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Somatom sessions 24

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Somatom sessions 24

  1. 1. SOMATOM Sessions The Difference in Computed Tomography Cover Story SOMATOM Defi nition Flash: Impressive Performance Page 6 News Functional Imaging Widens the Clinical Spectrum for CT Page 12 Business Chest Pain: Clarity with CT Page 20 Clinical Results SOMATOM Defi nition Flash: The Entire Heart Scanned in Just 270 ms with 0.95 mSv Page 32 Science Iterative Image Reconstruction Moves into Clinical Practice Page 65 24 Stanford-Edition May 2009 24 SOMATOM Sessions Issue Number 24/May 2009 Stanford-Edition I May 19th – 22th, 2009
  2. 2. Editorial 2 “With developing the SOMATOM Definition Flash, our company has once again set a new standard for radiation dose reduction in CT.” Sami Atiya, PhD, Chief Executive Officer, Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany Cover Page: A thorax scan for triple-rule out with the SOMATOM Defi nition Flash is possible in less than one second. Courtesy of University of Erlangen-Nuremberg, Erlangen, Germany SOMATOM Sessions · May 2009 ·
  3. 3. Editorial André Hartung, Vice President Marketing and Sales Business Unit CT Siemens Healthcare Forchheim, Germany SOMATOM Sessions · May 2009 · 3 Dear Reader, In the broad spectrum of diagnostic methods and equipment available to the medical industry today, computed tomog-raphy has assumed more and more impor-tance. The number of exams worldwide is increasing, not only because CT offers extremely high diagnostic certainty but also because the acquisition method is simple and results are permanent and reproducible. And because of CT’s versa-tility (cardiology, oncology, trauma, etc.), it is rapidly becoming a standard exam-ination at medical facilities around the globe – therefore it contributes to a sig-nificant amount of overall radiation expo-sure in the entire population. Other sources are natural background radiation (on average 2-4 mSv per year) and other diagnostic/therapeutic procedures, like X-ray, radiotherapy as well as long dis-tance flights. Because of this factor, all CT facilities and vendors assume a heavy and unavoidable responsibility to mini-mize radiation and maximize safety for their patients. The justification for the existence of the entire medical field is, of course, better healthcare for all patients. Siemens has always been a visionary company, believing that even the farthest techni-cal horizons were temporary and could be surpassed with consistent dedication to improved healthcare. This visionary approach has made Siemens the undis-puted innovation leader in CT over the last 35 years. But our innovative philoso-phy is based solidly upon the assumption that achieving the highest technical per-formance is only important when it meets the needs of the patient. And meeting the needs of the patient means respon-sible dose considerations. Our newest developments clearly illus-trate our commitment to lower dose exposure: for example, our UFC (Ultra- FastCeramic) detector, CARE Dose4D, organ-sensitive dose protection and our revolutionary, new Adaptive Dose Shield, introduced with the SOMATOM® Definition AS adaptive scanner. And with the SOMATOM Definition Flash, we made dose reduction the centerpiece of our research. Its core innovation – the unique low-dose Flash Spiral – can be summarized in four words: Flash speed. Lowest dose. Conventional, single source cardiac CT requires up to 30 mSv dose, except with extremely stable, low heart rates. Siemens’ introduction of Dual Source CT in 2005 radically improved this situation by reducing dose requirements regardless of heart rate. Now, Dual Source technology is combined with Flash speed making possible the industry’s fastest true temporal resolution of 75 ms and, most important, it reduces dose to an absolute minimum – for example, com-pleting a cardiac scan in less than 300 milliseconds with dose as low as below 1 mSv. For this issue of SOMATOM Sessions, we have been in constant contact and dis-cussions with our customers – medical experts in clinical practice who are faced every day with an unlimited variety of conditions and CT applications. We are therefore able to bring you the first clini-cal results of the SOMATOM Definition Flash, as well as reports and updates of our entire portfolio. Read in this issue and see for yourself how Siemens’ com-mitment to dose management compli-ments our technological and diagnostic excellence, significantly improving healthcare. Enjoy reading. Sincerely, André Hartung
  4. 4. Content Content 6 4 SOMATOM Sessions · May 2009 · Cover Story 6 SOMATOM Definition Flash: Impressive Performance News 12 syngo 2009 – Functional Imaging Widens the Clinical Spectrum for CT 13 Private Payers Reimburse for CT Colonography in the U.S. 13 500 SOMATOM Definition Dual Source Installations Prove Clinical Success 14 The syngo CT 2009E Software for the SOMATOM Emotion Further Increases the Clinical Capabilities of the Most Popular Scanner 15 Win with Excellent Image Quality at Lowest Dose 15 SOMATOM Definition Flash Intro-duced During ECR 2009 Business 16 The St. Paul Heart Clinic: A Model of Efficiency 20 Chest Pain: Clarity with CT 24 SOMATOM Emotion Around the Globe 28 Economical Benefits Drive Thin-Client Server Technology Cover Story SOMATOM Definition Flash CT 6 It’s said that experience is what separates promise from reality. But when it comes to the SOMATOM Definition Flash Dual Source CT scanner, experience shows that promise is reality. As the innovative new scanner is tested in daily clinical practice, it is exceeding nearly every expectation. Split-second thoracic scanning: proven. Sub-milliSievert cardiac scans: confirmed. Superb image quality: no question. 16 The St. Paul Heart Clinic: A Model of Efficiency
  5. 5. Content 66 Imaging Marine Animals in Okinawa Churaumi Aquarium SOMATOM Sessions · May 2009 · 5 Acute Care 52 SOMATOM Definition AS+: Polytrauma Patient Scanned in Seven Seconds 54 Triple Rule-Out in Flash Speed: Entire Thorax Scanned in less than a Second Orthopedics 56 High Resolution Follow-up of a Wrist Fracture of the Os Triquetrum with SOMATOM Definition AS+ and z-UHR Gastroenterology 58 Difficult Drainage After Cholecystectomy Science 60 Dual Energy in Clinical Routine with syngo CT Oncology 62 Dual Energy CT in Pulmonary Embolism 65 Iterative Image Reconstruction Moves into Clinical Practice 66 Okinawa Churaumi Aquarium: Imaging Marine Animals with the SOMATOM Spirit Clinical Results Cardiovascular 30 Dual Source CT Unveils Several High- Grade Stenoses of Coronary Arteries 32 SOMATOM Definition Flash: The Entire Heart Scanned in Just 270 ms with 0.95 mSv 34 Low Dose 3D Evaluation of a Child’s Heart with Anomalous Venous Return with the SOMATOM Sensation 36 Cardiac Scan Prior to Bariatric Surgery 38 Detection of Unusual Case of Aorto-Leftventricular Tunnel with Dual Source CT Oncology 40 Dual Source CT Kidney Tumor Imaging with VNC Dual Energy 42 Lung Perfused Blood Volume Imaging with Dual Energy 44 syngo WebSpace in Imelda Zieken-huis in Bonheiden, Belgium Neurology 48 SOMATOM Definition: Head CTA Brain Hemorrhage Examination with Dual Energy 50 SOMATOM Sensation: Subtracted 3D CT-Angiography for Evaluation of Arteriovenous Malformation 69 Spatiotemporal Multi-Band Filter for Reducing Artifacts and Dose Life 70 Clinical Workshops at the Pulse of CT Technology 71 Now is the Time to Elevate SOMATOM AR and SOMATOM Plus 4 Scanners 71 Free 90 Day Trial Licenses for Clinical Applications 72 Clinical Poster on CT-guided Vertebroplasty 72 GEST 2009: Siemens Healthcare Demonstrated Innovation Leader-ship in Interventional Oncology 73 ESGAR Workshops on CT Colonography 73 Frequently Asked Questions 74 News in the CT World 74 Clinical Workshops 2009 75 Upcoming Events & Congresses 75 Experience Lounge at ECR 2009 76 Siemens Healthcare – Customer Magazines 77 Imprint 54 Entire Thorax Scan in Less Than a Second
  6. 6. The SOMATOM Definition Flash makes a thorax scan for triple rule-out possible in less than one second. SOMATOM Definition Flash: Impressive Performance In everyday clinical use, the SOMATOM Defi nition Flash Dual Source CT scanner is proving to be innovative and versatile. By Catherine Carrington 6 SOMATOM Sessions · May 2009 · 1 1
  7. 7. Cover Story scan with Dual Energy. The Definition Flash does it all.” Thorax and Beyond At the University of Erlangen, radiologist Michael Lell, MD, has used the Definition Flash to perform thoracic imaging in approximately 40 patients. Typically, he is able to image the entire thorax in just 0.6 to 0.9 seconds. “This is definitely a breakthrough,” Lell says. “The scan is so fast, we can examine patients who don’t hold their breath, and we get perfect images.” The speed of the Definition Flash trans-lates to better patient safety and comfort. For trauma patients, the ability to scan the entire body in less than five seconds not only reduces motion and breathing artifacts, it has the potential to reduce delays in getting to surgery. Pediatric scanning promises to be easier and safer. And eliminating the need for breath-holding offers comfort to patients who are very sick or injured. “The scan speed is so fast that it’s really unnecessary to switch a respirator on and off in order to get sharp images,” Lell says. “We can just keep on with the respirator and do the fast scan, and we get perfect image quality.” Lell is especially pleased with both the efficiency and effectiveness of the Definition Flash in evaluating patients who come from the emergency room with chest pain. For these patients, he uses a triple rule-out protocol. It includes electrocardiographic gating, but avoids the low pitch and high radiation dose that once burdened triple rule-out studies on single source CTs. “We can do a single scan and rule out three major killers from chest disease: pulmonary embolism, aortic dissection, and coronary occlusion,” he says. “And with the new system, we just fly over the heart and thorax very fast. We don’t have redundant data anymore.” As a result, Lell has found that the radia-tion dose for a triple rule-out study per-formed on the SOMATOM Definition Flash amounts to just 1.6 to 1.9 mSv. “It’s really changing thoracic imaging,” he says. “On the one hand we have an extremely fast scan that offers outstand- SOMATOM Sessions · May 2009 · 7 It’s said that experience is what separates promise from reality. But when it comes to the SOMATOM® Definition Flash Dual Source CT scanner, experience shows that promise is reality. As the innovative new scanner is tested in daily clinical practice, it is exceeding nearly every expectation. Split-second thoracic scanning: proven. Sub-milliSievert cardiac scans: confirmed. Superb image quality: no question. “This is the scanner that gives you all options,” says cardiologist Stephan Achen-bach, MD, a professor of medicine at the University of Erlangen-Nuremberg in Erlangen, Germany. “You can scan at unprecedented low doses. You can scan at both low and high heart rates. You can “We can examine patients who don’t hold their breath, and we get perfect images.” Michael Lell, MD, PD, Department of Radiology, University of Erlangen-Nuremberg, Erlangen, Germany “The SOMATOM Defi nition Flash is the scanner that gives you all options.” Prof. Stephan Achenbach, MD, Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany ing image quality – and we get the coro-naries for free. On the other hand, we have the ability to perform Dual Energy studies. That’s very exciting.” Cardiac Imaging Stephan Achenbach has also been scan-ning patients on the Definition Flash since mid-February. So far, some 100 patients have been imaged using the new low-dose Flash Spiral mode, that acquires data in a single heart beat, during a 250 ms-pause in the cardiac cycle when the heart is in diastole. The results have been impressive. “The Flash scanner is superb,” says Achen-bach. “In cardiac imaging, what really counts is temporal resolution, and this is the fastest scanner on the market. The image quality is excellent.”
