Patent Grant
7065395
The invention concerns medical imaging in cardiology and, in particular, coronary angiography and, as the case may be, in ventriculography.
Radiological examinations in coronary angiography and ventriculography are usually carried out by dynamic filming from different fixed image planes around the heart, which constitute reference angulations. Several sequences of images are then obtained, typically for a few seconds each, making it possible to visualize as a whole, through those different planes, the structure of the coronary arterial tree, of the aorta and of the left ventricle, each plane offering a two-dimensional point of view.
The parts of interest are revealed by opacification by means of a contrast medium in liquid form introduced in well controlled areas. In order to perform those injections on a coronary angiography and venticulography examination, three different catheters are ordinarily used. A protocol according to which dynamic image sequences are obtained, each sequence being taken form a respective fixed plane.
The protocol as a whole is lengthy and labored owing to the fact that it requires successively introducing and withdrawing three different catheters, with an injection each time of contrast medium for each image plane. Furthermore, the total quantity of contrast fluid injected has to be limited because of its toxicity. The time allotted to the injections in the coronary arteries is therefore very short and may be insufficient to follow the progress of the product well. The protocol also has the disadvantage of requiring many repeated positionings of the source-detector tandem in order to make the different acquisitions, which also shortens the examination time. especially in the case of a cradle with manual displacement. As for costs, it is necessary to arrange, among other things, to make three different catheters available for a complete examination.
The invention is directed to a protocol, i.e., method, of coronary angiographic imaging, possibly accompanied by ventriculographic imaging, which makes better use of the contrast medium possible and which is well suited to three-dimensional dynamic imaging.
In particular, the invention concerns a method of cardiac radiological examination in coronary angiography, comprising:
a) introducing a contrast medium simultaneously in the left coronary artery and in the right coronary artery from the root of the aorta and, in parallel,
b) acquiring a sequence of dynamic images of propagation of the contrast medium in the loft and right coronary arteries with procession of the image plane, upon acquisition of images, on a given path.
The invention also concerns a device for injection of contrast medium in a catheter intended for cardiac radiology, which it is guided by a signal detecting cardiac rhythms, so as to inject-the contrast medium during cycles synchronized with given phases of the cardiac rhythm.
The invention will be more clearly apparent, with reference to the attached drawings, in which:
The three different catheters are positioned respectively as shown in
In contrast to catheters 28, 30 intended for the coronary arteries, the 32c of the pigtail catheter contains several outlets for the contrast fluid, uniformly distributed on the periphery of its wall just before its termination point. Hence, the contrast fluid is appreciably dispersed uniformly around the end portion and rapidly fills the cavity of the left ventricle.
Catheters 28, 30, 32 are introduced in the body from a part distant from the heart, generally from a peripheral artery or vein. The catheters are guided along the arteries by a wire contained inside and which keeps the injection ends appreciably straight until approaching the point of arrival. The wire is then withdrawn from the end to enable the latter to recover its adapted shape. The opposite end of the catheter is connected either to a manually operated syringe, in the case of catheters intended for the coronary arteries, or to an electrically controlled automatic injector, in the case of a pigtail catheter intended for the ventricle.
Referring to
As
For each sequence, a dosed quantity of contrast medium, normally about five cubic centimeters, is manually injected throughout the filming sequence. that is, over a period of five to six seconds. The rate of acquisition is 25 or 30 images per second (according to European or United States standards), giving a total in the order of 150 to 200 acquired images per plane.
The method begins by placing the source-sensor tandem 38, 40 for acquisition of the front sequence (stage E3). During the positioning, it is verified by fluoroscopy that the image plane is correctly framed and that the catheter is always well positioned (stage E4), making adjustments when necessary. Acquisition of the dynamic sequence is then controlled (stage E5) under X-rays and the contrast medium is simultaneously injected under the aforesaid conditions (stage E6). When acquisition is completed, the same procedure is undertaken for each of the following planes (OAG 70, OAG 90 and OAD 20), with the respective positioning stages (E7, E8, E9). Altogether, approximately 20 seconds of dynamic sequences of the left coronary artery are thus acquired, with a total dose in the order of 20 cubic centimeters.
