Cardiac and Pulmonary Imaging

Gautham P. Reddy, MD, MPH, Chief
Brett M. Elicker, MD
Charles B. Higgins, MD
Theodore J. Lee, MD
Alison K. Meadows, MD, PhD
Karen G. Ordovas, MD
W. Richard Webb, MD

The Cardiac and Pulmonary Imaging Section emphasizes the comprehensive evaluation of both the respiratory and cardiovascular systems using appropriate imaging modalities. Imaging studies supervised, performed, and interpreted include:

• chest radiographs in adults
• chest CT and high-resolution lung CT in adults
• cardiac CT and coronary CT angiography in adults and children
• cardiac MRI in adults and children
• thoracic MR angiography in adults and children
• MRI of the brachial plexus, thyroid, and parathyroid
• thoracic biopsies

The Cardiac and Pulmonary Imaging Section is responsible for studies performed at UCSF Medical Center, UCSF Children’s Hospital, Mt. Zion Medical Center at UCSF, and China Basin Landing. The section also manages and interprets most of the cardiothoracic imaging studies at the San Francisco VA Medical Center and San Francisco General Hospital.

Contact information:
Scheduling: (415) 353-2573
Office telephone: (415) 476-1397
Section chief’s telephone: (415) 476-3849
Fax: (415) 476-0616
Section chief’s email: gautham.reddy@radiology.ucsf.edu

Coronary CT Angiography Program
The Coronary CT Angiography Program is a collaborative effort run jointly by the Cardiac and Pulmonary Imaging Section and the Division of Cardiology.

Coronary CT angiography is a new and advanced non-invasive test performed on a 64-detector CT scanner; it is also known as the 64-slice CT scan. In about five seconds, the test provides direct visualization of the arteries and heart, allowing for highly accurate detection of early coronary artery disease (CAD) and the assessment of coronary artery obstruction. Recent studies have shown high accuracy of CT angiography for detection of coronary stenosis or occlusion, with a negative predictive value of 93-100 percent (aggregate of 97 percent).

Compared to a traditional CT scan, the 64-slice scan can acquire clear images of the heart and its blood vessels in multiple slices in rapid sequence without the blurring effects of cardiac motion. Using advanced technology, the information is reconstructed into 3-D views of the heart and its blood vessels, revealing not only narrowed areas of the blood vessels, but also early disease in the vessel walls that may not be narrowed. During the test, patients receive an IV injection of a contrast agent (“dye”). They are asked to hold their breath for five seconds during the scan. The entire procedure takes about an hour, including premedication with a beta blocker (usually IV metoprolol) and sublingual nitroglycerine, unless contraindicated. The test is only available at select leading Heart and Vascular Centers in the U.S.

Patients with suspected CAD typically undergo an exercise stress test, stress perfusion scintigraphy, or stress echocardiography, but these exams do not provide a direct look at the coronary arteries. Definitive diagnosis is based on catheter-based X-ray angiography, but this study is invasive and relatively expensive, and approximately 40 percent of diagnostic angiograms are normal.

CT angiography can eliminate the need for a catheter-based X-ray angiography in a substantial proportion of patients, particularly those who are at low to moderate risk for CAD. Indications include a history of atypical chest pain or a history of chest pain without EKG changes or elevated serum levels of cardiac enzymes. Other indications include evaluation of coronary bypass grafts, assessment of coronary anomalies, and early detection of coronary artery disease in the asymptomatic patient with multiple coronary risk factors, such as smoking, male gender, age over 40 years, elevated serum cholesterol, and family history of coronary disease.

CAD is the leading cause of morbidity and mortality in the United States and other industrialized countries.  Patients can present with chest pain, but sudden death is the initial presenting symptom in up to 50 percent of patients. By accurately and quickly detecting heart disease, CT angiography greatly reduces the risk of life-threatening problems related to CAD and means better treatment, a faster recovery time and increased comfort and convenience for patients at risk for CAD.