  8. 8. The worldwide first SOMATOM Definition Flash, installed at the University of Erlangen-Nuremberg, Erlangen, Germany. 8 SOMATOM Sessions · May 2009 · edented radiation dose of less than 1 mSv. Early testing focused on patients weigh-ing less than 90 kg (200 lbs) and used settings of 100 kV and 320 mAs. The result was an average dose of just 0.94 mSv. Stephan Achenbach is now evaluating whether dose can be reduced even further in thin patients and how settings might need to be adjusted in heavier patients. A sub-milliSievert radiation dose has the potential to expand the horizons of cardiac CT to include screening for pre-vention of cardiovascular disease. “We are now at a dose for CT angiography that is less than it used to be for calcium scoring,” Achenbach says. “This low dose could allow us to use cardiac CT for screening. The question is a medical one: Does it make sense to do screen-ing?” Preliminary data published in the Journal of the American College of Cardiology in 2007 and 2008 suggest that findings of non-calcified, non-obstructive plaque on CT angiography add new information that can be used in determining a patient’s cardiovascular risk and prognosis. But the clinical value of cardiac CT screening needs to be confirmed in larger studies, Achenbach says. It is a project he and his colleagues are already undertaking. “It’s possible we are going to find that there are specific patient groups who benefit from this test – patients who have diabetes or a strong family history of heart disease, for example,” Achenbach The Definition Flash, a second-generation Dual Source scanner, is equipped with two detectors and two X-ray sources set at an angle of approximately 95 degree to one another. With a gantry rotation time of 0.28 s, the scanner boasts a temporal resolution of just 75 ms. Moreover, an innovation introduced with the Definition Flash eliminates the need for the patient table to slowly inch forward during data acquisition. Instead, in low-dose Flash Spiral mode, the scanner achieves gap-less z-sampling even with the wide-open spiral created by a pitch of 3.2 and a table speed of more than 40 cm/s. This is because the two detectors create two complementary data spirals that together include all the information that would be found in a single spiral acquired at a much slower table speed – but without redundant, overlapping data and unnec-essary radiation exposure. During the first weeks of gathering clinical experience at the University of Erlangen- Nuremberg, the Flash mode has been used primarily to scan cardiac patients. This approach has produced flawless images free of motion artifacts. “This scanner allows us to do cardiac imaging at the lowest dose with the highest image quality,” says Prof. Willi Kalender, PhD, director of the Institute of Medical Physics at the University of Erlangen- Nuremberg. “We actually measured both spatial and temporal resolution in the Flash mode, and they are uncompro-mised. For cardiac imaging, no question, this is the best.” Equally important, both patient exami-nations and physics measurements con-clusively show that the Definition Flash can scan the complete heart at an unprec- “This scanner allows us to do cardiac imaging at the lowest dose with the highest image quality.” Prof. Willi Kalender, PhD, Director of the Institute of Medical Physics of the University of Erlangen-Nuremberg, Erlangen, Germany
  9. 9. Cover Story 2 With the latest DSCT technology, the heart can be visualized artifact free and with an ultra-low dose of 0.95 mSv in Flash speed. SOMATOM Sessions · May 2009 · 9 says. “We don’t have that data yet, but we now have a scan mode that would allow us to use this technology for screening if we find that it makes sense for the patient.” Dual Energy Dual Energy studies are a special interest of Hatem Alkadhi, MD, who heads both body CT and cardiovascular imaging at the Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland. He has performed hundreds of Dual Energy exams using the first-generation Dual Source scanner, the SOMATOM Definition, and now the new Definition Flash scanner as well. “Dual Energy gives radiologists additional information that we don’t have when making single energy scans,” says Alkadhi. “This is a great benefit of this technique.” Dual Energy imaging involves the simul-taneous operation of two X-ray sources at different energy levels. This enables differentiation of fat, soft tissue and contrast material on the basis of their unique energy-dependent attenuation profiles. As impressive as early versions of Dual Energy imaging have been, the Definition Flash brings new strengths to the table. An important new feature is the selective photon shield that pre-filters high kV X-rays, removing low-energy photons. This improves separation of the 80 kV and 140 kV images and, therefore, improves material differentiation by about 80%. In addition, the photon filter consistently reduces image noise and substantially cuts radiation dose. “With the second generation of Dual Energy, we’re finally able to deliver additional diagnostic infor-mation with dose levels comparable to a single energy scan. That’ll make the decision to use Dual Energy even easier for us,” Alkadhi says. An improved ability to separate materials has important clinical implications. It 2
  10. 10. The improved ability to separate materials with Dual Energy makes it easier to characterize the composition of urinary stones. 10 SOMATOM Sessions · May 2009 · ing another important application of Dual Energy CT – evaluation of suspected pul-monary embolism. Dual Energy imaging enables the radiologist to not only detect a blood clot that is cutting off blood flow through the pulmonary artery, but also to show the effect of the obstruction on perfusion of the lung tissue itself. In the past, the use of Dual Energy imag-ing was limited to the center of the lung because of the smaller size of the second detectors. A similar problem hampered Dual Energy imaging in the liver, where observing contrast uptake can aid in determining whether a lesion is hepato-cellular carcinoma or a hemangioma. To realize its full potential, Dual Energy must be able to image even lateral seg-ments of this large organ. “When we make a Dual Energy scan, makes it easier to characterize the com-position of urinary stones, for example, and guide clinical decisionmaking. If a stone is composed of uric acid, the urol-ogist has the option to try medical ther-apy, rather than immediately referring the patient for shock wave lithotripsy. “This is better for the patient,” Alkadhi says. “And our ability to use Dual Energy to separate materials of similar density is what makes it possible.” Similarly, Dual Energy imaging makes it simple to differentiate iodinated contrast material from bone, two materials with similar densities on standard CT. With a click of a button, bones can be removed from an image, leaving only the opaci-fied arteries for examination. In other circumstances, iodine can be subtracted from an image, creating virtual nonen-hanced images without need for a sepa-rate scan prior to contrast injection. This approach is helpful in reducing radiation dose when performing studies that would normally involve more than one imaging phase. It is also helpful when a suspicious inci-dental finding is noted on a contrast-enhanced scan, Alkadhi says. With stan-dard CT, it is impossible to determine in retrospect whether the lesion is simply a hyperdense mass or has the propensity to take up contrast, a worrisome clue that suggests malignancy. With Dual Energy imaging, a virtual “do-over” is possible. By subtracting iodine from the image, it is possible to create a precontrast image and evaluate lesion density in the absence of contrast enhancement. The SOMATOM Definition Flash is improv- 3 3
  11. 11. Cover Story “With the second generation of Dual Energy the fi eld of view is so large we can cover the entire lung.” Hatem Alkadhi, MD, PD, Institute of Diagnostic Radiology, University Hospital Zurich, Switzerland SOMATOM Sessions · May 2009 · 11 we want to cover the whole organ of interest – the whole lung, the whole liver, the whole abdomen,” Alkadhi says. “If you can’t, it limits the practicability of your technique and the willingness of the radiologist to use it. Obviously Siemens understood this. The Definition Flash is a big step forward with the large Dual Energy field of view.” Now the Definition Flash is outfitted with two 4-cm detectors, and the field of view is no longer a limitation in large organs like the lung and liver. “With the new system the field of view is so large we can cover the entire lung,” Alkadhi says. “The lung parenchyma is completely displayed with Dual Energy properties, including the periphery.” Dose Dose savings are built into the SOMATOM Definition Flash. Besides the reduced radiation exposure that directly results from the high table speed, the scanner has several other dose-sparing features. Previously, Dual Energy imaging typically exposed patients to between 10% and 20% more radiation than a corresponding single energy scan. Now, the photon shield eliminates the dose penalty in most types of Dual Energy studies, Kalender says. In addition, the new scanner is equipped applies to shorter scan ranges, such as for the heart or the brain, or in pediatric imaging. We can expect a higher percent reduction as compared to standard scan-ning.” “For example, the radiation dose could be reduced by as much as 50% for a scan of the heart performed at high pitch on the Definition Flash, when compared to the same type of scan without the dose shield,“ Kalender says. Another dose-saving feature designed for the Definition Flash is X-CARE. This technique, which provides organ-specific dose reduction, enables the radiologist to turn off the X-ray tube during the por-tion of the gantry rotation that would directly expose radiation-sensitive organs, such as the breast, thyroid gland, or eye. According to a study Kalender published in European Radiology last year, the X-CARE technique can cut radiation dose to the breast by 50% during thoracic imaging. “It’s the best way to reduce dose to the female breast,” Kalender says. “It’s an exciting prospect.” Further Information somatom-definition-flash Direct exposure of dose sensitive organs can be significantly reduced by using X-CARE. 4 with adaptive dose shielding, which blocks the X-rays at the beginning and end of each spiral acquisition that will not be used in image reconstruction. In the case of cardiac scans, adaptive dose shielding cuts radiation dose by as much as 25% when the studies are performed using a conventional pitch. However, the dose savings are expected to be much greater when patients are scanned using the Flash mode. “The percent dose reduction with the adaptive dose shield is greater the higher the pitch and the shorter the scan range,” Kalender says. “That means as we go to even higher pitch values, the effect of shielding on dose is greater. The same Catherine Carrington is a medical writer and holds a master’s degree in journalism from the University of California Berkeley. She is based in Vallejo, CA. 4 Low dose High dose
  12. 12. News syngo 2009 – Functional Imaging Widens the Clinical Spectrum for CT By Karin Barthel and Stefan Wünsch, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Germany Siemens is further strengthening its commitment to deliver software products that can significantly increase diagnostic speed and confidence in everyday radi-ology as well as maintaining the innova-tion leadership for functional CT. The latest syngo 2009 software focuses on the new era of functional imaging in CT. With the launch of new applications such as syngo Dual Energy Lung Nodules, syngo Dual Energy Xenon, syngo Volume Perfusion Myocardium* and major improvements in syngo Volume Perfusion CT, more functional aspects are added to the classical morphological information of CT images. Applying a newly developed 4D Noise Reduction technique implemented in syngo Volume Perfusion CT Neuro, the radiation dose of dynamic CT exams can be reduced by a substantial amount with-out compromising on diagnostic image quality.* syngo DE Lung Nodules permits visualiz-ing the contrast agent concentration in the lung nodules without the use of an additional non-contrast scan (Fig. 1). It may support the differentiation of lung tumors. The new syngo Dual Energy Xenon sets a new trend in the evaluation of chronic and acute lung diseases. With the latest advances in CT imaging tech-nologies, the clinical evaluation of, for instance, COPD (chronic obstructive pul-monary disease), is rapidly moving from pure visualization to quantitative analysis of lung parenchyma abnormalities. The acquired information may contribute to a more accurate planning of a surgery. Furthermore, the application provides information about the effectiveness of medication in a very early stage of the treatment. The syngo Volume Perfusion Myocar-dium** allows the display and analysis of dynamic CT data of the heart utilizing the heart perfusion scanning mode of the SOMATOM® Definition Flash after contrast injection. The application not only helps to determine hemodynamic relevance of a myocardial infarction, it further provides information that can help to distinguish whether the myocardial infarction is old or fresh (Fig. 2). In addi-tion, syngo 2009 supports the fusion of dynamic data of other modalities e.g. 12 SOMATOM Sessions · May 2009 · dynamic angiographic data from Dyna CT with 4D CT data, thereby obtaining further functional information. Of course, since the last major software version was released, many more improvements in routine and advanced applications e.g. in Expert-i, syngo CT Oncology, syngo InSpace as well as in syngo Neuro DSA have also been made. To benefit from the latest enhancements within existing applications only a soft-ware upgrade is needed.*** To test the dedicated applications in advance, 90 days trial licenses can be ordered. In case of interest, the local Siemens sales representative should be contacted. * requires syngo 2009B. ** a prerequisite is syngo VPCT Body. *** dependent on workstation configuration. ct-applications 1 1 Solitary pulmonary nodule in an adult patient displayed with DECT: iodine enhancement is shown as colored overlay to a virtual non-contrast image; the semi-automatic segmentation result is indicated in blue. Courtesy of Asan Medical Center, Seoul, Korea. 2 2 SOMATOM Definition Flash Heart Perfusion: Minor perfused myocardium (arrows) scanned with spatial resolution 0.33 mm, rotation 0.28 s, 2 x detector coverage .
