Current Role of Cardiac and Extra-Cardiac Pathologies in Clinically Indicated Cardiac Computed Tomography with Emphasis on Status Before Pulmonary Vein Isolation

Abstract

Purpose: The aim of this study was to assess the incidence of cardiac and significant extra-cardiac findings in clinical computed tomography of the heart in patients with atrial fibrillation before pulmonary vein isolation (PVI).

Materials and Methods: 224 patients (64 ± 10 years; male 63 %) with atrial fibrillation were examined by cardiac 64-slice multidetector CT before PVI. Extra-cardiac findings were classified as “significant” if they were recommended to additional diagnostics or therapy, and otherwise as “non-significant”. Additionally, cardiac findings were documented in detail.

Results: A total of 724 cardiac findings were identified in 203 patients (91 % of patients). Additionally, a total of 619 extra-cardiac findings were identified in 179 patients (80 % of patients). Among these extra-cardiac findings 196 (32 %) were “significant”, and 423 (68 %) were “non-significant”. In 2 patients (1 %) a previously unknown malignancy was detected (esophageal cancer and lung cancer, local stage, no metastasis). 203 additional imaging diagnostics followed to clarify the “significant” findings (124 additional CT, costs 38 314.69 US dollars). Overall, there were 3.2 cardiac and 2.8 extra-cardiac findings per patient. Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p <0.05).

Conclusion: Cardiac CT scans before PVI should be screened for extracardiac incidental findings that could have important clinical implications for each patient.

Key points:

• Cardiac and extra-cardiac findings are common in patients with an indication for pulmonary vein isolation on previous CT scans.

• Malignancies can be detected in 1 % of all patients.

• 32 % of all extra-cardiac findings can be of significant relevance with consequences for patients.

• Altogether, there are 3.2 cardiac and 2.8 extra-cardiac findings in patients with indication for pulmonary vein isolation and CT.

• Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p <0.05).

Citation Format:

• Sohns JM, Menke J, Staab W et al. Current Role of Cardiac and Extra-Cardiac Pathologies in Clinically Indicated Cardiac Computed Tomography with Emphasis on Status Before Pulmonary Vein Isolation. Fortschr Röntgenstr 2014; 186: 860 – 867

Zusammenfassung

Ziele: In dieser Studie wurde bei Patienten mit Vorhofflimmern die Inzidenz von kardialen und signifikanten extra-kardialen Befunden im CT vor Pulmonalvenen-Isolation untersucht.

Material und Methoden: 224 Patienten (64 ± 10 Jahre; männlich 63 %) mit Vorhofflimmern wurden vor PVI mit einer kardialen 64-Zeilen CT untersucht. Extra-kardiale Befunde wurden als „signifikant“ bezeichnet, wenn zusätzliche Untersuchungen oder Therapien empfohlen wurden; andernfalls wurden sie als „nicht signifikant“ bezeichnet. Die kardialen Befunde wurden ebenfalls ausgewertet. Die Befunde waren dem analysierenden Kardiologen und Radiologen vor dem CT unbekannt. Zusätzlich wurden Kosten für anschließende Bildgebungen ausgewertet, die zur Verifikation von möglichen pathologischen Befunden erforderlich waren.

Ergebnisse: Insgesamt wurden 724 kardiale Befunde bei 203 Patienten detektiert (91 % der Patienten). Zusätzlich wurden 619 extra-kardiale Befunde in 179 Patienten gefunden (80 % der Patienten). Bei diesen extra-kardialen Befunden waren 196 (32 %) „signifikant“ und 423 (68 %) „nicht signifikant“. Bei 2 Patienten (1 %) zeigten sich maligne Befunde, die vorher nicht bekannt waren (Ösophaguskarzinom und Bronchialkarzinom). 203 weiterführende bildgebende Untersuchungen folgten den primär detektierten Befunden im ersten CT, um die signifikanten extra-kardialen Befunde zu verifizieren (124 zusätzliche CT, Kosten 38 314,69 US Dollar). Insgesamt kamen auf einen untersuchten Patienten 3,2 kardiale und 2,8 extra-kardiale Befunde. Extra-kardiale Befunde kamen signifikant häufiger vor bei Patienten über 60 Jahren, Rauchern und Patienten mit einem kardialen pathologischen Befund (p < 0,05).

