Somatom sessions 24

SOMATOM Sessions
The Difference in Computed Tomography
Cover Story
SOMATOM Defi nition
Flash: Impressive
Performance
Page 6
News
Functional Imaging
Widens the Clinical
Spectrum for CT
Page 12
Business
Chest Pain:
Clarity with CT
Page 20
Clinical
Results
SOMATOM Defi nition
Flash: The Entire Heart
Scanned in Just 270 ms
with 0.95 mSv
Page 32
Science
Iterative Image
Reconstruction Moves
into Clinical Practice
Page 65 24
Stanford-Edition May 2009 24 SOMATOM Sessions
Issue Number 24/May 2009
Stanford-Edition I May 19th – 22th, 2009

Editorial
2 “With developing the
SOMATOM Definition
Flash, our company
has once again set a new
standard for radiation
dose reduction in CT.”
Sami Atiya, PhD, Chief Executive Officer,
Business Unit Computed Tomography, Siemens Healthcare, Forchheim, Germany
Cover Page: A thorax scan for triple-rule out with the SOMATOM Defi nition Flash is possible in less
than one second. Courtesy of University of Erlangen-Nuremberg, Erlangen, Germany
SOMATOM Sessions · May 2009 · www.siemens.com/healthcare-magazine

Editorial
André Hartung,
Vice President
Marketing and Sales
Business Unit CT
Siemens Healthcare
Forchheim, Germany
SOMATOM Sessions · May 2009 · www.siemens.com/healthcare-magazine 3
Dear Reader,
In the broad spectrum of diagnostic
methods and equipment available to the
medical industry today, computed tomog-raphy
has assumed more and more impor-tance.
The number of exams worldwide
is increasing, not only because CT offers
extremely high diagnostic certainty but
also because the acquisition method is
simple and results are permanent and
reproducible. And because of CT’s versa-tility
(cardiology, oncology, trauma, etc.),
it is rapidly becoming a standard exam-ination
at medical facilities around the
globe – therefore it contributes to a sig-nificant
amount of overall radiation expo-sure
in the entire population. Other
sources are natural background radiation
(on average 2-4 mSv per year) and other
diagnostic/therapeutic procedures, like
X-ray, radiotherapy as well as long dis-tance
flights. Because of this factor, all
CT facilities and vendors assume a heavy
and unavoidable responsibility to mini-mize
radiation and maximize safety for
their patients.
The justification for the existence of
the entire medical field is, of course,
better healthcare for all patients. Siemens
has always been a visionary company,
believing that even the farthest techni-cal
horizons were temporary and could
be surpassed with consistent dedication
to improved healthcare. This visionary
approach has made Siemens the undis-puted
innovation leader in CT over the
last 35 years. But our innovative philoso-phy
is based solidly upon the assumption
that achieving the highest technical per-formance
is only important when it meets
the needs of the patient. And meeting
the needs of the patient means respon-sible
dose considerations.
Our newest developments clearly illus-trate
our commitment to lower dose
exposure: for example, our UFC (Ultra-
FastCeramic) detector, CARE Dose4D,
organ-sensitive dose protection and
our revolutionary, new Adaptive Dose
Shield, introduced with the SOMATOM®
Definition AS adaptive scanner.
And with the SOMATOM Definition Flash,
we made dose reduction the centerpiece
of our research. Its core innovation – the
unique low-dose Flash Spiral – can be
summarized in four words: Flash speed.
Lowest dose. Conventional, single source
cardiac CT requires up to 30 mSv dose,
except with extremely stable, low heart
rates. Siemens’ introduction of Dual
Source CT in 2005 radically improved this
situation by reducing dose requirements
regardless of heart rate. Now, Dual Source
technology is combined with Flash speed
making possible the industry’s fastest
true temporal resolution of 75 ms and,
most important, it reduces dose to an
absolute minimum – for example, com-pleting
a cardiac scan in less than 300
milliseconds with dose as low as below
1 mSv.
For this issue of SOMATOM Sessions, we
have been in constant contact and dis-cussions
with our customers – medical
experts in clinical practice who are faced
every day with an unlimited variety of
conditions and CT applications. We are
therefore able to bring you the first clini-cal
results of the SOMATOM Definition
Flash, as well as reports and updates of
our entire portfolio. Read in this issue
and see for yourself how Siemens’ com-mitment
to dose management compli-ments
our technological and diagnostic
excellence, significantly improving
healthcare.
Enjoy reading.
Sincerely,
André Hartung