  13. 13. News Private Payers Reimburse for CT Colonography in the U.S. By Joachim Buck, Business Unit CT, Siemens Healthcare, Forchheim, Germany 500 SOMATOM Defi nition Dual Source Installations Prove Clinical Success By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany SOMATOM Sessions · May 2009 · 13 Stunning results of several CT Colonog-raphy (CTC) trials (e.g. ACRIN1 6664) have motivated the American Cancer Society (ACS) to add CTC to its five-year colon screening guidelines in 2008. Despite this fact, CMS (Centers for Medi-care and Medicaid Service) announced a proposed non-coverage decision for CTC, at least for the time being. However this proposed decision won’t discontinue the success story of CTC. Two major commercial payers, Blue Cross Blue Shield of Delaware (BCBSDE) and Philadelphia region’s largest health insurer, Independence Blue Cross (IBC), have started to reimburse for CTC. BCB-SDE has agreed to reimburse the patent- With currently 500 installations world-wide, the SOMATOM® Definition has redefined the face of CT. Within three years, DSCT has proven itself in clinical routine as state-of-the-art with more than 1,500,000 coronary CTAs performed, 250 peer-reviewed papers, and 200,000 Dual Energy scans. Together with the SOMATOM Definition Flash, introduced in 2008, the SOMATOM Definition family will continue to define – and redefine – the expanding world of CT. pending Integrated Virtual Colonoscopy™ model from Colon Health Centers (CHC)2 of America, a Philadelphia-based company that partners with pre-eminent gastro-intestinal physician groups in a region, enabling them to provide CTC as an option to traditional colonography for colon cancer screening. BCBSDE is providing a single, bundled, episode-of-care payment “per screening event” for CTC and believes that it is essential to have the capability to provide same-day, same-prep thera-peutic colonography for patients who undergo CTC. CHC of America is expecting several Mid-Atlantic region Blue Cross plans and other commercial insurers to begin to reimburse CTC within the next several months. Payers are encouraged and positively responding to the high sensitivity, safety and convenience that CTC offers patients, as well as the signifi-cantly lower ”per screening event” costs. With colorectal cancer (CRC) screening rates hovering in the dismal 50% range, payers are looking for other screening options to get their members off the ‘screening sidelines’. CTC is that new option. For example, nearly 50% of the patients screened at CHC of America sites report that the availability of patient-friendly CTC was the force motivating them to receive life-saving CRC screen-ing. CT Colonography will definitely play a large role in CRC screening for the fore-seeable future. With this, CTC is definitely the wave of the future and it is highly expected that other private payers will follow in the near future. This map shows where SOMATOM Definition DSCT scanners are installed worldwide in Diagnostic Imaging Centers (red dots), Community Hospitals (blue dots), Departments of Cardiology (deep red dots), Emergency Departments (yellow dots) and University Hospitals (deep blue dots). References 1 ACRIN (American College of Radiology Imaging Network) 2 Enhanced diagnostic confidence using syngo Colonography PEV as a second reader option for colon polyp detection.
  14. 14. News The syngo CT 2009E Software for the SOMATOM Emotion Further Increases the Clinical Capabili-ties of the Most Popular Scanner By Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany The release of the syngo CT 2009E software version for all new SOMATOM® Emotion systems further reinforces Siemens Healthcare’s dedication to con-tinuously increase clinical capabilities throughout the product portfolio. syngo CT 2009E makes remote access to the scanner workplace available for the first time through the introduction of syngo Expert-i. Siemens’ leading applications, such as syngo CT Oncology, are available for the first time on the SOMATOM Emotion CT Workplace, and a number of leading syngo applications have been even further enhanced. Additional capabilities on Acquisition Workplace With the syngo CT 2009E release, Expert-i will allow physicians or senior CT technol-ogists to connect remotely to the scan-ning workplace. This functionality enables the CT users to seek an expert clinical opinion quickly and efficiently without the need to physically go to the CT suite, resulting in improved workflow and better clinical outcomes for patients. In interven-tional CT, the simple and efficient work-flow for which the SOMATOM Emotion is known is further enhanced with the addition of a laser grid to increase the speed and accuracy of CT interventional procedures. With the release of this software Siemens also continues the philosophy of reduc-ing dose in CT. To assist users in this con-tinual process, a comprehensive and exportable dose report is now available on the SOMATOM Emotion with the syngo CT 2009E release. Additional capabilities on CT Workplace Through the introduction of the syngo CT 2009E software, leading applications, including syngo CT Oncology, are now 14 SOMATOM Sessions · May 2009 · available on the CT Workplace with the additional convenience of a linked data-base with the CT system. syngo CT Oncol-ogy increases the speed and accuracy of CT oncology imaging through the use of automated lesion measurements, routine volume calculations, and auto-matic lesion matching for follow-up staging studies. In addition to syngo CT Oncology, syngo Neuro Perfusion Weighted Map, e-Logbook, and InSpace Circulation PE Detection are now also available on the CT Workplace with the potential to significantly improve workflow in acute care imaging. syngo CT 2009E has been available on all new Emotion 6- and 16-slice configu-rations since the beginning of April 2009.
  15. 15. News Win with Excellent Image Quality at Lowest Dose By Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany SOMATOM Defi nition Flash Introduced During ECR 2009 By Carolin Knecht and Peter Seitz, Business Unit CT, Siemens Healthcare, Forchheim, Germany SOMATOM Sessions · May 2009 · 15 Seeing is better than believing. Therefore Siemens CT will launch a global contest to underline that the Definition family is the choice for achieving the best results when it comes to image quality. In 2005, Siemens CT introduced its Dual Source Technology with the highly successful SOMATOM® Definition. Since then, more than 500 systems have been installed, proving that Dual Energy has become a routine application and thus making the SOMATOM Definition the proven Dual Source CT. In 2007, Siemens then launched the most flexible scanner sys-tem in the market, the SOMATOM Defini-tion AS which adapts to any patient, while at the same time also adapts for complete dose protection with innova-tive technologies. Since its introduction, the SOMATOM Definition AS has achieved the fastest ramp-up in Siemens CT history. But these cutting edge systems were Themed, “Ask the Ultimate Power in Imaging,” Siemens Healthcare intro-duced its latest imaging innovation, the SOMATOM® Definition Flash, at the European Congress of Radiology (ECR) 2009 from March 6 to March 10 in Vienna, Austria. This latest computer tomograph is designed to be the industry’s most patient friendly CT by requiring less dose through faster speed. During the congress, dose reduction was obviously of universal interest for the visitors. Many wanted to know more details about technical features of the SOMATOM Definition Flash that enable users to scan with highly reduced radia-not the end of CT’s innovation potential: Last year, CT continued its Dual Source success story with the introduction of the SOMATOM Definition Flash, allowing scanning the entire thorax in less than one second and imaging the heart with a radiation exposure of less than 1 mSv, only a fraction of the natural background radiation. Consequently, the time has come to prove the superior image quality of the SOMATOM Definition family obtained with significantly reduced dose. As the best proof is customers’ voice, Siemens CT will host a contest for all Definition users addressing highest image quality at low-est dose which will be introduced in June 2009. Participants are welcome to send in cases scanned on any Definition scanner (single and Dual Source). A jury of highly qualified experts and medical advisers will discuss each case and deter-mine the finalists. Therefore, beginning immediately, all Definition customers are invited to participate in this contest and start collecting their outstanding low dose cases and demonstrate their achievements in cutting-edge CT. The new SOMATOM Definition Flash was introduced to the European market during the European Congress of Radiology (ECR) 2009 featuring a special “healthy” version of the low-dose scanner. tion dose, for example, heart scan with less than 1 mSv. The fast scan speed of 43 cm/s and the temporal resolution of 75 ms were also subjects of great gener-al interest at the Siemens booth. At a Joint Satellite Symposium of Siemens Healthcare and Bayer Schering Pharma, first clinical results of the SOMATOM Definition Flash were presented, together with updates on the entire range of SOMATOM Definition scanners. According to the theme “For better patient care: What’s new in CT,” leading clinical experts once again complimented the innovative power of Siemens CT and made it one of the most visited symposia at ECR 2009. The SOMATOM Definition Family: Revolutionizing CT imaging since its intro-duction in 2005.
