Cardiac CT Protocol Guide

Series
Coronary CT Angiography
10 Steps to Success
Coronary CT Angiography
10 Steps to Success Series

Check List

1 Patient Preparation & Positioning

2 Breath-Hold Training (HR Steady?)

Quick Reference Guides 3 Calcium Scoring Scan (CACS)

4 Determine the Start and End Positions for the CTA

5 Planning the Coronary CTA Scan

Coronary CT Angiography
10 Steps to Success Series 6 Use SURE Cardio to Select the Scan Parameters
with Automated Breath-Hold Training
Table of Contents
7 Calculate the Contrast Bolus
Check List 3

Examination Guidelines 4 - 12 8 Acquire the S&V Image for SUREStart

1) Patient Preparation & Positioning 4
2) Breath-Hold Training 4
3) Calcium Scoring Scan (CACS) 5 9 Final Check – GO Coronary CTA
4) Determining the Start and End Positions for the CTA 6
5) Planning the Coronary CTA Scan 6
6) Using SURECardio to Select the Scan Parameters in Breath-Hold Training 8 10 Cardiac Reconstruction
7) Calculating the Contrast Bolus 9
8) Acquiring the SUREStart S&V Image 10
9) Final Check – GO Coronary CTA 10
10) Cardiac Reconstruction 11-12

Disclaimer: Any reference to X-ray exposure is intended as a reference guideline only. The guidelines in this document do not substitute for the judgment of a
healthcare provider. Each scan requires medical judgment by the healthcare provider about exposing the patient to ionizing radiation. In clinical practice, the use
of the AIDR 3D (Adaptive lterative Dose Reduction 3D) features may reduce CT patient dose depending on the clinical task, patient size, anatomical location and
clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the
particular clinical task.
Due to local regulatory processes, some of the products included in this brochure may not be available in each country. Please contact your sales representative
for the most current information.

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10 Steps to Success Series

Examination Guidelines

1 Patient Preparation & Positioning 3 Calcium Scoring Scan (CACS)

4-Hour fast. NO caffeine! Select the Calcium Score eXam Plan.
Give the patient a full explanation of the procedure. Acquire AP and lateral scanograms.
Place a 20- or 18-gauge IV cannula in the RIGHT arm. Position the scan to cover the entire heart.
Position the patient for AP scanogram. - Visually set a plan to cover the range from the bifurcation of the
Offset the patient to the right so the heart is at the center of the scan field. trachea to below the apex of the heart.
Place the patient's arms above their head with the ECG leads outside the scan range. Reduce the display FOV to about 200-220 mm.
At many sites, sublingual nitrates may be administered about 5 minutes before the CTA - A smaller FOV results in a higher in-plane spatial resolution.
scan.

Confirm that a clean ECG signal is displayed before continuing!

2 Breath-Hold Training
Have the patient practice breath-holding before starting the examination. The breath-hold
instruction given should be the same as the breathing instruction recorded in the scanner.
This should be a single "breathe in and hold" command.

The patient should be instructed to hold their breath at about 75% of maximum lung capacity NOTE The calcium scoring protocol uses prospective ECG gating. Adjust the %R-R trigger
(“take a comfortable breath in”) and to take the same size breath each time they are told. according to the patient’s heart rate as shown in the table below.

This important step has two purposes:

This menu can be accessed in the Protocol tab.
To ensure that the patient can hold their breath for the required scan time.
To monitor the patient's heart rate during breath-holding. Make sure that a steady heart rate Heart Rate (bpm) % Cardiac Phase (Trigger)
is displayed with a clean ECG signal. <71 75
≥71 40
The patient’s heart rate should not fluctuate by more than ±10% during
breath-hold training.

Refer to the guidelines for beta blocker administration protocol (Page 13)

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10 Steps to Success Series

Examination Guidelines

4 Determining the Start and End Positions for the CTA
From the calcium scoring examination, select the start and end positions for the CT angiogram.
Protocol Selection
Low Dose CTA mode is a low-dose scanning technique in which exposure is performed for only a
portion of the R-R interval (generally diastole). The desired exposure phase is set as a percentage
of the R-R interval, so the actual exposure time varies depending on the patient’s heart rate. The
exposure phase setting can be expanded to include systole if the heart rate is high, and a
function is provided to perform such setting based on the results of breathing exercise.
Multisegmental reconstruction is also available for patients with high heart rates. Functional
analysis is not possible in this scan mode because exposure does not cover the entire R-R
interval.

