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Cardiac Imaging |
1 From the Departments of Clinical Radiology (K.U.J., D.M., E.M.F., W.H., R.F.) and Cardiology and Angiology (M.G., T.W.), University of Muenster, Albert-Schweitzer-Strasse 33, D-48149 Muenster, Germany. Supported in part by grants from the Foundation of Innovative Medical Research (IMF: FI120029), Muenster, Germany. Received January 16, 2003; revision requested March 20; final revision received August 11; accepted August 21. Address correspondence to K.U.J. (e-mail: kujuerg@uni-muenster.de).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: In 30 patients (mean age, 59.2 years ± 7.1 [SD]) known to have or suspected of having coronary artery disease, four-channel multi–detector row CT was performed with standard technique, and diastolic and systolic image reconstructions were generated. With commercially available analysis software capable of semiautomated contour detection, end diastolic and end systolic LV volumes were determined from short-axis secondary CT reformations. Steady-state free-precession cine MR images were acquired in short-axis orientation within 48 hours and analyzed by using dedicated software. Bland-Altman analysis was performed to calculate limits of agreement and systematic errors between CT and MR imaging.
RESULTS: Mean end diastolic (138.8 mL ± 31.9) and end systolic (53.9 mL ± 21.2) LV volumes as determined with CT correlated well with MR imaging measurements (142.0 mL ± 32.5 [r = 0.93] and 54.9 mL ± 22.8 [r = 0.94], respectively [P < .001]). LV ejection fraction (61.6% ± 10.6 for CT vs 62.3% ± 10.1 for MR imaging; r = 0.89) and stroke volume (84.6 mL ± 20.9 for CT vs 86.9 mL ± 21.5 for MR imaging; r = 0.88) also showed good correlation (P < .001). Bland-Altman analysis showed acceptable limits of agreement (±9.8% for ejection fraction) without systematic errors.
CONCLUSION: In selected patients, semiautomated analysis software enables LV volumetric and functional analysis based on multi–detector row CT data sets, the results of which correlate well with MR imaging findings.
© RSNA, 2003
Index terms: Computed tomography (CT), multi–detector row, 524.12112, 524.12115, 524.12116, 524.12117 • Heart, CT, 524.12115 • Heart, MR, 524.12142 • Heart, ventricles
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Until recently, the use of multi–detector row CT for LV functional analysis has been hampered by the lack of standardized analysis software. Analysis software has now been adapted and developed for multi–detector row CT purposes and is capable of semiautomated contour detection. The software was adapted from MR imaging analysis software, which has been validated in research and clinical studies for the past decade. Thus, the objectives of this study were to determine LV volumetric and functional parameters from retrospectively ECG-gated multi–detector row CT of the heart by means of semiautomated analysis software and to correlate the results with those of steady-state free-precession cine MR imaging.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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CT Protocol and Image Acquisition
All patients underwent oral premedication with 80 mg of propanolol (Dociton; Zeneca, Plankstadt, Germany) following assessment of vital signs (blood pressure and pulse rate) 30 to 45 minutes before CT scanning. CT coronary angiography was performed by using a four–detector row spiral CT scanner (Somatom Volume Zoom, release VA 41; Siemens Medical Solutions, Forchheim, Germany). Patients were placed in supine position. After a localizing scan was obtained, image acquisition was performed in the craniocaudal direction within a single breath hold at end inspiratory suspension, while the patient’s ECG trace was recorded simultaneously. Scan parameters were 500-msec gantry rotation time, 120 kV, 300 mA, 4 x 1-mm detector configuration, and 3-mm/sec table feed. One hundred forty milliliters of contrast medium (iomeprol, Imeron 300; Byk Gulden, Koustanz, Germany) (300 mg of iodine per milliliter at a flow rate of 3 mL/sec) was administered intravenously, followed by a 50-mL saline chaser bolus by means of a power injector (LF903000; Liebel Flarsheim Company, Cincinnati, Ohio).