Schlussfolgerungen: Kardiale CT Untersuchungen vor Pulmonalvenen-Isolation sollten auf extra-kardiale Nebenbefunde untersucht werden, da diese für die Patienten relevant sein können, wie beispielweise die Detektion von Malignomen.

Kernaussagen:

• Kardiale und extra-kardiale Befunde treten bei Patienten mit der Indikation zur Pulmonalvenen-Isolation relativ häufig auf.

• Bei 2 Patienten (1 %) zeigten sich maligne Befunde, die vorher nicht bekannt waren (Ösophaguskarzinom und Bronchialkarzinom ohne Metastasierung).

• Unter den extra-kardialen Befunden fanden sich 196 (32 %) die als „signifikant“ bezeichnet wurden und die teils für die Patienten klinisch relevant waren.

Key words

cardiac - CT angiography - angiography - thorax - mediastinum - cost-effectiveness

• References

• 1 Raff GL, Gallagher MJ, O’Neill WW et al. Diagnostic accuracy of noninvasive coronary angiography using 64-slice spiral computed tomography. J Am Coll Cardiol 2005; 46: 552-557
• 2 Kuettner A, Kopp AF, Schroeder S et al. Diagnostic accuracy of multidetector computed tomography coronary angiography in patients with angiographically proven coronary artery disease. J Am Coll Cardiol 2004; 43: 831-839
• 3 Lessick J, Mutlak D, Rispler S et al. Comparison of multidetector computed tomography versus echocardiography for assessing regional left ventricular function. Am J Cardiol 2005; 96: 1011-1015
• 4 Raman SV, Cook SC, McCarthy B et al. Usefulness of multidetector row computed tomography to quantify right ventricular size and function in adults with either tetralogy of Fallot or transposition of the great arteries. Am J Cardiol 2005; 95: 683-686
• 5 Wood MA, Wittkamp M, Henry D et al. A comparison of pulmonary vein ostial anatomy by computerized tomography, echocardiography, and venography in patients with atrial fibrillation having radiofrequency catheter ablation. Am J Cardiol 2004; 93: 49-53
• 6 Jongbloed MR, Dirksen MS, Bax JJ et al. Atrial fibrillation: Multi-detector row CT of pulmonary vein anatomy prior to radiofrequency catheter ablation–initial experience. Radiology 2005; 34: 702-709
• 7 Takakuwa KM, Halpern EJ. Evaluation of a "triple rule-out" coronary CT angiography protocol: Use of 64-section CT in low-to-moderate risk emergency department patients suspected of having acute coronary syndrome. Radiology 2008; 248: 438 (436)
• 8 Manghat NE, Morgan-Hughes GJ, Roobottom CA. Multi-detector row computed tomography: Imaging in acute aortic syndrome. Clin Radiol 2005; 60: 1256-1267
• 9 Schoepf UJ, Goldhaber SZ, Costello P. Spiral computed tomography for acute pulmonary embolism. Circulation 2004; 109: 2160-2167
• 10 Horton KM, Post WS, Blumenthal RS et al. Prevalence of significant noncardiac findings on electron-beam computed tomography coronary artery calcium screening examinations. Circulation 2002; 106: 532-534
• 11 Onuma Y, Tanabe K, Nakazawa G et al. Noncardiac findings in cardiac imaging with multidetector computed tomography. J Am Coll Cardiol 2006; 48: 402-406
• 12 Schietinger BJ, Bozlar U, Hagspiel KD et al. The prevalence of extra-cardiac findings by multidetector computed tomography before atrial fibrillation ablation. Am Heart J 2008; 155: 254-259
• 13 Hunold P, Schmermund A, Seibel RM et al. Prevalence and clinical significance of accidental findings in electronbeam tomographic scans for coronary artery calcification. Eur Heart J 2001; 22: 1748-1758
• 14 Schragin JG, Weissfeld JL, Edmundowicz D et al. Non-cardiac findings on coronary electron beam computed tomography scanning. J Thorac Imaging 2004; 19: 82-86
• 15 Martins RP, Muresan L, Sellal JM et al. Incidental extracradiac findings in cardiac computed tomography performed before radiofrequency ablation of atrial fibrillation. Pace 2011; 34: 1665-1670
• 16 GOÄ 2012. Hermanns PM, Filler G, Roscher B, (Hrsg) 6. Aufl. Berlin Heidelberg: Springer-Verlag; 2012.