To schedule a patient, please call (415) 353-2573

Research Directions:

• CT angiographic assessment of coronary atherogenesis after heart transplantation
• Use of cardiac CT for pre-surgical clearance
• Evaluation of coronary atherosclerosis in patients with HIV infection
• CT assessment of the heart after stem cell therapy
• Quantitative assessment of function in congenital heart disease
• Characterization of myocardial ischemic injury by contrast-enhanced MRI
• Quantitative assessment of function in congenital heart disease
• Development of the concept of endovascular therapy using MRI guidance 
• High-resolution CT diagnosis of lung disease
• Clinical outcomes following negative CT for acute pulmonary embolism
• Predictors of poor outcome in patients with acute PE diagnosed by helical CT

Recent Publications:

Akhtar M, Ordovas K, Martin A, Higgins CB, Michaels AD. Effect of chronic sustained-release dipyridamole on myocardial blood flow and left ventricular function in patients with ischemic cardiomyopathy. Congest Heart Fail. 2007; 13:130-5.

Elicker BM, Cypel YS, Weinreb JC. IV contrast administration for CT: a survey of practices for the screening and prevention of contrast nephropathy. AJR Am J Roentgenol. 2006;186:1651-8.

Higgins CB. Promise of MR and CT in ischemic heart disease. J Magn Reson Imaging. 2007; 26:1-2.

Hom JJ, Ordovas KG, Reddy GP. Velocity-encoded cine phase-contrast MR imaging in aortic coarctation: functional assessment of hemodynamic compromise. Radiographics.

Hoxworth JM, Hanks DK, Araoz PA, Elicker BM, Reddy GP, Webb WR, Leung JW, Gotway MB. Lymphoepithelioma-like carcinoma of the lung: radiologic features of an uncommon primary pulmonary neoplasm. AJR Am J Roentgenol. 2006;186:1294-9.

Jacquier A, Higgins CB, Martin AJ, Do L, Saloner D, Saeed M. Injection of adeno-associated viral vector encoding vascular endothelial growth factor gene in infarcted swine myocardium: MR measurements of left ventricular function and strain. Radiology. 2007; 245:196-205. 

Jacquier A, Higgins CB, Saeed M. MR imaging in assessing cardiovascular interventions and myocardial injury. Contrast Media Mol Imaging. 2007; 2:1-15.

Jun SL, Chanani NK, Moore P, Higgins CB. Images in cardiovascular medicine. Magnetic resonance imaging of a posttraumatic myocardial infarction and ventricular septal defect with a closure device in place. Circulation. 2007; 115(2):e13-5.

Kim RJ, de Roos A, Fleck E, Higgins CB, Pohost GM, Prince M, Manning WJ; Society for Cardiovascular Magnetic Resonance (SCMR) Clinical Practice Committee. Guidelines for training in Cardiovascular Magnetic Resonance (CMR). J Cardiovasc Magn Reson. 2007; 9:3-4.

Kinder BW, Collard HR, Koth L, Daikh DI, Wolters PJ, Elicker B, Jones KD, King TE Jr.  Idiopathic nonspecific interstitial pneumonia: lung manifestation of undifferentiated connective tissue disease? Am J Respir Crit Care Med. 2007; 176:691-7.

Kline JA, Runyon MS, Webb WB, Jones AE, Mitchell AM. Prospective study of the diagnostic accuracy of the simplify D-dimer assay for pulmonary embolism in emergency department patients. Chest. 2006;129:1417-23.

Kramer CM, Neubauer S, Kraitchman D, Higgins CB, Fogel MA, Friedrich MG, Manning WJ.    Meeting highlights of the 9th annual scientific sessions of the society for cardiovascular magnetic resonance: Miami, Florida, January 20-22, 2006. J Am Coll Cardiol. 2006; 48:187-92.
           
Marcus GM, Yang Y, Varosy PD, Ordovas K, Tseng ZH, Badhwar N, Lee BK, Lee RJ, Scheinman MM, Olgin JE. Regional left atrial voltage in patients with atrial fibrillation. Heart Rhythm. 2007;4:138-44.

