Handbook of Cardiovascular CT Essentials for Clinical

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Preface

This book has been created as a primer to help cardiologists, radiologists, and other
cardiac-imaging enthusiasts to have a handy reference tool for the answers to impor-
tant questions related to cardiovascular computed tomography (CCT). CCT has
evolved from novel technology to research tool to essential clinical imaging moda-
lity at an astounding pace. The technology has great relevance for the multitude
of medical and surgical disciplines focused on the treatment of cardiovascular dis-
ease. Imaging of anatomy, physiology, and tissue characteristics from large-to-small
vessel within seconds, and reconstruction to multimodal 2- and 3-D images within
minutes, has facilitated practical clinical applications important to cardiovascular
diagnosis, risk stratification, and procedure guidance. The new wave in technology
requires education and training of initial generations of readers and users of CCT
focused on providing an understanding of the essentials of methodology, technique,
and image analysis for clinical application. This text serves as a primer for the practi-
cal performance and interpretation of CCT. The breadth and depth of the knowledge
of the individual authors have provided concise chapters on essential topics, with
additional teaching pearls as well as key images.

Matthew J. Budoff
Torrance, California, USA

Jerold S. Shinbane
Los Angeles, California, USA

v
Acknowledgments

I would like to thank the authors of the chapters not only for their excellent and
concise contributions, but also for their innovations that continue to move this field
forward. To my family, especially Vicky, Daniel and Garrett, who put up with my
long hours in front of my laptop while creating this book. To Jerold, who did the
lion’s share of work for this book, for without his encouragement and assistance,
this never would have come to be.

Matthew J. Budoff, MD FACC, FAHA

I would like to thank Matthew Budoff, whose dedication, enthusiasm, and intel-
lectual curiosity has continued to move the field of cardiovascular CT forward in
innovative directions. I would also like to thank the chapter authors for their ability
to instill their significant expertise in cardiovascular CT into clear, concise, and
accessible chapters. To my family, especially Rosemary, Anna, and Laura, thank
you for your continued encouragement and support.

Jerold S. Shinbane, MD FACC

vii
Contents

1 Cardiovascular CT Angiography: Concepts Important to Image

Acquisition and Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Matthew J. Budoff, Songshou Mao, Patrick M. Colletti,
and Jerold S. Shinbane

2 Cardiovascular CT Imaging: Essentials for Clinical Practice:

Patient Selection and Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Tracy Q. Callister

3 Cardiovascular Calcium: Assessment and Impact of Interventions . . . 23

Stamatios Lerakis, Antonio Bellasi, and Paolo Raggi

4 Assessment of Cardiac Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

John A. Rumberger

5 CTA as an IVUS Equivalent: Plaque Characterization

and Percutaneous Coronary Intervention . . . . . . . . . . . . . . . . . . . . . . . . . 39
Harvey S. Hecht

6 Coronary Angiography of Native Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Matthew J. Budoff

7 Coronary CT Angiography after Percutaneous Coronary

Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Wm Guy Weigold

8 Coronary Angiography after Surgical Revascularization . . . . . . . . . . . . 69

Ian S. Rogers and Udo Hoffmann

9 Perfusion and Delayed Enhancement Imaging . . . . . . . . . . . . . . . . . . . . . 77

Joao Lima and Ilan Gottlieb

ix
x Contents

10 Cardiac SPECT and PET: Complementary Roles

with Cardiac CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Daniel S. Berman, Leslee J. Shaw, Alan Rozanski, John D. Friedman,
Sean W. Hayes, Louise E.J. Thomson, Piotr J. Slomka, and Guido
Germano

11 CCT Imaging: Cardiac Electrophysiology Applications . . . . . . . . . . . . 97

Jerold S. Shinbane

12 Pericardial /Myocardial Disease Processes . . . . . . . . . . . . . . . . . . . . . . . . 111

Michael D. Shapiro, Ammar Sarwar, and Khurram Nasir

13 Assessment of Cardiac and Thoracic Masses . . . . . . . . . . . . . . . . . . . . . . 119

Patrick M. Colletti, Jabi E. Shriki, and William D. Boswell

14 Computed Tomography Evaluation in Valvular Heart Disease . . . . . . . 131

Javier Sanz, Susanna Prat-González, and Mario J. Garcı́a

15 The Aorta and Great Vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

David M. Shavelle

16 Adult Congenital Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Louise E.J. Thomson, Ronald P. Karlsberg, John D. Friedman,
Sean W. Hayes, Rola Saouaf, and Daniel S. Berman

