 Hello friends. You are welcome in this very special webinars. The title of the webinar is Non-Invasion, Imaging of Coronary RT Disease. Topic to be discussed and highlighted by. Doctor Colonel ML Vera who is a consultant and head of the Department of Radiology in Manipal Hospital, Dwarka, New Delhi. Doctor Vera is eminent. Personality in the field of CT imaging of coronary artery. He's going to talk about what is the current perspective of CT in evaluation of coronary RT disease and he will also highlight what is going to come in this area. This is ever advancing field and we cardiac surgeon are getting benefit out of this technology. Now we are just waiting. Can we intervene? On the basis of information given by the city. To carry out coronary artery bypass surgery that. Area is still not in horizon. I'm sure in coming future we are going to have advanced technology where we could be able to operate on the basis of CT findings. So we cannot do the coronary artery bypass surgery on the CT finding, but we are able to do a lot of other procedures based on CT evaluation, particularly the valve surgery. Early days we used to ask for innovative coronary artery. Evaluation and now. Because of advancement in the city. We could able to get the information and we can operate well. Patients who are 40 years or above where there is a possibility of coronary artery disease. So only based on. City findings. There are so many other. Diseases where we need preoperative. Coronary evaluation and their CT comes very handy to us. This is a procedure which is non invasive can be done on OPD basis. And patient is comfortable. There is no prick. Just IV die, which I am sure that where I is going to take us all the way. So let me thanks Doctor Vera for and highlighting us. Non invasive imaging in coronary artery disease Doctor Vera please. Thank you Doctor Michelle Sir for nice introduction. I'm delighted. Today. I'll be discussing about non invasive imaging in coronary artery disease, the current applications and the future prospects. The current decade. Has seen MRI and MDCT as valuable imaging tools for effective evaluation and monitoring of coronary artery disease. Both MRI and MDCT has shown their ability to examine various structural and functional aspects of heart with a level of details. Not just possible. Future prospects of MRI and CT is identifying and evaluating you audio vascular risk markers are in offering and needs to be. Now let's go to the MRI. Am I a non invasive non energy imaging tool or evaluation of heart and coronary arteries? Cardiac MRI is now considered cold standard or assessment of cardiac function and myocardial viability. Cardiac MRI is increasingly used to evaluate rest and stress possible and identifying my cardiac is an impact. But it is. Despite significant technology and advancement, suspecting imaging of my MRI has not really had to be. Let's see the MDCT. MDCT has wide available non-invasive imaging tool for evaluation of heart and coronary artery. It assists in assessing cardiovascular risk factor like calcine stores if you carry a radical tissue in your serious space. Provide unmatched morphological evaluation of heart and coronary arteries in excellent regional assessment and characterization. Health and effective treatment planning by assessing myocardial viability, non-veg measurement of functional flow result. Effective non-veg imaging being tool for cells discharge of the patient in a patient's needy that is to have to do a lot. Let's compare the various aspects for cardiac and cardiac CT. Morality-wide cardiac and coronary imaging where is the CT energy tool. Scanning time biodegradable number I takes so long. Time, where is scanning, is the sort of scanning I can get. CV, adiabasca, this transcription, very poor MRI score, so calcine score, heat and acid concerns. Adiabasca is a form of CT, excellent. Values and coronary artery play characterization and assessment is a good number. Where is excellent in CT? Evaluation of grafts and stents is poor in MRI. Where is it excellent in CT? Evaluation of myocardial contract, cardiac function, myocardial perfidium, and viability is poor. Standart of a MRI concern that can be done in MRI. Non-veg functional flow result is not possible in MRI. It is ideal to convey to MBC the ideal knowledge we put. Triple rule out of a MRI concern for the people who love this kind of whole standard in emergency management. Let's see a point why to take various aspects of MRI in CT and compare it with numeral ionizing, CT ionizing to MRI and non-IMG, so for cardiovascular registration, CT is excellent. MRI is a possible structural assessment, cardiac functional integrity, it is possible in CT, but good MRI is excellent. Myocardial perfidium, viability