Retrospectively ECG-gated image reconstruction (1,2) was performed on the scanner’s workstation (Navigator, Adaptive Cardiac Volume Algorithm, release VA 41; Siemens Medical Solutions) by using the following reconstruction parameters: section thickness of 1.25 mm, increment of 0.6 mm, medium-soft kernel, image matrix of 512 x 512 pixels, and field of view of 200 mm. By using the biphasic reconstruction algorithm, the achievable temporal resolution ranged between 125 and 250 msec in patients with a heart rate above 65 beats per minute and was 250 msec in patients with a heart rate below 65 beats per minute. To identify the maximal systolic constriction and diastolic relaxation phases, transverse test images were acquired in 5% steps through the entire RR interval at the midventricular level to show the anterior LV papillary muscles and the anterior and posterior leaflet of the mitral valve. End diastolic and end systolic phases were identified with ECG and were controlled visually as the images showing the largest and smallest LV cavity areas, respectively. The reconstruction windows were determined and were used for diastolic and systolic image calculation (Fig 1).
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CT Data Analysis
LV end diastolic and end systolic volumes were determined with Syngo Argus software implemented on a Leonardo workstation (Siemens Medical Solutions): diastolic and systolic MPR basal and apical sections were identified visually and marked manually by one reader (M.G.) with 4 years of experience in cardiac CT. Endocardial borders were traced semiautomatically in both image series, starting with a software-generated ellipsoid or circular figure placed into the middle of the LV cavity. Contours were checked visually for correctness and, if necessary, manually adjusted to endocardial contours by using a software tool ("nudge tool"). Papillary muscles were included in the LV cavity. By definition, the most basal section to be included had to cover more than 50% of the LV muscular ring (Fig 2). Results were reviewed visually and corrected manually if necessary (Fig 3).
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MR Imaging Protocol and Image Acquisition
MR imaging was performed with a whole-body 1.5-T unit (Gyroscan Intera, release 8.1.3; Philips Medical Systems, Best, the Netherlands) by using a five-element cardiac synergy coil for signal reception. After survey scout images were obtained in transverse, coronal, and sagittal orientations, a prospectively ECG-gated breath-hold steady-state free-precession cine sequence (balanced fast field-echo 3.5/1.7 [repetition time msec/echo time msec], flip angle of 50°, matrix of 256 x 256, field of view of 350 x 200 mm or less, mean temporal resolution of 32 msec) was applied in a true short-axis image orientation at end expiratory suspension to encompass the entire heart with contiguous 8-mm sections (no intersection gap). A shimming procedure was performed for imaged areas to avoid magnetic field inhomogeneities. All MR images were suitable for analysis.
MR Imaging Data Analysis
MR imaging data analysis was performed by one reader (K.U.J.) with 5 years of experience in cardiac MR imaging. The reader was blinded to results from multi–detector row CT studies and used commercially available software on an off-line workstation for analysis (Easy Vision, release 5.1, Cardiac Package; Philips Medical Systems). The cine loops were viewed, and end diastolic and end systolic frames were chosen as the images with the largest and smallest LV cavities, respectively. Endocardial contours, including papillary muscles leading into the LV cavity, were traced manually for diastolic and systolic images. According to multi–detector row CT analysis, the most basal section to be included had to cover more than 50% of the LV circumference, excluding those sections that contained solely the left atrium. LV volume, ejection fraction, and stroke volume were calculated consecutively from the MR imaging data sets with software assistance, as described in detail previously (10,11). Mean analysis times for CT and MR images were measured and compared.