Content
Content 6
4 SOMATOM Sessions · May 2009 · www.siemens.com/healthcare-magazine
Cover Story
6 SOMATOM Definition Flash:
Impressive Performance
News
12 syngo 2009 – Functional Imaging
Widens the Clinical Spectrum for CT
13 Private Payers Reimburse for CT
Colonography in the U.S.
13 500 SOMATOM Definition Dual
Source Installations Prove Clinical
Success
14 The syngo CT 2009E Software
for the SOMATOM Emotion Further
Increases the Clinical Capabilities
of the Most Popular Scanner
15 Win with Excellent Image Quality
at Lowest Dose
15 SOMATOM Definition Flash Intro-duced
During ECR 2009
Business
16 The St. Paul Heart Clinic:
A Model of Efficiency
20 Chest Pain: Clarity with CT
24 SOMATOM Emotion Around
the Globe
28 Economical Benefits Drive
Thin-Client Server Technology
Cover Story
SOMATOM Definition
Flash CT
6 It’s said that experience is what
separates promise from reality. But
when it comes to the SOMATOM
Definition Flash Dual Source CT
scanner, experience shows that
promise is reality. As the innovative
new scanner is tested in daily clinical
practice, it is exceeding nearly every
expectation. Split-second thoracic
scanning: proven. Sub-milliSievert
cardiac scans: confirmed. Superb
image quality: no question.
16
The St. Paul Heart Clinic:

Content
66
Imaging Marine Animals in
Okinawa Churaumi Aquarium
Acute Care
52 SOMATOM Definition AS+:
Polytrauma Patient Scanned in
Seven Seconds
54 Triple Rule-Out in Flash Speed:
Entire Thorax Scanned in less than
a Second
Orthopedics
56 High Resolution Follow-up of a Wrist
Fracture of the Os Triquetrum with
SOMATOM Definition AS+ and z-UHR
Gastroenterology
58 Difficult Drainage After
Cholecystectomy
Science
60 Dual Energy in Clinical Routine with
syngo CT Oncology
62 Dual Energy CT in Pulmonary
Embolism
65 Iterative Image Reconstruction
Moves into Clinical Practice
66 Okinawa Churaumi Aquarium:
Imaging Marine Animals with
the SOMATOM Spirit
Clinical Results
Cardiovascular
30 Dual Source CT Unveils Several High-
Grade Stenoses of Coronary Arteries
32 SOMATOM Definition Flash: The
Entire Heart Scanned in Just 270 ms
with 0.95 mSv
34 Low Dose 3D Evaluation of a Child’s
Heart with Anomalous Venous
Return with the SOMATOM Sensation
36 Cardiac Scan Prior to Bariatric Surgery
38 Detection of Unusual Case of
Aorto-Leftventricular Tunnel with
Dual Source CT
Oncology
40 Dual Source CT Kidney Tumor
Imaging with VNC Dual Energy
42 Lung Perfused Blood Volume Imaging
with Dual Energy
44 syngo WebSpace in Imelda Zieken-huis
in Bonheiden, Belgium
Neurology
48 SOMATOM Definition: Head CTA
Brain Hemorrhage Examination with
Dual Energy
50 SOMATOM Sensation: Subtracted
3D CT-Angiography for Evaluation of
Arteriovenous Malformation
69 Spatiotemporal Multi-Band Filter
for Reducing Artifacts and Dose
Life
70 Clinical Workshops at the Pulse of
CT Technology
71 Now is the Time to Elevate
SOMATOM AR and SOMATOM Plus 4
Scanners
71 Free 90 Day Trial Licenses for
Clinical Applications
72 Clinical Poster on CT-guided
Vertebroplasty
72 GEST 2009: Siemens Healthcare
Demonstrated Innovation Leader-ship
in Interventional Oncology
73 ESGAR Workshops on CT
Colonography
73 Frequently Asked Questions
74 News in the CT World
74 Clinical Workshops 2009
75 Upcoming Events & Congresses
75 Experience Lounge at ECR 2009
76 Siemens Healthcare – Customer
Magazines
77 Imprint
54
Entire Thorax Scan in Less
Than a Second

The SOMATOM Definition Flash makes a thorax scan for triple rule-out possible in less than one second.
SOMATOM Definition Flash:
Impressive Performance
In everyday clinical use, the SOMATOM Defi nition Flash
Dual Source CT scanner is proving to be innovative and versatile.
By Catherine Carrington
1
1