The catheter 28 is then withdrawn (stage E10) and, in its place, the catheter 30 intended for the right coronary artery is introduced in the aperture of the latter (stage E11). The PA procedure of acquisitions of dynamic sequences described above is then restarted. That PA procedure can possibly be modified at the reference positions in order to better suit the configuration of the structure of the right coronary artery. After the sequence acquisitions for the right coronary artery, the catheter is withdrawn (stage E10′).
The method continues with ventriculography by introduction of the pigtail catheter 32 in the cavity of the left ventricle (stage E12), with a right anterior oblique positioning of the image plane at 30° (OAD 30) (stage E13). The acquisition of a dynamic image sequence is then begun over a period in the order of three or four seconds (stage E14). During that acquisition approximately 40 cubic centimeters of contrast medium is injected by means of an electromechanical injector (stage E15). Exploration of the ventricle makes it possible to visualize its general shape and to observe the manner in which it is contracted. In some cases, views are also acquired in the OAG 60 axis, when it is a question of detecting anomalies of movement of the wall of the septum. Finally, the catheter 32 is withdrawn on completion of the examination protocol (stage E10″).
Embodiments of the invention are presented within the context of a radiology apparatus which enables displacements of the source-detector tandem to be made along a so-called “left” curve (i.e., not situated on a single plane), as described in FR00 07155. However, the invention can also be used with a standard radiological imaging apparatus.
As
The arrangement of axes 42, 52 and 54 permits a three-dimensional displacement in space of the source-detector tandem 48, 50 with degrees of freedom on two perpendicular planes, respectively aligned with the craniocaudal axis and with the right-left axis of the patient. The movements in each of these degrees of freedom are controlled independently by means of respective programmable actuators (not represented), although it is possible to form paths of the axis 52 of the source-detector tandem 48, 50 following left surfaces. The element of interest for that path being the sensitive surface of the detector 50, a path will be defined below in terms of displacement of the center of the image plane, comparable to the center of that sensitive surface 50. This central point therefore captures the radiation coming from the focal point of the source 48 after having crossed the patient at the isocenter 56.
It is also possible to have programming displacements of the image plane on a path which turns around the craniocaudal axis and is displaced toward the patient's head or feet on approaching its front view.
The entire operation of the apparatus 34 is managed by a microprocessor-based control unit 58 with an access console for the different functions 60 and a screen 62 for visualization of the different parameters and radiological images acquired. In the embodiment, the control unit is connected to an electrocardiograph machine 64 in order to synchronize certain actions with the movements of the heart and to an electromechanical injector 65 of contrast fluid having an injection tube 65a intended to fit into a catheter 32.
The functionalities managed by the control unit 58 are: (1) the respective actuators for the displacements of the source-detector tandem 48, 50 around axes 42, 54, with programming of: the path along a left (or flat) curve, the course of the rate of displacement (accelerations, decelerations) and stops on the path; (2) filming parameters: control of activation of the source and detector; and (3) operation of the injector 65, including control of an injection sequence divided into several injection cycles, with the following parameters: the start and interruption of an injection sequence synchronized with the start and stop of the image acquisition sequence, the beginning and end of each injection cycle as a function of the electrocardiogram (ECG) delivered by the electrocardiograph machine 64, the number of injection cycles and the injection delivery.
The control unit 58 also calculates a path and/or to memorize it. The path can be calculated from angulations, which can be indicated either by the user via the console 60 or by manually positioning the mobile unit of the apparatus 34 according to that angulation and memorizing it. For example, by defining an angulation by three angles along the three three-dimensional marking axes 42, 52 and 54 linked to the apparatus 34, the user can, for instance, define a first angulation of coordinates (0, 0, 0), a second angulation of coordinates (0, 0, α) and a third angulation of coordinates (0, 0, β) with α and β not nil. The path can, of course, be programmed on a greater number of angulations. The control unit 58 then determines a path to be followed by the moving parts of the apparatus, by controlling the actuators in an appropriate manner, in order to make the image plane 50 pass through the angulations programmed, while taking into account the characteristics of the apparatus, such as: (1) possible angulations prohibited, because of the risk of causing collisions with the table 59, the patient, the source 48 or the detector 50, and (2) the mechanical or electromechanical stresses of the apparatus, such as maximum angular acceleration for each axis and the travel time, which should be as short as possible in order to minimize the total dose of contrast fluid to be injected.
