The Bradford Teaching Hospitals are operated by the Bradford Teaching Hospitals NHS Foundation Trust and are affiliated with the Leeds School of Medicine (Leeds University). The Bradford Teaching Hospitals serve a core population of 500,000 and provide specialist services to around 1.1 million people.
Leading the Way
The Cardiology Department at Bradford Teaching Hospitals delivers a full range of adult cardiac services, including tilt tests, diagnostic and interventional coronary angiography, stress echocardiography, and trans-oesophageal echocardiography. It provides first-line investigation for patients with stable chest pain. It is also used for acute aortic presentations, transcatheter aortic valve insertion (TAVI) assessments, and problem-solving for incidental cardiac and aortic findings.
Bradford Teaching Hospitals NHS Foundation Trust, West Yorkshire, United Kingdom, has developed its Cardiology Department over the years and now provides a comprehensive range of diagnostic and clinical cardiac services to the large population that it serves. Dr Mark Kon, Thoracic Radiologist at Bradford Teaching Hospitals, explains how Canon Medical Systems has delivered imaging solutions that have enabled the Hospitals to meet the continually increasing demands, notably the Vitrea Advanced Visualization post-processing solution, which extends the possibilities with their Aquilion ONE CT scanners.
Dr Kon has been a consultant at the Hospitals for 20 years and has used Canon Medical equipment for a long time. His role includes lung cancer imaging, ultrasound CT-guided thoracic intervention, in collaboration with cardiology colleagues and cardiac CT.
Seeing Beyond
Vitrea Advanced Visualization is an intuitive post-processing software that improves workflow and ensures accurate and efficient clinical diagnosis, supporting healthcare professionals in delivering high-quality patient care. It is especially useful for his work in cardiac CT.
With the Aquilion ONE and Vitrea Advanced Visualization, Bradford Teaching Hospitals were able to develop a regional service that led the way in coronary CT angiography, while adjacent hospitals were still developing their services.
“We started cardiac CT in Bradford over 15 years ago,” he remarked. “Back then, we were using 64 MDCT and developed various beta-blocker regimes to gain heart rate control to minimise radiation dose. We were reliant on well-controlled heart rate with regular sinus rhythm to obtain diagnostic quality images.”
“On-table intravenous beta blocker became routine, and low radiation doses allowed a wider range of patients to be safely scanned.”
Over fifteen years’ experience with intravenous metoprolol, a cardio-selective beta-blocker, allows them to gain rapid heart rate control on table. Patients are scanned at 20-minute intervals allowing for eight to ten patients in a three-hour session.
Robust Imaging
Bradford Teaching Hospitals opened a new CT suite equipped with an Aquilion ONE / PRISM Edition CT scanner in April 2024. With Canon Medical System’s Aquilion ONE imaging, Dr Kon can scan every patient prospectively with one heartbeat scanning.
“Irregular heart rhythms are irrelevant when we only need a single heartbeat,” he said. “Acquiring images in systole and diastole means that even faster heart rates can be successfully imaged. And with such robust imaging, we never turn away any patients.”
The acquisition time with the single heartbeat scanner is less than one second. This means that contrast only has to be present in the coronary arteries for a very short duration, so we only require a short, sharp bolus of contrast, typically 30-50ml at 5-6 ml/s.
By monitoring contrast arrival in the descending aorta, bolus tracking allows the use of trigger acquisition precisely, just when contrast has arrived at the coronary arteries. This avoids wasting time, contrast, and radiation compared to test bolus techniques.
Aquilion ONE now utilises Canon Medical System’s Precise IQ Engine (PIQE). An AI-based Deep Learning Reconstruction algorithm trained on a 0.25 mm dataset which generates sharp, noise-free images. “Reporting cardiac CT seems almost a pleasure with PIQE images!”
Taking a Closer Look
Once the axial dataset has been acquired, Dr Kon and thoracic radiology colleague Dr Marjoram review the images on the Vitrea Advanced Visualization workstation, which automatically generates curved multiplanar reformatted images of the coronary arteries and side branches. It is available to them as an integrated client on any workstation at the different hospital sites of the Bradford Teaching Hospitals.