Statistical Analysis
For all parameters, means ± SDs are given. Results for LV end diastolic and end systolic volume, stroke volume, and ejection fraction as determined with multi–detector row CT and MR imaging, as well as the results of the subanalysis on the influence of patient heart rate, were compared with the pairwise Wilcoxon signed-rank test. For linear correlation analysis, the Pearson correlation coefficient R was computed by using SPSS analysis software, release 10.0 (SPSS, Chicago, Ill). Bland-Altman analysis (12) was performed for each pair of values of LV end diastolic and end systolic volume, stroke volume, and ejection fraction to calculate limits of agreement and systematic errors between the two modalities. Retrospective power analysis was performed by using a paired t test. The resulting power of this study was about .999. A P value of .05 or less was considered to indicate a statistically significant difference.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The mean LV ejection fraction was 61.6% ± 10.6 with CT and 62.3% ± 10.1 with MR imaging (Figs 4, 5). Correlation between the two modalities was good (ejection fraction, R = 0.89; P < .001). Mean LV stroke volume was 84.6 mL ± 20.9 with CT and 86.9 mL ± 21.5 with MR imaging (stroke volume, R = 0.88; P < .001). Bland-Altman analysis in the comparison of CT and MR imaging results demonstrated a mean difference of 0.2% ± 4.9 and 0.2 mL ± 10.6 for LV ejection fraction and stroke volume, respectively.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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With the use of subsecond gantry rotation times and dedicated cardiac reconstruction algorithms by means of four-channel multi–detector row spiral CT scanners, thin-section coronary angiograms have shown their ability to depict significant proximal coronary artery stenosis in patients known to have or suspected of having coronary artery disease (3,4). From the same thin-section multi–detector row CT data sets, diastolic and systolic image reconstructions can be generated by using a retrospective ECG-gating technique. Finally, thin-section secondary reformations in true short-axis orientation at diastolic and systolic windows enable calculation of LV volumes and, consecutively, functional parameters. So far, only initial results and findings in studies with small numbers of patients have been reported for the evaluation of LV volume and function by means of multi–detector row CT in comparison to cardiac MR imaging (8,9).
An initial study (5) on the comparison of LV ejection fraction as determined with multi–detector row CT and biplanar cineventriculography yielded a better correlation if the Simpson method was used as opposed to the area-length method. The reported interobserver variability in LV ejection fraction for multi–detector row CT studies was 7.4% with short-axis images and 9.8% with the area-length method. Regions with previous myocardial infarction could be delineated clearly, showing a thinned LV wall and a reduction or absence of systolic myocardial wall thickening (5). These results were confirmed by Wintersperger and co-authors (6), who stated that three-dimensional data from retrospectively ECG-gated multi–detector row CT studies enable calculation of LV volumes for the estimation of systolic function.
Investigators in initial studies on the determination of volumetric and functional LV parameters with multi–detector row CT showed that results for LV end systolic volume slightly overestimated those determined with biplanar cineventriculography (5,6) and cine MR imaging (9). Consecutively, LV ejection fraction and stroke volume were underestimated. It is likely that the limited temporal resolution of 125–250 msec achieved with four-channel multi–detector row CT technology is the reason for impaired depiction of minimal systolic LV volumes and, hence, an overestimation of LV end systolic volume. On the other hand, it has to be taken into account that a systematic error might be caused by the conventional turbo gradient-echo MR sequence used in that study. By using conventional turbo gradient-echo sequences, cine MR imaging had become the noninvasive diagnostic standard of reference for determination of LV volumes and global as well as regional LV myocardial function and demonstrated a high diagnostic accuracy and low inter- and intraobserver variability (13,14). Recently developed steady-state free-precession cine MR sequences provide much more robust image quality and excellent contrast between blood and LV myocardium. By using state-of-the-art steady-state free-precession MR technology, no systematic error in the comparison of volumetric measurements from multi–detector row CT data sets and those of cine MR imaging were found in the present study. Mean volumetric and functional results as determined with steady-state free-precession cine MR imaging (LV end diastolic volume, 142 mL ± 32; LV end systolic volume, 54 mL ± 22; LV ejection fraction, 62% ± 10) were well within ranges of measurements reported by Thiele and co-authors (11), who investigated patients with different cardiac diseases, particularly coronary artery disease, in comparison to healthy volunteers.