is good. The MBC group had a good understanding of cardiac function. Obnary IP evaluation assessment is excellent. CT is not so good in MRI. Standart graph values CT is excellent. MRI is possible. Non-IMG, FFR, CT is a modality choice. Now, non-IMG, why is MRI not? So far, if you compare cardiac CT of outperformed cardiac MRIs. Now, let's see, I'll give you a detail about the clear changes of the emergency changes. Why it is so important? It is a non-IMG, widely available and safe procedure. A single data set provides much more information like cardiac operation assessment, like hormonal treatment, post-limation of the patient, and it would be safe to assess what are the various states. Excellent vascular antimia morphology and blood characterization is the same data set. Evaluation of cardiac morphology, cardiac function, like medical, or cardiac injection functions are possible with the same data set. Myocardial perfidium and CT, FFR are possible in the same data set. And triple rule out in emergency situations. These are all possible from the single data set in MDCT. Let's go for the cardiovascular risk assessment. MDCT helps in assessing cardiovascular risk factors associated with atherogenesis, like coronary calcine score, epicardial adipose tissue estimation, and adipose tissue stress. Calcine score is now considered as gold standard for evaluation of coronary calcine score, and why we would for cardiac risk assessment. Epicardial adipose tissue, some way a potential quantifiable risk marker for atherogenesis. And endothelial stress, a biomechanical risk factor responsible for atherogenesis. All three can be evaluated with the MDCT. Let's go over the calcine score. It is widely used best and calculated based on Augustine scoring protocol, plays a relevant role in the stratification of cardiovascular risk. Calcine score is significantly associated with major cardiovascular risk event. Let's note about the in-patient of diabetes malatas, the risks compared to general population are higher. In the same, say, 100 calcium score, if a normal population, his factor is 10% in the diabetes, it will be 15 or 20% higher than this. Augustine, how it is calculated? Reflect the total area of calcium deposits and density of calcium per voxel and calculated as cumulative unit. By calculating based on the summation of units of plaque density per voxel agenda, say, 130, 298, say, unit one, 200 to 298, unit three, 300 to 399, unit four, and above 400 homeskill, unit four. So summation of all in the entire calcium is calculated based on this and the total point is a total calcium score. Calcium, how the risk is done? Calcium score, say, 0 to 10, is minimal plaque load, very low risk. Here, the predicted chance of cardiovascular risk is when over 10 years is around 1 to 2%. Similarly, calcium score of 11 to 100 is mild plaque load, relatively low risk. Predicted chance of cardiovascular event over 10 years is around 2 to 6%. Score 101 to 400 moderate plaque load, intermediate risk factor. Predicted chance of cardiovascular event over 10 years is around 13 to 16%. Score over 401 to 999 high calcium load, plaque load, high risk factor. Predicted chance of cardiovascular event over 10 years is around 20 to 29%. Score over 1,000, very high plaque load, very high risk. Predicted chance of cardiovascular event over 10 years is around 37% and above. So this is the areas how to stratify the risk factors. This is how we calculate the calculation. On the left side, we can see how we can take the various calcium. And summation of this is the total calcium score. This is the zero, it is absolutely free. Here, you can see about 250 score. Here, the focal risk rate, let's say, and the current, here, the diffuse, about 1200 and above. Diffuse, dense calcification, the common artery. There is a or, that means one is a normal left man, LED, here the dense diffuse calcifications. Let's say the pericardial epicardial adipose tissue, the it. It is a visceral head and position between the visceral and parietal pericardium. It is biologically active organ and associated with the heterogenesis. Higher risk of cardiovascular events has been noted in individual having higher heat volume. Epicardial adipose tissue is a quantifiable risk marker in CAD. It forms about 20% of the heart mass and covers 80% of the heart surface. Optimal cutoff for epicardial fat thickness and pericardial fat thickness are 6.8 millimeter and 13.0 millimeter respectively. Similarly, percentage CAD has higher heat volume. It's 158.58% plus minus 558.9% compared to normal heat volume of 120.9% for plasma's 81 CC in normal percent. So pericardial fat plays a definite role in the heterogenesis. It can be accurately measured and quantified with the help of