Cover Story
scan with Dual Energy. The Definition
Flash does it all.”
Thorax and Beyond
At the University of Erlangen, radiologist
Michael Lell, MD, has used the Definition
Flash to perform thoracic imaging in
approximately 40 patients. Typically, he
is able to image the entire thorax in just
0.6 to 0.9 seconds.
“This is definitely a breakthrough,” Lell
says. “The scan is so fast, we can examine
patients who don’t hold their breath,
and we get perfect images.”
The speed of the Definition Flash trans-lates
to better patient safety and comfort.
For trauma patients, the ability to scan
the entire body in less than five seconds
not only reduces motion and breathing
artifacts, it has the potential to reduce
delays in getting to surgery. Pediatric
scanning promises to be easier and safer.
And eliminating the need for breath-holding
offers comfort to patients who
are very sick or injured.
“The scan speed is so fast that it’s really
unnecessary to switch a respirator on
and off in order to get sharp images,”
Lell says. “We can just keep on with the
respirator and do the fast scan, and we
get perfect image quality.”
Lell is especially pleased with both the
efficiency and effectiveness of the
Definition Flash in evaluating patients
who come from the emergency room
with chest pain. For these patients, he
uses a triple rule-out protocol. It includes
electrocardiographic gating, but avoids
the low pitch and high radiation dose
that once burdened triple rule-out studies
on single source CTs.
“We can do a single scan and rule out
three major killers from chest disease:
pulmonary embolism, aortic dissection,
and coronary occlusion,” he says. “And
with the new system, we just fly over the
heart and thorax very fast. We don’t have
redundant data anymore.”
As a result, Lell has found that the radia-tion
dose for a triple rule-out study per-formed
on the SOMATOM Definition
Flash amounts to just 1.6 to 1.9 mSv.
“It’s really changing thoracic imaging,”
he says. “On the one hand we have an
extremely fast scan that offers outstand-
It’s said that experience is what separates
promise from reality. But when it comes
to the SOMATOM® Definition Flash Dual
Source CT scanner, experience shows that
promise is reality. As the innovative new
scanner is tested in daily clinical practice,
it is exceeding nearly every expectation.
Split-second thoracic scanning: proven.
Sub-milliSievert cardiac scans: confirmed.
Superb image quality: no question.
“This is the scanner that gives you all
options,” says cardiologist Stephan Achen-bach,
MD, a professor of medicine at
the University of Erlangen-Nuremberg in
Erlangen, Germany. “You can scan at
unprecedented low doses. You can scan
at both low and high heart rates. You can
“We can examine
patients who don’t
hold their breath,
and we get perfect
images.”
Michael Lell, MD, PD,
Department of Radiology, University
of Erlangen-Nuremberg, Erlangen,
Germany
“The SOMATOM
Defi nition Flash
is the scanner
that gives you all
options.”
Prof. Stephan Achenbach, MD,
Department of Cardiology,
University of Erlangen-Nuremberg,
Erlangen, Germany
ing image quality – and we get the coro-naries
for free. On the other hand, we
have the ability to perform Dual Energy
studies. That’s very exciting.”
Cardiac Imaging
Stephan Achenbach has also been scan-ning
patients on the Definition Flash since
mid-February. So far, some 100 patients
have been imaged using the new low-dose
Flash Spiral mode, that acquires data
in a single heart beat, during a 250 ms-pause
in the cardiac cycle when the
heart is in diastole. The results have been
impressive.
“The Flash scanner is superb,” says Achen-bach.
“In cardiac imaging, what really
counts is temporal resolution, and this is
the fastest scanner on the market. The
image quality is excellent.”

The worldwide first SOMATOM Definition Flash, installed at the University of Erlangen-Nuremberg,
Erlangen, Germany.
edented radiation dose of less than 1 mSv.
Early testing focused on patients weigh-ing
less than 90 kg (200 lbs) and used
settings of 100 kV and 320 mAs. The
result was an average dose of just
0.94 mSv. Stephan Achenbach is now
evaluating whether dose can be reduced
even further in thin patients and how
settings might need to be adjusted in
heavier patients.
A sub-milliSievert radiation dose has
the potential to expand the horizons of
cardiac CT to include screening for pre-vention
of cardiovascular disease. “We
are now at a dose for CT angiography
that is less than it used to be for calcium
scoring,” Achenbach says. “This low
dose could allow us to use cardiac CT
for screening. The question is a medical
one: Does it make sense to do screen-ing?”
Preliminary data published in the Journal
of the American College of Cardiology
in 2007 and 2008 suggest that findings
of non-calcified, non-obstructive plaque
on CT angiography add new information
that can be used in determining a patient’s
cardiovascular risk and prognosis. But
the clinical value of cardiac CT screening
needs to be confirmed in larger studies,
Achenbach says. It is a project he and his
colleagues are already undertaking.
“It’s possible we are going to find that
there are specific patient groups who
benefit from this test – patients who
have diabetes or a strong family history
of heart disease, for example,” Achenbach
The Definition Flash, a second-generation
Dual Source scanner, is equipped with
two detectors and two X-ray sources set
at an angle of approximately 95 degree to
one another. With a gantry rotation time
of 0.28 s, the scanner boasts a temporal
resolution of just 75 ms. Moreover, an
innovation introduced with the Definition
Flash eliminates the need for the patient
table to slowly inch forward during data
acquisition. Instead, in low-dose Flash
Spiral mode, the scanner achieves gap-less
z-sampling even with the wide-open
spiral created by a pitch of 3.2 and a
table speed of more than 40 cm/s. This
is because the two detectors create two
complementary data spirals that together
include all the information that would
be found in a single spiral acquired at a
much slower table speed – but without
redundant, overlapping data and unnec-essary
radiation exposure.
During the first weeks of gathering clinical
experience at the University of Erlangen-
Nuremberg, the Flash mode has been
used primarily to scan cardiac patients.
This approach has produced flawless
images free of motion artifacts. “This
scanner allows us to do cardiac imaging
at the lowest dose with the highest
image quality,” says Prof. Willi Kalender,
PhD, director of the Institute of Medical
Physics at the University of Erlangen-
Nuremberg. “We actually measured both
spatial and temporal resolution in the
Flash mode, and they are uncompro-mised.
For cardiac imaging, no question,
this is the best.”
Equally important, both patient exami-nations
and physics measurements con-clusively
show that the Definition Flash
can scan the complete heart at an unprec-
“This scanner allows
us to do cardiac
imaging at the lowest
dose with the highest
image quality.”
Prof. Willi Kalender, PhD,
Director of the Institute of Medical Physics
of the University of Erlangen-Nuremberg,
Erlangen, Germany

