Table Of ContentProblem Solving in
Radiology
Cardiovascular Imaging
Suhny Abbara, MD, FSCCT
Associate Professor of Radiology
Harvard Medical School
Director, Cardiac Imaging Fellowship
Department of Radiology
Director of Education
Cardiac MR/PET/CT Program
Massachusetts General Hospital
Boston, Massachusetts
Sanjeeva P. Kalva, MD, FSIR
Associate Division Head
Vascular Imaging and Intervention
Director, Center for Image-Guided Cancer Therapy
Massachusetts General Hospital
Assistant Professor of Radiology
Harvard Medical School
Boston, Massachusetts
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
PROBLEM SOLVING IN RADIOLOGY: CARDIOVASCULAR IMAGING ISBN: 978-1-4377-2768-5
Copyright © 2013 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the Publisher. Details on how to seek permission, further infor-
mation about the Publisher’s permissions policies, and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treat-
ment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluat-
ing and using any information, methods, compounds, or experiments described herein. In using such
information or methods, they should be mindful of their own safety and the safety of others, includ-
ing parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered to verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence, or otherwise, or from any use or operation of any methods, products, instruc-
tions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Problem solving in radiology. Cardiovascular imaging / [edited by] Suhny Abbara, Sanjeeva P. Kalva.
p. ; cm.—(Problem solving in radiology)
Cardiovascular imaging
Includes bibliographical references.
ISBN 978-1-4377-2768-5 (hardcover : alk. paper)
I. Abbara, Suhny. II. Kalva, Sanjeeva P. III. Title: Cardiovascular imaging. IV. Series: Problem solving in
radiology.
[DNLM: 1. Cardiovascular Diseases—diagnosis. 2. Diagnostic Imaging—methods. 3. Diagnostic
Techniques, Cardiovascular. WG 141]
616.1’0757--dc23 2012040007
Content Strategist: Helene Caprari
Content Development Specialist: Joanie Milnes
Publishing Services Manager: Anne Altepeter
Senior Project Manager: Doug Turner
Designer: Steve Stave
Printed in the People’s Republic of China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To Amanda and Tyler,
Marlene and Yasser,
Mona, Richard, Lenni, and Nora,
Susu, Martin, Mark, and Marie
SA
To Sanjeevarayudu and Bhagyalakshmi,
Vijaya, Praneeth, and Praveen,
Christos Athanasoulis, Mathew Cherian, and Subbarao Kakarla,
My mentors, colleagues, residents, and fellows
SPK
Foreword
Early in the twentieth century, physicians recognized University in which they described the phenomenon of
the power of noninvasive imaging to guide diagnosis delayed myocardial enhancement, which allowed for
and patient management in cardiovascular disease. By the prediction of functional recovery after revasculariza-
the 1980s both echocardiography and rest and stress tion. This triggered further development of the assess-
nuclear perfusion imaging had become part of routine ment of myocardial structure and perfusion, and today
patient assessment, which focused primarily on the we are able to differentiate and predict infarct territory,
assessment of left ventricle function and perfusion. At including the core of microvascular obstruction with
the time, however, assessment of coronary artery disease irreversible loss of function from myocardial edema and
was limited to invasive coronary angiography, and struc- reversible dysfunction. In fact, in coronary disease, coro-
tural imaging of the myocardium was not yet possible; nary CT angiography has developed into the primary
thus imaging remained a small and easily overlooked assessment tool for patients without known coronary
field within cardiovascular medicine. We have come a artery disease, whereas MRI is a very potent guide for
long way since as we have seen a revolution in cardio- revascularization in patients with already known coro-
vascular imaging driven by the introduction and devel- nary artery disease, a group of patients that is steadily
opment of cardiac computed tomography (CT) and growing. MR technology has also developed from 1.5T
magnetic resonance imaging (MRI). to 3T magnets, and today cardiac MRI is a routine diag-
In the early 1990s, IMATRON, a small company out nostic tool available at most major institutions.
of San Francisco, introduced cardiac electron beam CT Thus today’s imagers are faced with an ever-increasing
(EBCT) to the general public, and that changed cardio- choice of advanced and steadily evolving imaging tech-
vascular medicine forever. I remember how impressed niques and increasing subspecialization in all aspects of
I was as a medical student examining patients on an the diagnosis and management of cardiovascular disease.
