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  • 1.  help!

    Posted 08-04-2021 13:14
    Hi everyone!
    I am a cardiothoracic radiologist in San Juan, PR. I recently started working after finishing my cardiothoracic radiology fellowship and I am starting from zero cardiac imaging centers in PR. Even though I passed my SCCT boards (thankfully!) I feel I need some guidance establishing protocols individualized to the CT scanners and equipment we have available. If someone has the time and would be so nice and offer me some knowledge I would greatly appreciate it!
    Thank you in advance,
    Camila Saade

  • 2.  RE: help!

    Board of Directors
    Posted 08-05-2021 02:34
    Hi Camila
    What CT scanners are you working with?
    I found the SCCT acquisition and reporting guidelines really helpful when I was starting out even though they weren't scanner specific - 

    Dr Michelle Williams
    University of Edinburgh

  • 3.  RE: help!

    Posted 08-05-2021 14:31
    Hi Michelle, Kimberly, Thi Thanh and everyone else,

    Thank you so much for reaching out. I decided to answer in the group chat instead of individually since a couple of you reached out to me.

    Yes, I used this great article (2016 SCCT guidelines for the performance and acquisition of CCTA...) to start redacting my protocol and it has helped me a lot but it is not scanner specific and most of the recommendations need to be individualized with the scanner to be used and that's were I am having problems with.

    I have been working with a Philips Brilliance 64 row detector and recently with a Philips Ingenuity 128 row detector in another hospital. I believe the fastest gantry rotation time for Philips CTs is 0.4 sec as for temporal resolution, which I know is one of the most important things in cardiac imaging, so I know administering metoprolol is a most in order to get diagnostic images. We give metoprolol IV (up to 25 mg) to control HR, ideally get it to be 60 or so but I feel even with this HR I still get a lot of motion artifact. I recently sent an email to cardiologists as to please prescribe metoprolol for patients to take 12 h before exam as I read it helps a lot to achieve target HR the day of the exam (in there are no contraindications of course); hopefully this will work out. 

    Sometimes images are very noisy and I know we should increase mAs to improve noise, but is that something we do (me and technologist) or the scanner does that automatically? I have the same question for kVp; I know we should use higher kVp for big patients but how much more and above which BMI? Should I follow the standard recommendations or is this something that changes depending on the scanner? Also, does the scanner does this automatically or we have to manually change it?

    How do I choose the contrast volume? I know this depends on several things (scan duration, body weight, injection rate). We use Optiray 350 and our CT techs give 125 ml for "normal/small" patients and 150 ml for obese patients, this is a standard they use for every CT exam, but I feel this is a lot and not sure if this is right. We have dual injectors.
    We do bolus tracking with ROI in the DA. In the beginning we put ROI in the AA but attenuation was suboptimal so we changed to the DA to give contrast more time to travel and it worked. I am pretty sure we don't give saline although I know it is recommended to decrease streak artifact in the RA.  

    For TAVR exams we scan patient twice for heart CTA and then again for ab/pel CTA because scan is not fast enough with a 64 detector CT so we divide contrast in half and administer twice (maybe with the 128 we can scan once).

    I know if HR is great (60 or less) we are supposed to do prospective EKG gating to decrease dose but so far every exam has been done retrospective. Is this something that the tech chooses or the scanner does this automatically? I am not even sure our cardiac package has capability for prospective triggering...is this possible?

    As for image reconstruction and post processing, which slice thicknes should we use? smallest possible? is this something that the scanner/cardiac package selects automatically? 

    For nitro, recommendations are 0.4-0.8, should I give one tablet/spray or two?

    I know this is a lot of information/questions but anything you can help me with and help me clarify I would be eternally grateful. I feel so grateful to have all of you smart ladies as a resource and for support!

    Warm hug from Puerto Rico,


    Camila Saade MD
    University of South Florida Program

  • 4.  RE: help!

    Posted 08-06-2021 03:50

    Hi Camila,

    I wrote very long, and it was disappeared after website refeshed. I will type in word and post later for you.

    City international hospital

  • 5.  RE: help!

    Posted 08-07-2021 12:26
    Dear Camila,

    I did not find any ward in your emIl about breathing instruction, respiratory delay, padding and noise level that smart machines would calculate for you before starting imaging.

    It would be very helpfulto reduce the noise level ahead.

    Let me know if it helps

  • 6.  RE: help!

    Posted 08-07-2021 13:43
    Hello Nawal,

    As for breathing instructions, we tell our patients to hold their breath before scanning but we don't practice before or anything. I am not exactly  sure what you mean about respiratory delay. Padding you mean increasing the time the tube current is on in prospective imaging? Theoretically I know what this is but not sure if that's something we can do or how it helps. I would need to see the capabilities of our scanner to see how it adjusts the noise and if it does it automatically. 


    Camila Saade MD
    University of South Florida Program

  • 7.  RE: help!

    Posted 08-07-2021 14:03
    We do train our patient ahead of scanning for breathing instruction, we instruct them not to move during scanning.
    We give breathing instruction during scout and timing bolous as well.. this help them train while inside the machine as well..
    The patient has instruction for breathing: take breath>> breath out.. take breath again and hold your breath inside.
    About 3 seconds delay between breathing and scanning is good to reduce noise.

    We gate the scanning with ECG and we choose the diasolic diatasis period between 70-75 or 70 and 80% (padding) of the cardiac cycle if we study the coronaries, this will depend on the heart rate and rate variability, will be asjusted for the clinical indication as well.
    We observe the patient during scanning for compliance of breathing instruction and for movemene as well.

    I hope this could help.

  • 8.  RE: help!