17 Cardiovascular CT: Assessment of the Lower

Extremity Vasculature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
John R. Lesser, Bjorn P. Flygenring, Alan T. Hirsch, Thomas
Knickelbine, Terrance F. Longe, and Robert S. Schwartz

18 Imaging Decisions: Cardiovascular CT Versus

Cardiovascular MR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Jerold S. Shinbane, Jabi Shriki, and Patrick M. Colletti

19 Radiation Safety: Radiation Dosimetry and CT Dose

Reduction Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Kai H. Lee

20 Competency, Appropriateness, and Quality

in Cardiovascular CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Allen J. Taylor, Lance E. Sullenberger, and Todd C. Villines

21 Cardiac Anatomy by Computed Tomographic Imaging . . . . . . . . . . . . . 215

Ambarish Gopal

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Contributors

Antonio Bellasi, MD
Department of Urology, Department of Medicine and Division of Car-
diology, Emory University School of Medicine, Atlanta, GA, USA,
e-mail: [email protected]
Daniel S. Berman, MD
Department of Imaging, Cedars Sinai Medical Centre, Los Angeles, CA 90048,
USA, e-mail: [email protected]
William D. Boswell, MD, FACR
Department of Radiology, Los Angeles, CA, USA, e-mail: [email protected]
Matthew J. Budoff, MD, FACC, FAHA
Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center,
Torrance, CA, USA, e-mail: [email protected]
Tracy Q. Callister, MD
Department of Cardiology, Tennessee Heart and Vascular Institute, Sumner, 353
New Shackle Island Road, Nashville, TN 37075 USA,
e-mail: [email protected]
Patrick M. Colletti, MD
Department of Radiology and Medicine, University of Southern California, Los
Angeles, CA, USA, e-mail: [email protected]
Bjorn P. Flygenring, MD
Cardiovascular Services Division, Minneapolis Heart Institute, Minneapolis,
MN, USA, e-mail: [email protected]
John D. Friedman, MD
Department of Imaging, Cedars-Sinai Medical Centre, Los Angeles, CA, USA,
e-mail: [email protected]
Mario J. Garcı́a, MD, FACC, FACP
Cardiovascular Institute, Mount Sinai Hospital, New York, NY 10029, USA,
e-mail: [email protected]

xi
xii Contributors

Guido Germano, PhD

Artificial Intelligence Programme, Cedars-Sinai Medical Centre, Los Angeles,
CA, USA, e-mail: [email protected]

Ambarish Gopal, MD
Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-
UCLA Medical Centre, Torrance, CA, USA, e-mail: [email protected]

Ilan Gottlieb, MD
Department of Medicine/Cardiology, John Hopkins University, Baltimore,
MD, USA, e-mail: [email protected]

Sean W. Hayes, MD
Department of Cardiac Imaging, Cedars-Sinai Medical Centre, Los Angeles,
CA, USA, e-mail: [email protected]

Harvey S. Hecht, MD, FACC

Department of Cardiology, Lenox Hill Heart and Vascular Institute, New York, NY,
USA, e-mail: [email protected]

Alan T. Hirsch, MD
Vascular Medicine Programme, Minneapolis Heart Institute Foundation and the
University of Minnesota, Minneapolis, MN, USA, e-mail: [email protected]