MDCT. Measuring epicardial fat thickness, where epicardial and pericardium is a simple way to assess it. Estimation of epicardial fat volume is a relatively complex procedure. It has a semi-automatic, automatic methods are there. We have to have a software to optimize the volume. This is the coronary CT scan. This is the epicardial fat between the visceral and parietal pericardium. This thickness, this is the epicardial fat and where the vessels are there passing through the interventricular serpent is the pericornary weight. So it can be measured, there's like a four millimeter, it is a 13 millimeter, these are within normal range. Now, this is another how you get the epicardial fat volume. You see the, you have to parietal, visceral, parietal, take it out, then you have to configure it by a software. That is how you get the total epicardial fat volume. Malata, endothelial sharing stress. Estimation of endothelial share stress with atherogenesis is oil established now. Low ESS predispose the development of atherogenic plaque and their subsequent progression. Share stress is difficult to measure directly in vivo. RM-ESS measurement is dependent on immunogenic procedures like catheter angiogram and IVAS followed by muscular mapping uses computational fluid dynamics. It provides accurate assessment of local ESS and helps in characterizing plaque. However, the immunogenic nature of that test limits is widespread use. Non-invasive measurement of ESS can be done by using computational fluid dynamics if an accurate description of the reserge geometry is available, 3D model of ESS. Advanced MDCT technology with volume data set provides excellent 3D image of coronary arteries. Several studies have shown that MDCT provides accurate 3D model of coronary arteries which can be used for CFB calculation and measurement of case. Now, these are the three-dimensional image of heart. This is a coronary artery in the left side. This is a mullicomidine zone. This is a wide view. This is one of the coronary artery internals. So, they give excellent data, 3D volume data for case measurements. This is the various data showing the end pascals up to a normal value of ESS 1.5 to 3. Beyond that is high and less than it is less. So, this is counted in the case of pascals. This is the left coronary artery, various data how it can be calculated and color map for the ESS measurement. Evaluation of coronary arteries. various ways like anomalous originators, like high-tech up, single coronary artery, anomalous origin of RCF from LN, LCX from RCN, LAD from LSE. This is various combinations are there. This is the anomalous left coronary artery from pulmonary artery. This is known as alcappa. Dominal measurement, play characterization and evaluation of stents and grafts is all possible with the same volume data set. Let's say this is one of the single coronary artery. This is the only from the X and this is coming out. This is coming in front of the RVOT and going and passing to the left side along the internal septum, LSEX. And posteriorly the PDI is just going behind the apex and coming up along the internal septum to form the distal LAD and diagonal branch. This is single coronary artery. This is a very interesting case of 48 years old moment had come with a dyspnea only. KF-NGO they tried they could not calculate the left coronary artery. So CT was done, but we can see the very, very, very prominent coronary artery. Right RCA is very large and arising left LNG, not visual eye. Next phase and you see LNG just coordinating from the pulmonary artery. So this is alcappa. Anomalous left coronary artery arising from the pulmonary artery. One of the very interesting case, young lady, a paramedicalist of, he would have breathlessness when he exerted more and he used a very high rate of blood, placed on a lot for long. But suddenly she asked for a CT and I did it. Now this is the findings. RCA is arising from the left men and it has a force between the aorta and the pulmonary artery between the two pressure chamber. So anytime any exertion, these artery get pressed up and see to get chest pain and displacement. This is also known as the malignant form of anomalous RCA. This is about the unmatched member. This is the normal. This is the detail of the coronary artery. This is the LAD. This is the ayurvedic, ayurvedic. This is the remasin terminal. This is LCH. Up to margin of Z. RCA, this is a much detail of the morphology. Here about the graph. This is SVG2OM. This is the lima to the LAD. The graph details are excellent with the CT scan. Now this is the case, which has come with a stand for some chest pain CT scan was done. You can see a long stand in the RCA. You can see it, but in the proximal part of the stand, there is a thin woman