Comparison of a High-Pitch Non-ECG-Gated and a Prospective ECG-Gated Protocol for Preprocedural Computed Tomography Imaging Before TAVI/TAVR

Abstract

Purpose Preprocedural computed tomography (CT) imaging before transcatheter aortic valve implantation/replacement (TAVI/TAVR) requires high diagnostic accuracy without motion artifacts. The aim of this retrospective study is to compare the image quality of a high-pitch non-electrocardiography (ECG)-gated CT protocol used in patients with atrial tachyarrhythmias with a prospectively ECG-gated CT protocol used in patients with sinus rhythm.

Materials and Methods We retrospectively included 108 patients who underwent preprocedural CT imaging before TAVI/TAVR. 52 patients with sinus rhythm were imaged using a prospectively ECG-gated protocol (Group A), and 56 patients with atrial tachyarrhythmias were imaged using the high-pitch non-ECG-gated protocol (Group B). Image quality was rated subjectively by two experienced radiologists and assessed by objective parameters including radiation dose, image noise, contrast-to-noise ratio (CNR), and signal-to-noise ratio (SNR) at the levels of the aortic root and abdominal aorta.

Results Subjective image quality was equally good with both CT protocols, and interrater agreement was substantial in both groups but tended to be higher in Group B at the level of the aortic root (Group A: κw = 0.644, Group B: κw = 0.741). With the high-pitch non-ECG-gated CT protocol, image noise was significantly increased (p = 0.001), whereas the SNR, CNR, and radiation dose were significantly decreased (p = 0.002, p = 0.003, and p < 0.001, respectively) at the level of the aortic root compared to the prospectively ECG-gated CT protocol.

Conclusion The high-pitch non-ECG-gated protocol yields images with similar subjective image quality compared with the prospectively ECG-gated CT protocol and allows motion-free assessment of the aortic root for accurate TAVI/TAVR planning. The high-pitch non-ECG-gated protocol may be used as an alternative for preprocedural CT imaging in patients with atrial tachyarrhythmias.

Key Points: 

• In patients with atrial tachyarrhythmias, a high-pitch non-ECG-gated CT protocol achieves similar subjective image quality compared to a prospective ECG-gated CT protocol.

• At the level of the aortic root, image noise is significantly increased, whereas SNR and CNR are significantly decreased using the high-pitch non-ECG-gated protocol.

• Radiation dose is reduced by 55 % using the high-pitch non-ECG-gated protocol.

Citation Format

• Shnayien S, Beetz N, Bressem KK et al. Comparison of a High-Pitch Non-ECG-Gated and a Prospective ECG-Gated Protocol for Preprocedural Computed Tomography Imaging Before TAVI/TAVR. Fortschr Röntgenstr 2023; 195: 139 – 147

Zusammenfassung

Ziel Die präinterventionelle Bildgebung mittels Computertomografie (CT) vor geplanter Transkatheter-Aortenklappen-Implantation (TAVI) erfordert eine hohe diagnostische Genauigkeit ohne Bewegungsartefakte. Ziel dieser retrospektiven Studie ist es, die Bildqualitäten eines „high-pitch“ nicht Elektrokardiogramm (EKG)-getriggerten CT-Protokolls bei Patienten mit atrialer Tachyarrhythmie und eines prospektiv EKG-getriggerten CT-Protokolls bei Patienten mit Sinusrhythmus zu vergleichen.

Material und Methoden Es wurden 108 Patient*innen mit einer präinterventionellen CT-Bildgebung vor geplanter TAVI retrospektiv eingeschlossen. 52 Patient*innen wurden mit dem prospektiv EKG-getriggerten CT-Protokoll untersucht (Gruppe A), während 56 Patient*innen mit atrialer Tachyarrhythmie mit dem „high pitch“ nicht EKG-getriggerten CT-Protokoll untersucht wurden. Die Bildqualität wurde von 2 erfahrenen Radiologen beurteilt. Zudem wurden die objektiven Bildparameter Strahlendosis, Bildrauschen, Kontrast-Rausch-Verhältnis und Signal-Rausch-Verhältnis auf Höhe der Aortenwurzel und der abdominellen Aorta verglichen.