Udo Hoffmann, MD, MPH

Cardiac MR PET CT Program, Department of Radiology, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, USA,
e-mail: [email protected]
Roland P. Karlsberg, MD
Cardiovascular Medical Group of Southern California, Cedars Sinai Medical
Centre, Los Angeles, CA, USA, e-mail: [email protected]
Thomas Knickelbine, MD, FACC, FSCAI
Department of Cardiology, Minneapolis Heart Institute Foundation and the Univer-
sity of Minnesota, Minneapolis, MN, USA, e-mail: [email protected]
Kai H. Lee, PhD
Department of Radiology, Los Angeles County and University of Southern
California Medical Center, Los Angeles, CA, USA, e-mail: [email protected]
Stamatios Lerakis, MD, PhD
Department of Medicine, Division of Cardiology, Emory University School
of Medicine, Atlanta, GA, USA, e-mail: [email protected]

John R. Lesser, MD
Department of Cardiology, Minneapolis Heart Institute Foundation and the
University of Minnesota, Minneapolis, MN, USA, e-mail: [email protected]
Contributors xiii

João Lima, MD, MBA

Department of Medicine/Cardiology, John Hopkins University, Baltimore, MD,
USA, e-mail: [email protected]
Terrence F. Longe, MD, FACC
Department of Cardiology, Minneapolis Heart Institute Foundation and the Univer-
sity of Minnesota, Minneapolis, MN, USA, e-mail: [email protected]
Songshou Mao, MD
Department of Cardiology, Los Angeles Biomedical Research Institute,
Harbor-UCLA Medical Center, Torrance, CA, USA, e-mail: [email protected]
Khurram Nasir, MD, MPH
Cardiac MR PET CT Programme, Massachusetts General Hospital, Boston,
MA, USA, e-mail: [email protected]
Susanna Prat-González, MD
Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA,
e-mail: [email protected]
Paolo Raggi, MD, PhD
Department of Medicine and Division of Cardiology, Emory Cardiac Imaging
Centre, Emory University School of Medicine, Atlanta, GA 30322, USA,
e-mail: [email protected]
Ian S. Rogers, MD, MBA
Cardiac MR PET CT Program, Division of Cardiology and Department of
Radiology, Massachusetts General Hospital, Harvard Medical School, Boston,
MA, USA
Alan Rozanski, MD
Department of Medicine, St Luke’s Roosevelt Hospital Centre, Clifton, NJ, USA,
e-mail: [email protected]
John A. Rumberger, MD, PhD, FACC
Director of Cardiac Imaging, Cardiovascular Diseases, The Princeton Longevity
Centre, Princeton, NJ, USA; Clinical Professor of Medicine, The Ohio State
University, Columbus, Ohio, e-mail: [email protected];
Javier Sanz, MD
Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA, e-mail:
[email protected]
Rola Saouaf, MD
Department of Imaging, Cedars Sinai Medical Centre, Los Angeles, CA, USA
Ammar Sarwar, MD
Cardiac MR PET CT Programme, Massachusetts General Hospital, Boston,
MA, USA
xiv Contributors

Michael D. Shapiro, DO
Cardiac MR PET CT Programme, Massachusetts General Hospital, Boston,
MA, USA, e-mails: [email protected], [email protected]
David M. Shavelle, MD, FACC, FSCAI
David Geffen School of Medicine at UCLA, Division of Cardiology, Harbor-UCLA
Medical Centre, Torrance, CA, USA, e-mail: [email protected]
Leslee J. Shaw, PhD
Department of Medicine, Emory University School of Medicine, Atlanta, GA,
USA, e-mail: [email protected]
Jerold S. Shinbane, MD, FACC
Division of Cardiovascular Medicine, USC Keck School of Medicine, Los Angeles,
CA, USA, e-mail: [email protected]
Jabi E. Shriki, MD
Department of Radiology, LAC + USC Medical Centre, Los Angeles, CA, USA,
e-mail: [email protected]
Robert S. Schwartz, MD, MS
Minneapolis Heart Institute Institute Foundation and the University of Minnesota,
Minneapolis, MN, USA, e-mail: [email protected]
Piotr J. Slomka, PhD
Department of Imaging, Cedars-Sinai Medical Centre, Los Angeles, CA, USA,
e-mail: [email protected]
Dr Lance E. Sullenberger, MD
Cardiology Service, Walter Reed Army Medical Center, Washington, DC, USA;
Uniformed Services University of the Health Sciences, Bethesda MD, e-mail:
[email protected]
Allen J. Taylor, MD
Walter Reed Army Medical Centre, Department of Cardiology, Washington, DC,
USA, e-mail: [email protected]
Louise E.J. Thomson, MBChB
Department of Imaging, Cedars Sinai Medical Centre, Los Angeles, CA, USA;
Uniformed Services University of the Health Sciences, Bethesda MD,
e-mail: [email protected]
Todd C. Villines, MD
Department of Cardiology, Walter Reed Army Medical Centre, Washington,
DC, USA
Wm Guy Weigold, MD
Division of Cardiovascular Disease, Dept. of Medicine, Washington Hospital
Centre, Washington, DC, 20010, USA, e-mail: [email protected]
Chapter 1
Cardiovascular CT Angiography: Concepts Important
to Image Acquisition and Reconstruction

