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Ann Thorac Surg 2005;79:1344-1351
© 2005 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Multislice Computed Tomography for Preoperative Evaluation of Right Ventricular Volumes and Function: Comparison With Magnetic Resonance Imaging

^a Department of Radiology, Berlin, Germany
^b Department of Cardiovascular Surgery, Charité University Medicine Berlin, Medical School of Free University and Humboldt University, Berlin, Germany
^c Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Accepted for publication September 7, 2004.

^_* Address reprint requests to Dr Lembcke, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, White Building, Room 270, Boston, MA 02114 (E-mail: alexander.lembcke{at}gmx.de).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: This study was performed to validate preoperative right ventricular measurements obtained from multislice spiral computed tomography data sets in comparison with magnetic resonance imaging.

METHODS: Before cardiac surgery, 25 patients (among them 12 patients with compromised right ventricular function) underwent contrast-enhanced retrospectively electrocardiogram-gated multislice spiral computed tomography and cine magnetic resonance imaging in a standardized fashion. Right ventricular end-diastolic, end-systolic and stroke volume, ejection fraction, and myocardial mass were calculated according to the slice summation method. Measurements obtained with both modalities were compared using Pearson's correlation coefficient (r), Student's t test for paired samples, and Bland-Altman analysis.

RESULTS: The right ventricle was completely visualized with invariably adequate image quality on all multislice spiral computed tomography and magnetic resonance images. For all measurements a close correlation between multislice spiral computed tomography and magnetic resonance imaging was found (end-diastolic volume, r = 0.93; end-systolic volume, r = 0.95; stroke volume, r = 0.91; ejection fraction, r = 0.96; mass, r = 0.94). Mean values of all measurements did not differ significantly between both modalities, and limits of agreement were in an acceptable range.

CONCLUSIONS: When compared with magnetic resonance imaging as a reference method, multislice spiral computed tomography seems to be an accurate and reliable noninvasive technique for evaluating right ventricular measurements.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The recent introduction of submillimeter, subsecond electrocardiogram gated multislice spiral computed tomography (MSCT) into the clinical routine has led to new possibilities in the field of cardiac imaging, in particular with regard to the noninvasive evaluation of coronary vessels, myocardial infarct size, and coronary artery bypass grafts [1–9]. Because MSCT has a high negative predictive value concerning the presence of significant coronary artery stenosis it may be used as an alternative noninvasive imaging tool for the preoperative evaluation and risk stratification in cardiac surgery. Without the need for additional examinations, the acquired three-dimensional raw data set can be reconstructed over the entire cardiac cycle. Thus the reconstructed image data that was obtained allowed for determining cardiac function measurements such as ven-tricular end-diastolic volume and end-systolic volumes, stroke volume, and ejection fraction, as well as myocardial mass. First studies comparing MSCT (with 4 detector rows) in evaluating left ventricular function measurements with established techniques showed a good correlation between MSCT and magnetic resonance imaging [10–13], conventional angiography [14], and echocardiography [15], although a number of these studies indicated that the accuracy of MSCT was somewhat limited by its rather low temporal resolution.

However there are as yet no data on the usefulness of MSCT for measuring right ventricular dimensions and function. To fill this gap, the present work was performed. We hypothesized that MSCT can measure right ventricular volumes, ejection fraction, and myocardial mass with acceptable accuracy and reproducibility. Thus we directly compared measurements of right ventricular measurements obtained by MSCT with the results of cine magnetic resonance imaging (MRI) as the currently accepted gold standard for volume measurements of the cardiac chambers.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The population of our study consisted of 25 patients (18 males, 7 females; mean age, 54.9 ± 13.7 years) who underwent both an MSCT and MRI examination as part of their preoperative diagnostic work-up (Fig 1). Our patient population was divided into two subgroups. The first subgroup consisted of 12 patients with known right heart failure due to pulmonary valve dysfunction (n = 6), postvalvular pulmonary artery stenosis (n = 4), or tricuspid valve incompetence (n = 2). The second subgroup consisted of 13 patients with normal right ventricular function who suffered from aortic valve disease (stenosis, insufficiency, or both) with consecutive left ventricular myocardial hypertrophy, but without left ventricular dilatation, preserved normal left ventricular ejection fraction, and pulmonary artery pressures. All examinations were performed for accepted clinical indications. The preoperative MSCT scans were obtained to determine the extent of calcifications in the cardiac valves and in thoracic vessels and to exclude a hemodynamically significant coronary artery stenosis. The preoperative MRI scans were acquired for measurements of the flow volumes and velocities in the left and right ventricular outflow tracts and for visualization of valve morphology. The mean interval between both examinations was 1.2 ± 0.8 days (range, 0 to 2 days).

