The era of interventional imaging has arrived: what role for computed tomography and magnetic resonance?

Abstract

Coronary computed tomography angiography (CCTA) is the first-line investigation test to 'rule out' significant coronary artery disease in low-risk patients. By performing blood flow simulations using computational fluid dynamics, it is possible to derive fractional flow reserve (FFR) from CCTA (FFRCT) images. Coronary computed tomography angiography and FFRCT are now utilized in higher-risk patients to choose the revascularization mode. Furthermore, new applications of CCTA and FFRCT include a planning tool for percutaneous coronary intervention (PCI), which allows the cardiologist to assess lesion-specific ischaemia, plan stent locations and sizes, and use virtual remodelling of the lumen (virtual stenting) to assess the functional impact of PCI. Moreover, CCTA can assist in planning surgical and percutaneous revascularization by determining the disease complexity, vessel size, lesion length, and tissue composition of the atherosclerotic plaque, as well as the best fluoroscopic viewing angle; it may also help in selecting adjunctive percutaneous devices (e.g. rotational atherectomy) and in determining the best landing zone for stents or bypass grafts. Coronary computed tomography angiography has become also the gold standard for pre-procedural annular assessment, device sizing, risk determination of annular injury, coronary occlusion or left ventricular outflow tract obstruction, calcification visualization and quantification of the target structure, and prediction of a co-planar fluoroscopic angulation for transcatheter interventions in patients with structural heart disease. Coronary computed tomography angiography and cardiac magnetic resonance could be used also in electrophysiology procedures of atrial fibrillation and ventricular arrhythmias ablation (imaging during clinical evaluation and pre-procedural evaluation and intra-procedural live integration). The era of interventional imaging has arrived, and it is based on the cooperation of different figures with specific competences (cardio-imagers, electrophysiologists, cardiac surgeons, and invasive cardiologists).