In the disclosed embodiment, the path is programmed to describe a first passage around the patient in the left-right direction, followed by a second passage in the right-left direction, or vice versa, in order to define a loop. The loop can be open (end point not matching the starting point) or closed (end point matching the starting point). The rate of displacement of the image plane on the path is further programmed to be reduced on passages at angulations corresponding to chosen reference planes and increased between those points. Furthermore, the displacement of the image plane along the path is controlled with the electrocardiograph machine, so that the arrival at a reference plane systematically occurs at the time the heart is in a same given phase of its cycle, for example, the filling phase. That control is accomplished by an analysis of the electrocardiogram (ECG) produced by the electrocardiograph machine 64, the periodicity of which makes it possible to anticipate the different phases.
The protocol of coronary angiographic examination according to an embodiment of the invention, made with the apparatus of
An initial phase of programming of the path of the image plane (stage E20) is provided. The programming starts with the location of positions of the image plane which are going to constitute reference angulations. These reference angulations are represented by large dots P1–P5 in
To those three angulations, two others are added, P4 and P5, chosen, for example, to better discern the structure of the right coronary artery.
In general, the following reference points can be considered. For a good visualization of the left coronary artery, a reference position in right anterior oblique view at 30° makes it possible to analyze the circumflex branch and a part of the left anterior descending artery. Another reference position on angulation of slightly caudal type, i.e., with the detector 50 close to the patient's feet, while maintaining the azimuth angle of 30°, can be used to visualize another part of the left anterior descending artery and to avoid having it covered on the image by the circumflex branch of the intermediate vessels. Conversely, a reference position in cranial-type angulation on right anterior oblique projection makes possible a good visualization of the diagonal arteries.
The reference position in left anterior oblique angulation at 60° can be used for study of the diagonal arteries and of a part of the anterior interventricular artery (IVA). With a cranial angulation at 20°, the left anterior oblique angulation at 60° can be applied to avoid shortening of a part of the IVA and provides good images of the left main trunk and diagonal branches. In side view, i.e., with the axis of the X-ray beam horizontal, particularly in left side view, another part of the IVA and the different parts of the first diagonal artery and of the marginal artery of the left edge can be optimally seen.
For the right anterior artery, a reference position in angulation of left anterior oblique type at 45° can be used associated with a caudal angle of 15°. The reference position in left anterior oblique angulation at 90° with caudal deflection of 15° can be used for analysis of the vertical part of the right coronary artery and collateral branches, right ventricular artery and right edge marginal artery. The reference position in right anterior oblique angulation at 45° with caudal deflection of 15° can be used for visualization of the posterior interventricular artery and collateral branches, right ventricular artery and right edge marginal artery.
When the reference angulations P1–P5 have been programmed, the control unit 58 calculates a path which passes over each of them. As shown in
The displacement of the image plane on that whole path will be designated by the term “rotation,” the filming and recording of images on a rotation being designated by the term “rotation acquisition.”
The third part T3 of the path serves essentially to create a closed loop, i.e., to bring the image plane back to the starting point. In that way, it is possible to perform a succession of rotations without interruption.
The path T is calculated to produce a fluid movement of the image plane, with phases of acceleration at the start and deceleration at the approach of each reference angulation P1–P5. The movement is further subject to the ECG, so that the rapid displacements between two reference angulations occur during the diastole phase (when the heart is in quasi-stationary phase) and the slow passages at the reference angulations occur during the systole phase of the heart. Furthermore, synchronization on the ECG ensures that the heart will be in the same phase on passage at each of the reference angulations P1–P5.
By way of indication, the duration of the dynamic acquisition sequence on a rotation acquisition corresponds to four or five heart beats, that is, approximately five seconds. During the acquisition sequence, the source 48 and the detector 50 are activated with suitable adjustments of X-ray emission and filming.
