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3. Cardiovascular Computed Tomography
     X-ray heart examination, just as electrocardiography, dates a century ago. Since the first attempts of cardiac examination until today examination technology has made important progress. Nowadays, computed tomography (CT) is one of the most advanced methods of X-ray diagnostic, which allows an advanced examination of the structure, vascularization and heart function.
     Generally, the difficulty of cardiac examination is determined by a number of factors such as structures’ constant motion due to contraction, heart motion due to the pulsating phenomenon and respiratory motion. To obtain qualitative and useful diagnostic image CT system must be equipped with a range of advanced technical innovations. These requirements can be reflected by the technical feature of Siemens Somatom Sensation system from the German Diagnostic Center. The scanner tube rotates at a speed of 0.28 ms, which means that, it will make three rotations per second. With 64 rows of detectors available we get 192 sections in a second. This allows us to scan completely the heart during 10 – 14 seconds, enough time for the patient to hold his breath and for us to get a set of 1200-5000 images, with a thickness of 0.6 mm. The explanation is simple and does not specify complex technologies that make the examination possible. In should be noted that CareDose 4D technology, together with ECG tube modulation, allows considerable decrease of the radiation dose. Thus, the radiation dose is often smaller than in the CT of the abdomen.
Figure 1 – Virtual reconstruction of the heart and coronary arteries.
     The main indication of heart CT is the evaluation of heart arteries, named coronary arteries, hence the name of the second CT-investigation – “Coronary angiography”. With age heart arteries are often affected by atherosclerotic plaques* (fat deposits on the wall). Atherosclerotic plaques gradually close the lumen, resulting in chest pain called “Angina”, which in 70% of cases can cause death of the heart muscle, called “heart attack”. Actual heart attack is the main cause of people’s death. It should be noted that in 50% of cases patients do not accuse pain and stenosis (artery narrowing) is not significant.

     CT coronary angiography allows detecting the atherosclerotic plaques, appreciating localization, number and degree of affection. This diagnosis method is recommended to patients having no diagnosis or atypical presentation. The patients with an unestablished diagnosis need Conventional Coronary Angiography – partially invasive method.
Figure 2 – Left anterior descending coronary artery (LAD) has multiple calcified and non-calcified atherosclerotic plaques.Figure 3 – Stent in the middle segment of the right coronary artery (RCA). Proximal segment of the stent has an occlusion (“closing”) of stent by thrombus.

     CT coronary angiography is also recommended to patients who have coronary stents or by-pass of the heart vessels. In this case it is the single method that allows appropriate evaluation of coronary circulation.

     Another rarer indication of coronary angiography is diagnosis of abnormalities of the coronary arteries development in young people with heart disorders.

     Cardiac CT is efficient in the diagnosis of pathologies of the heart muscle called “cardiomyopathy”, such as myocardial hypertrophy, cardiac enlargement and myocarditis. It is useful in the evaluation of valvular pathology, pathology of heart pericardium and tumors. It allows diagnosis of abnormalities of the heart development in children and adults, both pre-surgery and for postoperative dynamic control. Cardiac CT allows accurate diagnosis of listed pathologies and is recommended in case of contraindications for cardiac MRI.
Figures 4 and 5 - Virtual reconstruction of left ventricular in systole and diastole.
     Cardiac CT can be used as a screening method to predict the risk of heart attack. The evaluation is called “Ca scoring” and determines the deposition of calcium in coronary atherosclerosis plaques. The method does not determine the degree of damage to heart vessels. It is just a tool to forecast the risk of heart attack in patients who suffer from angina. It is recommended to patients with risk factors such as heritable coronary disease, diabetes mellitus, arterial hypertension, smoking and people with high cholesterol or dyslipidemia.

     Summarizing, Cardiac CT is recommended as follows:
1. Coronary angiography in patients with suspected ischemic cardiopathy or atypical clinical presentation;
2. Coronary angiography in patients with stents or by-pass of coronary arteries;
3. Coronary angiography at the suspicion of abnormal development of coronary arteries;
4. Cardiac CT in patients with inherent heart abnormalities for preoperation and postoperation evaluation if cardiac MRI is prohibited;
5. Cardiac CT in case of diseases of the heart muscle, pericardium, tumors and etc., if cardiac MRI is prohibited;
6. Ca scoring to assess the resistance to heart attack in patients with well-known risk factors.

     The procedure has a certain degree of complexity and is carried out by well-trained staff. The patient needs a primary consult of the radiologist, who identifies complaints and clinical status of the patient and determines the type of preparation required, which regularly takes 30-60 minutes. In some rare cases the patient can be rescheduled in 3-4 days as it requires special preparation. It would be very useful if at the investigation the patient hands out his ambulatory card, electrocardiogram and knows medicines that he takes.

On the right lower quadrant of the virtual reconstruction LAD coronary artery stent is visualized. On the standard cardiac plan heart attack of lateral inferior wall is visualized, presenting wall thinning and reducing motion, which also decreases global left ventricular contraction function.
 In the left upper quadrant the values of the global left ventricular contraction are visualized. Left ventricular volume changes in different phases of contraction are visualized in the lower right quadrant.
 The structure of the mitral valve and its function* (cusps opening and closing).
 The mitral valve and aortic valve and normal function of the left ventricular outflow tract.
 The structure of aortic valve and its function *(cusps opening and closing).

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