  16. 16. Business St. Paul Heart Clinic, Saint Paul, Minnesota, USA. The St. Paul Heart Clinic: A Model of Efficiency The leading physician overseeing the construction and equipping of a new clinic in the State of Minnesota (USA) has found that making a big investment in state-of-the-art technology for cardiac imaging pays big dividends for patient care. By Ron French The cardiovascular imaging center in the St. Paul Heart Clinic (St. Paul, Minnesota, USA) is unique in more ways than one. It is the first independent cardiology prac-tice in the world to incorporate both Siemens MRI and SOMATOM® Definition Dual Source CT scanning technology, thereby offering state-of-the-art imaging and unprecedented patient and customer efficiencies. And what’s even more unique 16 SOMATOM Sessions · May 2009 · is that the clinic has designed a success-ful business model around these cutting edge technologies. At the heart of this success story is Uma Valeti, MD, Director of Cardiovascular
  17. 17. Business of Siemens sites and talked to the engi-neers in detail. Siemens offered a well integrated cardiovascular imaging solu-tion with these two modalities that was unparalleled by other vendors at the time. Since our installation of Siemens equip-ment we have been able to compare our efficiencies and workflow – as well as the satisfaction of our patients, nursing staff and technologists – and we’ve been extremely happy with our choice. A limitation of most cardiac CT scan-ning technology has been its inability to capture clear images of a beating heart. Some patients had to be placed on beta-blockers to slow their hearts to 60 beats a minute and had to wait for an hour for the medication to kick in. And the chests of obese patients were too dense to permit a clear image. As many as 10 percent of the images were non-diagnostic. How has the SOMATOM Definition improved imag-ing SOMATOM Sessions · May 2009 · 17 efficiencies? What we found with Dual Source CT was that there were very few exclusions, for previously common reasons like high heart rate, asthma or large body habitus. Patients didn’t have to take beta-blockers mandatorily to reach a heart rate below 60 beats/minute, and the system was better able to deal with irregular heart rates, so there was no need to wait for hours prior to the scan. We saw that it would be advantageous and improve workflow. The patients are happy due to the ease of the exams, the physicians are happy because they did not need to exclude many patients that were previ-ously excluded, and finally our staff is happy due to less work involved in pre-paring a patient for the study. And the improved workflow cut costs? The improved workflow meant more efficient patient throughput. The non-diagnostic scan rate is now less than three percent, which is less than half of what it was before with regular 64-slice scanners. Additionally, the time and dol-lar savings on mandatory beta-blocker administration and aftercare are not tak-en into account in this consideration. Siemens SOMATOM Definition Dual Source CT also offers a low-dose option – reducing patient radiation from the industry standard of up to 30 mSv per scan to below 3 mSv, without compro-mising image quality. And with the new SOMATOM Definition Flash you can even reach levels of below 1 mSv. Was that a selling point? Yes, it was a big selling point. The one big knock against CT was always the radiation level. It’s important to lower the radiation dose as much as possible, without compromises in image quality. This fits into our goals of patient first, safety first. Being able to offer low dose cardiac CT is a clear differentiator and a competitive advantage. And the latest DSCT is setting a new benchmark in this dose battle among CT vendors, strongly reducing concerns about dose. CT/MRI, at the St. Paul Heart Clinic (SPHC). Four years ago, Valeti moved from the Mayo Clinic in Rochester, Minnesota, to SPHC to build the Cardio-vascular MRI/CT imaging center. He oversaw not only the selection and pur-chasing of the imaging technology, but also the communications and customer service that have been integral to the center’s growth. Valeti shares the steps St. Paul Heart Clinic took to build the advanced imaging practice in an inter-view with SOMATOM Sessions – steps that other physician groups could emu-late. It’s unusual for an independent cardi-ology practice to have both MRI and CT imaging. Why did you choose to include both in your practice and what were some of the challenges you anti-cipated when you were building the advanced imaging program? Our practice has 38 cardiologists and we are a tertiary care facility. We get a lot of complex cases referred to us in addition to the usual mix of cardiac pathology. We were convinced that cardiac CT and MR imaging were leading a paradigm shift in the future of general cardiac imaging and not just limited to complex cardiac diseases. We wanted to have all the ad-vanced modalities to diagnose and man-age the routine and complex patients re-ferred to us not only for patient care but also to enhance our ability to recruit highly talented physicians looking to in-tegrate cutting edge clinical care and re-search into their professional careers. Your clinic is designed so that, if needed, patients can go seamlessly from the MRI lab to the CT lab. Your imaging rooms are separated by a glassed-in control room, which is the nerve center of both imaging labs. There were many choices for equip-ment. Why did you pick SOMATOM Definition Dual Source CT and Siemens Avanto MRI? We had no previous experience with Siemens. We had worked with CT and MR scanners from different vendors and went out and looked at a number The SOMATOM Definition scanner delivers clear images for save diagnoses – even in patients with fast or irregular heart beats or with an obese body habitus.
  18. 18. Business Anterior-oblique volume rendered view of the heart of an obese patient depicting the right coronary artery (RCA) and left artery descending (LAD) with the Dual Source CT SOMATOM Definition. 18 SOMATOM Sessions · May 2009 · at various small and large group confer-ences. The message was simple and consistent. We kept saying, “Here are all the imaging modalities and clinical solu-tions we have, and here’s what they can offer. If you feel they can benefit your patient, here’s the number to call.” We also made it very simple for them to re-fer patients. Everybody in the group had extensive education about each modality, appropriate indications as defined by the guidelines including the scheduler, the technologists, the nurses and the pro-gram administrator in addition to being aware of the unique Siemens technologi-cal benefits. At first, we turned down many referring providers who were order-ing studies that did not meet the appro-priateness criteria, at the risk of offending them. However, the initial emphasis was on letting our referring providers realize that our program was a credible patient centric program and if they know we were being very careful to prevent un-necessary utilization eventually we would get more appropriate studies. In addition, we had a constant line of com-munication with all the referring provid-ers with access to an imaging physician at all times for any question related to the appropriate use of advanced imag-ing modalities. It sounds as if you have to be as good as a businessman as a physician. We are fortunate to have an outstanding administrative leadership team for busi-ness planning. Therefore the credit goes to them. From my perspective, what the doctors and third-party payers really want to know is: Is this a layered test? Are you just adding another test to patients already getting stress tests and MRIs or an angiogram? Even before we began the program, we engaged all the parties involved – all the cardiologists, the pri-mary care providers and the third-party payers – and informed them that we are going to start this program, and shared our pilot data with them to reassure them that there would not be layering of tests. On the contrary, we shared data about the large cost savings to the system based on our initial pilot of 250 patients. We also informed them that every year we Full cardiac evaluation possible with syngo Circulation which is automatically included in CT Cardiac and Acute Care Engine. What were some of the challenges you anticipated and what did you do to build market share to the point that the clinic could work economically? What was your marketing plan? Because this is new technology, we real-ized the biggest hurdle would be aware-ness and education. Although we are a tertiary care practice, most physicians within our practice and in the community were not aware of the benefits and appro-priate use of these advanced technolo-gies and how they can improve clinical diagnoses, management and treatment of their patients, as well as decreasing the overall costs of working up patients. Members of my group gave about 200 formal and informal talks in the first year 1 1
  19. 19. Business SOMATOM Sessions · May 2009 · 19 would come back and show the data to the third-party payers. And what happened? At the end of the first year, we invited all the major payers to come to our practice. The data was remarkable. In a study of more than 1,000 cardiac CT scans, only 15 percent of patients went on to have angiograms. Normally, if CT was not in the picture, more than 50 percent of these patients would go on to have angiograms based on previous studies of patients with equivocal or mildly positive stress tests. However, invasive angiograms carry a higher procedural risk and are 5 to 10 times more expensive than CT scans. You are a busy interventional cardiol-ogist. What is your perspective on cardiac CT? Being an interventional cardiologist, I am very skeptical of anything that is por-trayed in the media as a replacement to an invasive angiogram. But I can’t argue with the fact that for 30 to 40 percent of patients that are currently referred for diagnostic angiography, cardiac CT is in fact a safer and equally effective proce-dure in addition to being cost effective for the health system due to its very high negative predictive value. What would really help in convincing decision makers like cardiologists, primary care “The improved workfl ow means greater patient throughput and the non-diagnostic scan rate is now three percent, less than half of what it was before.” Uma Valeti, MD, Director of Cardiovascular CT/MRI, St. Paul Heart Clinic, St. Paul, Minnesota, USA. Further Information ct-cardiology physicians and the third-party payers is data from large multicenter trials, prov-ing the benefit of the cardiac CT in a wide patient population. Your equipment was installed in 2006. In those three years, your market share has grown to 90 percent of cardiac MRI and CT imaging in your region. There are more than 20 clinics referring to your center. How do you account for that rapid growth? The key has been good, relevant informa-tion that was immediately conveyed to the referring providers along with the outstanding patient experiences during the process of scheduling, scanning and follow up. Consequently our program has been growing steadily for the past three years with a wide range of clinical pathol-ogy. Our advanced imaging program sup-ports several sub-speciality clinics and helped in their growth (for example: vas-cular clinic, adult congenital clinic, CHF clinic, Hypertrophic Cardiomyopathy clin-ic, Pulmonary Hypertension clinic etc). We were also very successful in educating our referring providers about the techno-logical benefits offered by our CT and MR imaging equipment. For instance, the low dose cardiac CT protocols, the high image quality even in difficult patients, the lack of a mandatory need for oral beta-block-ers and lack of a large list of exclusion criteria was very attractive for them. We were also able to recruit eight highly talented physicians in the last three years, at a time when most practices in the re-gion had trouble recruiting and retaining cardiologists. An important reason is be-cause St. Paul Heart Clinic offered them advanced imaging modalities that provide exciting and unique capabilities and ser-vices. Do you have any advice for other clinics that are considering investing in SOMATOM Definition CT technology? We believed in the technology and believed that it would inevitably move to mainstream modality in a few years. You have to spend a lot of time in educating the people who will be using it and pay-ing for it. This is a long-term strategy and you will need to believe in the para-digm shifts occurring in cardiac imaging. That’s why we invested in it. Ron French is a senior writer and award-winning journalist for the Detroit News, where he specializes in coverage of health care and the economy.