Ergebnisse Unabhängig von dem verwendeten CT-Protokoll war die Bildqualität gleich gut und die Interrater-Reliabilität substantiell, aber tendenziell besser in Gruppe B auf Höhe der Aortenwurzel (Gruppe A: κw = 0.644 und Gruppe B: κw = 0.741). Bei der Verwendung des „high-pitch“ nicht EKG-getriggerten CT-Protokolls war das Bildrauschen auf Höhe der Aortenwurzel signifikant erhöht (p = 0.001), wogegen das Kontrast-Rausch-Verhältnis, das Signal-Rausch-Verhältnis sowie die Strahlendosis signifikant reduziert waren (p = 0.002, p = 0.003, und p < 0.001) im Vergleich zum prospektiv EKG-getriggerten CT-Protokoll.

Schlussfolgerung Das „high-pitch“ nicht EKG-getriggerte CT-Protokoll bietet eine ähnliche subjektive Bildqualität verglichen mit dem prospektiv EKG-getriggerten CT-Protokoll und erlaubt eine bewegungsfreie Beurteilung der Aortenwurzel für eine akkurate TAVI-Planung. Das „high-pitch“ nicht EKG-getriggerte CT-Protokoll könnte eine Alternative für die präinterventionelle CT-Bildgebung bei Patient*innen mit atrialer Tachyarrhythmie darstellen.

Kernaussagen: 

• Bei Patient*innen mit atrialer Tachyarrhythmie kann das „high-pitch“ nicht EKG-getriggerte CT-Protokoll im Vergleich zu dem EKG-getriggerten CT-Protokoll eine vergleichbare subjektive Bildqualität erzeugen.

• Bei dem „high-pitch“ nicht EKG-getriggerten CT-Protokoll ist das Bildrauschen auf Höhe der Aortenwurzel signifikant erhöht, während das Kontrast-Rausch-Verhältnis und Signal-Rausch-Verhältnis signifikant verringert sind.

• Bei dem „high-pitch“ nicht EKG-getriggerten CT-Protokoll wird die Strahlendosis um 55 % reduziert.