Cover Story
2 With the latest DSCT technology, the heart can be visualized artifact free and with an ultra-low dose of 0.95 mSv in Flash speed.
says. “We don’t have that data yet, but we
now have a scan mode that would allow
us to use this technology for screening
if we find that it makes sense for the
patient.”
Dual Energy
Dual Energy studies are a special interest
of Hatem Alkadhi, MD, who heads both
body CT and cardiovascular imaging at
the Institute of Diagnostic Radiology,
University Hospital Zurich, Switzerland.
He has performed hundreds of Dual
Energy exams using the first-generation
Dual Source scanner, the SOMATOM
Definition, and now the new Definition
Flash scanner as well.
“Dual Energy gives radiologists additional
information that we don’t have when
making single energy scans,” says Alkadhi.
“This is a great benefit of this technique.”
Dual Energy imaging involves the simul-taneous
operation of two X-ray sources
at different energy levels. This enables
differentiation of fat, soft tissue and
contrast material on the basis of their
unique energy-dependent attenuation
profiles. As impressive as early versions
of Dual Energy imaging have been, the
Definition Flash brings new strengths to
the table.
An important new feature is the selective
photon shield that pre-filters high kV
X-rays, removing low-energy photons.
This improves separation of the 80 kV and
140 kV images and, therefore, improves
material differentiation by about 80%.
In addition, the photon filter consistently
reduces image noise and substantially
cuts radiation dose. “With the second
generation of Dual Energy, we’re finally
able to deliver additional diagnostic infor-mation
with dose levels comparable to
a single energy scan. That’ll make the
decision to use Dual Energy even easier
for us,” Alkadhi says.
An improved ability to separate materials
has important clinical implications. It
2

The improved ability to separate materials with Dual Energy makes it easier to characterize the composition of urinary stones.
ing another important application of Dual
Energy CT – evaluation of suspected pul-monary
embolism. Dual Energy imaging
enables the radiologist to not only detect
a blood clot that is cutting off blood
flow through the pulmonary artery, but
also to show the effect of the obstruction
on perfusion of the lung tissue itself.
In the past, the use of Dual Energy imag-ing
was limited to the center of the lung
because of the smaller size of the second
detectors. A similar problem hampered
Dual Energy imaging in the liver, where
observing contrast uptake can aid in
determining whether a lesion is hepato-cellular
carcinoma or a hemangioma.
To realize its full potential, Dual Energy
must be able to image even lateral seg-ments
of this large organ.
“When we make a Dual Energy scan,
makes it easier to characterize the com-position
of urinary stones, for example,
and guide clinical decisionmaking. If a
stone is composed of uric acid, the urol-ogist
has the option to try medical ther-apy,
rather than immediately referring
the patient for shock wave lithotripsy.
“This is better for the patient,” Alkadhi
says. “And our ability to use Dual Energy
to separate materials of similar density
is what makes it possible.”
Similarly, Dual Energy imaging makes it
simple to differentiate iodinated contrast
material from bone, two materials with
similar densities on standard CT. With a
click of a button, bones can be removed
from an image, leaving only the opaci-fied
arteries for examination. In other
circumstances, iodine can be subtracted
from an image, creating virtual nonen-hanced
images without need for a sepa-rate
scan prior to contrast injection. This
approach is helpful in reducing radiation
dose when performing studies that would
normally involve more than one imaging
phase.
It is also helpful when a suspicious inci-dental
finding is noted on a contrast-enhanced
scan, Alkadhi says. With stan-dard
CT, it is impossible to determine in
retrospect whether the lesion is simply
a hyperdense mass or has the propensity
to take up contrast, a worrisome clue that
suggests malignancy. With Dual Energy
imaging, a virtual “do-over” is possible. By
subtracting iodine from the image, it is
possible to create a precontrast image and
evaluate lesion density in the absence of
contrast enhancement.
The SOMATOM Definition Flash is improv-
3
3