  20. 20. Topic Business Chest Pain: Clarity with CT It’s not an insignifi cant problem, nor a cheap one. With more than six million patients a year presenting at emergency departments with chest pain, costing an estimated eight billion dollars, the importance of an accurate, effi cient and quick way to determine which patients need inter-ventional treatment and follow-up is hard to ignore. Dual Source CT scan-ners meet these criteria perfectly. They are enhancing diagnostic capacity for adult and pediatric patient populations that would have formerly been excluded from CT scans because of conditions such as obesity, high heart rates, atrial fi brillation or contra-indications to beta-blockers. By Louisa Kasdon 20 SOMATOM Sessions · May 2009 · “You can do the ‘triple rule-out’ in real time, confi rming three diagnoses with one scan.” Udo Hoffmann, MD, MPH, Director of Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, MA, USA “With the new SOMATOM Defi nition Flash technology, you will be able to image the entire chest in less than one second.” Harold I. Litt, MD, PhD, Assistant Professor of Radiology and Medicine, Chief, Cardiovascular Imaging Section, Department of Radiology, University of Pennsylvania Health System, Philadelphia, PA, USA
  21. 21. Topic “With the CT of the heart being less than one milliSievert, radiation will basically no longer be an issue.” Gilbert Raff, MD, Director, Ministrelli Center for Advanced Cardiovascular Imaging, William Beaumont Hospital, Royal Oak, MI, USA SOMATOM Sessions · May 2009 · 21 The “Holy Grail” in the emergency depart-ment, according to Gilbert Raff, MD, of William Beaumont Hospital in Royal Oak, Michigan, USA, is figuring out which patients to send home, and which to keep for further observation and treatment. Raff, a cardiologist with more than thirty years of clinical experience, says that misdiagnosing a patient and sending him or her home with a potentially fatal heart attack, is the nightmare scenario for every ER doctor. The tricky part is to identify the 10 to 20%, out of the patient cohort, who really do need immediate treatment. A Roundtable at the University of Pennsylvania A group of prominent American inter-ventional radiologists and cardiologists, specialists at the forefront of their pro-fessions, suggest that immediate triaging to a CT scan for patients presenting with chest pain has the potential to radically streamline the diagnostic process and speed up the door-to-balloon interval. SOMATOM Sessions recently met with three of these experts for a roundtable discussion at the University of Pennsyl-vania – Harold I. Litt, MD, PhD, Assistant Professor of Radiology and Medicine, Chief, Cardiovascular Imaging Section, Department of Radiology, University of Pennsylvania Health System in Philadel-phia; Udo Hoffmann, MD, MPH, Director of Cardiac MR PET CT Program at the Massachusetts General Hospital (MGH) of Harvard University in Boston; and Gilbert Raff, MD, Director, Ministrelli Cen-ter for Advanced Cardiovascular Imag-ing, William Beaumont Hospital, Royal Oak, Michigan – and listened in as they revealed their vision for a new “gold standard” for the diagnosis of chest pain. These clinicians believe that scanning patients with a Dual Source CT (DSCT) SOMATOM® Definition can save billions of dollars in healthcare costs annually. “The work-up of those patients who do end up not having a heart attack costs us about eight billion dollars a year. A big chunk, with the potential for big health-care savings,” says Hoffmann. Litt con-curs, “we conducted a large trial, with more than 640 individuals, about the actual financial comparison of different strategies to evaluate patients with potential acute coronary syndrome.“* “Herein we compared the CTA group (A) with the two groups being treated the standard or current way,” describes Litt. These two groups are the clinical decision unit group with serials of biomarkers and stress test (B) and the usual care group Business which was defined as admission with serial biomarkers and hospital-directed evaluation (C). The main outcomes were actual cost of care (facility direct and indirect fixed, facility variable direct labor and supply costs), length of stay, the 30-day read-mission rate as well as safety measured in 30-day death or myocardial infarction rate. The study showed an overwhelming result. The standard of care group B and the usual care group C revealed median costs of $2,913 – $4,024 per patient and an average length of stay of 26.2 to 30.2 hours. The rate of myocardial infarction and death was 0.7 to 3.1%. The readmission rate was between 2.3 and 12.2% here, which means that addi-tional cost has to be considered for the patients coming back for further test and treatment. Those results were com-pared with the new CTA strategy. The cost per patient in the CTA group A were found to be only $1,240 which was a 57% to 69% saving. Similar results been revealed for length of stay with eight hours in CTA group, which was a time advantage of 69 – 73%. Interestingly the rate of myocardial infarction or death in the CTA group (A) was 0%, which can be explained with the high negative predic-
  22. 22. Business tive value of almost 100% of the DSCT. Also the 30 day readmission rate was 0% which means no patients coming back for additional testing or treatment, which saves additional time and money. Litt and his group found that, using total facility cost in their analysis, immediate CTA was the least costly method of eval-uation. It also resulted in reduced length of stay, decreased rate of admission, lower rate of return visits, and at least equivalent 30-day outcomes. Other strategies that required inpatient or ob-servation unit admission were more costly, had more prolonged length of stay, and did not detect any more dis-ease than the immediate CTA strategy. The subset of patients who received ’usu-al care’ accompanied by cardiac testing (stress echo, treadmill testing, or cardiac catheterization) had a mean cost of $4,154 compared to $1,239. A Unique Tool for a Better Image Beyond economic and efficiency issues, any new technology has to support better patient care. These three doctors feel strongly that the new generation of Dual Source CT scanners enables them to iden-tify cardiac issues with more clarity, and yields diagnostic information to prevent future disease. There is a big impact on patient care. “We now have a unique tool 22 SOMATOM Sessions · May 2009 · with the spatial and temporal resolution that can help us noninvasively visualize the disease,” Hoffmann explains. At MGH, Udo Hoffmann is conducting a randomized trial where both low-risk and high-risk patients are put into a CT scanner. For the high-risk patients with a suspicion of pulmonary embolism, aortic dissection, or acute coronary syn-drome, he is finding the Dual Source scanners high-image-quality, even at high heart rates or with obese patients, extremely helpful. “You can do the ‘triple rule-out’ in real time, confirming three separate diagnoses with one scan,” says Hoffmann. For the low-risk patient sub-clinical disease can be captured also and treatment can be started that could pre-vent a heart attack in the future.” The Heart is a Moving Target Another advantage of the Dual Source CT scan seems to be speed. “Because the heart is moving, in order to get images of it that don’t have motion artifacts, you need to be able to scan as quickly as possible,” says Litt. He enthuses that a DSCT scanner like the SOMATOM Definition Flash scanner “can freeze the heart’s motion twice as fast as other com-peting technologies. This is a particularly important benefit for patients who come to the emergency room and cannot take a beta-blocker to lower their heart rate so that the heart beats more slowly. “In our patient population,” Litt explains, “we have patients with asthma or suspi-cion of other lung problems like pulmo-nary embolism, people who have taken cocaine recently – and you can’t use these types of drugs on them. With the new Dual Source CT, it is possible to do a thorax scan in a split second without holding breath. We can scan patients with higher heart rates and have confi-dence that we’re going to get good image quality.” Obese patients represent another clinical challenge. Litt says: “With the Dual Source CT technology, we’re able to get better image quality at lower radiation doses in Dual Source scanners deliver high image quality, even at high heart rates.
  23. 23. Business With sub-milliSievert heart scanning, the SOMATOM Definition Flash raises the bar higher in terms of cardiac dose saving. Louisa Kasdon is a Cambridge, Massachusetts-based writer who specializes in health, medi-cine, nutrition, food and business. She writes about health issues for Fortune magazine, the Boston Globe and the Christian Science Monitor. * Chang AM, Litt HI et al.: Actual Financial Comparison of Four Strategies to Evaluate Patients with Potential Acute Coronary Syndromes. ACADEMIC EMERGENCY MEDICINE. 2008; 15: 649-655. SOMATOM Sessions · May 2009 · 23 obese patients, even those who weigh more than 350 pounds.” At Raff’s hospi-tal in Michigan, using a new software package, that he terms the cardio obese model, in combination with the Dual Source CT allows him to scan 90% of obese patients and get a diagnostic image. Next Steps for CT Scanners? As the technology continues to improve, the doctors look ahead to a new era of even greater clinical utility as equipment like the Flash scanner comes into clinical use. When they see that one could now image at 83 milliseconds, they understand immediately that this is a tremendous improvement, really a quantum leap from the 64-slice CT. It opens up their patient population to patients who were previously considered not suitable – for example, those with calcification – and lets a diagnosis become even more quan-titative. Litt concurs, that with SOMATOM Definition Flash it is possible to image very quickly. “Typically a chest CT on an average high-end scanner might take five to ten, perhaps twenty seconds. With the new technology, you will be able to image the entire chest in less than one second. That will allow us to get very clear images of the heart, the pulmonary arteries, and the aorta without the patient needing to hold his breath. Similarly, in children and infants who can’t understand the direction to take a deep breath and hold it, you will be able to get motion-free images of the entire chest or the body in a time frame where the patient can remain still.” With sub-milliSievert heart scanning, the SOMATOM Definition Flash raises the bar even higher in terms of cardiac dose saving. Raff pronounces, “that with the CT of the heart being below 1 milliSievert, radiation will basically no longer be an issue.” Hoffmann says that, due to its low dose, it is even conceiv-able that, in the future, this technology could be used for early detection and prevention of acute myocardial infarc-tion. Another priority for the future is collect-ing better clinical data. The physicians are working together to launch several, large, multi-center trials to get demon-strable data and validation of the new triage pattern for their colleagues, for the NIH, and for the large public and private insurers such as Medicare in the USA, all of whom will have to be convinced of the CT scanner’s superiority as a diagnostic tool as well as its ability to increase work-flow and efficiency in emergency depart-ments all across the country. Other pri-orities for the doctors are education and training. Unless young physicians and radiological technicians are trained to use and interpret CT scans, the benefits of the technological advances will be limited to the most sophisticated medi-cal centers. Further Information somatom-definition
