A one-stop solution for cardiac patients using detector-based spectral CT

The need for imaging that’s first-time-right has never been greater, given the increased demand, pressure on staff and cost challenges that imaging organizations are facing today. What’s the real value of acquiring spectral results within a single exposure, for any clinical procedure, and without special scan modes? Dr. Vañó Galván gives his perspective on care for cardiac patients and others, detector-based spectral workflow, speed to diagnosis and increase in referrals made possible by the always-on capability of detector-based spectral scanning with Spectral CT 7500.

The challenge is confidently managing patient volume and resources in a high-pressure environment while conducting comprehensive and efficient cardiac and oncology assessments. The solution is Philips Spectral CT 7500, which supports a one-stop approach to cardiac assessment, providing comprehensive cardiac evaluations in under 15 minutes, including perfusion and delayed enhancement studies, all without increased radiation dose.

Dr. Vañó Galván has found that better visualization of stents, highly calcified vessels and the coronaries leads to more accurate assessment of coronary artery disease. With regard to cardiac scanning, Dr. Vañó Galván says, “I think that the benefit is that you can say confidently if the myocardium is viable or not, if the cardiologist has to revascularize that diseased vessel or not. That saves a lot of time. You don’t have to wait for cardiac MR, so you can go directly to making decisions about the management and revascularize or starting the optimal medical therapy for that patient. Having that information is really important for ischemic patients, but also for ruling out non-ischemic causes of heart or chest pain. For example, myocarditis or any other cause of delayed enhancement that you may find. It’s really useful for diagnosing that patient earlier. Otherwise, you have to wait for an MR and the availability for MR is not as good as for CT. So, it’s really game-changing and a one-stop solution for all of these cardiology patients.”

A delayed enhancement study demonstrates the value of spectral detector CT as a one-stop-shop. The patient had severe tandem lesions in the LAD and the first diagonal branch. The iodine density delayed enhancement spectral CT images acquired seven minutes after the last contrast injection revealed an almost transmural enhancement of the anterolateral wall of the left ventricle (non-viable myocardium). The spectral CT extracellular volume (ECV) map in the same plane indicated a clearly increased extracellular volume of 33.5% in the infarcted myocardium. The cardiac MRI delayed enhancement images in short-axis (superior) and long-axis (inferior) views, confirmed the previous findings.

When it comes to acquisition, Dr. Vañó Galván believes results are more important than number of heartbeats in the acquisition. “With this scanner, you are able to acquire results from difficult patients: those with atrial fibrillation or irregular heartbeat. You can really have all the information that you need without acquiring it in a single heartbeat. With proper beta blocking, we are acquiring more than 99% of the patients without any problem. So, in the balance, it’s worth it for me having all the spectral information in the evaluation of the coronary arteries, muscle of the myocardium and of complicated cases such as high calcification or with stents.”

“In the end, when you’re reporting a study at your workstation, it doesn’t matter whether the data was acquired in a single heartbeat or a few. What truly matters is having all the right information for confident diagnosis. That’s where spectral CT is a game-changer as it allows you to provide critical insights that enhance patient management and support clinicians in making informed decisions. I believe spectral information is far more important than just the speed of acquisition, which only takes a heartbeat. Obtaining high-quality spectral images is straightforward and you can consistently get excellent quality images across a wide range of patients. The most important thing is that you have all the right information available, allowing you to provide fast, confident diagnosis.”

“When we schedule the patient, it’s 15 minutes, even taking into account that in many patients, we are acquiring delayed enhancement. So, we have to wait at least five or six minutes before the second scan. Even with that inclusion of delayed enhancement in 15-minute slots, we can manage our cardiac CCTAs without any problem,” he says.

“That’s the best proof that for radiographers, it’s an optimal workflow. Probably in that specific patient in which we have to acquire delayed enhancement, that in all these past months we are obtaining even more patients due to the clinical value of the tissue characterization. But maybe we delay a little bit, maybe three minutes for that specific patient slot. But for the next patient, we can recover that time because in a normal and efficient workflow, we are using less than 15 minutes for coronary CTA. It’s really fast and convenient. In the end, this efficiency is important, given the increasing number of these types of examinations.”

Dr. Vañó Galván has seen the beneficial effect on the patient care journey that detector-based spectral CT brings, helping clinicians to identify patients who can avoid catheterization procedures.

“We are the gatekeeper. Right now, we are almost the first diagnostic test for chronic chest pain, and we are categorizing and stratifying the risk of the patient. If we say that a patient even with a high-risk clinical profile has a normal or almost normal non-obstructive coronary artery disease, they are not going to a cath lab,” he says.

“Probably some years ago, or using conventional CT, that profile of patients would have gone to the cath lab. And right now, we can stratify the risk. And to the contrary, when we have difficult cases with highly calcified vessels, we are improving our diagnostic confidence and the degree of stenosis. So, we can also avoid some cath labs for moderate-lesion patients when we are confident about that.”

Dr. Vañó Galván further highlights what the clinic’s use of Spectral CT 7500 has been able to do for his colleagues, referring physicians and, ultimately, patients.

The certainty, simplicity and reliability of detector-based spectral CT is increasing diagnostic confidence, easing workflow, adding value and advancing patient care not only for cardiac patients, but also across radiology and oncology.