View larger version (69K): [in this window] [in a new window]   Fig 1. (A, B, C, D) Images from a preoperative examination of a 29-year-old man who suffered from tetralogy of Fallot with atresia of the pulmonary trunk, and who had undergone reconstruction of the right ventricular outflow tract using an aortic valve-containing allograft and a Dacron prosthesis as a child. However, now the conduit was extremely calcified and partially obstructed causing right heart failure that required reoperation. (A) Volume-rendered reconstruction of the entire multislice spiral computed tomography (MSCT) data set visualizing the heart with the coronary arteries and great vessels including the implanted horse-shoe Dacron conduit which was positioned in a nonanatomic manner anterior to the aortic root. The calcification of the conduit is also visible. (B) Section through the same MSCT data set in an angulated sagittal orientation demonstrating the extreme calcification and partial obstruction (arrows) of the Dacron conduit. (C) Section through the same MSCT data set in an axial slice orientation at end-diastole (left) and end-systole (right) with the endocardial and epicardial drawings of the right ventricle. The right ventricle shows global dilatation, reduced ejection fraction, and marked hypertrophy of the myocardium. (D) Corresponding magnetic resonance images of the same patient (similar slice position as in Fig 1C at end-diastole [left] and end-systole [right]). (A = anterior; Ao = aorta; L = left; LA = left atrium; LV = left ventricle; P = posterior; R = right; RA = right atrium; RV = right ventricle.)

MSCT
All patients were examined in the supine position with a MSCT unit of the latest generation with 8 or 16 detector rows and a maximum gantry speed of 400 ms (Aquilion Fx Pro, Toshiba, Otawara, Japan) in a standardized fashion. With simultaneous registration of the electrocardiogram a spiral scan from the level of the tracheal bifurcation to the diaphragm was performed during end-inspiratory breath-hold with the following measurements: gantry rotation time of 400 ms (500 ms for heart rates of 95 to 105 bpm and 600 ms for heart rates of 75 to 85 bpm), a collimation of 0.5 to 1.0 mm, a pitch of 0.20 to 0.25, a tube current of 300 mA, and a tube voltage of 120 kV. Contrast material with an iodine content of 370 mg/mL was administered into a cubital vein at a flow rate of 3 to 4 mL/s during the entire scan. To ensure optimal opacification of cardiac chambers scanning was started by bolus tracking in the pulmonary artery using the system's bolus tracking ("sure start") option. Image data sets of the entire heart were retrospectively reconstructed according to the simultaneously recorded electrocardiogram up to 20 different phases of the cardiac cycle at every 5% of the RR interval. To improve the temporal resolution and to avoid motion artifacts the so-called multisegmental reconstruction algorithm (utilizing raw data from up to four cardiac cycles) was used for generating images in each case.

MRI
Each patient was examined with a state-of-the-art 1.5 Tesla whole-body MRI system (Magnetom Vision, [Siemens, Erlangen, Germany]) using a specialized body phased-array coil in the supine position. Data acquisition was performed in a sectionwise manner in the axial slice orientation during end-inspiratory breath-hold with a prospectively electrocardiogram triggered two-dimensional fast low angle shot cine sequence with k-space segmentation and echo-sharing (repetition time, 80 to 100 ms resulting in a temporal resolution of 40 or 50 ms; echo time, 4.8 ms; flip angle, 20°; matrix, 128 x 256; field of view, 340 to 400 mm; slice thickness, 5 mm without gap or overlap).

Volumetric Evaluation
Analyses of the MSCT and MRI data sets were performed with the systems implemented standard software by an experienced observer who was blinded to patient details and to the results of prior examinations.