Key words

aortic valve - cardiac - CT-angiography

Publikationsverlauf

Eingereicht: 05. Januar 2022

Angenommen: 19. Juni 2022

Artikel online veröffentlicht:
05. September 2022

• References

• 1 Mack MJ, Leon MB, Thourani VH. et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med 2019; 380: 1695-1705 DOI: 10.1056/NEJMoa1814052.
• 2 Leon MB, Smith CR, Mack M. et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363: 1597-1607 DOI: 10.1056/NEJMoa1008232.
• 3 Ismail TF, Cheasty E, King L. et al. High-pitch versus conventional cardiovascular CT in patients being assessed for transcatheter aortic valve implantation: a real-world appraisal. Open Heart 2017; 4: e000626 DOI: 10.1136/openhrt-2017-000626.
• 4 Achenbach S, Delgado V, Hausleiter J. et al. SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr 2012; 6: 366-380 DOI: 10.1016/j.jcct.2012.11.002.
• 5 Blanke P, Weir-McCall JR, Achenbach S. et al. Computed Tomography Imaging in the Context of Transcatheter Aortic Valve Implantation (TAVI)/Transcatheter Aortic Valve Replacement (TAVR): An Expert Consensus Document of the Society of Cardiovascular Computed Tomography. JACC Cardiovasc Imaging 2019; 12: 1-24 DOI: 10.1016/j.jcmg.2018.12.003.
• 6 Francone M, Budde RPJ, Bremerich J. et al. CT and MR imaging prior to transcatheter aortic valve implantation: standardisation of scanning protocols, measurements and reporting-a consensus document by the European Society of Cardiovascular Radiology (ESCR). Eur Radiol 2020; 30: 2627-2650 DOI: 10.1007/s00330-019-06357-8.
• 7 Salgado RA, Leipsic JA, Shivalkar B. et al. Preprocedural CT evaluation of transcatheter aortic valve replacement: what the radiologist needs to know. Radiographics 2014; 34: 1491-1514 DOI: 10.1148/rg.346125076.
• 8 Dahl JS, Brandes A, Videbæk L. et al. Atrial fibrillation in severe aortic valve stenosis – Association with left ventricular left atrial remodeling. IJC Heart & Vessels 2014; 4: 102-107
• 9 Greve AM, Gerdts E, Boman K. et al. Prognostic importance of atrial fibrillation in asymptomatic aortic stenosis: the Simvastatin and Ezetimibe in Aortic Stenosis study. Int J Cardiol 2013; 166: 72-76 DOI: 10.1016/j.ijcard.2011.09.064.
• 10 Mushtaq S, Conte E, Melotti E. et al. Coronary CT Angiography in Challenging Patients: High Heart Rate and Atrial Fibrillation. A Review. Acad Radiol 2019; 26: 1544-1549 DOI: 10.1016/j.acra.2019.01.022.
• 11 Andreini D, Pontone G, Mushtaq S. et al. Image quality and radiation dose of coronary CT angiography performed with whole-heart coverage CT scanner with intra-cycle motion correction algorithm in patients with atrial fibrillation. Eur Radiol 2018; 28: 1383-1392 DOI: 10.1007/s00330-017-5131-2.
• 12 Kang TS, Park S. Antihypertensive Treatment in Severe Aortic Stenosis. J Cardiovasc Imaging 2018; 26: 45-53 DOI: 10.4250/jcvi.2018.26.e9.
• 13 Kalisz K, Buethe J, Saboo SS. et al. Artifacts at Cardiac CT: Physics and Solutions. Radiographics 2016; 36: 2064-2083 DOI: 10.1148/rg.2016160079.
• 14 Horehledova B, Mihl C, Boswijk E. et al. Retrospectively ECG-gated helical vs. non-ECG-synchronized high-pitch CTA of the aortic root for TAVI planning. PLoS One 2020; 15: e0232673 DOI: 10.1371/journal.pone.0232673.
• 15 Shnayien S, Bressem KK, Beetz NL. et al. Feasibility of a High-Pitch Protocol for Transcatheter Aortic Valve Replacement Evaluation in Patients not Suitable for ECG-Gated CT. PREPRINT available at Research Square 2020; 1 DOI: 10.21203/rs.3.rs-123721/v1.
• 16 Shnayien S, Bressem KK, Beetz NL. et al. Radiation Dose Reduction in Preprocedural CT Imaging for TAVI/TAVR Using a Novel 3-Phase Protocol: A Single Institution’s Experience. Fortschr Röntgenstr 2020; DOI: 10.1055/a-1150-7646.
• 17 Wielandner A, Beitzke D, Schernthaner R. et al. Is ECG triggering for motion artefact reduction in dual-source CT angiography of the ascending aorta still required with high-pitch scanning? The role of ECG-gating in high-pitch dual-source CT of the ascending aorta. Br J Radiol 2016; 89: 20160174 DOI: 10.1259/bjr.20160174.