With regard to workflow, he says, “I think the key word is ‘usability’. With this scanner and proper integration in your network and your PACS, you don’t really lose any time. It’s even to the contrary: you report faster because you are more confident. You can review only low MonoE, for example, in an oncologic study, and you get more conspicuity for detecting new lesions or even being confident about the diagnosis of those lesions.”

Convenient spectral workflow with spectral capability that is always on, means there is no need to decide on a spectral study upfront for a patient. “The most important thing about workflow is that you can manage your own images, your own reconstructions from your PACS workstation,” he says.

“You don’t have go to another physical workstation. So, everything really works and is integrated. You right-click in your PACS system, and you have all your spectral images available. And that’s the key for using it. It’s not useful to have another type of equipment where you have to call your technician: ‘Please make me this special reconstruction’ so that the technician wastes time, and the radiologists are also waiting for that reconstruction, so they cannot sign the final report. But with this scanner, taking into account that you know your technology, you don’t lose any time working with your spectral images and you don’t interrupt the workflow of the technician while they keep acquiring new studies without any problem. So, I think all those factors are perfect for keeping high productivity in the service.”

Dr. Vañó Galván explains a crucial distinction of detector-based spectral CT. “For technicians and for the workflow, it’s really convenient. They have always the same acquisition, so it’s absolutely similar to a conventional scanner, as all the spectral information is always available because of the dual-layer detector. They don’t have to choose if they want a spectral study on and off, or decide for a specific patient. Spectral is always on, always available for spectral information. And that’s the key to improving the workflow and increasing your workload. So, the daily routine, it doesn’t change. You can simplify protocols,” he says. “You can avoid reinjecting some patients because of the contrast enhancement or for extravasation. If the study is suboptimal, they know that we will probably be able to rescue that study and to have enough quality in the low MonoE results.”

Dr. Vañó Galván believes that referring physicians intuitively grasp the benefits of spectral that are available with every scan. “When we have the opportunity to explain to our referring physicians about the technology, to show the images and compare conventional with the spectral images and show the additional results that spectral provides, they really understand it in the first second of the explanation,” he says. “And, for example, in our clinical sessions here in the hospital, all the referring physicians, they already know about low MonoE. They already know about iodine density, about differentiating, about assessing the liver and a solid lesion.”

“They really want spectral CT for their patients because they know the advantages. They even know the specific advantages for some indications. For example, for cardiac imaging, they know about the possibility of characterizing myocardial tissue. They know in the small liver lesion, or even oncologic patients in general, about the better detection of lesions. For example, the oncologists know about the hypervascular tumors. So that is extremely important to acquire those patients in a detector-based spectral CT.”

“I think that referring physicians, they really understand, and they know how this scanner has changed our diagnostic confidence and precision. And they are really increasing all the referrals; I estimate referrals have increased at least 10% compared to offering only conventional CT. In the ideal world in which we can scan all the patients with spectral, I think a lot of protocols will change.”

Using spectral results enhances patient management. Dr. Vañó Galván says, “It’s really easy and confident. You can say ‘that’s a benign adrenal nodule, or it’s not benign’, so maybe a metastasis or another kind of adrenal nodule that you can confidently say if that patient does not need any additional MR.”

“With liver lesions in oncologic patients, with adrenal nodules that you cannot say if they are cystic or solid nodules, that changes absolutely the management of the patients. And the same for cardiac viability. You are scanning a patient in a coronary CTA, and you see severe lesions in three vessels. So, the next question for the cardiologist is ‘what are we doing with this patient?’ How can we manage this patient? So, the decision is to revascularize or not. Having the information, if you have viable myocardium, it’s absolutely key for that patient. You are anticipating. You are maybe saving the patient several weeks for the final decision. That’s really important and convenient for the patients.”

“Myocardial viability is the same as myocardial rest, the static perfusion. Until now, it was almost impossible to evaluate with CT. The same for small liver lesions, maybe an 8-millimeter liver lesion that is frequent--it’s common to find incidentally in any oncologic patient. Until now, we could not say confidently if that’s a solid or cystic lesion. And with Spectral CT, you are confident about that. So, this is really game-changing. You are changing the information that you can give to the patient. And at the end, it’s a faster diagnosis and better management for patients.”

You can avoid a lot of true non-contrast studies or even avoid some arterial phase studies for a venous delayed phase. For example, in a digestive hemorrhage patient, in younger patients, you can go for a delayed phase and you will see more conspicuously the hemorrhage and you still can delineate the vessels. So that’s a good example of avoiding internal contrast. But the security also goes for the dose of the contrast iodine media. Because you may use 30% less contrast as you would from conventional CT that you now acquire with Spectral CT 7500,” he says.

“And also, not only less volume of contrast for more security for the kidney of the patients, but also less flow. So, you can avoid extravasation of the contrast. You can use catheters with a smaller diameter, and they are easy to manage by the technicians or the nurses. It’s easy to get the IV line in. It’s because you are injecting less flow with a better catheter, and you are avoiding repetitions as well because of the extravasation, because you can’t rescue some studies. So, I think for the patient, it’s an important concept that they will have not only a better diagnosis, but also much more security at the moment of the acquisition.”

Beyond providing a one-stop solution for the evaluation of cardiac patients, Dr. Vañó Galván says, “I think it’s powerful equipment in which the workflow is really efficient. And you can scan from pediatric to bariatric patients in a single CT scanner. It’s really efficient because the technician does not have to decide which mode of acquisition to use. It’s always the same. Spectral is always on for radiologists. When you always scan in the detector-based spectral CT, you will have all the information available.”