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Computed Tomography of
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the Adult Cardiac Surgery
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Patient: Principles
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and Applications

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Andreas A. Giannopoulos • Frank J. Rybicki
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• Tarang Sheth • Frederick Y. Chen
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Advances in computed tomography (CT) technology have improvements. One of the major technological advances
revolutionized the diagnosis of cardiovascular disease. CT has has been the incorporation of multiple elements into the
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dramatically reduced, and for some clinical scenarios elimi- CT detector system, called Multi-Detector CT (MDCT).
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nated, the need for additional testing such as diagnostic arte- MDCT is synonymous with multislice CT. Since all mod-
rial catheterization. In the process, CT has become invaluable ern scanners have multiple detectors, the semantics can
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in cardiac diagnosis and surgical planning. and should be eliminated; this chapter simply uses “CT” to
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CT is based on an x-ray source and detector system describe the technology.
mounted on the “CT gantry” that rotates around the patient. Data from each of CT detector is used to reconstruct an
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Major technology advances have enabled CT to image the axial slice perpendicular to the long axis, or z-axis, of the
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beating heart, and routine CT at Brigham and Women’s patient. The width of the detectors determines the minimum
Hospital (BWH) has noninvasively excluded coronary artery slice thickness and thus the ability to resolve small anatomic
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disease in one heart beat (Fig. 6-1) for over 7 years.1 How- detail (spatial resolution) of the scanner. Thinner slices yield
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ever, the role of CT extends far beyond the coronary arter-
ies alone. Using roughly the same CT acquisition strategies,
native coronary imaging can be extended to coronary bypass
grafts, the beating myocardium, valve motion, the ventricles
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superior spatial resolution; however, comparing two scanners
that produce the same number of slices, the scanner with
thinner slices will have less z-axis (ie, craniocaudal) coverage
per gantry rotation and thus will have a longer scan time.

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and ventricular outflow tracks, and cardiac lesions. To date, the minimum detector width and largest number of
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In order to understand the clinical contribution of CT detector rows is 0.5 mm and 320, respectively.2,3 This yields
and to avoid pitfalls in image interpretation, it is essential for 16 cm (0.5 mm × 320) z-axis coverage per gantry rotation,
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the surgeon to appreciate the basic principles of CT used in and thus the entire heart can be imaged with data acquired
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cardiac imaging. This chapter is divided into two parts. The over a single R-R interval.
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first part describes the technical considerations for cardiac

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CT. By understanding each component, the surgeon will be TEMPORAL RESOLUTION

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better able to distinguish image artifacts from pathology. The

second part reviews those CT examinations that are most fre- Successful cardiac imaging by any modality relies on the
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quently performed in the noninvasive cardiovascular imaging ability of the hardware to produce motion-free images or, in
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program at BWH, detailing the strengths and limitations of other words, to image faster than the heart beats. Because it
each exam. requires that the gantry be rotated around the patient, CT is
inherently slower than digital subtraction angiography (DSA)
where each frame corresponds to a single projection image.
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As described below, CT has become faster so that cardiac CT

PART 1.  CARDIAC CT PROTOCOLS
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is now being routinely performed.

Most advances in cardiac CT, for example in coronary CT Temporal resolution is the metric that measures imaging
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angiography (CTA), have focused on the development of speed. For a CT scanner with a single photon source, the tem-
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protocols consistent with the rapid incremental technology poral resolution is one half of the CT gantry rotation time.
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Part I  Fundamentals

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For single-source scanners, temporal resolution can be
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improved by adopting a so-called “multisegment” image

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LAD reconstruction. The difference between single-segment and

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multisegment reconstruction is that in the former, 180° of
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Lt main data is acquired from a single heart beat, while multisegment
reconstruction uses several heart beats to obtain the one half
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Ramus
gantry CT data. For example, in a two-segment reconstruc-
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tion, two heart beats are used to generate a single axial slice,
and thus the temporal resolution is halved. Similarly, if four
heart beats are used (four-segment reconstruction), only 45°
of data are used from each heart beat. This yields a fourfold
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LCx reduction in the effective temporal resolution, making it
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theoretically possible to perform high spatial resolution car-

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diac CT in patients with a rapid (eg, >70 beats per minute)
heart rate. However, since multiple heart beats are used to fill
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the 180° of gantry rotation necessary for the reconstruction,
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stable periodicity of the heart is essential. When beat-to-beat
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variations in heart rate occur, image quality is degraded sig-

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FIGURE 6-1 Selected coronary computed tomography angiogra- nificantly. In our experience, multisegment reconstruction
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phy (CTA) image of the proximal left coronary arterial system in a works well in patients with high heart rates who are being
patient scheduled for isolated mitral valve surgery. Using the protocol studied for clinical indications where the highest image
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detailed in this chapter, CT demonstrated normal coronary arteries in
this patient, eliminating the need for arterial catheterization.
quality may not be required (eg, studies of graft patency or
pericardial calcification). For more demanding applications
(eg, native coronary CTA) we still routinely employ beta-
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blockade for heart rates >60 beats per minute.
This is because image reconstruction requires CT data acquired
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from one half (180°) of a complete gantry rotation. All manu-
facturers have gantry rotation times on order of 300 ms or less.
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Using this gantry rotation time as an example, an electrocar- BETA-BLOCKADE FOR HEART RATE
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diogram (ECG)-gated cardiac image can be reconstructed CONTROL
(using single-segment reconstruction, described below) with
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As suggested above, beta-blockade is an important compo-
CT data acquired over 150 ms of the cardiac cycle. Thus, the
nent of most coronary-based CT examinations. As the tem-
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reconstructed images inherently display the average of the car-
poral resolution of cardiac CT improves, the dependence on
diac motion over the roughly 150 ms during which the data
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lowering the heart rate will naturally be mitigated. However,
was acquired. This is how ECG gating enables cardiac CT.
the speed of all CT scanners is inferior to coronary catheter-
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Without gating, cardiac images are nondiagnostic because
ization, and thus beta-blockade is recommended for the large
the reconstruction “averages” the motion over the entire R-R
majority of patients in whom it is safe. In our experience,
interval, for example, over 1000 ms for a patient with a heart
many surgical patients have standing orders for beta-blockers
rate of 60 beats per minute.
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as part of their medical therapy, and image quality is excel-
There are important strategies to improve temporal resolu-
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lent. When this is not the case, either oral and/or IV meto-
tion. The first uses two independent x-ray CT sources and
prolol is routinely administered.
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two independent (64 or greater slice) detector systems built
into the CT gantry.4 The second x-ray source is positioned
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90° from the first x-ray source, and the second detection sys- ECG GATING fre
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tem is positioned 90° from the first detection system. With
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respect to temporal resolution, the practical consequence of ECG gating refers to the simultaneous acquisition of both
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this CT configuration is that 180° of gantry rotation can the patient’s ECG tracing and CT data. By acquiring both
be achieved in half the time (eg, 75 ms as opposed to 150 pieces of information, CT images can be reconstructed using
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ms). This halves the temporal resolution (to 75 ms), and only a short temporal segment of the R-R interval. Each seg-
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thus for this “dual-source” CT configuration, motion is aver-
aged over only 75 ms. Another strategy uses both X-ray CT
source-detector systems to sample the entire heart within a
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ment is named by its “phase” in the cardiac cycle; the com-
mon nomenclature is to name the percentage of a specific
phase with respect to its position in the R-R interval. For
example, reconstruction of 20 (equally spaced) phases would

single R-R interval by rapidly moving the patient through the

scanner.5 Both implementations have technical advantages be named as 0%, 5%, 10%, ..., 95%. The period in which
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and disadvantages that are beyond the scope of this chap- the heart has the least motion is usually (but not always) in
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ter. However, cardiac imaging in a single heart beat can be mid-diastole, near 75%. Thus, the CT exposure (and sub-
sequent patient radiation level) can be lowered by limiting
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achieved using the same heart rate control as noted below.

