Invited ReviewAnalysis of ventricular function by CT
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:
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Assessment of LV function after ACS or HF in patients with inadequate images from other noninvasive methods.
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Quantitative assessment of RV function.
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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:
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Cardiac morphology of the left and right atria and ventricles,
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Qualitative global LV and RV function (if requested),
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Regional wall motion abnormalities, and
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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.
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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.