Invited Review
Analysis of ventricular function by CT

https://doi.org/10.1016/j.jcct.2014.11.007Get rights and content

Highlights

  • Cardiac CT is an alternative modality for the assessment of left and right ventricular function.

  • Incremental value of CT functional evaluation needs to be weighed with the increase radiation and contrast agent required.

  • Qualitative and quantitative functional data can be reported, with “inclusion” or “exclusion” of papillary muscle.

Abstract

The assessment of ventricular function, cardiac chamber dimensions, and ventricular mass is fundamental for clinical diagnosis, risk assessment, therapeutic decisions, and prognosis in patients with cardiac disease. Although cardiac CT is a noninvasive imaging technique often used for the assessment of coronary artery disease, it can also be used to obtain important data about left and right ventricular function and morphology. In this review, we will discuss the clinical indications for the use of cardiac CT for ventricular analysis, review the evidence on the assessment of ventricular function compared with existing imaging modalities such cardiac magnetic resonance imaging and echocardiography, provide a typical cardiac CT protocol for image acquisition and postprocessing for ventricular analysis, and provide step-by-step instructions to acquire multiplanar cardiac views for ventricular assessment from the standard axial, coronal, and sagittal planes. Furthermore, both qualitative and quantitative assessments of ventricular function as well as sample reporting are detailed.

Introduction

Although the mainstay for cardiac CT is the assessment of coronary artery disease, the isotropic submillimeter spatial resolution, high temporal resolution, and good contrast between ventricular lumen and myocardium make CT very well suited to obtain valuable information on ventricular function.1, 2, 3 Currently, several noninvasive imaging techniques are available for the assessment of ventricular function, each with their own limitations. Cardiac magnetic resonance imaging (CMR) is considered the gold standard.4 However, CMR is costly, time consuming, and has limited availability to predominantly tertiary medical centers. Furthermore, some patients may not be able to undergo a CMR examination, for example, because of metallic devices or clinical conditions such as claustrophobia and the inability to lay flat.2 Transthoracic echocardiography (TTE) is the cheapest and most routinely used method for the measurement of ventricular function but may be limited by poor acoustic windows in patients with obesity, chronic obstructive pulmonary disease, narrow rib intercostal spaces, or prior cardiothoracic surgery.5, 6, 7 Furthermore, assessment of the right ventricle can be difficult especially when assessing structural abnormalities such as arrhythmogenic right ventricular (RV) cardiomyopathy or dysplasia (ARVC/D).8 Cardiac CT, with some modifications to the acquisition protocol, can be used to obtain accurate ventricular assessments comparable to CMR.9 Tube current modulation with improved noise reduction strategies have allowed for reduction of radiation dose with preserved image quality.10, 11, 12 For patients that are difficult to image by echocardiography and are undergoing CT imaging for coronary artery disease (CAD) without previous ventricular assessment, especially with a history of acute coronary syndrome (ACS) or heart failure (HF), or for patients who need specific assessment of RV function or morphology, evaluation of ventricular contractile function by cardiac CT should be considered.

Section snippets

Multimodality comparison of LV volumes, function, and mass

As temporal resolution has improved, cardiac CT can be used to obtain important information on ventricular function, regional wall motion, and left ventricular (LV) mass, and results are comparable to measurements obtained via CMR.13, 14, 15, 16 Unlike the evaluation of the coronary arteries, cardiac function can be accurately assessed without the need to alter heart rate via administration of beta blockers.17 In retrospective analysis of 40 patients with suspected CAD where cardiac CT (with

Indications for cardiac CT

Per the most recent guidelines, the appropriate use criteria for the assessment of LV or RV function by cardiac CT include the following22:

  • Assessment of LV function after ACS or HF in patients with inadequate images from other noninvasive methods.

  • Quantitative assessment of RV function.

  • Assessment of RV morphology in suspected ARVC/D.

Data acquisition protocols

Cardiac CT imaging should be performed using at least 64-slice CT scanner technology according to the vendor-specific protocol for the evaluation of ventricular function. General recommendations for cardiac CT typically include a minimal contrast flow rate of 5 mL/s, but for specific analysis of ventricular function, lower injection rates may be sufficient. Retrospectively ECG-gated image reconstruction is necessary to reconstruct images through all phases of the cardiac cycle. Tube current

Image processing and evaluation

Although there lack data on how best to postprocess functional data sets, in our experience the following pointers may be taken into consideration. For functional analysis, a multiphase reformatted data set of maximally 1.5-mm thick axial images without overlap should be reconstructed at 10% increments (10 phases) for single-source CT scanners or 5% increments (20 phases) for dual-source CT scanners throughout the cardiac cycle from the onset of the R-wave for the assessment of global and

Manual vs automated quantification

It remains a trade-off with automated postprocessing software vs manual contours for delineating the endocardial and epicardial boundaries with respect to time required for quantification. The development of automated EF assessments has reduced the time needed for postprocessing and has shown good agreement for the estimation of EF compared to semiautomated or manual assessments even if significant differences in LVEDV were observed.64 Automated postprocessing software can automatically

Data elements to be included in the report

Data elements suggested to be included in a report regarding ventricular function are as follows:

  • Cardiac morphology of the left and right atria and ventricles,

  • Qualitative global LV and RV function (if requested),

  • Regional wall motion abnormalities, and

  • Quantitative LV and RV (if requested) EFs and volumes including indexing to body surface area.

Table 2 represents a sample report.