It is advisable to plan 1 cm above the superior image selected and 1 cm below the inferior
image selected in case the patient's breath-holding is inconsistent.
NOTE
Note that the proximal LAD is often located superior to the origin of the left main coronary
artery.
CTA/CFA scan mode is a scanning technique in which exposure is performed during the entire
R-R interval. Functional analysis can be performed using the data obtained. Multisegmental
reconstruction is available for patients with high heart rates. ECG dose modulation is also
available for reducing the mA during portions of the R-R interval in which high-resolution
imaging is not necessary.

NOTE Longer coverage is needed to visualize coronary artery bypass grafts.

Selecting the Exposure Dose

Exposure Cardiac is used to automatically select the mA based on the patient size.
SURE

5 Planning the Coronary CTA Scan The following settings are recommended for SUREExposure.

Select and execute the required scan protocol. SD IQ

SURE Max mA Min mA
CTA 33 Cardiac CTA 580 40
Low Dose Cardiac CTA
Cardiac CTA/CFA The kV can be adjusted by selecting the lowest kV where the mA graph does not reach the
maximum.
This examination uses the same scanogram as the CACS scan. The magnification factor used for Lower kV is desirable as the HU value of iodine is increased at lower kVs. Increasing the
the CACS scan is automatically applied to this protocol. enhancement of vascular structures allows you to potentially reduce the volume of contrast
required.
Enter the numerical start and end table positions in the examplan.

Large Patient Small Patient

NOTE For bypass scans, SUREStart can be placed at mid arch for easier triggering.

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Examination Guidelines

6 Using SURECardio to Select the Scan Parameters
in Breath-Hold Training
Open the SURECardio menu by clicking the Scan Details Tab.
Click the "Breath Ex." Icon to start the automated breath-hold practice routine.
SURE
Cardio monitors the patient's heart rate during breath-hold training.
The patient's recorded heart rate range is displayed and the scan parameters to
ensure optimal temporal resolution are automatically set.
7 Calculating the Contrast Bolus
As a general rule:
The injection rate should be increased for shorter scan times and larger patients!
CTA requires contrast medium with an iodine concentration of at least
350 mgI/mL.
The following formulas have been optimized for Coronary CTA:
1) Single Phase Contrast with Saline Flush
This protocol ensures complete washout of the right side of the heart. Streak artifacts from
undiluted contrast medium are eliminated, providing excellent visualization of the RCA. The
saline solution replaces about 20 mL (5 seconds of injection) of the contrast medium.

2) Biphasic Injection with a Contrast/Saline Mix

A biphasic injection protocol with a contrast/saline mix reduces streak artifact in the SVC and
right heart, but maintains adequate opacification of the right ventricle.
This may improve the detection of the ventricular septal wall for CFA.

Single Phase Contrast with Saline Flush Biphasic Injection with Contrast/Saline Mix
(Ensures complete right heart washout) (Maintains right heart contrast for CFA)
Phase 1 (Contrast) XX mL @ 4 mL/s* Phase 1 (Contrast) 60 mL @ 4 mL/s* (15 s)
Phase 2 (Saline) 40 mL @ 4 mL/s Phase 2 (Mix) XX mL @ 4 mL/s
Scan Delay after Breathing Instruction. 50% Contrast (Simultaneous injection of contrast
+ @ 2 mL/s & Saline @ 2 mL/s)
A 2 second delay time is set as system default for all ECG gated scans. This option is in the 50% Saline
XX = (Scan Time + 10 s) × 4*
Set-up utility menu.
(Injection Rate)
XX = (Scan Time s) × 4
In the above formula, the duration of In the above formula, the duration of mixed
contrast injection = Scan time + 10 s injection = Scan time.

* The Injection rate should be increased for larger patients to ensure adequate iodine flux and therefore good arterial enhancement.

The following guidelines are suggested for injection rates:

Weight (kilograms) Weight (pounds) Injection Rate

< 59 kg < 129 lb 3.5 mL/s
60 – 100 kg 130 – 219 lb 4 mL/s
> 100 kg > 220 lb 5 mL/s

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Examination Guidelines

8 Acquiring the SUREStart S&V Image 10 Cardiac Reconstruction

Confirm that the descending aorta can be clearly identified on the SUREStart slice. Coronary CTA

phaseXact - Fully automated phase selection software

The phaseXact software automatically determines the optimal cardiac phase for
motion-free imaging. Phase selection is performed in the raw data domain and
requires no operator intervention.

phaseXact is set ON in the eXamplan.