Image window and level settings were individually adjusted for each examination to achieve the best contrast between the myocardium and blood as well as adjacent pericardial tissue. In a stack of contiguous axial images with a slice thickness of 5 mm, the myocardial contours were delineated on images depicting the end-diastolic and end-systolic phases, which were identified visually as those with the largest and smallest chamber areas, respectively. Papillary muscles and the trabecula of the right ventricle were carefully excluded from the lumen. The right ventricular chamber volumes and muscle mass were calculated using the slice summation method (by multiplying the slice areas by the slice thickness and then adding all sections).

Descriptive and Statistical Analysis
For data analysis, a commercially available software program was used (SPSS for Windows, release 11.0; SPSS Inc, Chicago, IL). Data are presented as mean value ± standard deviation. The level of significance for all statistical tests was defined at p < 0.05.

Comparison Between MSCT and MRI
The correlation between both modalities was tested by two-variable linear regression analysis including calculation of Pearson's correlation coefficient. To further examine the agreement of both modalities, the method of Bland and Altman was used [16]. The degree of agreement between both modalities was determined as the mean difference, the standard error of estimation for the mean difference, the 95% confidence interval of the mean difference, and the limits of agreement for both modalities (mean ± 2 standard deviations). The statistical significance of the mean difference between both modalities was tested by Student's t test for paired samples.

Evaluation of Variability
For calculation of intraobserver and interobserver variability manual tracing of myocardial borders was repeated after a time delay of at least 1 month by the same investigator, and in addition a second investigator, who were both unaware of the results from the initial study. The interobserver and intraobserver variability was then assessed by calculating the coefficient of variability (equal to the standard deviation of the difference between two measurements over the mean of the two measurements, expressed as percentage).

The comparison of the intraobserver and interobserver variability between MSCT and MRI was performed in a same way as already reported previously [17, 18] using a statistical method as described in detail by Bland (http://www.sghms.ac.uk/depts/phs/staff/jmb/compsd.htm). For each subject and modality, the squared difference between the two measurements is an estimate of the within subject variance for that modality times 2. Because the squared differences are not normally distributed, a natural log transformation of the squared differences was performed and the one-sample Kolmogorov-Smirnov test was used to validate the agreement between observed and normal distribution. Student's t test for paired samples was then applied to the logged squared differences for the two modalities.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The MSCT and MRI examinations were well tolerated and could be completed in all cases without having to repeat a study. No complications such as adverse effects of intravenous contrast material were observed.

The image quality of all cine studies performed was primarily sufficient for quantitative analysis in all patients. Breath-hold was maintained by all patients and right ventricular opacification was adequate to determine myocardial borders on all end-diastolic and end-systolic images.

No patient had to be excluded due to electrocardiogram triggering artifacts. All patients had a regular sinus rhythm with a mean heart rate of 74.3 ± 11.1 bpm (range, 56 to 93 bpm) in MSCT and 74.1 ± 10.9 bpm (range, 59 to 91 bpm) in MRI (p = 0.28). Using multisegmental image reconstruction, the effective length of the acquisition time window per cardiac cycle in MSCT was 123.8 ± 37.4 ms (range, 50 to 200 ms). This was significantly longer than the effective acquisition time of 45.6 ± 5.1 ms (range, 40 to 50 ms) in MRI (p < 0.001).

The time needed to acquire the data set with MSCT was 30 to 40 seconds; a complete examination took about 15 to 20 minutes. With MRI the complete data set was acquired in 15 to 20 minutes, and the overall examination time was 30 to 40 minutes. In both modalities the delineation of right ventricular contours took about 10 minutes.

Comparison Between MSCT and MRI
The mean values for right ventricular volumes, ejection fraction, and myocardial mass, and the analysis of the respective differences between MSCT and MRI are given in Table 1. The mean values of end-diastolic volumes and myocardial mass were in quite good agreement between both modalities. Although a slight overestimation of the end-systolic volume and a slight underestimation of the stroke volume and ejection fraction by MSCT in comparison with MRI were found, these differences were not relevant because the Student's paired t test showed no significant differences between MSCT and MRI for any of the measurements. The limits of agreement between both modalities were in an acceptable range for all measurements.