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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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the exposure to a small part of the R-R interval where coro- is roughly a decade for blood tumors and significantly lon-
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nary motion is expected to be a minimum. This is termed ger for solid tumors. Patients under consideration for repeat

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“prospective” ECG gating since the reconstruction phase and bypass surgery typically have a shorter life expectancy based

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width is determined prospectively. The disadvantage of this on cardiac status. Thus, it is essential that the surgeon not
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approach is that cine loops of the entire R-R interval cannot only recognizes that motion has degraded image quality, but
be reconstructed because a complete data set is not acquired also realizes that additional reconstructions, and even repeat
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throughout the R-R interval. If this is desired, the so-called imaging, can and should be performed. If the entire course of
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“retrospective” ECG gating can be used, at the expense of
higher radiation levels.
For patients who require imaging of bypass grafts, it is
important to note that periodic displacement of both saphe-
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the graft is not clear to the surgeon at a single cardiac phase, it
is almost always the case that another phase will yield motion-
free depiction of the graft segment that was poorly seen.
Open communication between the radiologist and the sur-

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nous vein grafts (SVG), radial grafts, and internal mammary geon for every case has eliminated this pitfall and ensures that
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artery (IMA) grafts is far less than the motion of the native the maximum amount of imaging data is incorporated into

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coronary arteries. Thus, for these vessels, a single reconstruc- presurgical planning.
tion at mid-diastole is usually sufficient (Fig. 6-2), and pro- In cine CT, such as imaging the aortic valve over the entire
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spective ECG gating is routinely used. However, the benefits R-R interval, images are acquired with retrospective ECG gat-
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of lower radiation in this population are relatively moot, ing and subsequently reconstructed throughout the cardiac
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since the latent period for a radiation-induced malignancy cycle and then played, in cine mode, to demonstrate function.
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A B
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FIGURE 6-2 ECG-gated CT images from a single reconstruction

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at mid-diastole for a patient scheduled for redo CABG. The patient is

status post-LIMA to LAD coronary bypass grafting. (A) Axial image
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demonstrates the LIMA graft coursing between two staples and adher-
ent to the posterior table of the sternum. (B) Multiplanar reformatting
is now performed routinely to detect and illustrate cases where repeat
thoracotomy through the sternal incision is likely to damage a pat-
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ent LIMA graft. An alternate surgical approach was required for this
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patient. (C) Selected image from a three-dimensional (3D) volume

rendering again demonstrates the course of the graft. Volume render-
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C ing fully surveys the thoracic landmarks and is useful for spatial rela-
tionships and the communication of important findings.
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Part I  Fundamentals

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body part. While details regarding cardiac CT dosimetry are
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beyond the scope of this chapter, discussions regarding CT

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dose must be based on sound principles. The radiation risk

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most commonly quoted relates to the probability that the
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CT scan will result in the development of a fatal radiation-
induced neoplasm.11 Human data for radiation at this low
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level (the level delivered in ECG-gated cardiac CT) is very
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sparse; all anecdotal reports support a long latency period as
described above. For this reason, patients should be separated
into two groups: those with a life expectancy of roughly 10
to 15 years or less, and those with a longer life expectancy. In
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the former group, the only dose consideration is whether the
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radiation could cause a skin burn (the only short-term com-

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plication of any consequence). X-ray skin burns are extremely
uncommon, particularly in CT (even for ECG-gated stud-
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ies), and typically result from multiple exams repeated at
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short-term intervals. Thus, for this subset of patients, radia-
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tion dose should not be a consideration in determining a modal-

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ity for cardiac imaging. For those patients for whom radiation
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FIGURE 6-3  ECG-gated CT image through the left ventricle and is an important consideration, prospective ECG gating
the aortic valve in a patient status post aortic root repair. Note the should be used. X-ray current modulation is standardly used
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pacemaker (right heart wires); magnetic resonance imaging (MRI) was to lower the radiation dose. The tube current (expressed as
contraindicated. The repair is well visualized and without complica-
the mA) is modulated over the course of the cardiac cycle so
tion, with only mild aortic valve calcification (cine images showed a
tricuspid valve with no significant stenosis). This image also demon- that the desired (high) diagnostic current is delivered only in
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strates a punctate calcified plaque along the superior course of the diastole. The patient dose is decreased because the tube cur-
rent is reduced for the remainder of the cardiac cycle. While
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proximal left main coronary artery, without a significant stenosis.
current modulation is helpful in many cases (eg, pediatric
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patients), the decision to use it should be made after consul-
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Each individual image (Fig. 6-3) offers an outstanding assess- tation between surgeon and radiologist because the potential
ment of the aortic valve and root structure. Cine CT can also drawbacks are significant. Most importantly, when current
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be used to assess ventricular-wall motion. In comparison with modulation is used, images reconstructed during phases with
low tube current are relatively noisy because less tube current
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magnetic resonance imaging (MRI), the reference standard
for global- and regional-wall motion abnormalities, CT often is used to generate them.
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has inferior temporal resolution. However, it is important to
emphasize that cine CT does not require a separate image
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acquisition. The entire CT data set (coronary, valve, myocar-
dium, and pericardium) is acquired in a single breath hold;
cine CT is simply part of the image postprocessing.
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SCANNING PARAMETERS
The scan time refers to the time required to complete the
CT acquisition along the z-axis of the patient. As described

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For surgical patients, CT has the distinct advantage over above, better temporal resolution decreases the scan time, not
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MR, in that it is by far the best imaging modality to identify only decreasing cardiac motion, but also enabling breath hold
and quantify calcification. Also, the most common contraindi- CT. This is important in cardiac CT because in comparison
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cations for cardiac CT (eg, impaired renal function as measured to nongated CT, ECG gating not only increases patient radia-
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by glomerular filtration rate or alternatively by serum creatinine) tion but also increases the scan time.
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differ from those for MR (pacemaker), and thus CT can often In practical terms, a 64-slice ECG-gated cardiac CT scan
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be used for patients who cannot have MR. As noted above, sin- (craniocaudal, or z-axis imaging over ~15 cm) can be per-
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gle heart beat cardiac CT is now a clinical reality, with an entire formed in roughly 10 seconds, versus 20 to 25 seconds with a
cardiac acquisition in approximately one second.1 In addition to 16-slice scanner. One great benefit of wide area detector CT is
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the fact that patient radiation is decreased, multiple scans can be faster (single heart beat) scans. If this option is not available,
performed with the same injection of iodinated contrast mate- increasing the thickness of the detectors increases the z-axis
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rial, creating the opportunity for a host of additional studies coverage per rotation and thus decreases the scan time. For
including myocardial perfusion6-10 that are, at present, largely in example, in a patient that cannot perform the breath hold,
the domain of cardiac MR and nuclear cardiology. using thicker detectors (eg, 1 mm thickness as opposed to
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0.5 mm thickness) will decrease the scan time by providing

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more z-axis coverage per rotation. However, routinely increas-

PATIENT IRRADIATION ing the width of the detectors for cardiac applications is
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Because ECG gating is required, ascending aorta and cardiac undesirable since it degrades the spatial resolution of the exam-
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CT delivers more patient irradiation than CT of any other ination. In general, spatial resolution refers to the ability to
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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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differentiate small detail in an image. This is essential compo- scan through the entire inferior wall of the heart and should
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nent to coronary imaging since the diameter of the proximal include several slices of the liver to account for cardiac dis-

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coronary arteries are on the order of 3 to 4 mm. Substitu- placement during breath holding. For bypass graft imaging,

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tion of 0.5 mm reconstructed images with 1 mm images thus the superior border of the FOV must include the subclavian
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impacts the ability to see detail that may be required for accu- arteries and the origin of both IMAs.
rate diagnoses. Routine consultation between the surgeon and
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radiologist is essential to best understand and optimize the
CONTRAST MATERIAL
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tradeoff between scan time and slice thickness. For example,
imaging of the myocardium and aorta almost never requires Most CT examinations are performed with iodinated con-
submillimeter slices, because the pathology is larger. Thus, for trast material. The exceptions are scans performed solely for
dyspneic patients who require only imaging of the ascending
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the assessment of cardiac and aortic calcification, plus imag-
aorta, thicker slices should be used to cut the scan time.
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ing of the aorta and great vessels for aneurysm size measure-
The scanning parameters that primarily determine the

