Coronary computed tomography angiography and endocardial leads - Image quality in 320-row CT using iterative reconstruction


      • Pacemakers show impairment in CCTA using current technique with iterative reconstruction.
      • SNR and CNR are reduced in coronary CT angiography with endocardial leads.
      • Significant image deterioration is found predominantly in segment 8.
      • CCTA is feasible with slight restrictions for patients with pacemakers.



      To investigate whether the presence of endocardial leads has an impact on image quality in coronary computed tomography angiography (CCTA), when current technique is employed using a 320-row computed tomography and iterative reconstruction.

      Materials and methods

      CCTA was performed in 1641 patients, from these we identified 51 patients (study group) with endocardial leads and 51 matched partners (control group) without endocardial leads.
      Noise was determined in the ascending aorta and the left ventricle; signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were determined in the left and right coronary artery.
      Subjective image quality was rated separately for the 15 segments of the coronary arteries by 2 radiologists.


      Current CCTA technique still shows slight impairment of objective image quality in patients with endocardial leads with inferior SNR in the aorta (median 15.04 versus 16.6; p = 0.004) and inferior SNR in the left/right coronary artery (median 15.3/13.81 versus 16.1/15.41; p = 0.013/0.002). CNR of the left/right coronary artery was also inferior (median 17.4/16.46 versus 19.26/19.24; p = 0.002/<0.001).
      The subjective image quality was rated significantly inferior only in segment 8 (p = 0.001) compared to the control group. Artifacts by ventricular leads were found in 65% of the patients in segment 8 with non-diagnostic rating in 9 cases (18%). Atrial leads resulted in artifacts predominantly in segment 1 (45%) with non-diagnostic rating in only 2 cases (4%).


      CCTA is feasible with slight restrictions for patients in the presence of implanted cardiac devices when current technique is used.


      AIDR 3D (adaptive-iterative-dose-reduction in 3D), BMI (body mass index), CCTA (coronary computed tomography angiography), CNR (contrast-to-noise ratio), CRT (cardiac resynchronization therapy), CT (computed tomography), HU (Hounsfield units), ICD (implanted cardioverter-defibrillator), kVp (kilovoltage peak), LCA (left coronary artery), LV (left ventricle), mAs (tube current – exposure time product), mSv (effective radiation dose), RCA (right coronary artery), SD (standard deviation), SEMAR (single-energy metal artefact reduction), SNR (signal-to-noise ratio)