With regard to analysis of global LV function, the use of multi–detector row CT in clinical practice has so far been limited by the lack of standardized analysis software. Semiautomated or automated methods of border detection have been developed for different cardiac imaging techniques, such as ECG and mono- and biplanar cineventriculography (15). By using analysis software adapted and developed for multi–detector row CT purposes to enable semiautomated contour detection, mean analysis time of CT volumetric LV measurements was 14 minutes ± 2, which was similar to that with cine MR imaging.
Study Limitations
Because of the prospective nature of our study, we investigated a highly selected group of patients known to have or suspected of having coronary artery disease, almost all of whom had normal LV size and configuration. Thus, results are valid only for that specific group of patients. It will have to be addressed in subsequent studies whether similar results can also be produced in patients with cardiac diseases that has more pronounced effects on LV geometry.
As discussed earlier, four-channel multi–detector row CT technology has a temporal resolution inferior to that of cine MR imaging and electron-beam CT. In the present study, images reconstructed from diastolic windows did not have motion artifacts. In patients with a mean heart rate above 65 beats per minute, however, systolic reconstructions had motion effects, which impaired delineation of endocardial contours. Thus, in these cases, tracing of endocardial contours may have had limited accuracy. While the duration of the total electromechanical systole is about 300 msec, the minimal ventricular volume is maintained for only 80–200 msec. Because of the possible temporal resolution of 125–250 msec provided by our multi–detector row CT system with use of current four-channel detectors, the precise definition and depiction of the peak or minimal systolic LV volume might be impaired. However, an advantage of multi–detector row CT in comparison to electron-beam CT is the assessment of LV functional parameters in the anatomically true short-axis orientation, as it is also applied in ECG and MR imaging. In contrast, the fixed setup of an electron-beam CT scanner results in volumetric measurements based on an assumption of short-axis orientation (16).
Although it has not been evaluated systematically in the present study, it seems to be important to adjust the position of the most basal section of diastolic and systolic MPRs from multi–detector row CT data sets to match that of the corresponding short-axis MR images when comparing volumetric measurements. In particular, analysis of the most basal section has a major influence on the calculated LV volume because of large cross-section area measurements multiplied by the section thickness of 8 mm. Thus, the most basal short-axis section in diastolic and systolic MPRs was adjusted parallel to the plane of the mitral valve that covered the most basal portion of the LV just forward of the atrioventricular ring. Another possible limitation is the administration of oral ß-blocking premedication preceding multi–detector row CT examinations, which might have caused a bias with regard to LV functional analysis in comparison to that of cardiac MR imaging.
Further Development
Progress concerning a more accurate determination of end systolic frames and maybe analysis of regional myocardial function can be expected from multi–detector row CT systems with increased rotation speeds and a concomitant increase in temporal resolution.
In recent MR imaging studies, a statistically significant decrease of LV ejection fraction was observed with increasing temporal resolution, which is more relevant than reduction of spatial resolution of less than 2 mm (10). The new generation of multi–detector row CT systems offers simultaneous acquisition of up to 16 submillimeter sections and provides a reduced gantry rotation time of 420 msec. Thus, an optimized temporal resolution down to 105 msec has become feasible. Because of physical limitations, however, a further increase in temporal resolution can only be realized by separating physiologic and physical acquisition times. Algorithms that process data from several gantry rotations can reduce the temporal resolution down to 70–90 msec (17,18).
Advantages of cardiac MR imaging compared with multi–detector row CT are the lack of radiation exposure, avoidance of iodinated contrast media, and improved temporal resolution. Furthermore, short-axis images are readily available, and time-consuming secondary reformations required in cardiac multi–detector row CT are not needed with cardiac MR imaging. Especially in patients with dyspnea and heart failure, multi–detector row CT has the advantage of being fast with regard to breath-hold data acquisition and is suitable for patients with pacemakers and implanted defibrillators. With regard to contrast medium application, radiation exposure, and limited temporal resolution, however, cardiac multi–detector row CT performed solely for analysis of cardiac function parameters does not seem reasonable at the present time. With regard to radiation exposure, a substantial reduction may be achieved with application of an ECG-triggered tube current modulation.