Matthew J. Budoff, Songshou Mao, Patrick M. Colletti,

and Jerold S. Shinbane

Meticulous attention to the methodology of image acquisition and reconstruction

is essential to performance and analysis of coronary artery CT angiography. High-
quality images must be captured during the most quiescent phase of coronary artery
motion while minimizing patient exposure to radiation and intravenous contrast
agents. Successful imaging requires an understanding of the temporal interplay of
multiple motions including the complexities of cardiac contraction, potential respi-
ratory motion, potential patient movement, table motion, gantry rotation, and timing
and movement of the bolus of intravenous contrast through the structures of interest
(Fig. 1.1). Additional factors relate to the use of x-ray energy to capture adequate
images balanced by the limitation of radiation to the lowest level possible.

1.1 Concepts for Image Acquisition

There are many interdependent factors that affect spatial and temporal resolution.
The goal of image acquisition is to visualize the target structures in their entirety
while limiting the field of view (FOV) to the region of clinical interest. For a given
voxel matrix, smaller FOVs yield smaller voxels and greater spatial resolution.
Voxel attenuation is measured (on a scale) with the attenuation values of different
substances represented by different Hounsfield units (HU) values [1]. Representa-
tive HU values include the following: air –1000, fat –50 to –100, water 0, muscle
10–40, contrast 300–500, and calcium 130–1500.
Conceptually, all multidetector computed tomography (MDCT) systems work
using similar principles, but vary in regard to specific components and features. A
MDCT system has an x-ray tube that is capable of extremely rapid rotation and a
collimated array of detectors. The x-ray tube provides radiation energy adjustable
through tube current (mAs) and tube voltage (kVP). Multiple rows of detectors
are arranged in a variety of arrays with the goal of covering a specified volume
during each gantry rotation. Advances in detector number and arrangement have

M.J. Budoff
Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
e-mail: [email protected]

M.J. Budoff, J.S. Shinbane (eds.), Handbook of Cardiovascular CT, 1

DOI: 10.1007/978-1-84800-091-9 1,  C Springer-Verlag London Limited 2008
2 M.J. Budoff et al.

Fig. 1.1 The multiple motions during cardiac CT acquisition. Red signifies the cardiac motion.
Yellow represents the gantry movement (rotation of the x-ray tube and detectors around the
patient). Black represents the table motion and blue represents potential respiratory motion. An
additional consideration is the time from the vein injection to the arrival of contrast in the coronary
circulation (green)

lead to increases in the volume of coverage per rotation, with the ultimate goal
being imaging the entire heart within one cardiac cycle.
The relationship between table movement, gantry rotation speed, and beam colli-
mation defines the volume coverage per rotation as well as the degree of overlap
between rotations. The concept of “pitch” quantifies this relationship. Pitch relates
to coverage obtained by the x-ray beam (through beam width and table move-
ment) during one rotation of the gantry and defines the amount of overlap of
acquired data. With a pitch value of less than 1, there is overlap between volumes
of coverage. Overlapping images allow for oversampling, permitting multisector
image reconstruction, at the expense of greater radiation exposure. The definition of
pitch has evolved with newer scanner technologies, and various equations have been
proposed depending on the specific type of scanner [2]. Newer systems have thinner
slice thickness and collimation, allowing for an even lower pitch resulting in more
images, thinner reconstruction intervals, and better visualization of the coronary
anatomy.
ECG triggering is essential to minimize the effects of cardiac motion on image
acquisition. Factors related to motion in the X, Y, and Z directions include coronary
artery and cardiac motion during the cardiac cycle related to heart rate and rhythm.
In MDCT, images are usually acquired with retrospective ECG gating. With this
approach, images are acquired throughout the cardiac cycle, and therefore can be
reconstructed at specific points in the cardiac cycle [3]. With image acquisition, an
ECG signal is simultaneously recorded with the raw dataset. Given the complexities
of coronary motion, the optimal timing for reconstruction can vary by artery or arte-
rial segment. The strength of this approach is that after data acquisition has occurred,
1 Cardiovascular CT Angiography 3