“I have used several coronary reconstruction software over the years, and I still believe Vitrea Advanced Visualization to be the most powerful,” said Dr Kon. “With a good study, any software can generate curved MPRs. However, when images are a little more challenging, for example, graft studies, tortuous vessels, or partially occluded vessels, Vitrea Advanced Visualization allows accurate correction using a suite of five tools.”
The most automated tool strips away the lungs and thoracic cage leaving the heart and coronary vessels. It automatically detects and tracks the three main coronary territories and generates curved MPRs. Larger branches may also be tracked, awaiting user confirmation for labelling.
A secondary tool enables the user to select any other branch or vessels for automated tracking. This is especially useful for coronary bypass grafts, aberrant origins, or anomalous vessels.
The third ‘pencil’ tool allows the user to manually trace with the mouse missing segments of an incomplete tracked artery. This works best when the segments of interest can be seen on the surface of the 3D-volume rendered model or when the vessel disappears under other cardiac structures, such as the left atrial appendage.
Vitrea Advanced Visualization’s fourth extend tool allows the user to extrapolate from the last tracked point to the final destination, often the aorta. Vitrea Advanced Visualization can successfully trace contrast in the vessel joining two endpoints.
Dr Kon considers Vitrea Advanced Visualization’s fifth tool, Centreline editing, to be the most powerful.
“Centreline editing in Vitrea Advanced Visualization requires a little manual dexterity, but it is this experienced application that makes it so robust,” said Dr Kon. “Literally, with pinpoint accuracy, the centreline of any vessel can be tracked with as few or as many points over as short or as long a segment as required. All without the interference of ‘line dragging’ automation especially seen with tortuous vessels.”
“With Vitrea Advanced Visualization, I can follow any course of any vessel as long as I can see it. And I can always see it,” he added.
Educating Others
Alongside their consultancy work, Dr Kon and his team run three Level Two Cardiac courses each year next to the CT scanning suite at Bradford Royal Infirmary. Vitrea Advanced Visualization has become a key part of the training. The candidates can work independently to learn how to read coronary CT using Vitrea Advanced Visualization software.
“Most of our candidates have very little experience of using software to manipulate coronary images,” explained Dr Kon. “In our courses, we teach them how to read coronary examinations on axial images and how to use the five tools to create curved MPRs. By the end of four days, they are all able to use Vitrea Advanced Visualization software to review cases.”
“Those who have had previous experience of other solutions often say that Vitrea Advanced Visualization is the most intuitive and user friendly,” he said. “I encourage them to explore it.”
Not only do candidates learn how to review images in the courses, but they also get to experience the live acquisition of over 20 cases in the CT scanning suite on both Canon Medical System’s Aquilion Prime 80 MDCT and Aquilion ONE 320 MDCT.
“This allows them to see the different techniques utilised with conventional 4cm scanning and 16cm wide detector single heartbeat scanning,” added Dr Kon.
In addition, Dr Kon presents cardiac CT cases at several meetings, including those organised by the British Cardiac Society, the British Society of Cardiovascular Imaging, and the European Congress of Radiology. Canon supports these shorter demonstration courses by providing a full workstation with the latest edition of Vitrea Advanced Visualization and a database of Dr Kon‘s cases.
“This is far better than using slides or a simple DICOM viewer, which can only demonstrate selected images or axial imaging. Having the full workstation allows me to demonstrate cases using all the tools that Vitrea Advanced Visualization has to offer,” said Dr Kon. “I start with simple axial viewing, moving to multiplanar reformats. Then, more complex coronary imaging, including grafts and stents. This gives me the chance to demonstrate all the tools Vitrea Advanced Visualization has to offer.”
“The simplicity of Vitrea Advanced Visualization and Aquilion ONE allows me to offer a complete service for my Cardiology colleagues and our patients.”