Ordovas KG, Tan C, Reddy GP, Weber OM, Lu Y, Higgins CB. Disparity between ratios of diameters and blood flows in central pulmonary arteries in postoperative congenital heart disease using MRI. J Magn Reson Imaging. 2007; 25:721-6.

Ordovas KG, Reddy GP, Higgins CB. MRI in non-ischemic acquired heart disease. J Magn Reson Imaging.

Paydar A,  Ordovas KG, Reddy GP. Magnetic resonance imaging for Loeffler endocarditis. Pediatr Cardiol.

Pujadas S, Reddy GP, Weber O, Tan C, Moore P, Higgins CB. Phase contrast MR imaging to measure changes in collateral blood flow after stenting of recurrent aortic coarctation: Initial experience. J Magn Reson Imaging. 2006; 24:72-76.

Reddy, GP. Multidetector CT of acute aortic syndrome. Imaging Decisions 2006; 10: 22-26.

Saeed M, Martin AJ, Lee RJ, Weber O, Revel D, Saloner D, Higgins CB. MR guidance of targeted injections into border and core of scarred myocardium in pigs. Radiology. 2006; 240:419-26.

Saeed M, Henk CB, Weber O, Martin A, Wilson M, Shunk K, Saloner D, Higgins CB. Delivery and assessment of endovascular stents to repair aortic coarctation using MR and X-ray imaging. J Magn Reson Imaging. 2006; 24:371-8.

Saeed M, Weber O, Lee R, Do L, Martin A, Saloner D, Ursell P, Robert P, Corot C, Higgins CB. Discrimination of myocardial acute and chronic (scar) infarctions on delayed contrast enhanced magnetic resonance imaging with intravascular magnetic resonance contrast media. J Am Coll Cardiol. 2006; 48:1961-8.

Saeed M, Saloner D, Martin A, Do L, Weber O, Ursell PC, Jacquier A, Lee R, Higgins CB.        Adeno-associated viral vector-encoding vascular endothelial growth factor gene: effect on cardiovascular MR perfusion and infarct resorption measurements in swine. Radiology. 2007; 243:451-60.

Stillman AE, Oudkerk M, Ackerman M, Becker CR, Buszman PE, de Feyter PJ, Hoffmann U, Keadey MT, Marano R, Lipton MJ, Raff GL, Reddy GP, Rees MR, Rubin GD, Schoepf UJ, Tarulli G, van Beek EJ, Wexler L, White CS. Use of multidetector computed tomography for the assessment of acute chest pain: a consensus statement of the North American Society of Cardiac Imaging and the European Society of Cardiac Radiology. Eur Radiol 2007; 17:2196-2207 and Int J Cardiovasc Imaging 2007; 23:415-427.

Webb WR. Thin-section CT of the secondary pulmonary lobule: anatomy and the image--the 2004 Fleischner lecture. Radiology. 2006; 239:322-38.

Weber OM, Higgins CB. MR evaluation of cardiovascular physiology in congenital heart disease: flow and function. J Cardiovasc Magn Reson. 2006; 8:607-17.
           
Woodard PK, Bluemke DA, Cascade PN, Finn JP, Stillman AE, Higgins CB, White RD, Yucel EK; American College of Radiology.        ACR practice guideline for the performance and interpretation of cardiac magnetic resonance imaging (MRI). J Am Coll Radiol. 2006; 3:665-76.

Yeh BM, Nobrega KT, Reddy GP, Qayyum A. Juvenile xanthogranuloma of the heart and liver: MRI, sonographic, and CT appearance. AJR Am J Roentgenol. 2007;189:W202-4.

Zamora AC, Collard HR, Wolters PJ, Webb WR, King TE. Neurofibromatosis-associated lung disease: a case series and literature review. Eur Respir J. 2007; 29:210-4.

Zamora AC, Wolters PJ, Collard HR, Connolly MK, Elicker BM, Webb WR, King TE Jr, Golden JA. Use of mycophenolate mofetil to treat scleroderma-associated interstitial lung disease. Respir Med. 2007 Sep 4; [Epub ahead of print]