TC CORONARICA: QUANDO? A CHI? - asiam · PDF filePARAMETRI SCANNER TC ... e del circolo...
Transcript of TC CORONARICA: QUANDO? A CHI? - asiam · PDF filePARAMETRI SCANNER TC ... e del circolo...
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TC CORONARICA:
QUANDO?
A CHI?
Carlo Bartolozzi
Alessandro Colleoni
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TC CORONARICA:
QUANDO?
A CHI?
………….
COME?
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TC CORONARICA
Esame non invasivo che consente la valutazione del cuore, delle arterie
coronarie e dei grossi vasi grazie alla possibilità di ottenere immagini ad alta
risoluzione e a strato sottile (sub-millimetrico), ricostruibili nei 3 piani
dello spazio (3D).
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Evoluzione tecnologica
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TC CORONARICA
REQUISITI TECNICI
Raff GL et al, J Cardiovasc Comput Tomogr 2014
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• Elevata risoluzione spaziale (0.5 mm) e di contrasto
– Visualizzazione della parete dei vasi di piccolo calibro
• Elevata risoluzione temporale (<200 ms)
– Riduzione degli artefatti da movimento (pazienti tachi-aritmici)
• Riduzione tempo di scansione (5-10 sec)
– Riduzione del tempo di apnea e del numero di battiti necessari
• Bassa dose radiante
• Sincronizzazione ECG
REQUISITI TECNICI
TC CORONARICA
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PARAMETRI SCANNER TC
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• Monitoraggio continuo dell’ECG
• Emissione di raggi X solo durante intervalli
predeterminati dell’intervallo R-R ed acquisizione deidati TC durante quelle fasi del ciclo cardiaco
Gating prospettico Gating retrospettivo
• Monitoraggio continuo dell’ECG
• Emissione di raggi X continua e
retroricostruzione dei dati TC durante fasiselezionate del ciclo cardiaco
GATING CARDIACO
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Paul JF et al, Int J Cardiovasc Imaging (2013) 29:651–657
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Imaging rapido
Elevato enhancement
vascolare (>250 HU)BOLO
COMPATTO
• Volumi ridotti (60-100ml)
• Alta velocità di iniezione (4-6 ml/s)
• Soluzione fisiologica (30-60ml)
IDR 1.6-2 gI/s
PRECISO TIMING
DELL’ACQUISIZIONE!
MEZZO DI CONTRASTO
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Ricostruzione dati
Preparazione del Paziente
Acquisizione dati
Selezione del Paziente
Post-processing
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POST-PROCESSING
• Tracking Vessel (2D):– Riformattazione multiplanare curve tracciando un asse
al centro del vaso
• Maximum Intensity Projection(MIP):– Immagini 3D simil-angiografiche dell’albero coronarico
• Volume Rendering (3D):– Rappresentazione tridimensionale
– Visione d’insieme del miocardio
e del circolo coronarico
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SCCT guidelines for the Interpretation and reporting of
coronary computed tomographic angiography
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MIP
VR
LAD
RCA
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Gaemperli O. et al, European Heart Journal (2011) 32, 2100–2108
Il problema della dose
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Stehli et al, J Am Coll Cardiol. 2014 Aug 26;64(8):772-80
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TC CORONARICA
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PROTOCOLLI “AD PERSONAM”
Halliburton SS et al, J Cardiovasc Comput Tomogr 2011
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• Maschio, 76 anni
• Sindrome metabolica in Paziente con obesità grave (peso: 130 Kg,
altezza: 180 cm; BMI: 40.1 Kg/m2)
• Dolore toracico atipico con stress-test ecografico inconclusivo
• TC coronarica per escludere coronaropatia
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• Scanner a 64 strati
• Acquisizione con gating ECG prospettico (FC < 50 bpm)
• Voltaggio: 140 kV, corrente: 600 mA, tempo di rotazione: 0.35 s
• Configurazione dei detettori: 64x0.625 mm, spessore: 0.625 mm
• Ricostruzioni interative
PARAMETRI ACQUISIZIONE TC
PARAMETRI INIEZIONE M.D.C.