EBCT prototype in Erlangen, Germany, as part of my Given today’s economic constraints in the health care
medical thesis. The EBCT scanner needed a second sector and the increasing need for efficient patient man-
large room to accommodate the cooling system and agement, it is important to provide educational materi-
computer power, but it allowed for the motion-free als that comprehensively cover the multiple modalities
visualization of the coronary artery tree with an assess- across cardiovascular imaging and decision support for
ment of stenosis on a regular basis because an image ordering physicians.
could be acquired within 50 msec (while traditional CT Drs. Abbara and Kalva, two well-recognized experts in
scanners at the time needed 1 full second). The EBCT the field, have brought together a wide range of authors
era culminated in an article by Stephan Achenbach who are leaders in their respective fields. All can be con-
in 1998 published in the New England Journal of gratulated for providing unique and in-depth coverage
Medicine, but surprisingly EBCT technology was used to the entire spectrum of cardiovascular disease, includ-
primarily to detect and quantify coronary artery calcifi- ing anatomy, diagnosis and patient management, and
cation in the setting of primary prevention on the West technical and risk benefit aspects across modalities.
Coast of the United States. However, it triggered the Published within the well-known Problem Solving
development of multidetector CT (MDCT), a technol- series, this book provides a compendium that also offers
ogy developed by Willy Kalender from Erlangen. What complimentary online access to regularly updated web
started in the late 1990s with four-slice MDCT has now content, which will ensure that readers can keep track of
grown into a technology with submillimeter spatial ongoing breakthroughs in this exciting field.
resolution and an image acquisition time of less than Problem Solving in Radiology: Cardiovascular Imaging is
1 second that reliably allows noninvasive assessment an excellent guide and source for residents, fellows, and
of coronary artery stenosis and atherosclerotic plaque practitioners in both cardiology and radiology and for
morphology and composition. With this improvement those who want to refresh their knowledge in the multi-
in CT technology came the ability to assess complex modality field of cardiovascular imaging.
cardiac morphology, heart valves, and myocardial per-
fusion and function. Today more than 3000 cardiac Udo Hoffmann, MD, MPH
imaging–capable units can be found in the United Associate Professor of Radiology
States alone. Harvard Medical School
Although cardiac MRI has been around more than 10 Division Head, Cardiac Imaging
years longer than CT, it has matured more slowly. Prob- Department of Radiology
ably the most important and novel finding was pub- Director, Cardiac MR/PET/CT Program
lished in the New England Journal of Medicine in 2000 Massachusetts General Hospital
by Raymond Kim and Bob Bonow from Northwestern Boston, Massachusetts
vii
Preface
This cardiovascular imaging textbook in the Problem The text is organized to systematically review the
Solving series publishes at a remarkable time. Since technical nuances and acquisition methods of the
the early 2000s there have been dramatic develop- various imaging modalities at our disposal, including
ments in the field of cardiovascular medicine and multidetector computerized tomography, MRI, radio-
imaging. These developments include (among many nuclide imaging, ultrasound and echocardiography, and
others) the creation and maturation of multidetector catheter angiography. This is followed by a review and
coronary computed tomographic angiography, newer illustration of the respective appearance of cardiac and
noncontrast magnetic resonance angiography (MRA) vascular anatomy within each of the imaging modalities
and blood pool–contrast MRA, magnetic resonance and a critical review of when to use which test. After this
imaging (MRI)-based scar and viability imaging, par- general discussion, this book is organized by disease
ticle tracking and other novel techniques, the ripening entities that affect the cardiovascular system. Each dis-
of alternatives to radionuclide imaging to demonstrate ease entity or spectrum of entities is reviewed in-depth,
myocardial ischemia, and many novel therapies. Most with a special emphasis on the role of imaging, problem
notable is the development of novel image-guided solving, and the multimodality imaging appearance of
minimally invasive therapies, which often rely on the diseases and their differential diagnostic entities.
noninvasive preprocedure imaging for planning pur- We hope that this initiative will prove useful in the
poses. These procedures include, but are not limited day-to-day care of patients with cardiovascular disease,
to, endoluminal stent graft placement to treat aortic serve as a stimulus for future research in basic and clini-
aneurysms, pulmonary vein isolation procedures to cal science, and provide a utilitarian reference source
treat atrial fibrillation, transcatheter device treatment for all health care professionals, trainees, scientists, and
of septal and other shunts, and transcatheter aortic biomedical researchers active in the field of cardiovas-
valve implantation/replacement (TAVI/R) to treat ste- cular medicine in the twenty-first century. Hopefully,
notic aortic valves, just to name a few. Hence many new in some way, all of the effort and expertise brought
applications and indications for cross-sectional cardiac together here will help advance our field. And on behalf
and vascular imaging have surfaced since 2000. New of all the authors, we truly hope that you will find this
or underrecognized disease entities have been brought text informative, enjoyable, and helpful, whether you
to light and the incidence of some anomalies, normal are a radiologist, cardiologist, nuclear medicine special-
variants, or conditions have had to be revised now that ist, resident, fellow medical student, or technologist.
we have better tools to visualize their respective struc-
tures. We have called upon a cadre of more than 90 Suhny Abbara, MD, FSCCT
expert contributors to systematically review the many Sanjeeva P. Kalva, MD, FSIR
new developments and present them in a didactically
meaningful way.
ix