The acquisition sequence covers the entire duration of the first and second parts T1, T2 of the path and possibly an initial portion of the third part T3. The acquisitions are made at a rate of 25 or 30 images per second. The portions of the path on which the images are acquired are symbolized by a series of small dots in
In general, the programming stage E20 is executed only on initialization of the apparatus 34 for the protocol; that stage is therefore omitted for the examinations on the following patients, except in case of change of parameters.
The examination proper then begins with the patient positioned on the table 59 and the introduction of a “pigtail” catheter 32, of gauge 6, for example, from the femoral artery to the aortic root, at the starting points of the left and right coronary arteries (stage E22). The positioning of the injection end of the catheter 32 is represented in
Once the catheter 32 is positioned, a first rotation acquisition is executed on the path T with the characteristics of acceleration-deceleration and ECG synchronization, as described above, and without injection of contrast medium (stage E26). That sequence without opacification makes possible the acquisition of reference images for digital image subtraction. It also makes it possible to visualize the patient's anatomical structures, notably, the general positioning of the heart relative to the thorax and to the vertebral column. A representation of one of the images acquired during that first rotation acquisition is given in
A second rotation acquisition identical to the first is then made, but with injection of contrast medium (stage E28). For that purpose, the catheter 32 is connected to the tube 65a of the injector 65, the latter being filled with contrast medium and capable of responding to the injection commands coming from the control unit 58. Thus, on injection of contrast medium, the latter is emitted with appreciably isotropic force and reaches the aperture of each of the left and right coronary arteries in order to be propagated along the coronary arterial tree. In the disclosed embodiment, the injection of contrast medium is not carried out continuously, but rather in spurts synchronized with the heart rate, so that the product is introduced on closing phases of the aortic valve (concomitant phase E30). The synchronization of the injection will be more specifically described by reference to
As the lower part of
The injector 65 is thus commanded in pulse mode to send a succession of contrast medium flows during the cycles indicated 72. The total quantity of contrast fluid injected is in the order of five to seven cubic centimeters, distributed over four or five injection cycles. The start and stop of all the injection cycles are generally synchronized respectively with the beginning and end of the image acquisition sequence of a rotation.
On that second rotation acquisition, the contrast fluid is propagated along the coronary arteries and dependent arteries in order to irrigate the myocardium. A series of images is then obtained, such as the one referenced II in
In order to visualize that opacification of the myocardium more specifically, a third rotation acquisition is carried out after the second one and following the same path characteristics, but without injection of contrast medium (stage E32). Normally, the contrast medium injected upon the second rotation acquisition will have had enough time to diffuse properly over the entire myocardium during the period of the third rotation acquisition, without it being necessary to mark a pause time after the second rotation acquisition. Such pause time can, however, be envisaged, if necessary. The third rotation acquisition thus makes it possible to obtain, without addition of a dose of contrast medium, a three-dimensional visualization of the wall of the left ventricle (
The embodiment of the invention makes it possible to continue with a ventriculographic examination by pushing the pigtail catheter 32 beyond the aortic valve into the ventricle (stage E34). When the catheter 32 is thus positioned, a fourth rotation acquisition is carried out with injection of contrast fluid (E36). The path for that acquisition can be the same as for the three preceding ones or can be different, depending on the images desired for that examination. During this period, approximately 40 cubic centimeters of contrast fluid are introduced at constant flow. The dynamic acquisitions upon that fourth rotation acquisition make it possible to visualize the course of the contrast fluid in the left ventricle (
At the end of the protocol, the pigtail catheter 32 is withdrawn (stage E38). From the set of images obtained upon the rotation acquisitions, different digital processings are possible in order to obtain static (3D) or evolving (4D) three-dimensional views.
As shown in the lower part of
The disclosed embodiment of the invention thus provide that: (1) all of the views indicated are obtained with the use of a single catheter 32 and a single injection of contrast medium; (2) the contrast medium is introduced simultaneously in the left coronary artery and in the right coronary artery, which makes it possible to visualize in a single sequence the opacification of all of the coronary arteries; (3) it is possible to obtain, some instants after injection of the contrast fluid in the coronary arteries and by simple repetition of a rotation acquisition, a view of the opacification of the tissues of the myocardium, which enables irrigation defects to be clearly detected; (4) by simple prolongation of the advance of the catheter into the left ventricle, the protocol can be continued with a dynamic examination of the movements of that part of the heart; and (5) introducing the contrast fluid into the left and right coronary arties solely during the phases of closing of the aortic valve, according to an embodiment, alone makes it possible to reduce the dose by approximately 50% or to make acquisitions over period twice as long at equal dose.
