title: Computed tomography angiography of coronary artery bypass grafts: robustness in emergency and clinical routine settings.
abstract: BACKGROUND
  There is a high probability for presence of irregular heart rates and artifacts in patients with previous coronary artery bypass graft (CABG) surgery. Previously reported diagnostic performance of ECG-gated 64-slice dual-source computer tomography angiography (CTA) in this patient group is based on pre-selection for normal heart rate and routine clinical setting.
  
  
  OBJECTIVE
  To investigate image quality and diagnostic performance of CTA in patients with previous CABG surgery in various clinical settings.
  
  
  METHODS
  Fifty-six non-selected, consecutive patients (110 grafts, 44 arterial, 66 venous) with previous CABG surgery were prospectively examined using a dual-source 64-slice CT (Siemens Definition, Forchheim, Germany) without utilization of CT-related pharmaceutical heart rate control. Patients were stratified according to the clinical setting: planned redo-cardiac surgery; emergency CTA within 30 days after CABG surgery; routine follow-up after CABG surgery. A reference standard was available for 30 patients (53.6%; 67/110 grafts). Image quality, artifacts, and graft patency were independently assessed by two observers.
  
  
  RESULTS
  All CTAs were diagnostic despite the presence of irregular heart rhythm (25% of cases) and artifacts (72.7% of grafts). CTA was accurate in all patient groups in assessing graft patency (97.9% sensitivity; 100% specificity; 98.5% accuracy) but artifacts decreased diagnostic performance for stenosis detection (60% sensitivity; 88.6% specificity; 84.1% accuracy). Arterial grafts exhibited more surgical clip artifacts compared to venous grafts, which predominantly showed motion artifacts. Overall diagnostic quality was rated excellent in 70.9%/56.4%, good in 23.4%/39.1%, and sufficient in 5.5%/4.5% by each observer, respectively. CTA detected acute findings in 10 cases (graft bleeding, graft occlusion, pericardial hematoma, sternal instability with retrosternal abscess formation, pericardial effusion, left ventricle thrombus) in the emergency group; seven cases required surgical revision.
  
  
  CONCLUSIONS
  Dual-source CTA is a robust and accurate method for assessment of graft patency and detection of relevant extra-cardiac pathologies in a non-selected patient population after CABG surgery in routine as well as emergency clinical settings. Artifacts caused by irregular heart rhythm or surgical clips do not impair graft patency evaluation but limit stenosis assessment.
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Heye
authors.forename: Hans-Ulrich
authors.initials: HU
authors.lastname: Kauczor
authors.forename: Gabor
authors.initials: G
authors.lastname: Szabo
authors.forename: Waldemar
authors.initials: W
authors.lastname: Hosch
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D023903:Coronary Restenosis / Q000175:diagnosis* / Q000601:surgery; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis* / Q000601:surgery; D006339:Heart Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed; D014654:Vascular Patency
keywords: CT angiography; Cardiac; adults; artefact; coronary artery bypass graft