The combination of noninvasive coronary artery imaging and assessment of global LV function within one breath-hold multi–detector row CT study might be an interesting approach to a fast and conclusive cardiac work-up in patients suspected of having coronary artery disease. It has to be addressed in further studies whether the introduction of the new generation of multi–detector row CT systems with improved temporal resolution will enable analysis of regional LV myocardial wall motion abnormalities.
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FOOTNOTES |
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Author contributions: Guarantors of integrity of entire study, K.U.J., W.H., R.F.; study concepts and design, all authors; literature research, K.U.J., M.G., R.F.; clinical studies, K.U.J., M.G., D.M., R.F.; data acquisition and analysis/interpretation, K.U.J., M.G., D.M., E.M.F., R.F.; statistical analysis, K.U.J., M.G., R.F.; manuscript preparation, K.U.J., M.G., R.F.; manuscript definition of intellectual content, K.U.J., M.G., D.R., W.H., R.F.; manuscript editing, K.U.J., M.G., W.H., R.F.; manuscript revision/review, K.U.J., M.G., D.R., T.W., W.H., R.F.; manuscript final version approval, all authors
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REFERENCES |
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 A. Lembcke, P. M. Dohmen, M. Dewey, C. Klessen, T. Elgeti, K.-G. A. Hermann, W. F. Konertz, B. Hamm, and D. E. Kivelitz Multislice Computed Tomography for Preoperative Evaluation of Right Ventricular Volumes and Function: Comparison With Magnetic Resonance Imaging Ann. Thorac. Surg., April 1, 2005; 79(4): 1344 - 1351. [Abstract] [Full Text] [PDF]
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T. Schlosser, K. Pagonidis, C. U. Herborn, P. Hunold, K.-U. Waltering, T. C. Lauenstein, and J. Barkhausen Assessment of Left Ventricular Parameters Using 16-MDCT and New Software for Endocardial and Epicardial Border Delineation Am. J. Roentgenol., March 1, 2005; 184(3): 765 - 773. [Abstract] [Full Text] [PDF]
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L. P. Lawler, D. Ney, H. K. Pannu, and E. K. Fishman Four-Dimensional Imaging of the Heart Based on Near-Isotropic MDCT Data Sets Am. J. Roentgenol., March 1, 2005; 184(3): 774 - 776. [Full Text] [PDF]
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M. Yamamuro, E. Tadamura, S. Kubo, H. Toyoda, T. Nishina, M. Ohba, R. Hosokawa, T. Kimura, N. Tamaki, M. Komeda, et al. Cardiac Functional Analysis with Multi-Detector Row CT and Segmental Reconstruction Algorithm: Comparison with Echocardiography, SPECT, and MR Imaging Radiology, February 1, 2005; 234(2): 381 - 390. [Abstract] [Full Text] [PDF]
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J. D. Schuijf, J. J. Bax, J. W. Jukema, H. J. Lamb, H. W. Vliegen, E. E. van der Wall, and A. de Roos Noninvasive Evaluation of the Coronary Arteries With Multislice Computed Tomography in Hypertensive Patients Hypertension, February 1, 2005; 45(2): 227 - 232. [Abstract] [Full Text] [PDF]
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 J. D. Schuijf, J. J. Bax, J. W. Jukema, H. J. Lamb, H. W. Vliegen, L. P. Salm, A. de Roos, and E. E. van der Wall Noninvasive Angiography and Assessment of Left Ventricular Function Using Multislice Computed Tomography in Patients With Type 2 Diabetes Diabetes Care, December 1, 2004; 27(12): 2905 - 2910. [Abstract] [Full Text] [PDF]
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