  24. 24. Topic “We are very pleased with the performance of the SOMATOM Emotion 16. The system reliability has been excellent.” Holly Klein, RT(R)(M), Director of Imaging/Cardiolab Services, Shannon Clinic, San Angelo, Texas, USA SOMATOM Emotion Around the Globe Worldwide sales of the SOMATOM Emotion CT system recently exceeded 6,500 units, making it globally the most popular CT system. SOMATOM Sessions asked eight clinics why they chose the Emotion system and how it has been put to use in their clinical environments. By Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany 24 SOMATOM Sessions · May 2009 · 6 “We were looking for a workhorse scanner, and the SOMATOM Emotion has proven to be that. We’ve never had any problems with the system – it’s great!” Reginald Moultrie, MD, Radiology Supervisor, Northside Hospital, Atlanta, Georgia, USA “The system has an extraordinary image quality – in fact, we have the best images in the entire city!” Ramírez Calderón, MD, Centro Médico de Diagnóstico Hermanos Ramírez Calderón, San Cristóbal, Táchira, Venezuela 5 7 Business
  25. 25. Topic Business “The image quality is excep-tional. SOMATOM Sessions · May 2009 · 25 The SOMATOM® Emotion has proven itself over and over again as a leading work-horse CT in almost all global CT markets. The SOMATOM Emotion has achieved this outstanding success through a com-bination of excellent image quality, lead-ing- edge clinical applications, efficient CT workflow and Siemens’ continued focus on system uptime. These factors offer Siemens customers enhanced clinical capabilities that translate into better clini-cal and financial outcomes. The success of this philosophy is easily recognized with over 6,500 satisfied and knowledge-able customers worldwide. On these pages, SOMATOM Sessions has put together a selection of quotes and stories from many successful SOMATOM Emotion installations from all corners of the globe. These sites are varied in nature, from outpatient clinics, to comprehen-sive trauma hospitals, and offer superb examples of why the SOMATOM Emotion is the world’s most popular CT system and The system enables us to scan and process patients’ images very fast. For emer-gency cases at night, we use only this system.” Yu Kang Chang, MD, CT Section Chief, Chie Mei Medical Center, Luiying, Tainan, Taiwan 2 “We examine practically the complete non-cardiac spectrum of patients on our SOMATOM Emotion 6 – from patients with diffuse lung disease to those with cerebral ischemia.” Pavel Elias, MD, PhD, Professor of Radiology, University Hospital Hradec Králové, Czech Republic “All examinations – head, whole body, thorax, abdomen and pelvis – are performed with the SOMATOM Emotion 16. The postprocessing is extremely fast.” Prof. Kunihiko Fukuda, MD, Tokyo Jikei University Hospital, Japan why it is the right choice for CT service installation. 1 Tokyo Jikei University Hospital, Japan. The Tokyo Jikei University Hospital is one of four hospitals associated with the Jikei School of Medicine. The hospital is large, with over 1,050 beds and 3,000 outpatient visits per day, six days a week. It has four CT systems to service both in- and outpatients. In 2006, the hospital 1 Business 8 3 4
  26. 26. Business installed a SOMATOM Emotion 16 to ser-vice all routine examinations and emer-gency cases. Professor Kunihiko Fukuda says that up to 70 patients are examined with the Emotion 16 per day: “All exam-inations – head, whole body, thorax, abdomen and pelvis – are performed with the SOMATOM Emotion 16 at our hospital. The postprocessing is extremely fast. The techs create MPR, MIP and 3D images in no time at all.” 2 University Hospital Hradec Králové Czech Republic. The Department of Radiology at the Uni-versity Hospital Hradec Králové is associ-ated with the Charles University in Prague. This facility ranks among the most significant healthcare facilities in the Czech Republic. The hospital serves a population of approximately 1,000,000 residents and many departments attract patients from the entire Czech Republic. The hospital is an important training cen-ter for physicians and secondary school educated medical workers. Every year, about 42,000 patients are admitted to 21 clinics with about 1,500 beds, and ap-proximately 660,000 patients are treated as outpatients. Since 2004, the lead CT system has been a SOMATOM Emotion. Pavel Elias, MD, PhD, from the University Hospital Hradec Králové says: “There are two CT scanners working in our facility. We examine practically the complete non-cardiac spectrum of patients on our SOMATOM Emotion 6 – from patients with diffuse lung disease to those with The SOMATOM Emotion has proven itself as a leading workhorse CT. cerebral ischemia. Perfusion studies or CT angiography are crucial for treatment pa-tients with cerebral ischemia, subarach-noid hemorrhage, or for patients with an-eurysmal dilation of aorta. We exam up to 50 patients per day.” 3 Chi Mei Medical Center, Luiying, Tainan, Taiwan. The Chi Mei Medical Center in Luiying, Taiwan, installed the SOMATOM Emotion 6 in mid-2004. Initially, the system was used to examine over 1,400 26 SOMATOM Sessions · May 2009 · patients per month until a second CT system was installed. The SOMATOM Emotion system provides 24-hour ser-vices for all routine and emergency cases. “The image quality of the SOMATOM Emotion is exceptional, even when com-pared to the 64-slice systems in our department,” says CT Section Chief Yu-Kang Chang, MD. “The workflow of the SOMATOM Emotion 6 enables us to scan and process patients’ images very fast. It’s the reason why we only use SOMATOM Emotion 6 for emergency cases at night instead of the other CT systems in the department.” 4 Treviso Santa Maria Cà Foncello Hospital, Italy. The workload at the Neuroradiology Department of Treviso Santa Maria Cà Foncello Hospital can be very heavy. Over 13,000 CT procedures were performed on the SOMATOM Emotion 6 during 2008. “The Emotion 6 performance in neuro-radiology is without any doubt satisfying as far as image quality and scanning speed are concerned,” says the chairman of the department, Francesco Di Paola, MD. Moreover, he praises the versatility of the system. At his hospital, the “The SOMATOM Emotion 6 performance in neuroradiology is without any doubt satisfying. It offers the quality-to-price ratio the hospital was looking for.” Francesco Di Paola, MD, Chairman Neuroradiology Department, Treviso, Santa Maria Cà, Italy
  27. 27. Business SOMATOM Sessions · May 2009 · 27 SOMATOM Emotion is used not only for neurological-related exams (brain, head, maxillo-facial, CT angiography of the carotids and intracranic vessels) but also for general radiology (thorax and abdo-men). “The SOMATOM Emotion,” says Di Paola, “offers the quality-to-price ratio the hospital was looking for.” 5 Centro Médico de Diagnóstico Hermanos Ramírez Calderón, San Cristóbal, Táchira, Venezuela. Since the opening of the Centro Médico de Diagnóstico Hermanos Ramírez Calderón in 2007, the CT department’s patient traffic has grown to around 35 examinations per day. “We are a family of physicians and decided to build this center for the benefit of the city of San Cristóbal. Since I have four children who are radiologists, we decided on the field of diagnostics,” says Ramírez Calderón, MD. From the onset, the team of doctors was convinced that this center should offer the highest technology with state-of- the-art equipment. “When we started, we decided to work only with the best systems available on the market,” says Ramírez Calderón. “The Emotion is a very good CT system, it has extraordinary images – in fact, we have the best images in the entire city!” 6 Shannon Clinic, San Angelo, Texas, USA. Shannon Clinic is a large, multi-speciality outpatient clinic with around 120 physi-cians. In 2000, the hospital purchased a Siemens SOMATOM Emotion single slice system. “The system was easy to use and very reliable,” says Holly Klein, RT(R)(M), Director of Imaging/Cardiolab Services. “Our technologists loved it. Due to the higher quality and performance, Shannon Clinic decided to upgrade to the Siemens SOMATOM Emotion 6 in 2004.” Then, in 2008, a decision was taken to upgrade the Emotion 6 scanner to the SOMATOM Emotion 16. Since the decision the num-ber of CT examinations has steadily been growing from a base of around 300 cases per month. “We are very pleased with the performance of the SOMATOM Emotion 16. The system reliability has been excel-lent. We use the scanner to perform high-quality routine examinations such as abdomen, pelvis, head, and chest,” says Holly Klein. “Feedback from our radiology staff has been very positive about the image quality of the SOMATOM Emotion 16,” Klein continues. “Furthermore, our patients are particularly happy with the shorter scan times.” 7 Northside Hospital, Atlanta, Georgia, USA. With imaging facilities spread across a large metropolitan area, Northside Hospital in Atlanta, Georgia, needed a CT solution that would reliably and effi-of CT procedures. In 2007 alone, North-side performed more than 78,000 CT exams. The SOMATOM Emotion was built with reliability in mind and has not dis-appointed the staff at Northside. “We’ve never had any problems with it since we’ve had it here,” says radiology super-visor Reginald Moultrie. “It’s great.” 8 Yunus Emre State Hospital, Eskisehir, Turkey. The Yunus Emre State Hospital was first opened under the name Eskis˛ehir SSK District Hospital on the 4th of April 1963. In early 2005, the hospital has been handed over to the Ministry of Health. “We have optimized our hospital workfl ow with the fast scan protocols of the SOMATOM Emotion.” Alper Yurdasiper, MD, Yunus Emre State Hospital, Eskisehir, Turkey Further Information somatom-emotion ciently allow its staff to image a large volume of patients with a broad range of medical needs. “Our goal is to make sure that our care is convenient and patient-centric while also providing our referring physicians with high-quality imaging – regardless of location,” says director of Radiology Services, Deidre Dixon. In January 2008, Northside chose to install five Siemens SOMATOM Emotion CT scanners across their network. As a result, Northside has been able to expand its imaging services while gaining effi-ciencies and measurable financial bene-fits from faster workflow. “We were looking for a workhorse scanner,” says radiologist Carolyn J. Weaver, MD, “and the SOMATOM Emotion has proven to be that.” In addition to superb image quality, Northside wanted a system that would efficiently handle its large volume The SOMATOM Emotion 16 was installed in February 2008. “With the SOMATOM Emotion CT, we are able to scan 90 patients per day on average,” says Alper Yurdasiper, MD. “Especially in periphal angiography studies, the diagnostic sharpness has increased due to the great image quality of our SOMATOM Emotion. Radiologists in our hospital are grateful to achieve such high-quality CT images. Moreover, we optimized our hospital workflow with the fast scan protocols of the SOMATOM Emotion.’’
