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Course on Cardiac CT - Advanced

The second part of the one-day Teaching course in cardiac CT was intended to provide a condensed curriculum of advanced CT imaging applications for non-CT imaging specialists. Koen Nieman (Stanford University, USA, and formerly Rotterdam, The Netherlands) discussed the value of Cardiac CT in patients with coronary stents and bypasses. He highlighted that despite many technological improvements, CT is still limited to assess in-stent luminal changes in small stents (<3mm diameter), or in patients with unfavourable characteristics for CT imaging (e.g. fast heart rate, motion artefacts, extensive calcifications). Venous and arterial bypass grafts often visualize very nicely on CT imaging, but native disease progression in such patients may escape CT imaging due to the high rate at which grafted native arteries tend to calcify.

Francesca Pugliese (Barts hospital, London, UK) covered in her presentation the recently emerged functional CT imaging possibilities: Transluminal attenuation gradient (TAG) and corrected contrast opacification (CCO), CT-based fractional flow reserve (FFR-CT) and CT perfusion. These techniques have shown promise for a comprehensive anatomo-functional assessment of coronary artery disease and have proven to add value to simple anatomical imaging. However, they involve considerable expertise and interpretational skills, and/or are more cost- or radiation-intensive. Therefore, their use is still restricted to large experienced centres.

Mohamed Marwan (Erlangen, Germany) discussed the current role of CT for structural heart disease (SHD) interventions, where (rather than being used as a diagnostic tool) CT is helpful for patient selection and procedural planning. Prior to transcatheter aortic valve implantation, CT provides accurate annular measurements, and can visualize the peripheral vessels, calcifications, angulations and best imaging projections. Other SHD interventions may also benefit from pre-procedural CT, e.g. left atrial appendage occlusion, paravalvular leak occlusion, mitral valve interventions, and congenital heart disease interventions.

Finally, Pal Maurovich-Horvath (Budapest, Hungary) covered the role of CT imaging for assessing coronary plaque and summarized CT plaque characteristics that are associated with proven risk of acute ischemic events: extensive atherosclerosis, large plaque volume, positive plaque remodelling, low CT density, spotty calcifications, the “napkin-ring” sign, flow-limiting properties, and increased shear stress. All these characteristics can be assessed with CT, but its clinical role in the context of cardiovascular preventive strategies has not been defined yet.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.