Cover Story
“With the second
generation of Dual
Energy the fi eld of
view is so large we can
cover the entire lung.”
Hatem Alkadhi, MD, PD,
Institute of Diagnostic Radiology,
University Hospital Zurich, Switzerland
we want to cover the whole organ of
interest – the whole lung, the whole
liver, the whole abdomen,” Alkadhi says.
“If you can’t, it limits the practicability
of your technique and the willingness
of the radiologist to use it. Obviously
Siemens understood this. The Definition
Flash is a big step forward with the large
Dual Energy field of view.”
Now the Definition Flash is outfitted
with two 4-cm detectors, and the field of
view is no longer a limitation in large
organs like the lung and liver. “With the
new system the field of view is so large
we can cover the entire lung,” Alkadhi
says. “The lung parenchyma is completely
displayed with Dual Energy properties,
including the periphery.”
Dose
Dose savings are built into the SOMATOM
Definition Flash. Besides the reduced
radiation exposure that directly results
from the high table speed, the scanner
has several other dose-sparing features.
Previously, Dual Energy imaging typically
exposed patients to between 10% and
20% more radiation than a corresponding
single energy scan. Now, the photon
shield eliminates the dose penalty in most
types of Dual Energy studies, Kalender
says.
In addition, the new scanner is equipped
applies to shorter scan ranges, such as
for the heart or the brain, or in pediatric
imaging. We can expect a higher percent
reduction as compared to standard scan-ning.”
“For example, the radiation dose could
be reduced by as much as 50% for a scan
of the heart performed at high pitch on
the Definition Flash, when compared to
the same type of scan without the dose
shield,“ Kalender says.
Another dose-saving feature designed
for the Definition Flash is X-CARE. This
technique, which provides organ-specific
dose reduction, enables the radiologist
to turn off the X-ray tube during the por-tion
of the gantry rotation that would
directly expose radiation-sensitive organs,
such as the breast, thyroid gland, or eye.
According to a study Kalender published
in European Radiology last year, the
X-CARE technique can cut radiation dose
to the breast by 50% during thoracic
imaging.
“It’s the best way to reduce dose to the
female breast,” Kalender says. “It’s an
exciting prospect.”
Further Information
www.siemens.com/
somatom-definition-flash
Direct exposure of dose sensitive organs can be significantly reduced by using X-CARE.
4
with adaptive dose shielding, which blocks
the X-rays at the beginning and end of
each spiral acquisition that will not be
used in image reconstruction. In the case
of cardiac scans, adaptive dose shielding
cuts radiation dose by as much as 25%
when the studies are performed using a
conventional pitch. However, the dose
savings are expected to be much greater
when patients are scanned using the
Flash mode.
“The percent dose reduction with the
adaptive dose shield is greater the higher
the pitch and the shorter the scan range,”
Kalender says. “That means as we go to
even higher pitch values, the effect of
shielding on dose is greater. The same
Catherine Carrington is a medical writer and
holds a master’s degree in journalism from the
University of California Berkeley. She is based
in Vallejo, CA.
4
Low dose
High dose

News
syngo 2009 – Functional Imaging Widens
the Clinical Spectrum for CT
By Karin Barthel and Stefan Wünsch, PhD, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Siemens is further strengthening its
commitment to deliver software products
that can significantly increase diagnostic
speed and confidence in everyday radi-ology
as well as maintaining the innova-tion
leadership for functional CT. The
latest syngo 2009 software focuses on
the new era of functional imaging in CT.
With the launch of new applications such
as syngo Dual Energy Lung Nodules,
syngo Dual Energy Xenon, syngo Volume
Perfusion Myocardium* and major
improvements in syngo Volume Perfusion
CT, more functional aspects are added to
the classical morphological information
of CT images.
Applying a newly developed 4D Noise
Reduction technique implemented in
syngo Volume Perfusion CT Neuro, the
radiation dose of dynamic CT exams can
be reduced by a substantial amount with-out
compromising on diagnostic image
quality.*
syngo DE Lung Nodules permits visualiz-ing
the contrast agent concentration in
the lung nodules without the use of an
additional non-contrast scan (Fig. 1). It
may support the differentiation of lung
tumors. The new syngo Dual Energy
Xenon sets a new trend in the evaluation
of chronic and acute lung diseases. With
the latest advances in CT imaging tech-nologies,
the clinical evaluation of, for
instance, COPD (chronic obstructive pul-monary
disease), is rapidly moving from
pure visualization to quantitative analysis
of lung parenchyma abnormalities. The
acquired information may contribute to
a more accurate planning of a surgery.
Furthermore, the application provides
information about the effectiveness of
medication in a very early stage of the
treatment.
The syngo Volume Perfusion Myocar-dium**
allows the display and analysis
of dynamic CT data of the heart utilizing
the heart perfusion scanning mode of
the SOMATOM® Definition Flash after
contrast injection. The application not
only helps to determine hemodynamic
relevance of a myocardial infarction, it
further provides information that can help
to distinguish whether the myocardial
infarction is old or fresh (Fig. 2). In addi-tion,
syngo 2009 supports the fusion
of dynamic data of other modalities e.g.
dynamic angiographic data from Dyna
CT with 4D CT data, thereby obtaining
further functional information.
Of course, since the last major software
version was released, many more
improvements in routine and advanced
applications e.g. in Expert-i, syngo CT
Oncology, syngo InSpace as well as in
syngo Neuro DSA have also been made.
To benefit from the latest enhancements
within existing applications only a soft-ware
upgrade is needed.***
To test the dedicated applications in
advance, 90 days trial licenses can be
ordered. In case of interest, the local
Siemens sales representative should be
contacted.
* requires syngo 2009B.
** a prerequisite is syngo VPCT Body.
*** dependent on workstation configuration.
www.siemens.com/
ct-applications
1
1 Solitary pulmonary nodule in an adult patient displayed with
DECT: iodine enhancement is shown as colored overlay to a virtual
non-contrast image; the semi-automatic segmentation result is
indicated in blue. Courtesy of Asan Medical Center, Seoul, Korea.
2
2 SOMATOM Definition Flash Heart Perfusion: Minor perfused
myocardium (arrows) scanned with spatial resolution 0.33 mm,
rotation 0.28 s, 2 x detector coverage .

