Multidetector CT (MDCT) 在心臟血管方面的 運用
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(2) coronary artery lumen Plaques. LV perfusion LV function.
(3) Left posterior aortic sinus Left main artery (LM) -- 1- 2 cm Left circumflex artery (LCx) 1.. Marginal branches. Intermedial artery. Left anterior descending (L AD) 1. Septal branches 2. Diagonal branches.
(4)
(5) coronary. anatomy. Left posterior aortic sinus Left main artery (LM) -- 1- 2 cm. Left anterior descending (L AD) 1. Septal branches 2. Diagonal branches. Left circumflex artery (LCx) 1. Anterior aortic sinsus Right coronary artery (RCA) 1.. Marginal branches. Marginal branches. Intermedial artery.
(6) coronary. anatomy. Right dominant (80%) 1.. Crux. 2.. Posterior descending artery (PDA). 3.. Posterior lateral branch (PL). Left dominant(). Balanced type.
(7) coronary. anatomy. 5 6 7 8 1. 9 10. 2. 3 15 PL. 4 PDA. 11 13 14 12. Seg.. Vess el. 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15. RCA RCA RCA PDA LM LAD LAD LAD D1 D2 Cx Mo CX MO PL.
(8) coronary artery. atheroma. Ca-X.
(9) coronary artery. atheroma Modified AHA. Calcified nodules. Density MDCT. >150 High. Pictrure. MSCT freatures of plaques (Modified AHA calcificatio n) Fibrocalcified p laque. Fibreous cap at heroma. Thin fibrous cap atheroma. Trombus. High/Low. 50-100 intermediate. 20-50 low. <20 very low.
(10) Coronary calcification • The need to detect coronary atherosclerosis early in its cours e has been well recognized by cardiologists for decades. • The presence and amount of coronary artery calcium have be en suggested as a means to assess patients at risk of advers e coronary events. • The presence of coronary calcium is always indicative of the p resence of coronary atherosclerosis. • Agatston et al. developed a calcium scoring algorithm that is n ow widely used in research and clinical practice. • The calcium score is derived from the product of the area of c alcification(mm2) and a factor determined by the maximal X-ra y density within this area. (calcification should be at least 1 m m2 and the X-ray density should exceed the threshold of 130H U).
(11) 冠狀動脈鈣化評分 冠狀動脈鈣化 右冠狀動脈 Agatston Volume (mm³) Mass (mg). 左主幹. 左迴旋枝 左前降枝. 總合.
(12) Area of plaque × weighting factor = Lesion score ∑ Lesion scores = Vessels score ∑ Vessels scores = Total calcium score (Agatston Scor e).
(13) ” 冠狀動脈鈣化評分” (the Agatston Calcium Score) 之說明 鈣化評 分. 粥狀硬化斑塊承載量 Plaque burden. 有意義冠狀血管阻塞的可能性 Significant CAD. 心血管之風 險 CV risk. 0. 無動脈粥狀硬化斑塊. 1-10. 極輕度的動脈粥狀硬化 可能性極低 ( < 10% ) 斑塊. 低. 11-100. 輕微的動脈粥狀硬化斑 具輕微或極輕度冠狀動脈狹 塊 窄的可能性. 中等. 101-400. 中等的動脈粥狀硬化斑 高度有冠狀動脈狹窄存在的 塊 可能性. 中高等. ＞ 400. 高量的動脈粥狀硬化斑 極有可能有冠狀動脈狹窄的 塊 存在. 高等. 可能性極低 ( < 5% ). 鈣化分數越高心血管疾病發生機率越高. 極低.
(14) How to use the calcium score? • CT calcium quantification can be used for the assessment of long-term risk and primary prevention of future adverse coronary events. • Calcium scoring should not be performed as a ‘standalone’ test but should be integrated into risk assessment with well recognized risk factors. Risk factors: 1, Sex. 2, Age. 3, Family history. 4, Blood lipids. 5, Smoking. 6, Diabetes. 7, Blood pressure. 8, Weight..
