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Published on: August 28, 2018
[Coronary computed tomography and cardiac devices : Diagnostic results or nothing but artifacts?]
Silvia Smolka1, Stephan Achenbach2
1Medizinische Klinik 2, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland. silvia.smolka@uk-erlangen.de.
Insights
Coronary CT angiography is safe for patients with cardiac devices, though metal artifacts can affect image quality. Advanced techniques can mitigate these artifacts, ensuring diagnostic accuracy in most cases.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Coronary computed tomography (CT) angiography is crucial for diagnosing cardiac conditions and planning structural heart interventions.
- Patients with implanted cardiac devices (pacemakers, ICDs) may face challenges with CT due to potential electromagnetic radiation effects and metal artifacts.
- Artifacts from device leads can reduce image quality, particularly affecting the assessment of coronary arteries.
Purpose of the Study:
- To evaluate the safety and diagnostic utility of coronary CT angiography in patients with implanted cardiac devices.
- To identify factors contributing to metal artifacts and their impact on image quality.
- To explore methods for artifact reduction and ensuring diagnostic assessability.
Main Methods:
- Review of coronary CT angiography procedures in patients with pacemakers, ICDs, and CRT systems.
- Analysis of artifact prevalence and characteristics based on lead type, positioning, and device specifics.
- Evaluation of dual-energy CT and postprocessing algorithms for artifact mitigation.
Main Results:
- Coronary CT angiography is a safe diagnostic test for patients with cardiac devices when indicated.
- Metal artifacts, especially from lead tips, can impair visualization of coronary arteries (e.g., RCA, LCX).
- Artifact severity correlates with lead material, unipolar leads, shock coils, and LV leads.
- Dual-energy CT and postprocessing can reduce artifacts, achieving diagnostic image quality in most patients.
- Predicting artifact occurrence and severity remains challenging.
Conclusions:
- Coronary CT angiography is safe and valuable for patients with cardiac devices.
- Metal artifacts are a known limitation but can often be managed with advanced CT techniques.
- Careful patient selection, optimized scanning protocols, and postprocessing are essential for maximizing diagnostic yield.
Abstract:
Coronary computed tomography (CT) angiography has become a major cornerstone in the diagnostic workup of cardiologic patients, particularly for evaluation of the coronary arteries and preprocedural planning of interventions for structural heart disease. Despite the possible problems that intensive electromagnetic radiation (including X‑rays) might cause when directly impacting on implanted cardiac devices, cardiac CT is a safe diagnostic test and should not be withheld from patients with devices if properly indicated. Sufficient image quality is paramount for the evaluation; hence, special attention should be paid to a low heart rate (< 60 bpm) and sufficient compliance with breathing instructions. Furthermore, pacemaker or implantable cardioverter-defibrillator (ICD) leads may cause metal artifacts, especially around the lead tip. Their dense material causes beam hardening and streak artifacts which may result in reduced image quality and limited diagnostic assessability. The prevalence of such artifacts depends not only on lead material but also on lead positioning relative to the gantry plane. Metal artifacts are more frequent in patients with unipolar leads and shock coils, which can impair the assessment of coronary arteries, mainly of the right coronary artery (RCA). Artifacts caused by left ventricular (LV) leads of cardiac resynchronization therapy (CRT) systems tend to affect assessment of the left circumflex artery (LCX). By using dual energy CT and postprocessing algorithms, the impact of artifacts can be reduced and diagnostic image quality can be achieved in most cases. Unfortunately, the actual occurrence of such artifacts or the degree of impairment of image quality cannot be reliably predicted.
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