News
Private Payers Reimburse for CT
Colonography in the U.S.
By Joachim Buck, Business Unit CT, Siemens Healthcare, Forchheim, Germany
500 SOMATOM Defi nition Dual Source
Installations Prove Clinical Success
By Rami Kusama, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Stunning results of several CT Colonog-raphy
(CTC) trials (e.g. ACRIN1 6664)
have motivated the American Cancer
Society (ACS) to add CTC to its five-year
colon screening guidelines in 2008.
Despite this fact, CMS (Centers for Medi-care
and Medicaid Service) announced a
proposed non-coverage decision for CTC,
at least for the time being. However this
proposed decision won’t discontinue the
success story of CTC.
Two major commercial payers, Blue
Cross Blue Shield of Delaware (BCBSDE)
and Philadelphia region’s largest health
insurer, Independence Blue Cross (IBC),
have started to reimburse for CTC. BCB-SDE
has agreed to reimburse the patent-
With currently 500 installations world-wide,
the SOMATOM® Definition has
redefined the face of CT. Within three
years, DSCT has proven itself in clinical
routine as state-of-the-art with more than
1,500,000 coronary CTAs performed,
250 peer-reviewed papers, and 200,000
Dual Energy scans. Together with the
SOMATOM Definition Flash, introduced
in 2008, the SOMATOM Definition family
will continue to define – and redefine –
the expanding world of CT.
pending Integrated Virtual Colonoscopy™
model from Colon Health Centers (CHC)2
of America, a Philadelphia-based company
that partners with pre-eminent gastro-intestinal
physician groups in a region,
enabling them to provide CTC as an option
to traditional colonography for colon
cancer screening. BCBSDE is providing a
single, bundled, episode-of-care payment
“per screening event” for CTC and believes
that it is essential to have the capability
to provide same-day, same-prep thera-peutic
colonography for patients who
undergo CTC. CHC of America is expecting
several Mid-Atlantic region Blue Cross
plans and other commercial insurers to
begin to reimburse CTC within the next
several months. Payers are encouraged
and positively responding to the high
sensitivity, safety and convenience that
CTC offers patients, as well as the signifi-cantly
lower ”per screening event” costs.
With colorectal cancer (CRC) screening
rates hovering in the dismal 50% range,
payers are looking for other screening
options to get their members off the
‘screening sidelines’. CTC is that new
option. For example, nearly 50% of the
patients screened at CHC of America sites
report that the availability of patient-friendly
CTC was the force motivating
them to receive life-saving CRC screen-ing.
CT Colonography will definitely play
a large role in CRC screening for the fore-seeable
future. With this, CTC is definitely
the wave of the future and it is highly
expected that other private payers will
follow in the near future.
This map shows where SOMATOM Definition DSCT scanners are installed worldwide in Diagnostic
Imaging Centers (red dots), Community Hospitals (blue dots), Departments of Cardiology
(deep red dots), Emergency Departments (yellow dots) and University Hospitals (deep blue dots).
www.siemens.com/dsct
References
1 ACRIN (American College of Radiology Imaging
Network)
2 www.colonhealthcenters.com
Enhanced diagnostic confidence using
syngo Colonography PEV as a second reader
option for colon polyp detection.