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ments alone. Contrast is administered from a peripheral vein,
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number of photons used to create a CT image are termed typically with a dual injection system. This injector has two
“mAs,” or milliamperes-seconds and “kV,” or kilovolts. The
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reservoirs to inject contrast followed by saline. For coronary
former represents the X-ray tube current; the latter refers to
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imaging, the contrast and saline delivery are timed so that
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the voltage applied within the tube. For the surgeon, choos- the left heart, aorta, and coronary arteries are enhanced with
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ing the best numbers (typical values are 550 to 700 effective
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contrast while the right heart is filled with saline. The use and
mAs, 120 kV) is far less important than understanding the the timing of the saline are essential parts of the examina-
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fact that modern cardiac CT pushes the limits of technology, tions because artifacts that limit interpretation of the RCA
and thus creates tradeoffs with respect to the x-ray CT source. will be induced if the right heart and central veins are densely
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The source generates photons that are either attenuated by enhanced with contrast (as opposed to saline).
the patient or reach the detectors. When more photons reach
the detectors, the image quality is higher because there is less
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noise. The decision to image with thinner slices (eg, 0.5 mm
as opposed to 1 mm) means that fewer photons reach the  ART 2.  APPLICATIONS IN CARDIAC
P
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detector; thus, thinner slices have more noise. This is espe- SURGICAL PATIENTS
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cially important in obese patients because their increased
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body mass absorbs more photons than thin patients. For the
same effective mAs and kV, images of obese patients can be CORONARY DISEASE
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dramatically degraded by greater image noise.
If there were no limit to the number of photons that an
Native Coronary CTA
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X-ray CT source could produce, the solution would be to sim- One of the most common clinical indications for cardiac
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ply increase the number of photons (and the radiation dose) CT is to evaluate the native coronary arteries for stenosis
until image noise was satisfactory. Unfortunately, because the (Figs. 6-4 to 6-7). Numerous validation studies have evalu-
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X-ray CT tube heats excessively when pushed to its maximum,
there is a limit to the number of photons that can be pro-
duced. This is why image noise becomes problematic with thin
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ated cardiac CT for this purpose.12-25 In these studies, data
are typically reported on a per coronary artery segment basis,
comparing CTA and DSA. A significant stenosis is gener-

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slice imaging of obese patients. When this is the case, consulta- ally defined as >50%, determined by quantitative coronary
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tion between the surgeon and radiologist is important because angiography. Data are also analyzed on a per patient basis
diagnostic images can often be obtained by increasing the regarding the value of CTA in ruling-in or excluding CAD.
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image thickness, scanning a smaller z-axis field of view (FOV), Literature to date reports on patient populations with a rela-
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or both. The latter can be particularly useful if the examination tively high prevalence of CAD (ie, patients already scheduled
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can be tailored to the most important structure. Scanning a for DSA). Among the most consistent findings is a very high
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smaller z-axis means that more photons can be generated and negative predictive value (NPV) of coronary CTA when per-
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used before the X-ray CT tube reaches its heat limit. formed with 64 or greater detector row scanners. The data
On the other hand, whenever possible, the z-axis FOV and our experience with 320 row scanners suggest a very
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should be generous, as unexpected pathology can extend in high NPV, arguing that cardiac CTA can effectively exclude
both cranially and caudally. For example, an ECG-gated car- CAD in patients with low to intermediate pretest probability
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diac and ascending aorta examination to evaluate extension of of disease. Furthermore, noncontrast CTA for evaluation of
the intimal flap into the coronary arteries can reveal extension coronary calcium score, an independent predictor of adverse
into the great vessels. Also, scanning must allow for variations cardiac events and all-cause mortality, is considered to be
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in the FOV induced by breath holding. As a general rule, for appropriate for intermediate-risk patients as well as for low-
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scanning the native coronaries alone, the superior border of risk patients with family history of premature CAD.26-28
the FOV is set at the axial slice corresponding to the top of Consequently, CTA has become increasingly useful for the
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the carina. This is typically 2 to 3 cm superior to the origin cardiac surgeon in managing patients scheduled for noncoro-
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of the left main coronary artery. The inferior border should nary cardiac surgery. If the clinical suspicion is low, but not
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Part I  Fundamentals

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FIGURE 6-4  Proximal RCA 50% stenosis diagnosed by coronary CT angiography and confirmed by conventional angiography. Double oblique
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maximum intensity projection image (4 mm thick) through proximal RCA (A) and LAO projection still image from conventional angiogram
(B) demonstrate a segment of approximately 50% stenosis (arrows).
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A C
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FIGURE 6-5  Proximal left circumflex

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greater than 50% stenosis diagnosed by
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coronary CT angiography and confirmed by

conventional angiography. Double oblique
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maximum intensity projection image (4 mm

thick) through proximal LCX (A) demon-
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strates a segment of calcified and noncalcified

plaque with significant luminal narrowing
(arrow). Finding is confirmed by true vessel
short axis multiplanar reformatted images
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through the proximal reference (B-left) and

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the lesion (B-right) which demonstrate mini-

mal residual lumen at the level of the lesion.
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B AP-Caudal projection still image from con-

ventional angiogram (C) confirms a greater
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Proximal reference Lesion than 50% in the proximal LCX (arrow).

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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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FIGURE 6-6  Right coronary artery greater than 50% stenosis diagnosed by CT and confirmed by conventional angiography. Double oblique
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maximum intensity projection images (4 mm thick) through ongoing RCA at 90° angles (A, B) demonstrate a segment of noncalcified plaque with
nonvisualization of lumen (black arrows). The PIV is also partially demonstrated (white arrow). Finding is confirmed by LAO (C) and AP-cranial
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(D) projection still images conventional angiogram (black arrow). The PIV is also seen (white arrow).
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insignificant, CTA affords the surgeon a method of assessing patients while also being appropriate even for the high-risk
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coronary disease without subjecting the patient to femoral CAD patients.28-32

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arterial puncture with its known complications. For example,

patients undergoing isolated mitral valve surgery for degen-
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erative, myxomatous disease have a low prevalence of CAD, CORONARY ARTERY BYPASS GRAFT
CTA—REOPERATIVE SURGERY
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making CTA an ideal alternative to conventional angiog-

raphy to exclude significant CAD. When the CT protocol Cardiac CT provides the cardiac surgeon with a noninvasive
described in Part 1 is followed, high-quality imaging is rou- method to assess graft patency after coronary artery bypass
tine, and when CTA excludes CAD, surgeons have increased graft (CABG). Studies using early 16 detector row CT scan-
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confidence in using CTA alone. Follow-up with DSA can be ners suggest 100% sensitivity and specificity for identify-
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reserved for those patients who might benefit from catheter- ing occluded versus patent grafts,33-35 with benefits from
based intervention. advanced image postprocessing tools.36 In similar fashion,
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Current guidelines from all major societies support the 64- and 320-slice CTA have demonstrated good diagnostic
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use of cardiac CT for evaluation of low- to intermediate-risk accuracy in the evaluation of significant venous or arterial
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Part I  Fundamentals

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Proximal reference Lesion
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FIGURE 6-7 Proximal LAD less than 50% stenosis diagnosed by coronary CT angiography. Double oblique maximum intensity projection
image (4 mm thick) through proximal LAD (A) demonstrates a segment of noncalcified plaque that is not associated with any significant luminal
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narrowing (arrow). True vessel short axis multiplanar reformatted images through the lesion (B-right) and through proximal reference segment
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(B-left) confirm minimal luminal narrowing. Low-density (ie, noncalcified) plaque with positive vessel remodeling is seen (arrow). This case high-
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lights the ability of CTA to detect early stages of subclinical atherosclerosis. This lesion would presumably not have been detected at a conventional
angiogram.
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grafts stenosis, nongrafted, and recipient vessels.37,38 The surgical history and unknown graft anatomy prior to DSA,
additional prognostic value of CTA helps enable long-term and in patients in whom conventional angiography fails to
risk stratification of CABG patients.39 In clinical practice, this demonstrate a known graft (Fig. 6-9). In the reoperative set-
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application is of value in the evaluation of the symptomatic ting, such data has virtually revolutionized surgical decision-
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patient in the early postoperative period in whom graft fail- making and planning prior to surgery in patients who have
ure is being considered (Fig. 6-8). It is particularly useful for already undergone CABG. Knowledge of anatomic place-
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the demonstration of graft patency in patients with a remote ment of prior grafts, cannulation sites, and previous incisions
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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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FIGURE 6-8  (A) Postoperative cardiac CT performed for evaluation of graft patency. Three-dimensional volume-rendered image demonstrates
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patent LIMA to LAD (black arrows), T-graft RIMA to obtuse marginal (white arrows), and SVG to RCA (grey arrows). This study was obtained in
a patient 1-day follow off-pump coronary artery bypass grafting. The patient had developed recurrent chest pain and an elevated troponin. Cardiac
CT ruled out early graft failure as a cause for the patient’s presentation. (B) Companion case in a different patient. Oblique multiplanar reformat-
ted images demonstrate an acutely occluded saphenous vein graft to obtuse marginal. Note the patent graft stump (black arrow) and thrombosed
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graft body (white arrows).

