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64-slice prospective gated axial coronary CTA (PGA) in select patients

Dr. Smuclovisky, Claudio South Florida Medical Imaging Cardiovascular Institute

Joel S. Morris, Claudio Smuclovisky

South Florida Medical Imaging Cardiovascular Institute

Boca Raton, Florida


Cardiac CTA is rapidly becoming widely accepted in the evaluation of patients with coronary artery disease (CAD). One of the important limitations of the current retrospective acquisition is the significant radiation dose to patients, particularly in younger ages. PGA (Step & Shoot) has recently become commercially available and can reduce the radiation dose by as much as 80% by selectively targeting a single phase (75%) of the cardiac cycle without significant loss of spatial resolution.


During a period of five months, PGA's were performed in fifty-seven (57) patients (39 males, 18 females) selected by the following criteria: low clinical suspicion of coronary obstruction, age <66, heart rate <65 bpm, no arrhythmias, no previous coronary intervention (PCI-CABG). Mean age was 56 years (26-65). All patients received prior IV metoprolol, average 15 mg (5-25). The studies were acquired in a 64 slice scanner with IV 100 cc of low-osmolar contrast, 350 mg/ml. The studies were reviewed independently by two experienced level 3 readers.


54 (95%) of the studies were diagnostic and reported with high degree of confidence. Three studies had excessive motion artifact due to acceleration of the heart rate during the acquisition and required to be repeated with retrospective technique. The mean radiation dose was 3.7 mSv (1.1-6.3).


PGA can be successfully performed in a select group of patients with up to 80% reduction of the radiation dose when compared to current CCTA, with dose modulation. By additional lowering of kV (80-100), further reduction in radiation can be achieved. PGA opens further opportunities in the paradigm of risk stratification and early treatment of CAD in younger patients and also potentially could replace calcium scoring. Limitations include the need to use beta blockers, no cardiac wall motion information and patient selection.





Case 1


Patient History: 31-year-old asymptomatic male with strong family history of CAD.


Images: 3-D volume rendered and 2-D map of the coronary tree.


Diagnosis: Normal coronaries.





Case 2


Patient History: 57-year-old male worked up for CAD had a coronary angiogram showing the LAD originating from the right coronary cusp. The CTA was ordered to demonstrate the course of the LAD.


Images: Coronary angiogram demonstrates LAD origin from the right cusp. VR and Oblique MIP demonstrating pre-pulmonic (benign) course of the LAD.


Diagnosis: Benign congenital coronary anomaly.





Case 3


Patient History: 66-year-old asymptomatic male with a history of questionable abnormal myocardial perfusion scintigram in the LV apex.


Images: 2-D Map and cMPR demonstrating critical obstruction in the mid RCA. Angiogram correlation with pre and post stenting.


Diagnosis: High grade critical obstruction in the mid RCA.





Case 4


Patient History: 43-year-old male with atypical chest pain.


Images: 2-D Map, cMPR and MPR stretched view demonstrating anomalous interarterial origin of a dominant RCA originating from the left coronary cusp.


Diagnosis: Congenital anomalous (malignant) origin of the RCA.





Case 5


Patient History: 54-year-old male for EP planning.


Images: Axial slices demonstrating left chamber dilatation with LV wall infiltration, adenopathy and lung parenchymal infiltrates. There is right chamber metal artifact from wire leads.


Diagnosis: Sarcoid cardiomyopathy.

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Feb 20, 2009

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Brilliance 64-channel
3D, artifacts, Brilliance v2.0, Cardiac, chest CTA, chest pain, coronary artery disease, Coronary CTA, EP Planning, LAD, MIP, MPR, myocardial perfusion, prospective, RCA, Step & Shoot, Vascular

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