  28. 28. Topic Business Emilio Vega, Manager, Image Processing Lab at NYU Langone Medical Center, integrated syngo WebSpace, Siemens’ thin-client server technology, into clinical workflow. Economical Benefi ts Drive Thin-Client Server Technology By Joachim Buck, PhD Business Unit CT, Siemens Healthcare, Forchheim, Germany CT is making 3D post-processing and advanced clinical applications a necessity for daily routine in radiology depart-ments. Large volumes of data with thou-sands of images per study require 3D imaging for faster diagnosis. 3D as diag-nostic tool increases reading efficiency and saves time. Due to the CT data explo-sion and the increasing spectrum of clinical applications, hospitals and other clinical enterprises are searching for technologically and economically feasible solutions to access and utilize CT volume data. Consequently, in recent years, Siemens has developed more powerful clinical applications for cardiac, oncology, neuro, and acute care CT. The availability of high quality CT volume data and the development of new clinical applications deliver more and better information to 28 SOMATOM Sessions · May 2009 · clinicians for their treatment choices. However, the delivery of huge CT volume data sets to the individual workstations of the involved physicians is a heavy bur-den for the IT system and performance can, and often does, slow down con-siderably. In addition, the purchase of several stand-alone workstations, each fully packed with clinical applications, puts heavy pressure on the hospital’s
  29. 29. Business SOMATOM Sessions · May 2009 · 29 budget. In view of the increased aware-ness of IT infrastructure, and its potential impact on the organization’s business success, the strong trend from stand-alone workplaces to thin-client, server-based solutions, such as Siemens’ syngo WebSpace, is very natural and driven primarily by the following economic benefits: 3D reconstructions immediately available anywhere: Several thousand images per CT exam are no longer an exception. Referring physicians, neuro and orthopedic surgeons, oncologists etc., cannot view and diagnose all these images. They need 3D reconstructions and the functionality to interactively modify the 3D representations according to the specific details they are interested in. A thin-client, server-based system centralizes the complete 3D volume pro-cessing at the server. The 3D results are immediately available to the physicians on their personal viewing stations. They can make use of basic viewing features such as MPR, MIP or VRT and advanced clinical applications for cardiac, oncology, neuro, and acute care CT. Usage of existing IT infrastructure: For image processing, volume data sets are sent from the CT scanner to the central server where all the image processing software (e.g. vessel analysis) is up and running. From each unit (e.g. PACS view-ing station) connected to the server via the IT network, the clinician can start the processing of a CT volume data set. Thus thin-client server technology does not place any additional burden on the local hospital’s IT infrastructure. Large amounts of CT data are no longer distributed across the entire IT network to several work-stations. Therefore, 3D image processing does not slow down the system for other image transfer purposes. Expensive upgrades of the whole IT infrastructure are avoided. Cost-effective maintenance: A thin-client, server-based solution reduces time and cost of keeping data and soft-ware up-to-date and consistent across the healthcare enterprise. It saves a lot of technical man-hours required for both the installation and maintenance. Faster workflow and patient through-put: Within the radiology department, thin-client server technology significantly increases productivity. Technologists no longer need to run pre-processing at the scanner’s acquisition console. Radiology departments are able to shift higher salaried personnel from time-consuming, routine tasks to more com-plex and demanding duties, resulting in faster and better diagnosis for the patient. Increased revenue: Thin-client, server-based technology makes 3D post-pro-cessing and advanced clinical applications available to other departments within the hospital or to referring physicians. Therefore hospitals can significantly increase reimbursement and revenue. Shorter reading times: 3D reading soft-ware provides significant added value for the patient’s diagnosis. Compared to stand-alone workplaces, thin-client, server-based solutions are capable of speeding up the 3D reading process by easily integrating into existing PACS installations. The end result of being able to access the very same case in 3D applications with just one click, can lead to an earlier therapy decision for the patient. Competitive edge for the hospital/ department: Ongoing cost pressure due to shrinking healthcare budgets is com-mon to all healthcare facilities. As this fact drives the competition among hos-pitals and healthcare providers, thin-client server technology can provide a competitive edge in attracting referring physicians and patients as well as recruiting qualified medical staff to join the hospital or department. Significant cost reduction: 3D thin-client images are instantaneously avail-able on virtually any clinical-quality PC, PACS workstation etc. Hospitals no longer have to incur additional costs of adding hardware for 3D post-processing throughout the hospital or in remote locations. Investment protection and flexibility: Investment into thin-client server technology enables hospitals and other healthcare enterprises to gradually invest, depending on varying needs, and thus spread costs over several budget cycles. Investment protection programs, such as Siemens’ exclusive e-Tune, are the key to keeping hospitals and other healthcare enterprises economically on the safe side. “syngo WebSpace allows our clinicians to access advanced post-processing tools from any computer at the offi ce or even at home. This has given us fl exibility thus becoming more effi cient.” Emilio Vega, Manager, Image Processing Lab at NYU Langone Medical Center
  30. 30. Clinical Results Cardiovascular Case 1 Dual Source CT Unveils Several High-Grade Stenoses of Coronary Arteries By Evgeny Egin, MD* and Andreas Blaha** * Department of Radiology, Cardio Center, Volgograd, Russia ** Business Unit CT, Siemens Healthcare, Forchheim, Germany VRT of the LM, CX and RCA revealed calcified lesions in LAD (arrow, Fig. 1A). Lateral VRT shows the entire course of the RCA (arrow, Fig. 1B). 30 SOMATOM Sessions · May 2009 · approximately 8 mm from the ostium. Significant calcified plaques in the proximal part of the right coronary artery (RCA) and the left coronary artery descending (LAD) causing high-grade stenoses with hemodynamic relevance were observed. An additional high-grade stenosis was found in D1. COMMENTS With the high temporal resolution of the Dual Source CT, it was possible to perform a reliable and quick diagnosis even with this extreme arrhythmic heart rate. HISTORY A 77-year-old male patient presented with chest pain at the radiology depart-ment of the Cardio Center, Volgograd, Russia, in preparation for aortic femoral bypass surgery. The patient had a known history of several atherosclerotic arteries, without hemodynamic relevant stenoses and atrial fibrillation. The patient also suffered from chronic iron deficiency, cerebral atherosclerosis with temperate Parkinson’s Syndrome and inter-vertebral osteochondrosis with neurovascular dis-orders. DIAGNOSIS Prior to the contrast enhanced scan, a calcium scoring native cardiac scan was performed. Almost every segment showed coronary artery calcifications. The coronary CTA was performed with an arrhythmic heart rate of 65–181 bpm, on average 94 bpm. Aorta and pulmo-nary artery trunk and branches were not dilated. The scan revealed a right dominant heart, wide left main coronary artery (LM), left circumflex artery (CX) and its marginal branch as well as the right ventricular branch, all without hemodynamic rele-vant stenoses. A high-grade stenosis was detected in first diagonal branch (D1), 1B 1 1A CX LAD RCA
  31. 31. Cardiovascular Clinical Results Curved Planar Reformats of RCA including plaque analysis (Fig. 2A); curved LAD, with syngo Circulation plaque SOMATOM Sessions · May 2009 · 31 EXAMINATION PROTOCOL Scanner SOMATOM Definition Scan mode Spiral Spatial resolution 0.33 mm Scan area Heart HR Independent Temporal Scan length 149 mm Resolution 83 ms Scan direction Cranio-caudal Slice collimation 0.6 mm Scan time 13 s Slice width 0.75 mm Heart rate 65 – 181 bpm, 94 avrg. Reconstruction increment 0.6 mm Tube voltage 120/120 kV Reconstruction kernel B26f Tube current 198 mAs/rot. Postprocessing CT Cardiac Engine Rotation time 0.33 s 2B 3B 2A analysis (Fig. 2B). Crossectional cut of LAD (Fig. 3A); Curved Planar Reformats of RCA, with syngo Circulation QCA (Fig. 3B). 3A 2 3
  32. 32. Clinical Results Cardiovascular Case 2 SOMATOM Defi nition Flash: The Entire Heart Scanned in Just 270 ms with 0.95 mSv By Stephan Achenbach, MD* and Andreas Blaha** ** Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany ** Business Unit CT, Siemens Healthcare, Forchheim, Germany HISTORY A 70-year-old female patient was referred to the cardiology department because of recurrent episodes of atrial fibrillation accompanied by typical chest pain. Prior to catheter ablation, coronary CT angiog-raphy was scheduled to assess pulmo-nary vein anatomy and to rule out coro-nary artery stenoses. DIAGNOSIS During coronary CT angiography, which was performed using a SOMATOM® Definition Flash Dual Source CT system, the patient was in sinus rhythm (52 bpm). In order to achieve accurate contrast timing, contrast agent transit time was determined using a test bolus approach after injection of 10 ml contrast agent (Ultravist 370), followed by 60 ml of saline solution. Coronary CT angiography was performed in Flash Spiral mode (prospectively ECG-triggered spiral acqui-sition, 0.28 ms rotation time, pitch 3.2), with a 270 ms scan in cranio-caudal direction, triggered at 55% of the RR interval. 60 ml of contrast agent was followed by 60 ml saline chaser, both injected with 6 ml/s flow to keep the bolus as compact as possible. CT angiography was able to clearly demonstrate the absence of coronary artery stenoses as well as the absence of calcified and non-calcified plaques. A minor calcified lesion was located at the aortic valve. Anatomy of the left atri-um and pulmonary veins was normal. For coronary CT angiography, using the 32 SOMATOM Sessions · May 2009 · prospectively ECG-triggered Flash Spiral mode, the dose length product was 68 mGy/cm, corresponding to an estimated effective dose of 0.95 mSv. COMMENTS With a fast rotation time of 0.28 seconds and two X-ray tubes, the SOMATOM Definition Flash system allows a new, prospectively ECG-triggered spiral scan mode that uses a very high pitch value. This fast scan mode requires only 270 ms of data acquisition time within one single cardiac cycle and provides a temporal resolution of 75 ms. It there-fore allows ultra-low dose, artifact free visualization of the heart and coronary arteries. EXAMINATION PROTOCOL Scanner SOMATOM Definition Flash Scan mode Flash Spiral Cardio Pitch 3.2 Scan area Heart DLP 68 mGy/cm Scan length 120 mm Slice collimation 128 x 0.6 mm Scan direction Cranio-caudal Slice width 0.75 mm Scan time 270 ms Spatial resolution 0.33 mm Tube voltage 100/100 kV Reconstruction increment 0.4 mm Tube current 320 mAs/rot Reconstruction kernel B26f CTDIvol 3.29 mGy Volume 60 ml contrast Effective Dose 0.95 mSv Start delay 24 s Rotation time 0.28 s Postprocessing CT Cardiac Engine
  33. 33. Volume 1A 1B 1 rendered image of the heart, highlighting the coronary arteries in the foreground as well as the left atrium in the background (LA in red). Curved planar reformation in MIP technique depicts the entire course of the RCA (Fig. 2A). The “angio like view” in MIP from ante-rior oblique direc-tion shows the entire coronary tree (Fig. 2B); image processing with syngo Circu-lation. Volume rendered image of the heart show-ing the right coro-nary artery (RCA, arrow) and right ventricular branch (RVB, arrowhead, Fig. 3A). Volume rendered image of the posterior descending artery (PDA, arrowhead) and the left artery descending (LAD, arrow, Fig. 3B). Curved planar reformation with syngo Circulation in MIP technique shows the entire course of the LCX (Fig. 4A) and the LAD (Fig. 4B) for interactive lesion evaluation. SOMATOM Sessions · May 2009 · 33 2A 2B 3A 3B 4A 4B 2 3 4
  34. 34. Clinical Results Cardiovascular Case 3 Low Dose 3D Evaluation of a Child’s Heart with Anomalous Venous Return with the SOMATOM Sensation By Robert Gilkeson, MD University Hospital, Case Medical Center, Cleveland, Ohio, USA HISTORY A 19-month-old male patient presented with failure to thrive. An echocardiogram demonstrated a markedly enlarged right ventricle and findings consistent with total anomalous venous return. A mark-edly enlarged common draining vein entering the superior vena cava (SVC) was identified. The echocardiogram was limited in delineating the full course of this anomalous vein. For pre-surgical eval-uation, a three dimensional evaluation was needed. A CT scan was requested by the surgical team. The patient’s weight was 14 kg (31lbs) with a heart rate of 132 bpm. A “feed and bundle” technique EXAMINATION PROTOCOL was performed, where the performance of the CT was coordinated with the last bottle-feeding. There was no need for patient sedation, the IV contrast was hand injected at a dose of 2cc/kg. A low-dose CT angiographic technique was performed with a protocol used to evalu-ate infants with congenital heart dis-ease. The X-ray dose that had to be ap-plied was 0.102 mSv with DLP 6 mGycm. DIAGNOSIS Volumetric and MIP reconstructions demonstrate a markedly enlarged anom-alous Scanner SOMATOM Sensation 40-slice configuration Scan mode Spiral, Care Dose4D, MinDose Spatial resolution 0.33 mm Scan area Chest Reconstruction increment 0.4 mm Scan length 130 mm Reconstruction kernel B20f Scan direction Cranio-caudal Volume 28 ml Scan time 5 s Start delay No actual “scan delay”. Heart rate 132 bpm Because of the small size of Tube voltage 80 kV these patients, a pressure Tube current 10 mAs/rot. injector was not used. Begin of Dose modulation Retrospective ECG gating with imaging as soon as approxi- MinDose technique mately ¾ of the contrast medium Rotation time 0.33 s has been infused. Slice collimation 0.6 mm Postprocessing syngo 3D Slice width 0.75 mm 34 SOMATOM Sessions · May 2009 · common draining vein emptying into the SVC. The right ventricle was markedly dilated. COMMENTS Due to the 0.33 s fast rotation time and corresponding high temporal resolution, the pediatric patient’s heart could be vi-sualized without motion artifacts despite the high heart rate of 132 bpm. These images were important in the surgical planning, and surgical redirection of the large anomalous vein into the left atri-um has been successfully performed.