(15) 冠狀動脈鈣化 性 別. 百 分 比. 男. 女. 年紀 <40. 4044. 4549. 5054. 5559. 6064. 6569. 7074. >74. 25 0. 0. 0. 1. 4. 13. 32. 64. 166. 50 1. 1. 3. 15. 48. 113. 180. 310. 473. 75 3. 9. 36. 103. 215. 410. 566. 892. 107 1. 90 14. 59. 154. 332. 554. 994. 1299 1774 198 2. n. 4238 4940 4825 3472 2288 1209 540. 235. 25 0. 0. 0. 0. 0. 0. 1. 3. 0. 50 0. 0. 0. 0. 1. 3. 24. 52. 75. 75 1. 1. 2. 5. 23. 57. 145. 210. 241. 90 3. 4. 22. n. 1024 1634 2184 1835 1334 731. 350 4. 641. 55 121 193 631 709 According to Hoff JA et .al410 JACC 2003;41;1008-12 438. 174.
(16) Level description. Low risk 0-1 risk factor. Intermediate 2 risk factor. High risk >3 risk factor. Risk of event within 10 yrs. <10%. 10-20%. >20%. Estimated prevalence adults. 35%. 40%. 25%. Ca. test useful. No. Yes. No. Intermediate (1)Calcium score < 80 Lower risk (2)Calcium score > 80 Higher risk.
(17) Electrical Activation of the Heart. ECG-Triggering/Gating 60% RR. 600 ms. 400 ms. % RR Interval Absolute Reverse Time.
(18) Retrospective ECG Gating “3D” Image Data. R. R. Recon. Delay. Recon. R. Recon. R. Recon. z - Position. us ed o u e tin Con can & F al S r i p S. Time. 加圖.
(19) small vessel. Challenges in MSCT coronary imaging • size of coronary arteries are small • LCA = 4.4 mm • LAD = 3.6 mm. distally = 0.8 mm. • CX = 3.4 mm. distally = 1.5 mm. • RCA = 3.0 mm. distally = 1.0 mm. • movement of mid RCA up to 45 mm/sec.
(20) small. Flat Panel. vessel. 64 dectector array. 4s. 16s. 64s. Rotation. 0.5. 0.42/0.37. 0.33. Temp resolution. 0.25. 0.21. 0.165. Spatial resolution. 1.0. 0.75. 0.35. Data per rotation. 4. 16. 64. Scan time. >40s. 20s. 14s. 16 dectector array.
(21) Vascular. Enhancement 4-slice. 16-slice. 64-slice. Volume. 120 ml. 100 ml. 80 ml. Rate. 3 ml/sec. 4 ml/sec. 5 ml/sec. Concentration > 350mg/ml Antecubital access.
(22) Patient Selection Small coronary arteries Fast heart rate >75 bpm Persistent irregular heart rhythm Respiratory impairment and related motion artifacts Diffuse and. calcified coronary atherosclerosis. Coronary stents Metal objects Renal dysfunction and contrast medium allergy.
(23) motion artifacts β- blocking agent - Metoprolol (Beloc ®) p.o.. 100 mg 1h prior to exam.. - Propranolol(Dociton ®) 80 mg 1h prior to exam. p.o. - i.v. Metoprolol. 5 mg @1mg/min i.v. check heart rate @ 5. minutes repeat @ 5 mg (15 mg Diastolic. max.) 60. NTG. NTG 60-80. Beta-blocker. 80. Systolic.
(24) Patient education 1. Breath holding 2. CM burning sensation. 64 dectector array : >9 sec. (12). 16 dectector array : >15 sec (20).
(25) coronary. anomaly. 1%.
(26) coronary. anomaly. bridge. Absent right coronary.
(27) coronary artery. lumen Left Anterior Descending stenosis.
(28) coronary artery. lumen. Proximal LAD stenosis.
(29) CABG.
(30) CABG. L. R.
(31) CABG.
(32) Volume. Contrast material. averaging (Bloomin g). Calcium. Stents.
(33) Bean. Prosthetic valve Contrast material. hardening. (Streak artifacts). Effective energy is shifted to higher value as the X-rays pass through an object stents. Pacemaker wires Calcium. Sternal wires. Surgical clips.
(34) Resolution small vessel (spatial resolution) motion artifacts (temporal resolution) Calcium/stent obstruction estimation. Radiation exposure. Furture.
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(36) Thanks for you attention!.
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