images can be reconstructed at the most optimal timing for the coronary arteries.
Additionally, acquisition of images throughout the cardiac cycle allows for volu-
metric assessment of cardiac function. The major drawback of this approach is that
radiation exposure is significantly greater than that with a prospective ECG-gated
approach. Tube current modulation leads to a significant decrease in radiation by
decreasing radiation exposure during the systolic phase of the cardiac cycle [4].
With prospective triggering, images are obtained at a set percentage of the R–R
interval. The advantage of this technique is the limitation to radiation exposure [5].
The disadvantage relates to the limited dataset obtained. If the images obtained
demonstrate significant motion artifact, there are no other images to reconstruct.
Given the variability of heart rate with arrhythmias, prospective gating can be prob-
lematic with significant ectopy or atrial fibrillation.
Breath hold is essential to limit motion of structures due to respiration during
image acquisition. Breath hold times have decreased significantly with advances in
technology and are in the range of 6–10 second. There is some controversy as to the
optimal phase of respiration for breath hold. Regardless of the phase chosen in an
individual lab, it is important to practice breath hold commands and exercises prior
to the scan. As an end-inspiratory breath hold will place structures more caudally
than an end-expiratory breath hold, consistent breath hold instructions need to be
given for preview images and actual scans.

1.2 Preview Scans

Cardiovascular CT is performed using planar scout images, a non-contrast calcium
scan, a timing scan for assessment of the circulation time, and a contrast scan.
Planar scout images are obtained in order to define the most cranial and caudal
scanning levels (z-axis) of the structures of interest. The scout images are obtained
in antero-posterior and lateral views and aligned to the patient by a laser system.
The scan volume is selected with the structures of interest placed within the center
of the scanning volume. Important landmarks can be identified including the left
atrial appendage, which is usually the most cranial structure of the heart, and the
ventricular apex, which is the most caudal structure. Although the carina serves as a
marker to localize the most cranial aspect of the heart, the distance from carina to left
main coronary artery is extremely variable [6]. Additionally, the LAD can course
cranial to the left main coronary artery (Fig. 1.2). For coronary artery imaging,
scanning 10 mm cranial to the left main coronary artery and 10 mm caudal to the
apex is subsequently performed with CT angiography. In patients with coronary
artery bypass grafts, the starting point is the top of the aortic arch or 10 mm higher
than the surgical metal clips. The mid-level of the right pulmonary artery can also
be used as the beginning of the scan level, if it can be defined in preview images.
After the scout images, a calcium scan is performed. This is a high-resolution
non-contrast cardiac-gated study, which provides important prognostic information
regarding future cardiovascular risk. For the calcium scan, the 2-D axial images
are analyzed with the identification of calcium using either manual or automated
4 M.J. Budoff et al.