• 130 ml Iodixanolo 270 ml l/ml iniettato a 9 ml/s
• 50 ml soluzione salina alla medesima velocità
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LAD
D2
LMACx
D1
S1
D2
S2
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Zimmerman SL et al, J Comput Assist Tomogr. 2014 ; 38(6): 949–955
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EXPERTISE
Graff et al, J Cardiovasc Comput Tomogr. 2014 Jul-Aug;8(4):254-71
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TC CORONARICA:
QUANDO?
A CHI?
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Quando? A chi?
• Sospetta coronaropatia (CAD)
• Valutazione di Pazienti con test funzionali non conclusivi
• Definizione anatomica delle arterie coronarie
• Valutazione di stent e by-pass (CABG)
• Valutazione pre-TAVI
• Valutazione pre-chirurgia valvolare – non cardiaca
• Definizione anatomica delle vene polmonari
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Sospetta coronaropatia
• Età
• Sesso
• Natura dei sintomi (angina tipica, atipica, dolore toracico non anginoso)
2013 ESC guidelines on the management of stable coronary artery disease, European Heart Journal (2013) 34, 2949–3003
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2013 ESC guidelines on the management of stable coronary artery disease, European Heart Journal (2013) 34, 2949–3003
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2013 ESC guidelines on the management of stable coronary artery disease, European Heart Journal (2013) 34, 2949–3003
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Paziente asintomatico/bassa PTP
NON
RACCOMANDATA
(CLASSE III)
Pz Asintomatico Pz Sintomatico
PTP Basso (<15%)
Classe Livello Classe Livello
Definizione anatomica di CAD
Coronarografia III A III A
TC coronarica III B III C
Test funzionali
Eco-stress III A III A
Imaging nucleare III A III A
RM-stress III B III C
Perfusione PET III B III C
Test di imaging ibrido o combinato
III C III C
2014 ESC/EACTS Guidelines on myocardial
revascularization, European Heart Journal (2014)
35, 2541–2619
Screening for silent
(asymptomatic) myocardial
ischaemia may be considered in
selected high-risk patients, such
as those with diabetes mellitus.
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2013 ESC guidelines on the management of stable coronary artery disease, European Heart Journal (2013) 34, 2949–3003
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2013 ESC guidelines on the management of stable coronary artery disease, European Heart Journal (2013) 34, 2949–3003
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Paziente sintomatico
CT is considered to perform best in the lower range of pre-test
probability (15-50%)
PTP
Basso (<15%) Intermedio (15-85%) Alto (>85%)
Classe Livello Classe Livello Classe Livello
Definizione anatomica di CAD
Coronarografia III A IIa A I A
TC coronarica III C IIb A III B
Test funzionali
Eco-stress III A I A III A
Imaging nucleare III A I A III A
RM-stress III C I A III B
Perfusione PET III C I A III B
Test di imaging ibrido o combinato
III C IIa B III B
2014 ESC/EACTS Guidelines on myocardial revascularization, European
Heart Journal (2014) 35, 2541–2619
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Andreini D et al, J Cardiovasc Med (Hagerstown). 2016 Feb;17(2):73-84
Paziente rivascolarizzato
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Anatomia coronarica
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TC ECG-Gated
2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. European
Heart Journal (2014) 35, 2873–2926
Lee SC et al, Int J Cardiovasc Imaging, 2012
Jun;28 Suppl 1:33-44
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Pronto Soccorso
Andreini D et al, J Cardiovasc Med (Hagerstown). 2016 Feb;17(2):73-84
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Fordyce CB et al, J Am Coll Cardiol 2016; 67(7), 843-52
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Prospettive future…
Koo HJ ert al, Int J Cardiovasc Imaging. 2015 Dec 14; DOI 10.1007/s10554-015-0825-5
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Perfusione miocardica
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2013 ESC guidelines on the management of
stable coronary artery disease, European Heart
Journal (2013) 34, 2949–3003
Fractional Flow Reserve (FFR)
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Non-invasive FFR
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Min JK et al, JACC Cardiovasc Imaging. 2015 Oct;8(10):1209-22
Koo HJ ert al, Int J Cardiovasc Imaging. 2015 Dec 14;
DOI 10.1007/s10554-015-0825-5
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Prospettive future
Koo HJ ert al, Int J Cardiovasc Imaging. 2015 Dec 14; DOI 10.1007/s10554-015-0825-5