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Part I  Fundamentals

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FIGURE 6-10  Surgical clip artifacts can limit cardiac CT evaluation
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of coronary bypass grafts. Double oblique maximum intensity projec-
tion image (10 mm thick) demonstrates multiple surgical clips placed
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along the length of a radial to PIV graft (black arrows). Artifact from
these metallic clips can partially or completely obscure the adjacent
vessel lumen precluding evaluation of these segments for the presence
FIGURE 6-9  Cardiac CT performed to evaluate possible radial graft or absence of stenosis. Although CT can unequivocally demonstrate
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occlusion. The patient had surgery 1 month prior and presented with graft patency based on the delivery of contrast throughout the entire
course of the graft, surgical clip artifact usually does not allow com-
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recurrent angina. The radial to RCA graft could not be selective cath-
eterized at conventional angiography and was also not seen at aortic plete graft evaluation to rule out graft stenosis.
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root injection. Three-dimensional volume-rendered image demon-
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strates patent radial graft (white arrows) to RCA (black arrow). The
anastomosis is not seen on this orientation.
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complications. Cardiac CT may also be used for routine post-
operative control of grafts following implementation of a new
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surgical technique in a local center practice (Fig. 6-12). How-
have impacted properative planning of the reoperative cardiac ever, to our knowledge, there are no published guidelines for
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surgery patient. appropriate use of cardiac CT in patients status post CABG.
Patients with recurrent angina after bypass surgery may
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have developed stenosis or occlusion in bypass grafts, or may
have progression of native coronary disease. In these patients, REOPERATIVE SURGERY
CTA can be more limited. For example, exclusion of signifi- Reoperative cardiac surgery with live coronary grafts after
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cant stenosis in a graft may be problematic due to metallic previous CABG represents one of the most difficult problems
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surgical clips that cause artifact (Fig. 6-10). Moreover, native in cardiac surgery. Reoperative sternotomy is challenging sec-
CAD in these patients is often advanced and heavily calcified. ondary to adhesions, loss of tissue planes, and the potential
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A large volume of calcium may result in an uninterpretable for injury to patent grafts, the aorta, and the right ventri-
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study for many segments of the native coronaries (Fig. 6-11). cle. Injury to a patent left internal thoracic artery graft to
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CTA for plaque assessment in such patients may not be defini- the left anterior descending artery (LAD) is associated with
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tive; consequently conventional angiography may be preferred a mortality of 50%.44,45 Cardiac CT has been revolutionary
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in this population.40 CTA is increasingly useful for patients in precisely defining the relationship of important structures
with less calcification and less metal artifact. (including the aorta, right ventricle, and live grafts) to the
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In the research context, graft patency is an important midline and sternum for reentry planning (Fig. 6-13). At
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outcome in the evaluation of different surgical techniques.
Randomized controlled trials utilizing conventional angiog-
raphy for assessment of graft patency typically demonstrate a
10 to 20% rate of noncompliance. This noncompliance is at
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BWH, every reoperative surgery includes a preoperative CTA
with z-axis coverage to include all grafts and the entire course
of the IMAs. Preoperative identification of all structures at
risk is mandatory, and different, specific operative approaches

least partly attributable to the invasive nature of the test.41-43 always remain in consideration.46 Experience suggests that
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Cardiac CT is an attractive, noninvasive, and very accurate preoperative cardiac CT will lead to a modification in surgi-
method to assess graft patency for clinical trials, again obviat- cal strategy for 1 in 5 patients undergoing re-do cardiac sur-
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ing a traditional arterial puncture with its risks and known gery.36 For example, if CT demonstrates a patent left internal
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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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FIGURE 6-12 Cardiac CT obtained for postoperative graft con-
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trol in patient who underwent MVST. Three-dimensional volume-
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rendered image demonstrates patent LIMA to LAD (white arrows)
and radial T-graft to obtuse marginal (black arrows).
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aortic valve replacement (AVR) in the setting of live grafts,
CTA allows the surgeon to plan preoperatively whether or
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not those grafts will have to be divided in carrying out the
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aortotomy for the AVR. As described above, CT also allows
the cardiac surgeon to preoperatively plan the precise location
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of the aortotomy itself.
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Minimally Invasive Surgery Coronary

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FIGURE 6-11 Cardiac CT is often limited in its evaluation of
native coronary arteries in the postcoronary artery bypass graft patient Artery Bypass Grafting (MIDCAB)
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due to the presence of advanced and heavily calcified coronary ath-
Minimally invasive coronary artery bypass surgery is becom-
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erosclerosis. Double oblique maximum intensity projection image
(4 mm) demonstrates (A) the proximal LAD (black arrows) and a large ing an alternative to open surgery. With limited intraopera-
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first diagonal branch (white arrow) and (B) the proximal right coro-
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tive access for direct visualization, aspects of coronary artery
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nary artery (white arrows). The white areas are very high attenuation anatomy such as vessel diameter, extent of calcification, and
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and represent calcification. All vessel segments demonstrated are heav- the presence of intramyocardial segments become even more
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ily calcified. The extent of calcification completely obscures the vessel

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important to define preoperatively (Fig. 6-14). In addition,

lumen and presence or absence of stenosis cannot be reliably assessed.
3D models that combine visualization of a partially trans-
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parent thoracic cage over mediastinal structures allow the

surgeon to obtain detailed preoperative understanding of the
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mammary artery (LIMA) is close to the midline or a right patient’s cardiothoracic anatomy (Fig. 6-15). Preoperative
ventricle directly adherent to the posterior table of the ster- CT has demonstrated usefulness for MIDCAB47 and totally
num, cardiopulmonary bypass is instituted prior to reentry. endoscopic coronary artery bypass surgery,48 whereas postop-
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Definition of live grafts with respect to their proximal place- erative CT has been utilized for graft patency evaluation in a
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ment of the aorta is instrumental in determining, before the prospective study.49 CT is also expected to become invaluable
operation, the precise manner in which those grafts will be for procedures such as multivessel small thoracotomy coro-
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handled. For example, in reoperative surgery for conventional nary revascularization.

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Part I  Fundamentals

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FIGURE 6-14  Preoperative planning for minimally invasive cardiac
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surgery (MIDCAB). Two chamber plane maximum intensity projec-
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A tion image (6 mm thick) demonstrates the LAD. A segment of heavy
calcification is identified in the proximal vessel (black arrow), this cor-
responds to the site of the stenotic lesion. No significant calcification
is present in the remainder of the vessel. Immediately beyond the cal-
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cified segment an intramyocardial segment is present (white arrows).
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FIGURE 6-13 Planning for reoperative coronary artery bypass

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grafting. Laterally orientated 3D volume-rendered image (A) from

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a patient who had previously undergone left internal mammary

artery (LIMA) coronary bypass grafting. The LIMA (white arrows) is
FIGURE 6-15  Preoperative planning for minimally invasive cardiac
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grafted to the left anterior descending coronary artery. Note the rela-
tively large distance between the grafted LIMA and the sternum (grey
arrow). Axial image (B) clearly shows the LIMA graft (white arrow)
to be clear of midline and well posterior to the sternum (grey arrow).
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surgery (MIDCAB). Specialized display protocols for 3D volume-
rendered images can be used to provide combined visualization of a
semi-transparent thoracic cage and underlying cardiac and mediasti-

Since the most common surgical approach in a redo CABG is repeat nal structures. These models can be rotated and viewed from any angle
or degree of magnification. With cardiac CT, 3D localization of target
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thoracotomy through the sternal incision, this study demonstrates

that surgical revascularization through sternal reentry has no signifi- vessels, accessibility from proposed incision site, and position of LV
apex with respect to chest wall can all be understood preoperatively.
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cant risk of damage to the patent LIMA graft.