  35. 35. Cardiovascular Clinical Results 1A 1B Low dose (0.1 mSv) axial image demonstrates the anomalous common vein draining into the SVC (white arrows). SOMATOM Sessions · May 2009 · 35 Axial image demonstrates anomalous drainage of pulmonary 1 veins (orange arrows) into common draining vein (white arrow). Coronal MIP image demonstrates large anomalous draining vein emptying into SVC (white arrows). Marked enlargement of right ventricle (RV) is clearly visible. 2 3 2 3 RV
  36. 36. Clinical Results Cardiovascular Case 4 Cardiac Scan Prior to Bariatric Surgery By Uma Valeti, MD Department of Cardiology, St. Paul Heart Clinic, Saint Paul, Minnesota, USA HISTORY A 57-year-old obese female patient with a body mass index (BMI) of 52, weight 305 lbs (138.6 kg), presented for a pre-operative evaluation to undergo a bar-iatric surgery. The patient had cardiac risk factors of hypertension (HTN), hyper-lipidemia and diabetes mellitus. An exer-cise cardiolite stress test was performed with equivocal results due to the pres-ence of attenuation and splanchnic arti-facts due to the large body habitus. DIAGNOSIS The patient, presented with a heart rate of 78 beats per minute, was given 0.4 sublingual nitroglycerin (NTG) prior to the scan. The contrast flow rate was increased to 7 ml/s for improved contrast to noise ratio, total volume of contrast was set to 100 ml. The start of the coronary CTA was trig-gered by the Bolus Tracking approach, placing a region of interest in the aorta ascending. During the fast scan time of only eight seconds the scan revealed mild to moder-ate stenoses associated with mixed plaque in the proximal left artery descending (LAD, Figs. 4–5). COMMENTS The cardiac obese protocol done with combining information in 165 ms of the cardiac circle shows improvement in the signal to noise ratio compared to the standard of using 82 ms (Figs. 3A–3B). 1 36 SOMATOM Sessions · May 2009 · Colored volume rendered image of the heart (VRT) embedded in thoracic cage. VRT of the heart showing the entire course of LAD and first diagonal (D1) branch lesion marked with arrow. 2 1 2
  37. 37. 5 SOMATOM Sessions · May 2009 · 37 3A 3B Improved signal to noise ratio using 165 ms data acquisition (Fig. 3A) versus 82 ms data acquisition (Fig. 3B). 4 Moderate stenosis in proximal segment of LAD 3 4 (mixed plaque). Cross-sectional cut of the stenotic area perpendicular to the centerline of curved LAD path. 5 EXAMINATION PROTOCOL Scanner SOMATOM Definition Scan mode Obese Cardio Protocol Pitch 0.32 Scan area Heart Spatial resolution 0.33 mm Scan length 124 mm Slice collimation 64 x 0.6 mm Scan direction Cranio-caudal Slice width 0.75 mm Scan time 8 s Reconstruction increment 0.4 mm Heart rate 78 bpm Reconstruction kernel B26f Tube voltage 120 kV Volume 100 ml Tube current 205 mAs/rot. Flow rate 7 ml/s Start delay Bolus Tracking Effective dose 6.2 mSv Rotation time 0.33 s Postprocessing CT Cardiac Engine
  38. 38. Clinical Results Cardiovascular Case 5 Detection of Unusual Case of Aorto-Leftventricular Tunnel with Dual Source CT By Wolfgang Eicher, MD, Thomas Kau, MD, Klaus Armin Hausegger, MD Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria HISTORY A 16-year-old patient appeared at the department of radiology suffering with fever for the past week. A Magnetic Resonance Tomography (MRT) and an echocardiographic investigation showed a thickened bicuspid aortic valve and a perfused tissue structure, seeming to arise from left-ventricular outflow tract. A coronary fistula could not be diagnos-tically excluded with these methods due to the extreme adjacency to left cir-cumflex coronary artery (LCX) and left main coronary artery (LMCA). To clarify whether or not there was a coronary aneurysm or an endocarditic based paravalvular aneurysmatic aorto-leftventricular tunnel (ALVT), a Dual Source CT was conducted under the fol-lowing conditions: DLP 120, 2.04 mSv, slice 7 x 0,6 x 32 x 2 mm, RECON, Saline flush mix 5 ml KM and 40 ml NaCl, flow 6 ml/s. The heart rate during the examination was 75 bpm. DIAGNOSIS In the cardio CT, a close relation between the inflammatory ALVT and the LM could be observed (distance 1–2 mm), whereas the LM itself and their lumen were not affected. Additionally, a small left ventricular perforation adjoining the bicuspid aortic valve was visible. The tiny hole in the aortic root could be only supposed. These findings seemed to be accordable with EXAMINATION PROTOCOL Scanner SOMATOM Definition Scan mode Adaptive Cardio Sequence Rotation time 0.33 s Scan area Heart Slice collimation 0.4 mm Scan length 175 mm Slice width 0.6 mm Scan direction Cranio-caudal Spatial resolution 0.33 mm Scan time 8 s Reconstruction increment 0.4 mm Heart rate 75 bpm Reconstruction kernel B26f Tube voltage 100 kV Volume 80 ml Tube current 190 mAs/rot. Flow rate 6 ml/s Dose modulation ECG-pulsing on, Start delay 2 s from 70–74%, MinDose off Postprocessing CT Cardiac Engine CTDIvol 7.09 mGy 38 SOMATOM Sessions · May 2009 · an inflammatory ALVT, based on endo-carditis of the bicuspid aortic valve, which could be confirmed by thorax surgery and histological findings. COMMENTS Afterwards, the etiopathology was controlled by transoesophageal echo-cardiography. The patient was treated by a two-step surgery. After closure of the left ventricular defect, the sac of the tunnel was growing and compressed the LCA leading to significant ischemic ECG abnormalities and elevated CK-MB. In a second step, the aortic hole was closed by a patch-plastic and the ALVT was obliterated by using fibrin adhesive.
  39. 39. 1A 1B Cross-sectional cut in left ventricle and ALTV above aortic valve showing inverted VRT. Arrows indicate relevant 1 region on each image. 2 3 4A 4B SOMATOM Sessions · May 2009 · 39 Cross-sectional cut in left ventricle and ALTV above aortic valve (arrow). With VRT calculation (yellow) the size of the lesion (arrow) can be measured. 2 3 Extraction of left coronary artery (LM) and circumflex coronary artery left neighboured by the ALTV visualized 4 with syngo Circulation (Fig. 4A). The ALTV is nicely visible in the cross-sectional axial slice (Fig. 4B).
  40. 40. Clinical Results Oncology Case 6 Dual Source CT Kidney Tumor Imaging with Virtual Non-Contrast Dual Energy By Jiri Ferda, MD, PhD and Boris Kreuzberg, MD, PhD Clinic of Radiodiagnostics, University Hospital Pilsen, Pilsen, Czech Republic HISTORY A 56-year-old male patient was referred to the University Hospital Pilsen with abdominal pressure pain near the right kidney region. The patient also experi-enced fever and weight loss. A hematuria exists and has been proven by the gen-eral practitioner. The proximate ultra-sound showed a right kidney infiltration. DIAGNOSIS After a Dual Energy scan performed on the SOMATOM® Definition, the post pro-cessing of the images in VNC (Virtual Non- Conrast) displayed a color-coded iodine distribution map. The Dual Energy iodine assignment confirmed a tumor infiltra-tion of the right kidney and, emphasized by color-coding, the hypervascularized tumor tissue with involvement of the renal vein. The same SOMATOM Definition scan verified metastases in retroperitoneal lymph nodes. COMMENTS In the Dual Energy mode, two X-ray sources can be operated simultaneously at different kV levels. The results are two spiral data sets, acquired in a single scan, providing diverse information that 40 SOMATOM Sessions · May 2009 · allows one to differentiate, characterize, isolate, and distinguish the imaged tissue and material. Enhancement patterns of kidney regions can be clearly visualized with the Dual Energy VNC application. EXAMINATION PROTOCOL Scanner SOMATOM Definition Scan mode Spiral Scan area Abdomen Scan length 500 mm Scan direction Cranio-caudal Scan time 17 s Tube voltage A/B 140/80 kV Tube current A/B 60/360 Eff. mAs Rotation time 0.5 s Spatial resolution 0.33 mm Slice collimation 0.6 mm Slice width 0.6 mm Reconstruction increment 0.4 mm Reconstruction kernel D20f Postprocessing syngo DE Virtual Unenhanced (VNC)
  41. 41. 2 1 2 SOMATOM Sessions · May 2009 · 41 1 Dual Energy Virtual Non-Contrast (VNC) scan. Dual Energy scan shows vascularisation of tumor, composed data with contrast (arrows). Mixed visualization of VNC and iodine concentration. Dual Energy application highlights iodine concentration. 5 6 VRT with Bone Removal shows vascular status of the tumor (arrow). Coronal reformation of the right kidney using Optimum Contrast. 3 4 3 4 5 6