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        • Taylor A.J.
        • Cerqueira M.
        • Hodgson J.M.
        • Mark D.
        • Min J.
        • O'Gara P.
        • et al.
        ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance.
        Circulation. 2010; 122: e525-55
        • Mak G.S.
        • Truong Q.A.
        Cardiac CT: imaging of and through cardiac devices.
        Curr Cardiovasc Imag Rep. 2012; 5: 328-336
        • Mlynarska A.
        • Mlynarski R.
        • Wilczek J.
        • Sosnowski M.
        Can multi-slice computed tomography of the heart be useful in patients with epicardial leads?.
        Cardiol J. 2013; 20: 87-89
        • Sosnowski M.
        • Mlynarski R.
        • Wlodyka A.
        • Brzoska J.
        • Kargul W.
        • Tendera M.
        The presence of endocardial leads may limit applicability of coronary CT angiography.
        Scand Cardiovasc J. 2010; 44: 31-36
        • Wang Z.
        • Ding Z.X.
        • Di X.B.
        • Yuan J.H.
        Initial experience of 640-slice CT coronary angiography in pacemaker patients.
        Zhonghua Xin Xue Guan Bing Za Zhi. 2011; 39: 721-724
        • Tomizawa N.
        • Nojo T.
        • Akahane M.
        • Torigoe R.
        • Kiryu S.
        • Ohtomo K.
        AdaptiveIterative dose reduction in coronary CT angiography using 320-row CT: assessment of radiation dose reduction and image quality.
        J Cardiovasc Comput Tomogr. 2012; 6: 318-324
        • Tatsugami F.
        • Matsuki M.
        • Nakai G.
        • Inada Y.
        • Kanazawa S.
        • Takeda Y.
        • et al.
        The effect of adaptive iterative dose reduction on image quality in 320-detector row CT coronary angiography.
        Br J Radiol. 2012; 85: e378-82
        • Renker M.
        • Geyer L.L.
        • Krazinski A.W.
        • Silverman J.R.
        • Ebersberger U.
        • Schoepf U.J.
        Iterative image reconstruction: a realistic dose-saving method in cardiac CT imaging?.
        Expert Rev Cardiovasc Ther. 2013; 11: 403-409
        • Habets J.
        • Symersky P.
        • Leiner T.
        • de Mol B.A.
        • Mali W.P.
        • Budde R.P.
        Artifact reduction strategies for prosthetic heart valve CT imaging.
        Int J Cardiovasc Imaging. 2012; 28: 2099-2108
        • Cho Y.J.
        • Schoepf U.J.
        • Silverman J.R.
        • Krazinski A.W.
        • Canstein C.
        • Deak Z.
        • et al.
        Iterative image reconstruction techniques: cardiothoracic computed tomography applications.
        J Thorac Imaging. 2014; 29: 198-208
        • Odedra D.
        • Blobel J.
        • Alhumayyd S.
        • Durand M.
        • Jimenez-Juan L.
        • Paul N.
        Image noise-based dose adaptation in dynamic volume CT of the heart: dose and image quality optimisation in comparison with BMI-based dose adaptation.
        Eur Radiol. 2014; 24: 86-94
        • Blobel J.
        • Mews J.
        • Schuijf J.D.
        • Overlaet W.
        Determining the radiation dose reduction potential for coronary calcium scanning with computed tomography: an anthropomorphic phantom study comparing filtered backprojection and the adaptive iterative dose reduction algorithm for image reconstruction.
        Invest Radiol. 2013; 48: 857-862
        • Austen W.G.
        • Edwards J.E.
        • Frye R.L.
        • Gensini G.G.
        • Gott V.L.
        • Griffith L.S.
        • et al.
        A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association.
        Circulation. 1975; 51: 5-40
        • Hussein A.A.
        • Abutaleb A.
        • Jeudy J.
        • Phelan T.
        • Patel R.
        • Shkullaku M.
        • et al.
        Safety of computed tomography in patients with cardiac rhythm management devices: assessment of the U.S. Food and Drug Administration advisory in clinical practice.
        J Am Coll Cardiol. 2014; 63: 1769-1775
        • Pang B.J.
        • Joshi S.B.
        • Lui E.H.
        • Tacey M.A.
        • Alison J.
        • Seneviratne S.K.
        • et al.
        Proximity of pacemaker and implantable cardioverter-defibrillator leads to coronary arteries as assessed by cardiac computed tomography.
        Pacing Clin Electrophysiol. 2014; 37: 717-723
        • Pang B.J.
        • Lui E.H.
        • Joshi S.B.
        • Tacey M.A.
        • Alison J.
        • Seneviratne S.K.
        • et al.
        Pacing and implantable cardioverter defibrillator lead perforation as assessed by multiplanar reformatted ECG-gated cardiac computed tomography and clinical correlates.
        Pacing Clin Electrophysiol. 2014; 37: 537-545
        • Sommer A.
        • Kronborg M.B.
        • Norgaard B.L.
        • Gerdes C.
        • Mortensen P.T.
        • Nielsen J.C.
        Left and right ventricular lead positions are imprecisely determined by fluoroscopy in cardiac resynchronization therapy: a comparison with cardiac computed tomography.
        Europace. 2014; 16: 1334-1341
        • DiFilippo F.P.
        • Brunken R.C.
        Do implanted pacemaker leads and ICD leads cause metal-related artifact in cardiac PET/CT?.
        J Nucl Med. 2005; 46: 436-443
        • Jost S.
        • Deckers J.
        • Rafflenbeul W.
        • Reiber J.H.
        • Nikutta P.
        • Wiese B.
        • et al.
        Quantitative angiographic follow-up studies on the development of coronary artery disease: which coronary segments should be analyzed? Experience from INTACT.
        Int J Card Imaging. 1993; 9: 29-37
        • Meyer L.T.
        • Boll D.T.
        Novel technique for addressing streak artifact in gated dual-source MDCT angiography utilizing ECG-editing.
        Eur Radiol. 2008; 18: 2446-2448
        • Sucha D.
        • Willemink M.J.
        • de Jong P.A.
        • Schilham A.M.
        • Leiner T.
        • Symersky P.
        • et al.
        The impact of a new model-based iterative reconstruction algorithm on prosthetic heart valve related artifacts at reduced radiation dose MDCT.
        Int J Cardiovasc Imaging. 2014; 30: 785-793
        • Tatsugami F.
        • Higaki T.
        • Sakane H.
        • Fukumoto W.
        • Iida M.
        • Baba Y.
        • et al.
        Coronary CT angiography in patients with implanted cardiac devices: initial experience with the metal artefact reduction technique.
        Br J Radiol. 2016; 8920160493
        • Takayanagi T.
        • Arai T.
        • Amanuma M.
        • Sano T.
        • Ichiba M.
        • Ishizaka K.
        • et al.
        Pacemaker-induced metallic artifacts in coronary computed tomography angiography: clinical feasibility of single energy metal artifact reduction technique.
        Nihon Hoshasen Gijutsu Gakkai zasshi. 2017; 73: 460-466
        • Mlynarski R.
        • Sosnowski M.
        • Mlynarska A.
        • Tendera M.
        Computed tomography in patients with cardiac pacemakers: difficulties and solutions.
        Heart Vessels. 2012; 27: 300-306