Select “Best Phase”.

After the eXam Plan is completed, phaseXact finds and reconstructs the best motion-free
Place the SUREStart ROI over the descending aorta as shown above. cardiac phase. It may be necessary to reconstruct other phases to create a temporal window
Set the SUREStart trigger at 180 HU. to permit better assessment of the proximal and distal arteries.

NOTE Make sure that a suitable WW/WL has been set for real-time visualization.

OPTION You may prefer to trigger SUREStart using manual mode. Triggering SUREStart in manual mode
is easy, but you need to be confident of your anatomy. Remember that you will still get a
graphical readout of the ROI density. In manual mode, you can easily compensate for low
cardiac output by delaying the start of scanning.
imageXact - Guided image-based phase selection software
In rare cases, phaseXact may not be able to automatically determine the best motion-free
cardiac phase. In such cases, imageXact can help by guiding the operator through a simple
and precise manual phase selection process.

The concept of imageXact is to perform reconstruction at an absolute time point after the
R wave (R + ms). Phase selection is performed using a single image located at the mid-heart
9 Final Check - GO Coronary CTA level and reconstructed throughout the entire cardiac cycle.

Reassure the patient that it is normal to experience a sensation of warmth following contrast
administration. The following SUREIQ settings are recommended for cardiac reconstructions:
Inform the patient that the next breath-hold is the last one for the examination.
Confirm that the patient's heart rate is steady. IQ
SURE
FC OSR Dose Reduction Filter
Ca Score 12 Cardiac OFF OFF
It is a good idea to have someone monitor the first few seconds of contrast administration to
CTA 03 Cardiac AIDR 3D OFF
avoid extravasation.
Stent 05 Cardiac AIDR 3D OFF
GO Low Dose 02 Cardiac AIDR 3D OFF

Contrast injection and scanning are started simultaneously.

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Examination Guidelines Guidelines for Use of Beta-Blockers in Cardiac CT Studies

CFA (Cardiac Functional Analysis) The following protocol is intended to serve as general guidelines for the use of beta-blockers (specifically
metoprolol) in cardiac MDCT studies.
Available only in CTA/CFA scan mode Each site should evaluate their policies and procedures regarding the use of beta-blockers.

CFA is performed to evaluate left ventricular function. Quantitative measurements,
including the ejection fraction etc., can be obtained from the same data as that acquired
for the CTA examination when a full R-R interval has been scanned.
In order to perform CFA, we recommend that reconstruction be performed for 10 phases
from 0% to 90% at 10% intervals. The spatial resolution is not of primary importance in CFA,
so the amount of data can be reduced by reconstructing volumes with a 1 mm slice thickness
and 1 mm slice interval.
CFA reconstructions should be programmed into the eXam Plan to automatically perform
reconstruction after scanning is completed.
Beta-blockers are administered if the patient is found to have an average resting heart rate of
>70 bpm (regular rhythm) or >65 bpm (irregular rhythm).
NOTE Patients should be screened for any contraindications to the use of beta-blockers.
Exclude patients with systolic blood pressure < 100 mmHg.
1) Administer 50 mg of metoprolol as a single oral dose. (Exclude patients who have received medicinal
beta-blockers within the previous 4 hours.)
Monitor the patient every 15 minutes for 1 hour to check whether the heart rate has fallen to
within the desired range of ≤70 bpm (regular rhythm) or ≤65 bpm (irregular rhythm).

2) If the patient's heart rate has not fallen to within the desired range after 60 minutes, additional
metoprolol can be administered intravenously.

Administer 2.5 mg of metoprolol by slow intravenous push over 1 minute while monitoring the
patient’s heart rate and checking the blood pressure every 2 minutes.

If the patient's heart rate remains high after 5 minutes and there is no evidence of hypotension,
additional 2.5 mg doses of metoprolol may be administered up to a maximum of 15 mg.

Post-procedure guidelines

1) Patients who have received only oral metoprolol should remain in the department for 15 minutes
after the study. The blood pressure and heart rate should be checked.
Patients who are free of abnormal signs or symptoms may be released.

2) Patients who have received intravenous metoprolol should remain in the department for 30 minutes
after the study. The blood pressure and heart rate should be checked.
Patients who are free of abnormal signs or symptoms may be released.

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NOTES NOTES

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