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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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CARDIAC VALVES
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In patients with suspected valve dysfunction based on echo-
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cardiography, cine CT from retrospective ECG gating as
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described in Part 1 provides valuable additional data. As
noted earlier, reconstruction is performed for all phases of
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the cardiac cycle, and the reformatted data can be played in
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a cine loop. This has relevance in assessment in native, bio-
prosthetic, and mechanical aortic valves. Recent experience
suggests an excellent correlation between planimetric valves
areas obtained by CT, MRI and transesophageal echocardiog-
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raphy (TEE).50 Consequently, CT can be used as an alternate
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modality for evaluation of aortic valve area. This is relevant if

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trans-thoracic echocardiography (TTE) is of poor technical
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quality or discrepant with a clinically expected result. Since
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patients may be evaluated with CT for concomitant aortic
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aneurysm or CAD prior to aortic valve surgery, valve area
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may be obtained from CT with no additional scanning and

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only a small amount of image postprocessing. CT can be used
in correlation with valve area as determined with echocar-
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diography (Fig. 6-16).
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Postoperative evaluation of bioprosthetic valves may also
be conducted using CT scanning. Although echocardiog-
raphy determined trans-valvular gradients are the reference
standard for determination of “effective” orifice area, CT
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FIGURE 6-17 Seventy-seven-year-old man with a #23 Medtronic
Mosaic valve. The patient developed shortness of breath approxi-
mately 1 year following surgery. Echocardiography which demon-
strated a peak gradient of 78 mm Hg; the effective orifice area was

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provides a useful correlative modality—particularly when reported at 0.9 cm2. Subsequent cardiac CT showed a normal valve
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the echo is technically challenging or discordant with clinical area of 1.7 cm2, providing reassurance to both patient and surgeon.
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findings. In patients with unexpectedly high gradients post-
valve implantation, increasing use of CT will provide more
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information to guide management (Fig. 6-17). In patients Cardiac CT also permits high-resolution functional evalu-
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with suspected bioprosthetic valve endocarditis, CT can be ation of mechanical aortic valve prostheses without artifact
an invaluable modality to delineate para-valvular and valvular (Fig. 6-19). CT can be readily incorporated to evaluate valve
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sequela of the infection (Fig. 6-18). dysfunction, measure opening angles, and to elucidate the
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underlying cause of valve failure. Figure 6-20 illustrates cor-
relation between CT and surgical specimen in a mechanical
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aortic valve patient with restricted opening angle and elevated
gradients. CT readily made the preoperative diagnosis of pan-
nus in-growth.
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Trascatheter Aortic Valve Replacement
(TAVR)
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Although cardiac CT is traditionally a second line imag-

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ing modality for the evaluation of aortic valve disease, it

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holds a key role in preintervention planning for TAVR.51,52
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Contrast-enhanced CTA is considered by appropriateness

criteria guidelines as reference standard for both aortic valve
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plane planning as well as for supravalvular aorta and iliofemo-

ral system planning.53 The volumetric data and high spatial
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resolution afforded by CT makes it ideal for accurate 3D

measurements of the aortic annulus, the aortic root, and the
ascending aorta; precise measurements of the aortic annulus
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are particularly important in choosing the appropriate pros-

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FIGURE 6-16 Reformatted CT angiography through the aortic thesis size (Fig. 6-21). There is a potential risk that the native
valve shows calcification and stenosis with a valve area of 1.00 cm2 valve leaflets will be displaced superiorly during prosthetic
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measured by direct planimetry. valve placement, potentially blocking the coronary artery
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Part I  Fundamentals

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FIGURE 6-18  Patient with clinically suspected bioprosthetic valve endocarditis. Left image shows a pseudoaneurysm originating below the aortic
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valve ring and exerting mass effect on the adjacent left atrial wall. The right image shows nodular thickening of the aortic valve leaflets consistent
with vegetations.
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ostia. This risk can be assessed from the CT images by mea- the true short-axis diameters of the aorta in assessing aortic
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suring the coronary ostia heights from the leaflet hinge points aneurysmal growth and decision making regarding interven-
as well as the leaflet lengths. The optimal fluoroscopic projec- tion. As supported by appropriateness criteria guidelines56
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tions, oriented to the aortic valve plane, can also be identified and without question from a clinical perspective, any surgery
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by CT, allowing for improved periprocedural planning. involving the aorta (whether the root, the arch, the ascending,
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For TAVR planning, additional CTA images of the abdo- or the descending portion) requires preoperative and postop-
men and pelvis enables evaluation of candidate peripheral erative CTA for surgical decision-making and follow-up.
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access vessels, including diameter, distribution of calcifica-
tion, tortuosity, and angulation. This information is impor-
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tant given the large size of the introducer sheath and delivery Noncontrast CTA for Cross-Clamping
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catheter used for TAVR. The superior imaging of ECG-gated CTA better defines the
Although postintervention evaluation of TAVR requires pathology and hence facilitates the preoperative planning.
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a multidisciplinary imaging approach (MR, TEE, TTE),
potential complications can be readily identified with CTA.54
CT findings correlated with findings from echocardiography
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For example, noncontrast CTA is by far the best imaging
modality to clearly define aortic calcification. If portions of
the aorta are calcified on CTA, then aortic cross clamping

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allow for excellent assessment of both the postoperative aortic and cannulation for cardiopulmonary bypass at those sites are
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root as well as functional information in patients with para- contraindicated in order to avoid embolic phenomenon and
valvular leak or infection. We note that despite the critical stroke. Studies have supported the routine use of noncontrast
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role for CT in TAVR planning, to our knowledge there are no enhanced CTA for identifying ascending aortic calcification
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published guidelines for appropriate use of CT for postproce- and selecting the optimal surgery strategy in patients with
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dural TAVR assessment. aortic stenosis or hemodialysis.57,58 Preoperative cardiopul-

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monary bypass strategy and myocardial protection are often
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critically altered by preoperative CTA. At BWH, the majority

AORTA AND GREAT VESSELS of elderly patients increasingly undergo noncontrast CT to
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Surgery of the aortic root, the ascending aorta, the arch, and assess aortic calcifications.
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the descending aorta is becoming increasingly commonplace

as the population ages. CT has been used for many years to
assess the thoracic aorta and is considered to be the currently
Aortic Aneurysm
preferred imaging modality.55 Non-ECG-gated CT is highly As with calcification, CT is the most accurate modality to
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accurate in the assessment of the aortic arch and descending evaluate the aortic root, with both 2D and 3D visualization
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thoracic aorta since they are not subject to significant cardiac (Fig. 6-22). Not only can the aortic root be sized from mul-
motion. However, ECG-gating cardiac CT adds motion- tiple imaging planes, but also the exact location of the aneu-
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free imaging of the aortic root, aortic arch, and ascending rysmal pathology with respect to the valve and sinotubular
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aorta. Gated cardiac CTA is particularly useful for measuring junction can often be defined.59 This assessment is critical
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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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FIGURE 6-19 Evaluation of mechanical valve function with cardiac CT. Coronal oblique multiplanar reformatted images (A) demonstrate
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closed and open positions of mechanical AVR in a patient with suspected valve dysfunction based on echo-Doppler. Axial oblique slab maximum
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intensity projection images (B) demonstrate closed and open position of mechanical AVR in a patient in atrial fibrillation at the time of cardiac CT.
Although image quality is degraded by arrhythmia, optimization of the dataset with ECG-editing can result in diagnostic quality images. Four-
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chamber oblique multiplanar reformatted images (C) demonstrate closed and open positions of a mechanical MVR. Images can be generated over
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the cardiac cycle and displayed in a cine movie format to allow dynamic evaluation of valve function. Since the study is performed with contrast,
thrombus or perivalvular abscess can also be identified if present.
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Part I  Fundamentals