• 17 Kistler PM, Rajappan K, Harris S et al. The impact on image integration on catheter ablation of atrial fibrillation using electroanatomic mapping: A prospective randomized study. Eur Heart J 2008; 29: 3029-3036
• 18 de Chillou C, Adronache M, Abdelaal A et al. Evaluation of 3D guided electroanatomic mapping for ablation of atrial fibrillation in reference to CT-Scan image integration. J Interv Card Electropysiol 2008; 23: 175-181
• 19 Martinek M, Nesser HJ, Aichinger J et al. Impact of integration of multislice computed tomography imaging into three-dimensional electroanatomic mapping on clinical outcome, safety, and efficacy using radiofrequency ablation for atrial fibrillation. Pacing Clin Electrophysiology 2007; 30: 1215-1223
• 20 Johnson KM, Dennis JM, Dowe DA. Extracardiac findings on coronary CT angiograms: Limited versus complete image review. Am J Roentgenol 2010; 195: 143-148
• 21 Northam M, Koonce J, Ravenel JG. Pulmonary nodules detected at cardiac CT: Comparison of images in limited and full fields of view. Am J Roentgenol 2008; 191: 878-881
• 22 Lee CI, Tsai EB, Sigal BM et al. Incidental extracardiac findings at coronary CT: Clinical and economic impact. Am J Roentgenol 2010; 194: 1531-1538
• 23 Orme NM, Fletcher JG, Siddiki HA et al. Incidental findings in imaging research. Evaluating incidence, benefit, and burden. Arch Intern Med 2010; 170: 1525-1532
• 24 Kawano Y, Tamura A, Goto Y et al. Incidental detection of cancers and other non-cardiac abnormailities on coronary multislice computed tomography. Am J Cardiol 2007; 99: 1608-1609
• 25 Kim TJ, Han DH, Jin KN et al. Lung cancer detected at cardiac CT: Prevalence, clinicoradiologic features, and importance of full–field-of-view images. Radiology 2010; 255: 369-376
• 26 Wissner E, Wellnitz CV, Srivathsan K et al. Value of multislice computed tomography angiography of the thorax in preparation for catheter ablation for the treatment of atrial fibrillation: The impact of unexpected cardiac and extracardiac findings on patient care. Eur J Radiol 2009; 72: 284-288
• 27 Quint LE, Watcharotone K, Myles JD et al. Incidental findings at chest CT: A needs assessment survey of radiologists’ knowledge. Acad Radiol 2011; 18: 1500-1506
• 28 Wann S, Nassef AL, Jeffrey J et al. Ethical considerations in CT angiography. Int J Cardiovasc Imaging 2007; 23: 379-388
• 29 Mark DB, Berman DS, Budoff MJ. American College of Cardiology Foundation Task Force on Expert Consensus Documents et al. ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010 expert consensus document on coronary computed tomographic angiography: A report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Catheter Cardiovasc Interv 2010; 76: E1-E42
• 30 Earls JP. The pros and cons of searching for extracardiac findings at cardiac CT: Studies should be reconstructed in the maximum field of view and adequately reviewed to detect pathologic findings. Radiology 2011; 261: 342-346
• 31 Fischbach R, Miller S, Beer M et al. Empfehlungen der Arbeitsgemeinschaft Herzdiagnostik der Deutschen Röntgengesellschaft für den Einsatz der Computertomographie und Magnetresonanztomographie in der Herzdiagnostik. Teil 1 – Computertomographie. Rofo 2009; 181: 700-706
• 32 Lang RM, Bierig M, Devereux RB et al. Recommendations for chamber quantification. Eur J Echocardiogr 2006; 7: 79-108
• 33 Jacobs PC, Mali WP, Grobbee DE et al. Prevalence of incidental findings in computed tomographic screening of the chest: a systematic review. J Comput Assist Tomogr 2008; 32: 214-221
• 34 Yorgun H, Kaya EB, Hazirolan T et al. Prevalence of incidental pulmonary findings and early follow-up results in patients undergoing dual-source 64-slice computed tomography coronary angiography. J Comput Assist Tomogr 2010; 34: 296-301