CCTA becoming an essential tool for interventional cardiologists
Coronary computed tomography angiography (CCTA) is redefining how patients with suspected coronary artery disease are evaluated and treated, helping care teams accurately assess chest pain patients with fractional flow reserve CT (FFR-CT). The technology is also seeing rapid adoption in interventional cardiology as a way to eliminate the need for diagnostic catheterizations and only bring patients to the cath lab who need percutaneous coronary intervention (PCI).
Cardiovascular Business spoke with Ziad Ali, MD, DPhil, director of the DeMatteis Cardiovascular Institute and director of investigational interventional cardiology at St. Francis Hospital and Heart Center, about these trends. His center uses advanced photon-counting CT scanners and Heartflow’s artificial intelligence (AI)-enabled plaque assessment and FFR-CT software on a regular basis.
“Heartflow has made some major technological iterations over the last few years and made it a lot more user-friendly,” Ali said.
Originally developed as a noninvasive way to determine ischemia using FFR-CT, he said the company's technology has evolved to provide broader plaque morphology assessment and, more recently, to help guide PCI planning. The company’s newer Navigator CT-guided PCI tool uses AI to assess lesion morphology, determine appropriate stent length and diameter and complete procedural planning before the patient enters the cath lab.
"It really allows all of the PCI planning to be done upfront before you even walk into the cath lab,” Ali explained.
This approach may also address persistent gaps in the use of intravascular imaging. While adoption of optical coherence tomography (OCT) and intravascular ultrasound (IVUS) has increased significantly over the past decade, utilization remains far from universal, even with its inclusion in modern guidelines. He noted that the cost of intravascular imaging and FFR catheters remains a barrier, and CT offers a more accessible alternative.
“CT is a very cheap, highly effective anatomical assessment of coronary disease," Ali said.
He believes CT can help “democratize” access to algorithmic PCI planning strategies worldwide. In addition, FFR-CT strengthens CCTA’s role as a gatekeeper.
“It's hard to bring a patient to the cath lab without an assessment of ischemia,” Ali said. “FFR-CT allows you to do that upfront.”
While nuclear imaging, which provides only physiologic data, has long been that gatekeeper, he said CT delivers both anatomy and physiology in a single test.
Ali’s hospital has a very low threshold for using CCTA with FFR-CT, particularly in intermediate-risk patients whose symptoms might be managed medically.
Photon-counting CT enhances coronary imaging
The addition of photon-counting CT has further refined CCTA with even clearer imaging of soft plaques and the ability to see through stents and classified lesions. St. Francis now has two of these scanners dedicated to cardiac imaging. The technology enables higher-resolution imaging by detecting individual photons rather than accumulating energy signals.
Ali's team recently published findings in JACC showing that photon-counting CT significantly reduced indeterminate cases sent to the cath lab.[1] Patients who did proceed to invasive angiography were far more likely to undergo PCI, reducing unnecessary procedures and resource use.
"I think the future of interventional cardiology is photon-counting CT along with CT-guided PCI,” Ali said.
For centers still relying on workflows established more than a decade ago and not using routine cardiac CT, Ali said they really should consider the benefits of moving to a CCTA workflow.
“CT-guided PCI provides you anatomy and physiology," he explained. "It's a readily available tool you can get all of the things that you need to do with intravascular imaging, pre-PCI. It's just a question of using the right software and tools to help you become familiar with it. Once you learn it, it becomes the standard of care.”
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]