News
The syngo CT 2009E Software for the SOMATOM
Emotion Further Increases the Clinical Capabili-ties
of the Most Popular Scanner
By Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany
The release of the syngo CT 2009E
software version for all new SOMATOM®
Emotion systems further reinforces
Siemens Healthcare’s dedication to con-tinuously
increase clinical capabilities
throughout the product portfolio.
syngo CT 2009E makes remote access
to the scanner workplace available for
the first time through the introduction
of syngo Expert-i. Siemens’ leading
applications, such as syngo CT Oncology,
are available for the first time on the
SOMATOM Emotion CT Workplace, and
a number of leading syngo applications
have been even further enhanced.
Additional capabilities on
Acquisition Workplace
With the syngo CT 2009E release, Expert-i
will allow physicians or senior CT technol-ogists
to connect remotely to the scan-ning
workplace. This functionality enables
the CT users to seek an expert clinical
opinion quickly and efficiently without
the need to physically go to the CT suite,
resulting in improved workflow and better
clinical outcomes for patients. In interven-tional
CT, the simple and efficient work-flow
for which the SOMATOM Emotion
is known is further enhanced with the
addition of a laser grid to increase the
speed and accuracy of CT interventional
procedures.
With the release of this software Siemens
also continues the philosophy of reduc-ing
dose in CT. To assist users in this con-tinual
process, a comprehensive and
exportable dose report is now available on
the SOMATOM Emotion with the syngo
CT 2009E release.
Additional capabilities on
CT Workplace
Through the introduction of the syngo
CT 2009E software, leading applications,
including syngo CT Oncology, are now
available on the CT Workplace with the
additional convenience of a linked data-base
with the CT system. syngo CT Oncol-ogy
increases the speed and accuracy
of CT oncology imaging through the
use of automated lesion measurements,
routine volume calculations, and auto-matic
lesion matching for follow-up
staging studies.
In addition to syngo CT Oncology,
syngo Neuro Perfusion Weighted Map,
e-Logbook, and InSpace Circulation
PE Detection are now also available on
the CT Workplace with the potential to
significantly improve workflow in acute
care imaging.
syngo CT 2009E has been available on
all new Emotion 6- and 16-slice configu-rations
since the beginning of April
2009.

News
Win with Excellent Image Quality at Lowest Dose
By Jan Freund, Business Unit CT, Siemens Healthcare, Forchheim, Germany
www.siemens.com/CT-IQcontest
SOMATOM Defi nition Flash Introduced During
ECR 2009
By Carolin Knecht and Peter Seitz, Business Unit CT, Siemens Healthcare, Forchheim, Germany
Seeing is better than believing. Therefore
Siemens CT will launch a global contest
to underline that the Definition family is
the choice for achieving the best results
when it comes to image quality. In 2005,
Siemens CT introduced its Dual Source
Technology with the highly successful
SOMATOM® Definition. Since then, more
than 500 systems have been installed,
proving that Dual Energy has become a
routine application and thus making the
SOMATOM Definition the proven Dual
Source CT. In 2007, Siemens then
launched the most flexible scanner sys-tem
in the market, the SOMATOM Defini-tion
AS which adapts to any patient,
while at the same time also adapts for
complete dose protection with innova-tive
technologies. Since its introduction,
the SOMATOM Definition AS has
achieved the fastest ramp-up in Siemens
CT history.
But these cutting edge systems were
Themed, “Ask the Ultimate Power in
Imaging,” Siemens Healthcare intro-duced
its latest imaging innovation, the
SOMATOM® Definition Flash, at the
European Congress of Radiology (ECR)
2009 from March 6 to March 10 in
Vienna, Austria.
This latest computer tomograph is
designed to be the industry’s most patient
friendly CT by requiring less dose through
faster speed.
During the congress, dose reduction
was obviously of universal interest for
the visitors. Many wanted to know more
details about technical features of the
SOMATOM Definition Flash that enable
users to scan with highly reduced radia-not
the end of CT’s innovation potential:
Last year, CT continued its Dual Source
success story with the introduction of
the SOMATOM Definition Flash, allowing
scanning the entire thorax in less than
one second and imaging the heart with
a radiation exposure of less than 1 mSv,
only a fraction of the natural background
radiation.
Consequently, the time has come to
prove the superior image quality of the
SOMATOM Definition family obtained with
significantly reduced dose. As the best
proof is customers’ voice, Siemens CT
will host a contest for all Definition users
addressing highest image quality at low-est
dose which will be introduced in
June 2009. Participants are welcome to
send in cases scanned on any Definition
scanner (single and Dual Source). A jury
of highly qualified experts and medical
advisers will discuss each case and deter-mine
the finalists. Therefore, beginning
immediately, all Definition customers
are invited to participate in this contest
and start collecting their outstanding
low dose cases and demonstrate their
achievements in cutting-edge CT.
The new SOMATOM Definition Flash was
introduced to the European market during the
European Congress of Radiology (ECR) 2009
featuring a special “healthy” version of the low-dose
scanner.
tion dose, for example, heart scan with
less than 1 mSv. The fast scan speed of
43 cm/s and the temporal resolution of
75 ms were also subjects of great gener-al
interest at the Siemens booth.
At a Joint Satellite Symposium of Siemens
Healthcare and Bayer Schering Pharma,
first clinical results of the SOMATOM
Definition Flash were presented, together
with updates on the entire range of
SOMATOM Definition scanners. According
to the theme “For better patient care:
What’s new in CT,” leading clinical experts
once again complimented the innovative
power of Siemens CT and made it one of
the most visited symposia at ECR 2009.
The SOMATOM Definition Family:
Revolutionizing CT imaging since its intro-duction
in 2005.