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FIGURE 6-20  Patient with mechanical aortic valve. Low density material restricting leaflet opening on the undersurface of the valve is suspicious
for pannus in-growth causing restricted opening angle (left). Photograph of explant (right) demonstrates the pannus with high correlation with
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presurgical imaging.
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for preoperative decision-making and surgical planning. In
patients with ascending aortic aneurysm, if the aortic root is
determined to be aneurysmal near the coronary ostia, surgical
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with 3D volume-rendered images provides the surgeon with
preoperative visualization of aneurysm size and extent. The
extension of an ascending aortic aneurysm into the arch can

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decision-making changes from a simple tube graft repair for be demonstrated and, as mentioned above, the expected loca-
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the aneurysm to a much more complex composite root repair tion of aortic cross-clamping can be determined preoperatively
with coronary reimplantation. Three-dimensional volume ren- (Fig. 6-24). The location of normal aorta distally and the extent
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dering optimally depicts other aortic root pathologies such as of arch involvement will preoperatively determine the arterial
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coronary anomalies or a sinus of Valsalva aneurysm (Fig. 6-23). cardiopulmonary bypass cannulation site as well as the need
In patients with a sinus of Valsalva aneurysm, as opposed to a for concomitant arch repair, circulatory arrest, or selective ante-
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root aneurysm, CT alters surgical strategy for repair. grade perfusion. Selective antegrade cerebral perfusion itself is
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For known ascending aortic aneurysms that do not meet dependent on intact right axillary and innominate arteries, and
size criteria for surgery, CTA is excellent to periodically assess CTA is optimal for defining this anatomy. Since the success of
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size or change. For those patients who require surgery, CTA a procedure can be compromised by unexpected intraoperative
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FIGURE 6-21  Multiplanar reformatted image of the annulus of the aorta in a patient under evaluation for TAVR. The right-hand image shows
the routine annotation for measuring the annular area and dimensions in both short and long axis. Measurements are used for to determine the
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best sizing before the procedure.

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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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FIGURE 6-22  Demonstration of aortic root and aortic valve. Axial
oblique multiplanar reformatted image from a systolic dataset dem-
onstrates an open bicuspid aortic valve. Note the precise definition of
the aortic wall, free from the cardiac motion related artifacts that are
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FIGURE 6-23 Cardiac CT provides optimal visualization of
present at conventional thoracic CT scanning. Aortic root size mea-
complex aortic root pathology. Prior echocardiogram suggested the
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surements are highly accurate due to lack of motion artifacts and the
entire aortic root to be aneurysmal at greater than 4.5 cm. Three-
high spatial resolution of the cardiac CT scanning (<0.5 mm).
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dimensional volume-rendered image from cardiac CT demonstrates
a 2.6 cm sinus of Valsalva aneurysm arising off of the right coronary
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sinus (white arrow). The remainder of aortic root is normal.
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FIGURE 6-24 Comprehensive evaluation of ascending aortic aneurysm for preoperative planning. On the left, 3D volume-rendered image
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demonstrates an aneurysmal ascending aorta. Sagittal oblique maximum intensity projection image (20 mm thick) can be used to demonstrate
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aortic size measurements. The aneurysm can be seen to extend into the aortic arch. As the entire ascending aorta and proximal arch needed to
be replaced, cross-clamping could not occur proximal to the innominate in this patient and would have to occur in the mid-distal arch altering the
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surgical risk of the procedure.

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Part I  Fundamentals

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findings, CT has contributed enormously to surgical planning thus allowing the surgeon to understand the extent of the
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by defining anatomy that would not be preoperatively visual- intimal flap.56 In particular, ECG-gated CT offers informa-

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ized with any other imaging modality. tion regarding dissection of the ascending aorta (the proxi-

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mal extent of the dissection flap and its relationship to the
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Aortic Dissection and Aortic Intramural coronary arteries and the aortic valve) that was not available
before gating was routinely performed. In addition, motion-
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Hematoma (AIH) free images obtained with ECG gating allow for definitive
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CTA enjoys a sensitivity and specificity of almost 100% for exclusion of type A dissection (Fig. 6-25). The location of the
detection of aortic dissection and intramural hematoma, true and false lumen is critical in the preoperative planning,
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FIGURE 6-25  Although multiple modalities may be used for evaluation of the aortic root, cardiac CT is the gold standard for all pathology of the
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aorta, including the exclusion and characterization of type A dissection. Parasternal long-axis image from trans-thoracic echocardiogram (A) dem-
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onstrates a linear area of echogenicity (white arrow) above the noncoronary cusp of the aortic valve concerning for an intimal flap. The finding was
detected incidentally in a patient with recent stroke and possible PFO. Subsequent trans-esophageal echocardiogram (B) again demonstrated the
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finding. Axial image from cardiac CT scan (C) provides excellent visualization of the aortic root and definitively excludes the present of an intimal
flap. Sagittal oblique maximum intensity projection image (D) demonstrates aortic root and ascending aorta to be normal. No further evaluation
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is needed. Echocardiographic findings were presumed to be from artifact.

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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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the operative sequence, and the extent of repair. For example,
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in dissection of the descending aorta, end-organ perfusion

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is assessed by demonstrating contrast enhancement of indi-

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vidual organs and related compromise of the celiac, superior
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mesenteric, inferior mesenteric or renal arteries. As is the case
for a nonsurgical aneurysm, if a descending thoracic aor-
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tic dissection is stable and to be followed expectantly, CTA
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remains the reference standard for periodic assessment. Emer-
gency nonenhanced CT, followed by CT contrast-enhanced
angiography is the guideline endorsed recommendation,60
in particular when IMH or aortic dissection are suspected.
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Contrast-enhanced CTA is the appropriate,61 definitive test
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A
in patients with suspicion of aortic dissection.

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Traumatic Aortic Injury
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For patients with suspected trauma of the aorta and the great
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vessels contrast-enhanced CT is the guideline-endorsed60,62

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reference standard. Almost all polytrauma diagnostic algo-
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rithms include a combination of chest radiography plus CTA
for initial patient evaluation. The sensitivity and specificity
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of CT are close to 100% and it is the only imaging modality
that has NPV of 100%.63,64
Aside direct visualization of traumatic aortic injury, CT
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allows for simultaneous imaging of indirect signs including
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widened mediastinum, pulmonary contusion, left scapula
fracture, hemothorax, and pseudoaneurysm of the aortic wall
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(Fig. 6-26).65
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Pulmonary Embolism
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Growing evidence from recent studies and known societies
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guidelines66,67 support CT pulmonary angiography (CTPA)
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as the first-line imaging test to confirm or exclude the clini- B
cal suspicion of acute pulmonary embolism (PE).68 Com-
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bined with careful clinical assessment and specific biomarkers
(d-Dimers, NT-pro-BNP, Troponin I), CTPA can further
guide management in patients of low to moderate risk.
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FIGURE 6-26  Patient status post motor vehicle accident. (A) Multi-
planar reformatted image demonstrates traumatic aortic injury with a
contained pseudoaneurysm (arrow) at the level of the ligamentumar-

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Right ventricular dysfunction as demonstrated by an enlarged teriosum. (B) Image from conventional angiography were obtained at
RV diameter,69,70 abnormal position of interventricular sep- intervention. The modern diagnosis and exclusion of traumatic injury
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of the aorta rests almost entirely on CT.
tum and inferior vena cava contrast reflux, provides aside
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to diagnostic assistance, prognostic value and may predict
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adverse outcomes and patient mortality (Fig. 6-27).71

can sometimes be performed with a reduced iodine load with fre
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satisfactory image quality.
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HEART FAILURE
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Heart transplantation is the definitive therapy for end-stage