View larger version (26K): [in this window] [in a new window]   Fig 2. (A, B, C, D, E) Scatterplots showing the regression analysis between magnetic resonance imaging (MRI, horizontal axes) and multislice spiral computed tomographic (MSCT, vertical axes) measurements of the right ventricular end-diastolic volume (EDV, A), end-systolic volume (ESV, B), stroke volume (SV, C), ejection fraction (EF, D), and myocardial mass (E) for all patients. Each symbol represents data from 1 patient. Circles represent patients with compromised right heart function. Triangles represent patients with preserved normal right heart function. The regression lines (dashed lines) and the regression equation, including Pearson's correlation coefficients (r) are shown in each plot (level of significance, p < 0.001 in each case).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

Measurements of right ventricular dimensions and performance provide valuable information for the diagnosis, clinical decision making, follow-up, and prognosis of a broad spectrum of cardiac and pulmonary diseases [18, 19]. Furthermore right ventricular failure has been increasingly recognized as an important problem in cardiac surgery in general [20–22] and in patients undergoing surgery for acquired heart valve diseases as well as for congenital cardiac abnormalities in particular [23–34].

Different imaging modalities, such as echocardiography, cardiac catheterization techniques including conventional angiocardiography, radionuclide angiocardiography, and magnetic resonance imaging are used to determine the chamber volumes and the myocardial function of both the left and right ventricles [17, 18]. However, the right ventricle has a more complex morphology due to the crescent shape of its cavity, the conic shape of the subvalvular portion of its outflow tract, and its pronounced trabeculation. Therefore, simple geometrical formulas as they are used in biplane cine angiography or two-dimensional echocardiography may not be adequate for its description. Even in the case of the relative simple ellipsoid shape of the left ventricle, biplane, two-dimensional imaging has shown significant errors in volume determination, especially in patients with abnormally shaped, dilated ventricles [17].

Whereas conventional angiocardiography requires an invasive vascular access that is always associated with a certain risk, in echocardiography the right ventricle may be difficult to visualize due to its retrosternal localization, and accuracy of echocardiographic imaging crucially relies on the examiner's expertise and experience as well as the patient's individual sonication condition [33]. Three-dimensional echocardiography has shown acceptable results in the evaluation of end-diastolic volumes but may be inaccurate in the determination of end-systolic volumes [34].

Multislice spiral computed tomography and MRI do not rely on geometrical models of ventricular shape because a slice summation method is used. For MRI, accurate and reproducible measuring results have been reported even in cases with substantially deformed right ventricles (ie, in patients with complex congenital heart diseases in which there are significantly and individually malformed cardiac cavities) [27–29]. Given the fact that MSCT also is not restricted by geometrical assumptions it may theoretically be well suitable for right ventricular measurements in congenital heart disease. However, the radiation exposure may limit the applicability of MSCT in infants.

Because MRI has shown a high accuracy and reproducibility in the evaluation of both left and right ventricular volumes it is now considered the gold standard for cardiac volume measurements [17, 18]. A high temporal resolution (ie, an acquisition time per cardiac cycle of 50 ms or less) and planes of data acquisition that can be chosen freely for individual patients justify this claim. However, MRI is often contraindicated in patients with metal implants (eg, pacemakers or defibrillators), and severe claustrophobia of the patient may also lead to a problematic situation. In addition, longer examination times in a flat supine position and repeated breath-hold periods are not only stressful for patients with advanced congestive heart failure and high-grade dyspnea, but they may also result in a considerable impairment of image quality.

In contrast, MSCT allows for acquisition of the entire volume data set within a single breath-hold due to its relatively short scan time of 30 to 40 seconds, and it is also applicable in the immediate perioperative period for seriously ill patients, even for those from the intensive care unit. The acquired volume data set contains all structural and functional information of the heart, in particular with regard to the coronary vessels and the cardiac valves, as well as the dimensions of the cardiac chambers and myocardial performance. Metal implants, such as pacemakers and defibrillators may lead to an impairment of image quality but do not represent a contraindication for the examination. However, MSCT is associated with radiation exposure and requires intravascular administration of iodinated contrast material that may be problematic, especially in young, female patients as well as in patients with renal failure. In addition, cardiac arrhythmia may result in impaired image quality, which may significantly affect the accuracy of MSCT measurements.