Fig. 1.2 Serial axial slices from cranial (left) to caudal (right) demonstrating a case where the
left anterior decending (left panel arrow) is visible above the left main coronary artery (right panel
arrow)

methods with quantification of calcium score based on identification of HU units

with an attenuation of at least 130 HU in the areas of identified calcium. There are
two major methods of quantifying coronary artery calcium: the Agatston score and
the volumetric analysis. The Agatston score is based on the summation of plaque
area times a coefficient based on the peak HU units in the plaque for all identified
plaques [7]. Calcium volume score describes a volumetric analysis of calcium with
calculation based on volumetric reconstruction and is more reproducible on serial
studies [8]. The calcium score is a marker of plaque burden and is an independent
risk factor for CAD beyond traditional risk factors [9, 10].
The calcium scan is useful to the planning, performance, and interpretation
of the contrast CT angiogram. Assessment of the images can be used to ensure
that there is complete coverage of the coronary anatomy in the image set prior to
contrast angiography, as well as to determine the minimum volume to be covered
to minimize radiation exposure [11]. Extensive coronary calcification may prohibit
the accurate assessment of coronary artery stenoses. The calcium score as well as
the calcium distribution should be assessed prior to the performance of the CT
angiogram to determine whether the contrast study should be performed. Different
imaging centers use various cutoffs for the performance of CT angiography in the
setting of a significantly elevated calcium score, with some centers using >500 or
>1000. It is important to have an understanding of the specific goal of an individual
study, as depending on the question asked and the location of calcium, some studies
may still be performed. For example, in cases where the location and patency of
coronary artery bypass grafts is the clinical question, calcium in the native coronary
arteries may still not necessarily prohibit the study from being performed. In addi-
tion to traditional cardiac risk factors, knowledge of the calcium score is helpful
in assessing the pretest probability of coronary artery disease when interpreting the
contrast angiography images.
After performance of the calcium scan, a contrast angiography study is performed,
with the administration of iodinated contrast timed to enhance the structures of
interest. This may vary by the type of study, with some studies performed specifically
1 Cardiovascular CT Angiography 5

for assessment of coronary artery anatomy, while others performed for additional
assessment of thoracic structures, such as in the case of congenital heart disease.
Assessment of the circulation time is important for the appropriate timing from
contrast injection to the acquisition of images, to assure the optimal enhancement of
target structures. The test sequence for this typically consists of repetitively imaging
a single slice using a low mAs, low radiation dose technique. For coronary angiog-
raphy, scans are obtained at the level of the takeoff of the left main coronary artery,
to create a time–density curve to assess the time to peak opacification. The measured
transit time is then used as the delay time from the start of the contrast injection to
the start of the imaging for the CT coronary angiogram. Circulation times vary based
on factors including cardiac output and must be individually determined. Patients
with low-output states require increased time delays and those with high-output
states require decreased time delays. This step can be omitted with the use of bolus-
tracking software. These methods track the contrast enhancement within the vessel
of interest and automatically trigger image acquisition [12].
After determination of the circulation time, the contrast CT angiogram is
performed. The circulation time is useful for determining the time to begin scan-
ning, but the goal is to maintain the same level of vascular enhancement throughout
image acquisition. Multiphase contrast injectors with preset volumes and injection
velocities are used to maintain uniformity of contrast enhancement throughout the
study. The use of a saline bolus after contrast injection moves the residual contrast
in the intravenous tubing and arm veins into the heart and coronary vasculature. The
timing of the saline bolus is important, as in some studies, clearance of the venous
circulation and right heart structures can help in visualization of arterial structures,
while in other studies, enhancement of these structures is important for analysis.

1.3 Image Reconstruction and Analysis

Image reconstruction allows creation of a 3-D map of cardiovascular anatomy from

larger vessels to smaller vessels. Serial axial 2-D images are reconstructed into a
3-D data cube with subsequent use of software to edit out and analyze cardio-
vascular structure (Fig. 1.3). Interpretation of CT coronary angiography requires
reconstruction and analysis of multiple 2-D and 3-D projections so that findings
can be confirmed on multiple views and artifacts caused by a particular type of
reconstruction can be identified. Improved workstation software has dramatically
reduced the time for image editing and reconstruction. Systematic reconstruction,
serial automated editing, and analysis of the 3-D data cube allows one to glean
information important to characterization of the relationships between structures
essential to clinical diagnosis and planning and facilitation of cardiovascular proce-
dures. These reconstructions include the following:
1. Displays of thoracic structures in relation to skeletal structures (an example
would be relation of sternum to coronary and vascular structures in a patient
undergoing repeat sternotomy after prior coronary artery bypass grafting)