High-pitch versus conventional cardiovascular CT in patients being assessed for transcatheter aortic valve implantation: A real-world appraisal

Tevfik F. Ismail; Emma Cheasty; Laurence King; Sahar Naaseri; Olga Lazoura; Natalie Gartland; Simon Padley; Michael B. Rubens; Isabel Castellano; Edward D. Nicol

doi:10.1136/openhrt-2017-000626

High-pitch versus conventional cardiovascular CT in patients being assessed for transcatheter aortic valve implantation: A real-world appraisal

Tevfik F. Ismail, Emma Cheasty, Laurence King, Sahar Naaseri, Olga Lazoura, Natalie Gartland, Simon Padley, Michael B. Rubens, Isabel Castellano, Edward D. Nicol^*

^*Corresponding author for this work

Imaging and Biomedical Engineering

Fédération d'anesthésiologie-réanimation et de médecine hyperbare, hôpital d'instruction des armées du Val-de-Grâce, 75005 Paris, France; Inserm U676, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, UMRS 676, 75013 Paris, France; Centre for the Developing Brain, Department of Perinatal Imaging and Health, King's College London, London, Royaume-Uni. Electronic address: [email protected].
RBHT Royal Brompton & Harefield NHS Foundation Trust
Royal Marsden NHS Foundation Trust
Imperial College London

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Abstract

Objective High-pitch protocols are increasingly used in cardiovascular CT assessment for transcatheter aortic valve implantation (TAVI), but the impact on diagnostic image quality is not known. Methods We reviewed 95 consecutive TAVI studies: 44 (46%) high-pitch and 51 (54%) standard-pitch. Single high-pitch scans were performed regardless of heart rate. For standard-pitch acquisitions, a separate CT-aortogram and CT-coronary angiogram were performed with prospective gating, unless heart rate was ≥70 beats/min, when retrospective gating was used. The aortic root and coronary arteries were assessed for artefact (significant artefact=1; artefact not limiting diagnosis=2; no artefact=3). Aortic scans were considered diagnostic if the score was >1; the coronaries, if all three epicardial arteries scored >1. Results There was no significant difference in diagnostic image quality for either the aorta (artefact-free high-pitch: 31 (73%) scans vs standard-pitch: 40 (79%), p=0.340) or the coronary tree as a whole (10 (23%) vs 15 (29%), p=0.493). However, proximal coronary arteries were less well visualised using high-pitch acquisitions (16 (36%) vs 30 (59%), p=0.04). The median (IQR) radiation dose was significantly lower in the high-pitch cohort (dose-length product: 347 (318-476) vs 1227 (1150-1474) mGy cm, respectively, p<0.001), and the protocol required almost half the amount of contrast. Conclusions The high-pitch protocol significantly reduces radiation and contrast doses and is non-inferior to standard-pitch acquisitions for aortic assessment. For aortic root assessment, the high-pitch protocol is recommended. However, if coronary assessment is critical, this should be followed by a conventional standard-pitch, low-dose, prospectively gated CT-coronary angiogram if the high-pitch scan is non-diagnostic.

Original language	English
Article number	e000626
Number of pages	9
Journal	Open Heart
Volume	4
Issue number	2
Early online date	8 Aug 2017
DOIs	https://doi.org/10.1136/openhrt-2017-000626
Publication status	E-pub ahead of print - 8 Aug 2017

Keywords

aortic valve disease
coronary angiography
CT scanning
percutaneous valve therapy
valvular disease

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10.1136/openhrt-2017-000626Licence: CC BY-NC

High-pitch versus conventional _ISMAIL_Publishedonline8August2017_GOLD VoR (CC BY-NC)Final published version, 494 KBLicence: CC BY-NC

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Ismail, T. F., Cheasty, E., King, L., Naaseri, S., Lazoura, O., Gartland, N., Padley, S., Rubens, M. B., Castellano, I., & Nicol, E. D. (2017). High-pitch versus conventional cardiovascular CT in patients being assessed for transcatheter aortic valve implantation: A real-world appraisal. Open Heart, 4(2), Article e000626. Advance online publication. https://doi.org/10.1136/openhrt-2017-000626

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abstract = "Objective High-pitch protocols are increasingly used in cardiovascular CT assessment for transcatheter aortic valve implantation (TAVI), but the impact on diagnostic image quality is not known. Methods We reviewed 95 consecutive TAVI studies: 44 (46%) high-pitch and 51 (54%) standard-pitch. Single high-pitch scans were performed regardless of heart rate. For standard-pitch acquisitions, a separate CT-aortogram and CT-coronary angiogram were performed with prospective gating, unless heart rate was ≥70 beats/min, when retrospective gating was used. The aortic root and coronary arteries were assessed for artefact (significant artefact=1; artefact not limiting diagnosis=2; no artefact=3). Aortic scans were considered diagnostic if the score was >1; the coronaries, if all three epicardial arteries scored >1. Results There was no significant difference in diagnostic image quality for either the aorta (artefact-free high-pitch: 31 (73%) scans vs standard-pitch: 40 (79%), p=0.340) or the coronary tree as a whole (10 (23%) vs 15 (29%), p=0.493). However, proximal coronary arteries were less well visualised using high-pitch acquisitions (16 (36%) vs 30 (59%), p=0.04). The median (IQR) radiation dose was significantly lower in the high-pitch cohort (dose-length product: 347 (318-476) vs 1227 (1150-1474) mGy cm, respectively, p<0.001), and the protocol required almost half the amount of contrast. Conclusions The high-pitch protocol significantly reduces radiation and contrast doses and is non-inferior to standard-pitch acquisitions for aortic assessment. For aortic root assessment, the high-pitch protocol is recommended. However, if coronary assessment is critical, this should be followed by a conventional standard-pitch, low-dose, prospectively gated CT-coronary angiogram if the high-pitch scan is non-diagnostic.",