A shared limitation of MSCT and MRI is that image quality may crucially diminish because of motion artifacts due to breathing, particularly in babies and young children. However, in our clinical practice this problem usually does not exist because MRI and MSCT examinations in babies and young children typically require sedation with controlled ventilation.

When compared with MRI the most important issue in MSCT is its significantly lower temporal resolution. In MSCT the generation of an image using information from 180° of the gantry rotation (so-called half-scan reconstruction algorithm) achieves a temporal resolution of 200 ms (at a gantry rotation time of 400 ms). A further improvement of temporal resolution can only be achieved by using alternative reconstruction algorithms that combine the raw data required for half-scan image reconstruction, not from a single rotation within one cardiac cycle, but instead collect data from multiple partial rotations over several cardiac cycles to build the reconstructed images [5, 35–38]. In an ideal case this so-called multisegmental reconstruction (or multicycle, multisector, or multiphase reconstruction) provides a temporal resolution up to a maximum of 50 ms (at a gantry rotation of 400 ms). The factor by which this algorithm improves temporal resolution is equal to the number of partial rotations over several cardiac cycles used. However, a problem arises from the fact that the temporal resolution is directly determined by the heart rate, which, with a fixed gantry rotation time of 400 ms, yields a resolution of 200 ms at the worst. This problem arises from negative synchronization effects between gantry rotation speed and a patient's heart rate. Therefore a careful adjustment of the gantry rotation time to the patient's heart as used in our investigation may be useful [38].

Using the multisegmental reconstruction algorithm combined with individually adapted gantry rotation time, the effective acquisition time window per cardiac cycle for MSCT in our study was 126 ± 30 ms (range, 83 ms to 166 ms), but this was still significantly longer than the effective acquisition time of 45.6 ± 5.1 ms (range, 40 to 50 ms) in MRI. Thus, in some cases the longer acquisition time in MSCT could lead to substantial overestimation of the right ventricular end-systolic volume and subsequently to underestimation of the right ventricular ejection fraction when compared with MRI. However, despite different acquisition times between MSCT and MRI our study demonstrates a quite good agreement between both modalities regarding measurements of right ventricular volumes, ejection fraction, and myocardial mass with no significant differences of the mean values.

In the authors' view, the differences in temporal resolution between the two modalities are less important than the systematic or random measuring errors resulting from the geometry of the right ventricle. This holds true in particular for the precise identification of the tricuspid and pulmonary valve levels and the exclusion of the trabeculae when determining the volume of the right ventricle, which may cause considerable difficulties, even for a very experienced examiner. However, these problems occur with both modalities compared here. Another factor affecting the results is the intraindividual variability of cardiac function measurements in patients undergoing repeat examination.

Limitations
Our study is limited by the following factors: any comparison of two clinical imaging procedures which are not performed at exactly the same time may be impaired by the fact that differences in measurement may result not only from differences between both procedures but also from normal physiologic variation in the variables measured. This effect cannot be fully excluded.

Moreover, the volumetric data sets obtained with MSCT and MRI were analyzed with the respective implemented standard software on each scanner, which is the typical way of data analyzing in the routine clinical setting, but alone may lead to slight measuring differences between both modalities. Finally, it must be noted that we used fast low-angle shot sequences as an MRI reference method, but somewhat more sophisticated types of MRI techniques are now available. In particular, steady-state free precession sequences provide a slightly sharper delineation of the endocardial contours due to a higher contrast between blood and myocardium, and therefore may improve the measuring accuracy in the MRI.

In summary, the findings presented here suggest that MSCT is well suited for assessment of the right ventricle. The somewhat poorer temporal resolution of MSCT compared with MRI seems not to have any crucial effect on the measuring results, suggesting that MSCT provides measurements of right ventricular dimensions and ejection fraction of adequate accuracy for routine clinical use, in particular for preoperative evaluation.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We would like to thank Bettina Herwig (Charité) for excellent assistance in preparing the manuscript, for translation of parts of the text, as well as careful proofreading. We would also like to thank Juergen Mews (Toshiba Medical Systems) for technical advice and support.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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