• 18 Beitzke D, Wolf F, Edelhauser G. et al. Computed tomography angiography of the carotid arteries at low kV settings: a prospective randomised trial assessing radiation dose and diagnostic confidence. Eur Radiol 2011; 21: 2434-2444 DOI: 10.1007/s00330-011-2188-1.
• 19 Apfaltrer P, Hanna EL, Schoepf UJ. et al. Radiation dose and image quality at high-pitch CT angiography of the aorta: intraindividual and interindividual comparisons with conventional CT angiography. Am J Roentgenol 2012; 199: 1402-1409 DOI: 10.2214/ajr.12.8652.
• 20 Asano Y, Tada A, Shinya T. et al. Utility of second-generation single-energy metal artifact reduction in helical lung computed tomography for patients with pulmonary arteriovenous malformation after coil embolization. Jpn J Radiol 2018; 36 (04) 285-294
• 21 Wang R, Schoepf UJ, Wu R. et al. Diagnostic accuracy of coronary CT angiography: comparison of filtered back projection and iterative reconstruction with different strengths. J Comput Assist Tomogr 2014; 38: 179-184 DOI: 10.1097/rct.0000000000000005.
• 22 Christner JA, Kofler JM, McCollough CH. Estimating effective dose for CT using dose-length product compared with using organ doses: consequences of adopting International Commission on Radiological Protection publication 103 or dual-energy scanning. Am J Roentgenol 2010; 194: 881-889 DOI: 10.2214/ajr.09.3462.
• 23 Boone JM SK, Cody DD, McCollough CH. et al. Size-specific dose estimates (SSDE) in pediatric and adult body CT examinations. Report of AAPM Task Group 2011; 204
• 24 Mandrekar JN. Measures of interrater agreement. J Thorac Oncol 2011; 6: 6-7 DOI: 10.1097/JTO.0b013e318200f983.
• 25 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174
• 26 Min JK, Berman DS, Leipsic J. Multimodality imaging for transcatheter aortic valve replacement. Springer Science & Business Media 2013
• 27 Litmanovich DE, Ghersin E, Burke DA. et al. Imaging in Transcatheter Aortic Valve Replacement (TAVR): role of the radiologist. Insights Imaging 2014; 5: 123-145 DOI: 10.1007/s13244-013-0301-5.
• 28 Feuchtner G. Imaging of cardiac valves by computed tomography. Scientifica (Cairo) 2013; 2013: 270579 DOI: 10.1155/2013/270579.
• 29 Capilli F, Benndorf M, Soschynski M. et al. Assessment of aortic annulus dimensions for transcatheter aortic valve replacement (TAVR) with high-pitch dual-source CT: Comparison of systolic high-pitch vs. multiphasic data acquisition. Eur J Radiol 2020; 133: 109366 DOI: 10.1016/j.ejrad.2020.109366.
• 30 Matsumoto S, Yamada Y, Hashimoto M. et al. CT imaging before transcatheter aortic valve implantation (TAVI) using variable helical pitch scanning and its diagnostic performance for coronary artery disease. Eur Radiol 2017; 27: 1963-1970 DOI: 10.1007/s00330-016-4547-4.
• 31 Salgado R, El Addouli H, Budde RPJ. Transcatheter Aortic Valve Implantation: The Evolving Role of the Radiologist in 2021. Fortschr Röntgenstr 2021; 193: 1411-1425 DOI: 10.1055/a-1645-1873.
• 32 Popma JJ, Deeb GM, Yakubov SJ. et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients. N Engl J Med 2019; 380: 1706-1715 DOI: 10.1056/NEJMoa1816885.
• 33 Murphy DT, Blanke P, Alaamri S. et al. Dynamism of the aortic annulus: Effect of diastolic versus systolic CT annular measurements on device selection in transcatheter aortic valve replacement (TAVR). J Cardiovasc Comput Tomogr 2016; 10: 37-43 DOI: 10.1016/j.jcct.2015.07.008.
• 34 Kang EJ. Clinical Applications of Wide-Detector CT Scanners for Cardiothoracic Imaging: An Update. Korean J Radiol 2019; 20: 1583-1596 DOI: 10.3348/kjr.2019.0327.
• 35 Annoni AD, Andreini D, Pontone G. et al. CT angiography prior to TAVI procedure using third-generation scanner with wide volume coverage: feasibility, renal safety and diagnostic accuracy for coronary tree. Br J Radiol 2018; 91: 20180196 DOI: 10.1259/bjr.20180196.