, investigamos a reconstrução tridimensional da coronária baseando-nos apenas nas imagens de USIV, ou seja, sem a angiografia, como é feita a reconstrução atualmente. Na análise da dinâmica, fizemos um estudo para dispor volumes da coronária em diferentes fases do ciclo cardíaco de forma que estivessem alinhados espacialmente. Como consequência dos tratamentos propostos anteriormente, realizamos estudos sobre a quantificação de propriedades mecânicas dentro das condições oferecidas no intervalo de um ciclo cardíaco. As metodologias propostas foram aplicadas em simulações numéricas desenvolvidas neste trabalho e em exames reais. Obtivemos resultados compatíveis com os objetivos iniciais para reconstrução tridimensional da USIV em simulações numéricas. Na análise da dinâmica, a reconstrução de volumes em diferentes fases do ciclo e o alinhamento espacial possibilitaram a quantificação da variação setorial de volume da luz do vaso durante o ciclo cardíaco.

In percutaneous coronary interventions, intravascular ultrasound (IVUS) examination is used to retrieve quantitative and qualitative information about the at herosclerotic plaque progression, complementary to angiography examination. This thesis has as objectives to explore the tomographic characteristic of the IVUS examination, as well as its dynamics within a cardiac cycle. For that purpose, medical image processing techniques were developed. Firstly, we have investigated how to reconstruct the tridimensional coronary based only on IVUS images, that is, without angiography, as it is done nowadays. Regarding dynamic analysis, we have studied models to build volumes of the coronary in distinct phases of the cardiac cycle in a spatial aligned way. Conversantly, as a consequence of the previous image processing methods, we have studied the quantification of mechanical properties of the vessel wall within a cardiac cycle. The methodologies proposed were applied in numeric phantoms developed in this work and also in real IVUS examinations. As result, tridimensional reconstruction was successful in the numeric phantom approach. In dynamics analysis, the reconstruction in distinct cardiac phases and volumes spatial alignment enabled the quantification of lumen volume variation during the cardiac cycle.

Application value of prospective electrocardiogram-gating for 64-slice CT coronary angiography / 中国医学影像技术

Objective To compare radiation dose and image quality between prospective and retrospective ECG gating CT coronary angiography (CTCA) with 64-slice CT scanner. Methods Sixty patients with suspected coronary artery disease were selected, and randomly devided into two groups. Thirty patients in research group (average body-mass index [BMI]:[25.30±3.15] kg/m~2, heart rate ≤65 beats per minute [bpm]) underwent CTCA using prospective ECG-gating (120 kV, mA tailored to weight), while the rest 30 patients in control group (average BMI:[25.40±3.00] kg/m~2, heart rate ≤65 bpm) underwent CTCA using retrospective ECG-gating (120 kV, 650 mA). The average effective dose (ED) and standardizing radiation dose (ED_(Sd)) which was standardized by 12 cm length were respectively calculated, and statistical analysis was then conducted, meanwhile image quality was evaluated. Results The average ED of research group and control group was (5.97±1.04) mSv and (26.25±2.36) mSv, respectively (t_(A,B)=43.13, P<0.05). The ED_(Sd) of two groups was (5.49±0.45) mSv and (23.77±1.64) mSv (t_(Sd)=59.00, P<0.05). ED_(Sd) decreased by 76.62% in research group compared with that of control group. No significant difference of image quality was found between two groups (χ~2=4.26, P=0.235). Conclusion Prospective ECG-gating CTCA can effectively reduce radiation dose without compromising image quality.