surrounded by high potential around the stand. You can see very well visualized. This is nothing but in-depth real hyperplasticity. This is the luminal assessment. How do we assess the lumines of the visors? The excellent luminal assessment. And you can see the plaques, various eccentric plaques, there are calcification types of calcification, luminal assessment, the percentage of narrowing everything can be measured with the multi-city, multiple MDCT. And by electroclerization, whether it's a vulnerable plaque or not, various characters, finding such a vulnerable plaque, like it has got a necrotic central fetico, or if it's a napkin ring sign, or it has got a surrounding, inflammatory changes, inflammatory plaque. All these are considered as a vulnerable plaque can be done with the CT scan. This is a normal CT scan of the coronary artery, RCA possibility. This is of the day-on-specification, very difficult to assess the lumines. This is the various plaques with luminal irregularity, very gluminal narrowing. These are the plaques of the different. This is the plaque. This is the eccentric plaques. This is a reactive pressure. This is a possible vulnerable plaques. That is how we can characterize the plaque and load in the entire coronary arteries. This is a very, very interesting case, where a young man has come with a repeated low-grade chest pain, chest pain, and ultimately when they ask for the CT scan, coronary injury, or we have done the coronary injury, you see that. The amount of DG, this LED proximal LED, there is narrowing, there is a proximal LCS narrowing, there is a RCA narrowing, all together there is a narrowing multiple, all three major vessels are involved. This is the global view, we can see this is the LN, this is the LED proximal, this is the LCS involved, this is the RCA involved, this is the RCA involved, and this person, since the other triple vessel DG, went for the bypass surgery. This is how CTA and IVAS, how we can characterize the plaque. This can be color coded, based on the density. So calcium, patechore, and fibrous plaque, everything you can see. This is the same percent, this is not from my, this is from the literature. This is a CT NGO, and this is the IVAS, and character in the plaque, almost similar to that both the cases, so it is as good as IVAS. So far, characterization of plaque is concerned. Mycaryl functions, yes, mycaryl functions, various functions like mycaryl contractility, early systolic ventricular volume, early diastolic ventricular volume, ventricular rejection fractions, ventricular cardiac outflow, left revolve muscle mass, early filling volume, everything is possible with the CT scan. So this is one of the, how we can see the mycaryl contractility. You can see the mycaryl contractility, how we can see the measurement of the various volumetric stroke volume, your ejection fractions, your left ventricular, right ventricular, everything muscle mass, everything can be done, it come in a graphic, whether one's route do it properly. Mycaryl perfusion and CTF are, whether stenotic vessels, married treatment or not, has been left to nuclear perfusion imaging or MRA performance study, to assess the mycaryl validity or invasive catheter angiogram best FFR measurement. This is the present status where we decide whether it is a what type of treatment. Recent studies on CT mycaryl perfusion and non-invasive CTFR have established their grounds in SSC mycaryl perfusion and FFR CT non-invasively for effective treatment planning in coronary artery disease. In the latest development, the 432 European multi-center trial they have carried out, the results are combination of CT angiogram and CT perfusion and similar diagnostic power to the combination of catheter angio and spec, MPI, mycaryl perfusion in identifying vascularized patients at 30 days, re-vascularized patients 30 days. CT angiogram and CT mycaryl perfusion imaging has robust diagnostic accuracy for identifying patients with flow-limiting coronary artery disease in need of mycaryl vascularization. So this is all possible with the non-invasive with cut coronary CT angiogram as it is done with the invasive in catheter angio. This is our image of the spec MPI and CT perfusion. This is a rest image. You see there is some of that in the stress, there is a perfusion defect, there is a perfusion defect, apart with respect. MPI, CT fractional flow reserve, CT FFR, defecto study. This is done on the hot flows, CT flow software. This is very well developed, there is only limited, there is worldwide effort but there is no commercial availability of software. Various multi-centric trial has been taken out and found quite useful and quite accurate. The results are nearly 20% improvement in the ability to identify flow