Thus, a single stage of introduction of the contrast medium suffices to enable the structure of the coronary arterial tree to be visualized from the left and right coronary arteries. The fact that the image plane is made to file by upon acquisition makes possible a three-dimensional reconstruction of that structure by digital processing. It is to be noted that this possibility is hard to conceive of in the standard approach described in the introduction, where the planes are instead static.
The contrast medium is advantageously introduced cyclically during the dynamic image acquisition, each cycle of introduction corresponding to a phase of closing of the aortic valve in the cardiac rhythm. Thus, the dose of contrast medium is delivered in spurts and only at times during which the product is in a relatively static environment and therefore has the best chance of entering the two coronary arteries. This arrangement can be obtained subject to a diastole peak detected on the electrocardiogram of the heart examined. In a embodiment, each cycle of introduction of the contrast medium is begun at an instant situated roughly midway between a first and a second successive diastole peak and is interrupted approximately upon the appearance of that second peak. The path of the image plane advantageously defines a left curve evolving around the patient's head-to-toe axis and left-right axis. The path can define a loop, open or closed, with one part corresponding to a movement in a first direction around the head-to-toe axis and a second part corresponding to a movement in a second direction around the head-to-toe axis opposite to the first one. The path preferably embraces points of passage corresponding to reference angulations, the rate of procession of the image plane being increased outside the points of passage and reduced at the points of passage.
The procession of the image plane is advantageously synchronized with the cardiac rhythm, so that the moment of passage on each reference angulation is situated at a same phase of the cardiac cycle, notably in the systole phase of the heart.
An image subtraction technique may be used, in which, the method can further entail a preliminary stage consisting of acquiring a dynamic image sequence with procession of the image plane on the given path, without introduction of contrast medium.
The method can also provide a stage, following stage b), comprising acquiring a new dynamic image sequence with procession of the image plane, without introduction of contrast medium, making it possible to visualize the opacification of the myocardium. The examination can be continued by ventriculography, with injection of contrast medium and parallel acquisition of dynamic images with procession of the image plane.
Stage a) of introduction of the contrast medium is preferably carried out with the aid of a so-called “Pigtail” catheter or the like.
The acquired images are advantageously processed in order to make at least one of the following: (1) a three-dimensional reconstruction of the heart not opacified; (2) a three-dimensional reconstruction of the myocardium; (3) a three-dimensional reconstruction of the coronary artery tree evolving in time, and (4) a three-dimensional reconstruction of the left ventricle evolving in time.
It can thus be guided to inject the contrast medium only during closing of the aortic valve. For that purpose, it can contain an electrocardiogram signal input and means of detection of diastole peaks in that signal, the injection being interrupted on detection of a diastole peak.
The device can contain means of starting the injection of contrast medium at a predetermined time, which can be programmable, before the arrival of a diastole peak. This time can be roughly midway between two successive diastole peaks. The device can be further programmable to inject the contrast medium over a given number of injection cycles. The device can further contain means of synchronization of the overall start and stop of injection with the start and stop of a filming sequence.
Various modifications in structure and/or steps and/or function may be made by one skilled in the art without departing form the scope and extent of the invention as recited in the claims.
| Number | Date | Country | Kind |
|---|---|---|---|
| 01 03699 | Mar 2001 | FR | national |
This application is a continuation of international application number PCT/US02/08104, filed Mar, 15, 2002, which claims the benefit of a priority under 35 USC 119 to French Patent Application No. 0103699 filed Mar. 19, 2001, the entire contents of which are hereby incorporated by references.
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| Number | Date | Country | |
|---|---|---|---|
| 20030069499 A1 | Apr 2003 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | PCT/US02/08104 | Mar 2002 | US |
| Child | 10295055 | US |