keywords = "aortic valve disease, coronary angiography, CT scanning, percutaneous valve therapy, valvular disease",

author = "Ismail, {Tevfik F.} and Emma Cheasty and Laurence King and Sahar Naaseri and Olga Lazoura and Natalie Gartland and Simon Padley and Rubens, {Michael B.} and Isabel Castellano and Nicol, {Edward D.}",

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T1 - High-pitch versus conventional cardiovascular CT in patients being assessed for transcatheter aortic valve implantation

T2 - A real-world appraisal

AU - Ismail, Tevfik F.

AU - Cheasty, Emma

AU - King, Laurence

AU - Naaseri, Sahar

AU - Lazoura, Olga

AU - Gartland, Natalie

AU - Padley, Simon

AU - Rubens, Michael B.

AU - Castellano, Isabel

AU - Nicol, Edward D.

PY - 2017/8/8

Y1 - 2017/8/8

N2 - Objective High-pitch protocols are increasingly used in cardiovascular CT assessment for transcatheter aortic valve implantation (TAVI), but the impact on diagnostic image quality is not known. Methods We reviewed 95 consecutive TAVI studies: 44 (46%) high-pitch and 51 (54%) standard-pitch. Single high-pitch scans were performed regardless of heart rate. For standard-pitch acquisitions, a separate CT-aortogram and CT-coronary angiogram were performed with prospective gating, unless heart rate was ≥70 beats/min, when retrospective gating was used. The aortic root and coronary arteries were assessed for artefact (significant artefact=1; artefact not limiting diagnosis=2; no artefact=3). Aortic scans were considered diagnostic if the score was >1; the coronaries, if all three epicardial arteries scored >1. Results There was no significant difference in diagnostic image quality for either the aorta (artefact-free high-pitch: 31 (73%) scans vs standard-pitch: 40 (79%), p=0.340) or the coronary tree as a whole (10 (23%) vs 15 (29%), p=0.493). However, proximal coronary arteries were less well visualised using high-pitch acquisitions (16 (36%) vs 30 (59%), p=0.04). The median (IQR) radiation dose was significantly lower in the high-pitch cohort (dose-length product: 347 (318-476) vs 1227 (1150-1474) mGy cm, respectively, p<0.001), and the protocol required almost half the amount of contrast. Conclusions The high-pitch protocol significantly reduces radiation and contrast doses and is non-inferior to standard-pitch acquisitions for aortic assessment. For aortic root assessment, the high-pitch protocol is recommended. However, if coronary assessment is critical, this should be followed by a conventional standard-pitch, low-dose, prospectively gated CT-coronary angiogram if the high-pitch scan is non-diagnostic.

AB - Objective High-pitch protocols are increasingly used in cardiovascular CT assessment for transcatheter aortic valve implantation (TAVI), but the impact on diagnostic image quality is not known. Methods We reviewed 95 consecutive TAVI studies: 44 (46%) high-pitch and 51 (54%) standard-pitch. Single high-pitch scans were performed regardless of heart rate. For standard-pitch acquisitions, a separate CT-aortogram and CT-coronary angiogram were performed with prospective gating, unless heart rate was ≥70 beats/min, when retrospective gating was used. The aortic root and coronary arteries were assessed for artefact (significant artefact=1; artefact not limiting diagnosis=2; no artefact=3). Aortic scans were considered diagnostic if the score was >1; the coronaries, if all three epicardial arteries scored >1. Results There was no significant difference in diagnostic image quality for either the aorta (artefact-free high-pitch: 31 (73%) scans vs standard-pitch: 40 (79%), p=0.340) or the coronary tree as a whole (10 (23%) vs 15 (29%), p=0.493). However, proximal coronary arteries were less well visualised using high-pitch acquisitions (16 (36%) vs 30 (59%), p=0.04). The median (IQR) radiation dose was significantly lower in the high-pitch cohort (dose-length product: 347 (318-476) vs 1227 (1150-1474) mGy cm, respectively, p<0.001), and the protocol required almost half the amount of contrast. Conclusions The high-pitch protocol significantly reduces radiation and contrast doses and is non-inferior to standard-pitch acquisitions for aortic assessment. For aortic root assessment, the high-pitch protocol is recommended. However, if coronary assessment is critical, this should be followed by a conventional standard-pitch, low-dose, prospectively gated CT-coronary angiogram if the high-pitch scan is non-diagnostic.

KW - aortic valve disease

KW - coronary angiography

KW - CT scanning

KW - percutaneous valve therapy

KW - valvular disease

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High-pitch versus conventional cardiovascular CT in patients being assessed for transcatheter aortic valve implantation: A real-world appraisal

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