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Coronary CTA

Pt prep: Pt safety: RI, All, prg, claustrophobia, Contraindications: GFR 60 safe, 30-60 moderate risk, < 30 high risk, contraindicated GFR 30-60: - use non-ionic contrast, - IV hydration before and after, - acetylcysteine, - hemodialysis Claustrophobia: diazepam 5-10 mg PO Study quality: Motion: - breath hold (7-12 sec at 64 slice), arrhytmia - gating: A fib or frequent PVCs The Ideal pt: - HR < 65, NSR - Calm - Tin - Large veins - Pearl diver - ab;e to followcommands Prep: - No caffeine x 24 h - No Viagra x 48 h - No energy supplements x 24h - No food x 4h; contrast wil lmake you nauseus - No liquid x 1h - Cardica meds should not be suspended Prior non-anaphylactic reaction - 50mg prednisone at 13, 7, 1 h before exam - oral Benadryl 1 h prior exam IV access 18-20 gauge needle into RIGHT arm (shorter brachiocephalic and thus artifacts) 1h prior exam goal: HR < 65 pbm - Metoprolol PO 50-100mg, wait 90 min - Metoprolol IV 5mg, wait 20 min, additional 5mg x 2 KI: asthma, CHF, heart block, Aortic valve disease; consider verapamil Ca++ score: - center heart in scanner - from the carina to Costephrenic agles - Agatston score, volume, mass score - score 0: CAD unlikely - 400-1000 high risk of stenosis; 0 < Agatson score < 400-1000 Gating: - Retrospective no modulation: no change in mA; a lot of room for error; A fib - Retrospective w/ modulation: modulating mA, 500 mA during diastole, 100mA during systole; calculate function; HR > 70; dose goes up as HR drop - Prospective Triggered: by QRS, every other beat; reduce dose but most common to go wrong; dose stay the same regardless of HR - BMI < 28 kg/m2 - Weight < 85 kg - Ca++ score < 300 Agatston Change 120Kv to 100 kVp, dose saving up to 50% Post processive Filtered back projection Iterative Reconstruction ASIR, VEO Coronary attenuation: 300-350 HU Aorta: 250-300 80ml 6 ml/s: highest flow possible delay 5 sec phase 1: 80ml of contrast at 5-6ml/s: CA phase 2: 40ml of mix 1t 5-6ml/s: right heart phase 3: 50ml of saline 5-6ml/s: Nitroglycerin KI: - head truma/bleed - BP < 100 - Allergy - Viagra Adverse: HA NTG dilate CA approx by 1mm Recon Main recon: thin section 0.625 mm axial, 50% overlap cardiac kernel; FOV < 32 cm Phases: diastolic phase 65%; diastolic/systolic (65%, 35%) 512 x 0.625 = 32 cm FOV 512 x 0.4 = 20 cm FOV General interpretation - axial - vertical long axis - short axis - 4 chamber -- LV outflow tract -- aortic valve - right vertical long axis - aortic valve - RV outflow tract - Pulmonary valve --------------------------------- Cases: 1. Anomlaous pulmonary return: sinus venosus defect 2. Transposition of great vessels D/L: D as a death, L everything is perfectly switched 3. Pericardial fluid density mass denting on R atrium: loculated pericardial effusion 4. Cor triatriatum: bizzare shape of L atrium w/ septum in the middle of atrium 5. Cymetar sy, partial anomalous pulmonary vein return 6. Tricuspid regurgitation: Hetergoneous attenuation of the liver,ascites, IVC double the diameer of aorta, splenic varices, huge R atrium, enlarged ut not hypertrophic ventricle