Implantable Devices for Heart Failure
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heart failure whereas left ventricular assist devices (LVAD) For patients with implantable cardiac devices, ECG-gated
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represent a bridge to transplantation, a destination therapy,
or a bridge to recovery.72,73 Complications can appear either
acutely or gradually. Aside providing important anatomi-
cal information preoperationally, CT can be utilized for the
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cardiac CT is feasible, accurate, and enhances the diagnostic
evaluation of suspected LVAD dysfunction, further modify-
ing management.74,75
For LVAD assessment, CT is superior to echocardiography

assessment of proper device function and the early identifica- that has limited imaging depth and coverage volume with
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tion of complications. Since this patient population often has regards to the limited acoustic window and acoustic shadow-
impaired renal function, iodinated contrast-induced nephro- ing.76 Common complications such as in-device-thrombus
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toxicity is an important risk that should be carefully consid- formation, hemorrhage, cannula/driveline obstruction, peri-
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ered in discussion between the surgeon and radiologist. Scans cardium tamponade, or infections can be recognized; the
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Part I  Fundamentals

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B
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FIGURE 6-28 Heart failure patient status post VAD placement.
(A) Axial image demonstrates a fluid attenuation lesion containing a
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punctate amount of gas (arrow) at the level of the ventricular inser-
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tion. (B) Reformatted image shows the orientation of the ventricular
insertion pointed superiorly to the long axis of the left ventricle with
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impingement on the anterior heart.
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In patients with implantable pacemakers and defibrilla-
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tors, ECG-gated CT with multiplanar reformatting is useful
for identifying late (>1 month postimplantation) lead mal-
position, and in conjunction with echocardiography findings
B
can evaluate possible cardiac perforation.80
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FIGURE 6-27 Patient with acute hypoxia. (A) Saddle pulmonary
embolus (arrow) demonstrated by a large contrast (white) filling Heart Transplantation
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defect. Note the enlargement of the main pulmonary artery and (B) The role of cardiac CT is secondary for the diagnosis of acute
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relative enlargement of the RV (*) with respect to the LV. This finding
strongly suggests right heart strain.
transplantation complications, namely acute cardiac allograft
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rejection, as echocardiography and MR are used as the first-

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line imaging modalities.81 Coronary allograft vasculopathy

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orientation of the device can be assessed using multiplanar (CAV) affects almost half of the transplant recipients and
reformatted images (Fig. 6-28).77 represents one of the major mortality causes. CTA offers a
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The diagnosis of tamponade in patients with LAVD almost reliable diagnostic tool alternative to the traditionally used
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entirely relies on CT, and common findings include inferior
vena cava dilatation, right ventricle compression, and con-
trast material reflux into the azygos vein.77 Peridevice presence
of gas or fluid accumulation are indicative of infections, and
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interventional coronary angiography (ICA) and intravascu-
lar ultrasound. By offering an excellent NPV in relation to
reference ICA, CT can be utilized as a noninvasive approach,
thereby minimizing invasive procedures.82, 83 Important limi-

given the contraindication of MR, cardiac CT is considered tation is the inability to adequately visualize distal coronary
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to be the test of choice to evaluate for mycotic pseudoaneu- vasculature with a diameter of <1.5 mm where early CAV is
rysm.78 CT is recommended by guidelines79 for visualization usually recognized. Cardiac CT can exclude significant CAV
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of the native heart and LVAD components and may be valu- within the larger, major coronary segments that may be suit-
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able when other imaging modalities have not been revealing. able for stenting.84
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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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VARIOUS pericardial masses. However, CT may be desired, and
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potentially required, if the mass is known to extend into

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Imaging of the Pericardium
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the mediastinum, chest wall, or lung, or if the patient has

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In patients with clinically suspected constrictive pericarditis, a contraindication to MRI. CT also evaluates extra-cardiac
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cardiac MR or CT can be used to confirm and measure peri- thoracic structures with high spatial resolution; thus, it can
define the full extent of disease (Fig. 6-31). CT is also useful
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cardial thickening. In comparison with MR, CT far better
demonstrates the presence and extent of calcification as well as a single follow-up examination in patients with metas-
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as the localization and characterization of pericardial effusion,
cysts, or masses. This may be of value in confirming chronic
calcific pericardial thickening, supporting the diagnosis of
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tases to the heart and lungs because it avoids the need for
periodic assessment with both conventional chest CT and
cardiac MRI. Fat-containing lesions are very amenable to
evaluation by CT, since these low attenuation lesions have a

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constrictive pericarditis (Fig. 6-29). In these cases, 3D volume
characteristic appearance, appearing black relative to water
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rendering illustrates regional localization and distribution of
(Fig. 6-32).

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pericardial abnormality; CT is an outstanding preoperative
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planning tool prior to pericardial stripping (Fig. 6-30). Fur-
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thermore, retrospectively ECG-gated studies can guide func- Cardiac Infections
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tional evaluation of septal bounce or pericardial tethering.85
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Primary or metastatic pericardial masses are rare. CT and Infective endocarditis (IE) may involve native or prosthetic
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cardiac valves. The diagnosis is typically suggested on clinical

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MRI offer additional information on the localization and
sizing, detection of calcification, and tissue characterizations assessment. However, imaging confirms the clinical suspi-
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(presence of blood, thrombus, or fat). Usual image findings cion and demonstrates cardiac valve vegetations, paravalvular
include contrast enhancement and high-signal intensity T2W abscesses, complications, and further identifying and grad-
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images in CT and MR, respectively. Uncommon lesions such
as pericardium cysts and diverticula have typical appearance
on CT as well-circumscribed, thin-walled fluid collection
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ing heart failure. ECG-gated CT in IE may be appropriate
by guidelines,86,87 depending on the clinical presentation,
and is complimentary to echocardiography (TTE and TEE)

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most frequently found in the right cardiophrenic angle. for the evaluation of suspected paravalvular and myocardial
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abscesses, pseudoaneurysms and infections of prosthetic heart
valves (Fig. 6-33). CTA may be appropriate, again depending
Cardiac Masses
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on the clinical scenario, for identifying the coronary arteries
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Cardiac MRI is the preferred modality for high spatial origin prior to surgery.87 Vegetations smaller than 1 cm are
resolution cross-sectional imaging to evaluate cardiac and hard to detect with CT (NPV = 55.5%).
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CT MR
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FIGURE 6-29  Calcific constrictive pericarditis. Short axis multiplanar reformatted image from cardiac CT demonstrates extensive thickening
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and calcification involving left-sided pericardium. In the appropriate clinical setting, these findings would support the diagnosis of constrictive
pericarditis. Short axis double inversion recovery fast spin echo image from cardiac MR in the same patient also shows abnormal pericardial thick-
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ening, but is insensitive to calcification.

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Part I  Fundamentals

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FIGURE 6-30 Preoperative evaluation of chronic calcific pericardial thickening prior to pericardial stripping. Three-dimensional volume-
rendered images from cardiac CT demonstrate extensive regional pericardial calcification (white areas). This includes over the RVOT, right ven-
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tricle, right atrium, and entire inferior wall extending inferolaterally. Anterior and anterolateral pericardium was normal.
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FIGURE 6-31 Cardiac CT of undifferentiated LV sarcoma per-

formed to evaluate cardiac and extra-cardiac extent of disease. Four
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chamber multiplanar reformatted image (A) demonstrates invasive

myocardial mass centered on the lateral wall beginning at the mid-
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ventricular level with extension to involve the base of both papil-

lary muscles and distal circumferential involvement of the LV apex.
Large epicardial component is noted intimate with pericardium
(white arrows). There is no evidence of chest wall invasion. Left pleu-
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ral effusion is seen (black arrow). Sagittal oblique maximum intensity

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projection image (B) (12 mm thick) shows encasement but patency of

the LAD (black arrow) by tumor (white arrows) at the LV apex over a
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2.5 cm length. Full field of view axial image (C) shows LV mass with-
out gross chest wall invasion (black arrows), evidence of prior mastec-
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C
tomy (white arrow), and left pleural effusion.
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Chapter 6  Computed Tomography of the Adult Cardiac Surgery Patient: Principles and Applications

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FIGURE 6-32  Lipomatous hypertrophy of the interatrial septum. Oblique axial multiplanar reformatted image (A) demonstrates a low attenua-
tion mass (white arrow) insinuated between SVC (grey arrow) and left atrium (black arrow). Second more caudal image (B) demonstrates character-
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istic sparing of the fossa ovalis (white arrow). This lesion is nonencapsulated and can be quite extensive as in this case. Note presence of leads from
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pacemaker which precluded an MR study.
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FIGURE 6-33  Intravenous drug user who presented with fever of unknown origin. The four panels of the CT images demonstrate complex fluid (*)
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at the level of the aortic root, consistent with abscess (confirmed by sampling). The three orthogonal images (upper panels and lower right panel)
show the relationship with the elongated and narrowed left main coronary artery (arrow). The bottom left pane shows a 3D volume rendering that
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can be viewed at any angle for interventional planning.

