Welcome the new 1st year residents
- Anatomy
- Pathology
- History of Atherosclerosis
- Atherosclerosis
- Congenital Anomalies
- Embryology
- CTA Lecture
- My Teachers Go back a long way
- Van Praagh
- Segmental Approach to Complex Congenital Heart Disease
- Ongoing pursuit to find the underlying principles that govern complexity ( The Common Vein)
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Approach to structural evaluation in health and disease
- Parts and Connections
- Size
- Shape
- Position
- Character
- Time
- Whichever technology is able to fulfill these elements wins the prize
- And I believe it is CT(at least for the diagnosis of CAD)
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- It was advent of CT and its application that inspired me to
- hang up my triple headed Tycos
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At the time the perception of radiology was that
Working in a Dark Room
Subjectivity DominatedBut even in that world it gave birth to people like Dotter, Seldinger and Judkins
However it was my introduction to CT that sold Radiology to me
Nietsche – German philosopher
Believer in Perspectivism
Mother in Law Rosalie Fisher – Physicist
Looking at the the Pixel/Voxel from Many Angles
Gave numbers to the pixels
(just like the the 0 and 1 of computer science)
Enabled Objectivity – Ability to Accurately Measure
The pixel has a number embedded within it
This methodology is therefore able to provide objectivity, enabled by better measurement provided by better tools (computer algorithms)
- CT scan
- because of the nature of its acquisition
- it has the element of objectivity
Familiar to all is the Hounsfield Number relating to the density
Blooming Artifact
Resolution At the Vessel Level
- Coronary Artery
- diameter 3-4mm
- wall thickness ranges from 0.55 to 1.0 mm
- intima and adventitia .2mm – .3mm
- … and the vessels is moving
Subjectivity
Consensus in the Trials
- ACCURACY, Core-64 multicenter Study, CONFIRM Study, PROMISE Study, SCOT Heart Study Summary
- revealed that we had a tool with high sensitivity and low specificity
- SCOT Trial
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- prevented future major adverse cardiovascular event (MACE),
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- However over over the last 10 years or so we have developed new tools that are able to enhance and better use the information within the voxels which are
- readily applied because of the innate and sound basis of the digital acquisition of the information
- Advances include
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- improved resolution
- reduced radiation
- faster times of acquisition
- computational algorithms that are able to
- infer function from structure (FFR CT )
- methodology to characterize the tissues in the arterial wall
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using the digital information inside the voxels
The New Tools – “Game Changers”, “Paradigm Shift”
- Faster Acquisition –
- 256 to 320- 640 detectors
- 640-slice CT scanner can image the entire heart in less than one third of a second
- 256 to 320- 640 detectors
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- 640 slice CT scanner uses 80% less radiation
- Computerized Algorithms and AI
Calcium Score and Coronary CTA
- Acceptance and Recommendations by the Societies
- Class 1 recommendations
- 2016 Britain
- 2019 Europe
- ESC guideline
- 2021 US
- Class 1 recommendation
- patients with stable and acute chest pain
- (Narula J, et al 2021 Expert Consensus Document)
- Class 1 recommendation
Fractional ?ow reserve derived from CT – FFR CT
- measurement of
- pressure differences across a coronary artery stenosis (narrowing, usually due to atherosclerosis
- to determine the likelihood that the stenosis impedes oxygen delivery to the heart muscle
- maximum achievable blood flow in a diseased coronary artery and the
- theoretical maximum flow in a normal coronary artery.
- An FFR of 1.0 is widely accepted as normal.
- An FFR lower than 0.75-0.80 is generally considered to be associated with myocardial ischemia
- Abnormal <0.75-0.80
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- Normal = 1.0
- generally considered to be associated with myocardial ischemia
CT Perfusion
- CT Perfusion
- Core 320 Study Summary
- core 320 study Pub Med Link Full Text
- PERFECTION Study
- PERFECTION Study CTp vs FFR CT (Pub Med)
- Core 320 Study Summary
Plaque Characterization
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Atherosclerosis
CT-015-lo-res-scaled.jpg
Atherosclerosis starts as a fatty infiltration in the intimal and subintimal layer progressing in size stimulating the formation of fibrous tissue to create the so called fibrofatty plaque. Dystrophic calcification results
Ashley Davidoff MD
thecommonvein.netCT-016-lo-res-scaled.jpg
As the plaque grows , either as a fibrofatty plaque or a calcified plaque or a mixture and it slowly encroaches on the lumen causing progresive narrowing of the vessel and results in time wit decreased perfusion
Ashley Davidoff MD
thecommonvein.netThe Fatty Plaque with thin cap and neovascularity is a land mine waiting to explode
The Vulnerable Plaque
Parthenogenesis and Features of the Vulnerable Plaque
IVUS Virtual Histology
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CT and Vulnerable Plaque –
- Specific Definitions of High-Risk Plaque Features Improve Detection of Acute Coronary Syndrome
Results From the ROMICAT II Trial
Circulation Cardiovascular Imaging Vol 11 No.8 Coronary
Patient with Psoriasis, Atherosclerotic Disease Before and After Biologic Therapy
Conclusion and Summary
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I saw it for myself in Washington DC
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It is definitely on their minds
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Saw the writing on the walls (floor) of the
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National Airport
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Between Concourse B and C
Digital Make Up of the Coronary Artery
Concern for Lipid Infiltration into the Vessels
Concern for the Vulnerable Plaque
Focus to Treat and Help the Vulnerable Before it was too Late
Advancing Computerized Evaluation of Flow Dynamics
Remembering the Role of Shear Stress
Concern for Shortfalls of Energy Delivery
Attention to Myocardial Perfusion
Approaching a Problem from Many Angles to get to the Truth
- What we have learned is that we should approach CAD
- Chronic Illness
- Chest Pain – Stenotic Disease
- like we approach OA
- ie as a mostly a chronic illness
- Chest Pain – Stenotic Disease
- Chronic Illness
- Life threatening Disease –
- Acute potential
- (sneak attack methodologies)
- high suspicion for a hidden enemy
- like pathological fracture
- Identifying the high risk patients
- Look and comment on the coronary arteries in all CT’s
- assessing the risk of a
- future major adverse cardiovascular event (MACE),
- Acute potential
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References and Links
- Abdelraman et al JACC 2020
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