restricting arterial blockage over the use of CT alone and more than a two-fold increase in test sensitivity from 37 to 82% in arterial blockage of intermediate severity with no losses specifically in diagnostic offerings. So this is a great achievement non-visibly where the CTs are up to this standard. This is the comparative study I have taken out from the journal. So this is a CT NGO CT FFR, this is the Invisib-Cath NGO FFR. So you see, this is already you can see 0.62, here it is 0.65, almost similar. Same here it is 0.87, it is 0.89. RCA. So almost FFR is equal as per the at par with the Invisib procedures. So this is excellent tool for FFR. Evaluation of chest pain in emergency department. Coronary CT NGO grant is gaining ground as a fast non-registered chest pain screening tool in hospital emergency room because it has got negative predictive value of 99 to 100%, the advantage of this. Coronary CT NGO grant is ideal in ED for quick screening of low and medium risk patients to allow coronary artery disease. CT screening of chest pain patients help cut down healthcare post and reduces hospitalizations. The various study reports are there. That is all. With a single data set, you can see the entire avatar. I have not taken the luminogram. You can see any, or erotic dissection in the DNA. You can see the entire pulmonary tree who have a pulmonary thrombosis or not. And you can evaluate the entire coronary artery system to see whether the CT is there. And fourth dimension is the hemoporosis. It's also common cause for chest pain. So all four things can be said from the same data set. So it's quite useful. And now being widely used in the emergency department. Various studies, you want a CT state trial study. This is a coronary computed tomography and geographic persistent trial of a good chest pain patient to treatment trial, sender by trial. The results are coronary CTF, there are two protocols have been compared, coronary CT angiogram based and respect MBI based protocol. So coronary CT angiogram based protocol patients were diagnosed 54% faster than respect MBI protocols, cause 38% lesser than the respect MBI based protocols. No difference major advanced cardiac events in each diagnosis strategy. Lower convoluted radiation in coronary CT angiogram compared to respect MBI protocol. So coronary CT angiogram based protocol is faster, more accurate and less costly than implying respect MBI based protocol in the evaluation of acute lower risk chest pain patients in the emergency department which is published long back. So to say coronary CT angiogram is a novel imaging technique in cardiac imaging which provides a number of vital information needed in day-to-day cardiological practice starting from diagnosis to therapeutic decision-making and risk stratification for future prevention of coronary artery disease. Coronary CT angiogram is gaining ground as a fast non-imaging chest pain screening code in hospital emergency room. Thank you, have a nice day. Any questions now? Thanks Dr. Vera, great presentation. You have taken us as a diagnostic tool to helping the pain management, which is the new advancement and researches are definitely dealing with pain management and how quickly you are going to give us help by deciding whether the patient has got a dissection of my rota, patient has got a coronary syndrome or patient has a, has got a pulmonary thrombus. These are the things which always we have to keep in mind and in a single shot in a CT room, we get an answer in a no time. So this was the new horizon where we have to venture out and we are already up to, but going through very judiciously and getting your help is going to take us surgeons in a different horizon. You have also talked about FFR, which is really important and usually we used to see the CT as a two dimensional, but now we are seeing the three dimensional, which is based on, there's the only limitation, this is based on individual evaluation. You know, so the competence of individual who is high, who is actually evaluating the CT findings is very, very important. Here we have got a superiority over conventional coronary angiography, which we see as a two dimensional and CT is going to help us with the three dimensional and of course, we should add on to the FFR, which is really, really a boom for us. And of course, even for, there are certain situations where the invasive cardiologist may not be able to answer some of the queries regarding the severity of lesion. Now, with this kind of invention and newer technology, which is going to be available, we cardiac surgeons are going to get the help. Thank you. With that, I would like to encourage the people to ask the question and Dr. Vera is available for that. Thanks, Dr. Vera. Thanks.