Cardiac CT limitations

Compared with other modalities, assessment of ventricular function by cardiac CT requires radiation exposure and administration of contrast dye. Patients with significant contrast dye allergies or renal insufficiency are not candidates for contrast-enhanced cardiac CT. Premature atrial and ventricular beats and atrial fibrillation can cause arrhythmia and misregistration artifacts, resulting in poor visualization of the endocardial and epicardial contours as well as high radiation dose due to

Conclusion

In addition to the assessment of CAD, cardiac CT can be used to investigate LV function, RV function, and ventricular morphology. It serves as alternative option for functional assessment particularly when other imaging modalities such as echocardiography yield inadequate images or in patients with contraindications to CMR.

References (69)

  • M. Arraiza et al.

    Assessment of left ventricular parameters in orthotopic heart transplant recipients using dual-source CT and contrast-enhanced echocardiography: comparison with MRI

    Eur J Radiol

    (2012)
  • A.J. Taylor et al.

    ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance

    J Am Coll Cardiol

    (2010)
  • C. Bauters et al.

    Prognosis of patients with stable coronary artery disease (from the CORONOR study)

    Am J Cardiol

    (2014)
  • E.F. Lewis et al.

    Predictors of late development of heart failure in stable survivors of myocardial infarction: the CARE study

    J Am Coll Cardiol

    (2003)
  • A. Palazzuoli et al.

    Left ventricular remodelling and systolic function measurement with 64 multi-slice computed tomography versus second harmonic echocardiography in patients with coronary artery disease: a double blind study

    Eur J Radiol

    (2010)
  • H.G. Bezerra et al.

    Incremental value of myocardial perfusion over regional left ventricular function and coronary stenosis by cardiac CT for the detection of acute coronary syndromes in high-risk patients: a subgroup analysis of the ROMICAT trial

    J Cardiovasc Comput Tomogr

    (2011)
  • U. Hoffmann et al.

    Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial

    J Am Coll Cardiol

    (2009)
  • J. Hausleiter et al.

    Image quality and radiation exposure with prospectively ECG-triggered axial scanning for coronary CT angiography: the multicenter, multivendor, randomized PROTECTION-III study

    JACC Cardiovasc Imaging

    (2012)
  • Q.A. Truong et al.

    Quantitative analysis of intraventricular dyssynchrony using wall thickness by multidetector computed tomography

    JACC Cardiovasc Imaging

    (2008)
  • M.J. Boogers et al.

    Feasibility of diastolic function assessment with cardiac CT: feasibility study in comparison with tissue Doppler imaging

    JACC Cardiovasc Imaging

    (2011)
  • N. van der Bijl et al.

    Measurement of right and left ventricular function by ECG-synchronized CT scanning in patients with acute pulmonary embolism: usefulness for predicting short-term outcome

    Chest

    (2011)
  • P. de Groote et al.

    Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure

    J Am Coll Cardiol

    (1998)
  • L. Sugeng et al.

    Multimodality comparison of quantitative volumetric analysis of the right ventricle

    JACC Cardiovasc Imaging

    (2010)
  • Y.K. Guo et al.

    Accuracy and reproducibility of assessing right ventricular function with 64-section multi-detector row CT: comparison with magnetic resonance imaging

    Int J Cardiol

    (2010)
  • J. Therrien et al.

    Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair

    Am J Cardiol

    (2005)
  • C. Lee et al.

    Outcomes of pulmonary valve replacement in 170 patients with chronic pulmonary regurgitation after relief of right ventricular outflow tract obstruction: implications for optimal timing of pulmonary valve replacement

    J Am Coll Cardiol

    (2012)
  • C. Basso et al.

    Arrhythmogenic right ventricular cardiomyopathy

    Lancet

    (2009)
  • Y.W. Wu et al.

    Structural and functional assessment of arrhythmogenic right ventricular dysplasia/cardiomyopathy by multi-slice computed tomography: comparison with cardiovascular magnetic resonance

    Int J Cardiol

    (2007)
  • C. Bomma et al.

    Evolving role of multidetector computed tomography in evaluation of arrhythmogenic right ventricular dysplasia/cardiomyopathy

    Am J Cardiol

    (2007)
  • T. Nakajima et al.

    Utility of ECG-gated MDCT to differentiate patients with ARVC/D from patients with ventricular tachyarrhythmias

    J Cardiovasc Comput Tomogr

    (2013)
  • H. Tandri et al.

    Normal reference values for the adult right ventricle by magnetic resonance imaging

    Am J Cardiol

    (2006)
  • F.Y. Lin et al.

    Cardiac chamber volumes, function, and mass as determined by 64-multidetector row computed tomography: mean values among healthy adults free of hypertension and obesity

    JACC Cardiovasc Imaging

    (2008)
  • S.S. Mao et al.

    Dual-standard reference values of left ventricular volumetric parameters by multidetector CT angiography

    J Cardiovasc Comput Tomogr

    (2013)
  • O. Yamaoka et al.

    Evaluation of left ventricular mass: comparison of ultrafast computed tomography, magnetic resonance imaging, and contrast left ventriculography

    Am Heart J

    (1993)
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    Asim Rizvi and Roderick C. Deaño contributed equally to this work.

    Conflict of interest: Quynh A. Truong is supported by the National Institutes of Health (K23HL098370 and L30HL093896) and has received grant support from St. Jude Medical, American College of Radiology Imaging Network, and Duke Clinical Research Institute. James K. Min has served on the medical advisory boards of GE Healthcare, Arineta, Astra Zeneca, and Bristol-Myers Squibb and on speakers' bureau of GE Healthcare. He also received research support from GE Healthcare, Vital Images, and Phillips Healthcare.

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