    Posted 08-07-2021 12:54
    Hi Camila,

    Since I am traveling right now, when I return to work, Aug 16, I will put together a folder of information together for you to reference.

    Thank you.

    Kimberly Hatch RT R CT

    Sent from my iPhone. 😊

  • 9.  RE: help!

    Posted 08-07-2021 13:33
    Thank you so much, Kimberly! 
    Have nice travels ;)

    Camila Saade MD
    University of South Florida Program

  • 10.  RE: help!

    Posted 08-07-2021 13:46
    Hi Michelle,

    I am working with a Philips Brilliance 64 detector and Philips Ingenuity 128 detector.

    Yes! I used this article to redact the protocol I am still working with.


    Camila Saade MD
    University of South Florida Program

  • 11.  RE: help!

    Posted 08-05-2021 13:30
    Hi Camila,

    I need to know:
    - CT scanner name you work and model
    - Retrospective (spiral) or prospective (sequence): which one you prefer (most people choose prospective with stable heart rate to reduce dose)
       + In case you choose retrospective, I need to know Rotation time to check the lowest heart rate that you can scan, otherwise it will have interpolation artifact.

    Guidlines: https://cdn.ymaws.com/scct.org/resource/resmgr/SCCT_guidelines_for_the_perf.pdf

    I am Siemens user, so I can help you if you use Siemens too.


    City international hospital

  • 12.  RE: help!

    Posted 08-07-2021 09:21
    I am a CT technologist that has worked on a Phillips 64 Brilliance for the last 16 years working in a Cardiologist office.  I would be glad to share our scan protocols.   If you can email me at earleen.bigio@bswhealth.org.  (for some reason my work computer security blocks this communication thread) 
    To answer some questions that you ask:
    1.  We pre mediate our patients with Nadolol one pill the night before the exam and one pill the morning of the exam.   The dose is based on the patients weight, blood pressure,  ect.   We have very good luck in achieving a HR of below 60 for most patients.   If needed we can additionally give IV metoprolol 
     at the time of scan to help if HR is still above 70.     
    2.  We never raise our KVP (I know some technologist do) we do increase our mass, based on patients weight. The technologist has to adjust the mass.   We have had good success scanning 300lbs+  you have to give more contrast we would give 150ml.  We use Omnipaque 350, have tried other contrast but this one seems to work best for us. We also use a contrast flow rate of 6 on very large patients.  We use a mix of 70% contrast 30% mix (saline and contrast) followed by 50ml saline chaser.
    3. We use 100ml contrast on smaller patients, over 200lbs we start increasing the amount, anyone over 250lbs we use 150ml contrast using the mix above.  It is very important that you give the contrast at a rate of 5.5ml per second or 6.0ml per second.  Using a 18g IV.  We prefer to use the right arm, when we can.   
    4. We use the DA for the smart prep, was taught to measure 6mm for the carina and this proves to be a consistent marker, 16 years and I still measure each heart I do.  We use retrospective scanning, our cardiologist want to see multi phases (8 of them) with the 75% phase is usually the best.  
    Our older scanner does not do auto prospective scanning, we have a "Step and Shoot" protocol that reduces radiation but only provides one phase. our cardiologist want so see all the phases to provide the EF function.
    5. I can send you the scan/reconstruction protocols, yes you use a thin slice for the reconstructions.  Once you have your protocols built into the scanner then the technologist does not have to set these each time.  The factory protocols are a start but have to be adjusted as you learn what works best for you.  
    6. We use nitro, one spray or one tablet under the tongue.  Wait 2 min and then scan.  

    There is so much to learn when doing Cardiac CTA.  It is much more than just pressing the button and getting a scan.  The patients have to be instructed on breath holds, we even practice with them as breathing motion can make a horrible scan.  Explain the "hot" feeling that they will get from the contrast.   We have learned that if a patients HR is above 70 chances are your scan will not be good, it is better to reschedule than expose the patient to radiation and have a bad scan.  HR's are not always normal,  knowing when a EKG is not going to allow a good scan. (patient's in A-fib, PVC's)   Knowing the patients EF when possible as this effects the way the contrast goes thru the heart and effects the timing of the contrast.   
    A lot of this is  experience and each bad scan should be a learning tool to see why, what went wrong and how you can change something to make it better. 
    Hope this has helped, please send me a email and I will be glad to send the scan protocols in a pdf.  

    Earleen Bigio

    Earleen Bigio RT
    CT Technologist
    BS&W Cardiovascular Consultants Grapevine

  • 13.  RE: help!

    Posted 08-07-2021 13:59
    Hello Earleen,

    Thank you so much for all this information. This is very helpful. I will definitely email you for the protocols and thank you!

    Any reason why you premedicate with nadolol instead of metoprolol?

    Will look into increasing injection rate to 6 in very large patients. I am pretty sure we stay at 5 for everyone.

    So you do a biphasic injection and instead of giving just contrast initially you give a mixture of contrast and saline and then saline? Is this because just injecting contrast is too high of a concentration?...interesting.

    Thank you again!


    Camila Saade MD
    University of South Florida Program

  • 14.  RE: help!

    Posted 08-07-2021 19:58
      |   view attached

    Hi Camila,

    This file is 15 pages for my experience and also answer your questions in details. These pics I took from google and also myself, so... somes pics I did not add source because they are long time ago and I forgot where I download. Secondly, I will not mention medical contraindications. For TAVI, I also scan like you, the rest I answer in this file which yellow highlight. Because I lost all what I typed here when website refreshed @@. Hope can help you!

    City international hospital


    1.pdf   2.45 MB 1 version