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Part I  Fundamentals

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Additional imaging utilizing CT or MRI in acute infectious for reoperative surgery. Understanding the technical consid-
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pericarditis can be considered for association with clinical erations will allow the surgeon to appreciate the inherent

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findings and echocardiography in complicated cases. Non- strengths and weaknesses of cardiac CT and to optimally

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calcified pericardial thickening along with contrast enhance- communicate with the radiologist. This, in turn, will result in
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ment of visceral and parietal surfaces of the pericardial sac are the best quality diagnostic examination in the vast majority
common findings. CT provides information on the nature of of cardiac surgery patients.
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the effusion fluid by distinguishing between exudative versus
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transudative fluid (usually <10 HU), or hematomas.
REFERENCES
CT VERSUS MRI OF THE HEART
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1. Rybicki FJ, Otero HJ, Steigner ML, et al: Initial evaluation of coronary
images from 320-detector row computed tomography. Int J Cardiovasc
Throughout this chapter, comparisons between CT and MRI
co

co

co

co
Imaging 2008; 24:535-546.

c
have illustrated the strengths and limitations of each. Both 2. Steigner ML, Otero HJ, Cai T, et al: Narrowing the phase window width
e.

e.

e.

e.
modalities give the surgeon valuable pre- and postoperative in prospectively ECG-gated single heart beat 320-detector row coronary
re

fre

re

re
information. While the modality best suited for specific clini- CT angiography. Int J Cardiovasc Imaging 2009; 25:85-90.
3. Chen MY, Shanbhag SM, Arai AE: Submillisievert median radiation dose
cal indications evolves with the technology, at present cer-
sf

f
for coronary angiography with a second-generation 320-detector row CT
ks

ks

ks
tain generalizations can be made. Cardiac CT is invaluable in scanner in 107 consecutive patients. Radiology 2013; 267:76-85.
k

reoperative cardiac surgery as it offers higher quality noninva- 4. Flohr TG, McCollough CH, Bruder H, et al: First performance evalua-
oo

oo

oo

oo
tion of a dual-source CT (DSCT) system. Eur Radiol 2006; 16:256-268.
sive angiography of native coronary arteries and bypass grafts. 5. Achenbach S, Marwan M, Schepis T, et al: High-pitch spiral acquisition:
eb

eb

eb

eb
Since 3D volume rendering with CT has higher quality and a new scan mode for coronary CT angiography. J Cardiovasc Comput
better spatial resolution, it is preferred for preoperative plan- Tomogr 2009; 3:117-121.
m

ning for reoperative CABG or minimally invasive cardiac sur-
gery. All calcifications are poorly seen on MRI and superbly
seen with CT, and thus CT is far superior in demonstrating
m
m
6. Vavere AL, Simon GG, George RT, et al: Diagnostic performance of
combined noninvasive coronary angiography and myocardial perfusion
imaging using 320 row detector computed tomography: design and
implementation of the CORE320 multicenter, multinational diagnostic

m
coronary, myocardial, pericardial, and valvular calcifications. study. J Cardiovasc Comput Tomogr 2011; 5:370-381.
7. George RT, Arbab-Zadeh A, Cerci RJ, et al: Diagnostic performance of
co

co

co

co

The same is true for mechanical valve prostheses; because of
large areas of artifact on MR images, functional evaluation
e.
co
combined noninvasive coronary angiography and myocardial perfusion
imaging using 320-MDCT: the CT angiography and perfusion methods

e.

e.

e.
is only possible with CT. Finally, all patients with a surgical of the CORE320 multicenter multinational diagnostic study. AJR Am J
fre

fre

fre

fre
problem of the aorta require evaluation with CT. Roentgenol 2011; 197:829-837.
8. Rochitte CE, George RT, Chen MY, et al: Computed tomography angi-
The strengths of MRI include high temporal resolution,
ks

ks

ks

ks
ography and perfusion to assess coronary artery stenosis causing perfusion
greater blood-myocardial image contrast, multiparametric defects by single photon emission computed tomography: the CORE320
oo

oo

oo

oo
functional evaluation, and techniques for myocardial tissue study. Eur Heart J 2014; 35:1120-1130.
characterization. In addition, cardiac MRI is invaluable in 9. Rybicki FJ, Mather RT, Kumamaru KK, et al: Comprehensive assessment
eb

eb

eb

eb
of radiation dose estimates for the CORE320 study. AJR Am J Roentgenol
assessing myocardial function, contractility, and actual tissue 2015; 204:W27-W36.
perfusion and viability. For these reasons, MRI remains the
m

m
10. Kishi S, Magalhaes TA, George RT, et al: Relationship of left ventricular
reference standard to assess biventricular volumes, function, mass to coronary atherosclerosis and myocardial ischaemia: the CORE320
multicenter study. Eur Heart J Cardiovasc Imaging 2015; 16:166-176.
and myocardial mass. A variety of MRI pulse sequences can 11. Shu KM, MacKenzie JD, Smith JB, et al: Lowering the thyroid dose
accurately delineate areas of chronic myocardial infarction, in screening examinations of the cervical spine. Emerg Radiol 2006;
m

m
identify certain specific cardiomyopathies, and confirm the 12:133-136.
co

co

co

co

presence of neoplasm. With the use of parallel imaging tech-
niques to increase the speed of the MRI acquisition, very
e.
co
12. Hoffmann MH, Shi H, Schmitz BL, et al: Noninvasive coronary angiogra-
phy with multislice computed tomography. JAMA 2005; 293:2471-2478.

e.

e.

e.
13. Garcia MJ, Lessick J, Hoffmann MH: Accuracy of 16-row multidetec-
high temporal resolution (20–30 ms) can be obtained to tor computed tomography for the assessment of coronary artery stenosis.
re

fre

fre

study bioprosthetic and native valve function. In addition, JAMA 2006; 296:403-411.
fre
sf

measurements of flow parameters through a vessel cross- 14. Turkvatan A, Biyikoglu SF, Buyukbayraktar F, Olcer T, Cumhur T, Duru E:
ks

ks

ks
Clinical value of 16-slice multidetector computed tomography in symp-
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section can be used to, for example, accurately quantify val- tomatic patients with suspected coronary artery disease. Acta Radiol 2008;
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oo

vular regurgitant lesions. 49:400-408.

One distinct advantage of MRI over CT is that MRI deliv- 15. Hausleiter J, Meyer T, Hadamitzky M, et al: Non-invasive coronary com-
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eb

eb

puted tomographic angiography for patients with suspected coronary

ers no patient radiation. As detailed in Part 1, the radiation artery disease: the Coronary Angiography by Computed Tomography
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exposure in ECG-gated CT is higher than that for CT of any
other body part. In younger patients, who typically have less
comorbid disease and may require multiple follow-up exam-
inations over years or decades, MRI should be used when
m
with the Use of a Submillimeter resolution (CACTUS) trial. Eur Heart J
2007; 28:3034-3041.
16. Marano R, De Cobelli F, Floriani I, et al: Italian multicenter, prospective
study to evaluate the negative predictive value of 16- and 64-slice MDCT

m
imaging in patients scheduled for coronary angiography (NIMISCAD-
possible. Non Invasive Multicenter Italian Study for Coronary Artery Disease). Eur
co

co

co

co

co

Dramatic progress in CT technology has enabled advanced Radiol 2009; 19:1114-1123.

17. Shabestari AA, Abdi S, Akhlaghpoor S, et al: Diagnostic performance of
cardiac imaging for cardiac surgery patients. CT has rapidly
e.

e.

e.

e.

64-channel multislice computed tomography in assessment of significant

demonstrated broad ranging applicability, and in particular
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fre

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fre

coronary artery disease in symptomatic subjects. Am J Cardiol 2007;

CT has revolutionized the preoperative assessment of patients 99:1656-1661.
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ok

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oo

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eb

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eb
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