Business
St. Paul Heart Clinic, Saint Paul, Minnesota, USA.
The St. Paul Heart Clinic:
The leading physician overseeing the construction and equipping
of a new clinic in the State of Minnesota (USA) has found that making
a big investment in state-of-the-art technology for cardiac imaging
pays big dividends for patient care.
By Ron French
The cardiovascular imaging center in the
St. Paul Heart Clinic (St. Paul, Minnesota,
USA) is unique in more ways than one.
It is the first independent cardiology prac-tice
in the world to incorporate both
Siemens MRI and SOMATOM® Definition
Dual Source CT scanning technology,
thereby offering state-of-the-art imaging
and unprecedented patient and customer
efficiencies. And what’s even more unique
is that the clinic has designed a success-ful
business model around these cutting
edge technologies.
At the heart of this success story is Uma
Valeti, MD, Director of Cardiovascular

Business
of Siemens sites and talked to the engi-neers
in detail. Siemens offered a well
integrated cardiovascular imaging solu-tion
with these two modalities that was
unparalleled by other vendors at the time.
Since our installation of Siemens equip-ment
we have been able to compare our
efficiencies and workflow – as well as
the satisfaction of our patients, nursing
staff and technologists – and we’ve been
extremely happy with our choice.
A limitation of most cardiac CT scan-ning
technology has been its inability
to capture clear images of a beating
heart. Some patients had to be placed
on beta-blockers to slow their hearts
to 60 beats a minute and had to wait
for an hour for the medication to kick
in. And the chests of obese patients
were too dense to permit a clear image.
As many as 10 percent of the images
were non-diagnostic. How has the
SOMATOM Definition improved imag-ing
efficiencies?
What we found with Dual Source CT was
that there were very few exclusions, for
previously common reasons like high
heart rate, asthma or large body habitus.
Patients didn’t have to take beta-blockers
mandatorily to reach a heart rate below
60 beats/minute, and the system was
better able to deal with irregular heart
rates, so there was no need to wait for
hours prior to the scan. We saw that it
would be advantageous and improve
workflow. The patients are happy due to
the ease of the exams, the physicians
are happy because they did not need to
exclude many patients that were previ-ously
excluded, and finally our staff is
happy due to less work involved in pre-paring
a patient for the study.
And the improved workflow cut costs?
The improved workflow meant more
efficient patient throughput. The non-diagnostic
scan rate is now less than
three percent, which is less than half of
what it was before with regular 64-slice
scanners. Additionally, the time and dol-lar
savings on mandatory beta-blocker
administration and aftercare are not tak-en
into account in this consideration.
Siemens SOMATOM Definition Dual
Source CT also offers a low-dose option
– reducing patient radiation from the
industry standard of up to 30 mSv per
scan to below 3 mSv, without compro-mising
image quality. And with the
new SOMATOM Definition Flash you
can even reach levels of below 1 mSv.
Was that a selling point?
Yes, it was a big selling point. The one
big knock against CT was always the
radiation level. It’s important to lower
the radiation dose as much as possible,
without compromises in image quality.
This fits into our goals of patient first,
safety first. Being able to offer low dose
cardiac CT is a clear differentiator and
a competitive advantage. And the latest
DSCT is setting a new benchmark in this
dose battle among CT vendors, strongly
reducing concerns about dose.
CT/MRI, at the St. Paul Heart Clinic
(SPHC). Four years ago, Valeti moved
from the Mayo Clinic in Rochester,
Minnesota, to SPHC to build the Cardio-vascular
MRI/CT imaging center. He
oversaw not only the selection and pur-chasing
of the imaging technology, but
also the communications and customer
service that have been integral to the
center’s growth. Valeti shares the steps
St. Paul Heart Clinic took to build the
advanced imaging practice in an inter-view
with SOMATOM Sessions – steps
that other physician groups could emu-late.
It’s unusual for an independent cardi-ology
practice to have both MRI and
CT imaging. Why did you choose to
include both in your practice and what
were some of the challenges you anti-cipated
when you were building the
advanced imaging program?
Our practice has 38 cardiologists and we
are a tertiary care facility. We get a lot of
complex cases referred to us in addition
to the usual mix of cardiac pathology. We
were convinced that cardiac CT and MR
imaging were leading a paradigm shift
in the future of general cardiac imaging
and not just limited to complex cardiac
diseases. We wanted to have all the ad-vanced
modalities to diagnose and man-age
the routine and complex patients re-ferred
to us not only for patient care but
also to enhance our ability to recruit
highly talented physicians looking to in-tegrate
cutting edge clinical care and re-search
into their professional careers.
Your clinic is designed so that, if
needed, patients can go seamlessly
from the MRI lab to the CT lab. Your
imaging rooms are separated by a
glassed-in control room, which is the
nerve center of both imaging labs.
There were many choices for equip-ment.
Why did you pick SOMATOM
Definition Dual Source CT and Siemens
Avanto MRI?
We had no previous experience with
Siemens. We had worked with CT and
MR scanners from different vendors
and went out and looked at a number
The SOMATOM Definition scanner delivers clear images for save diagnoses – even in patients
with fast or irregular heart beats or with an obese body habitus.

Business
Anterior-oblique volume rendered view of the heart of an obese patient depicting
the right coronary artery (RCA) and left artery descending (LAD) with the Dual Source CT
SOMATOM Definition.
at various small and large group confer-ences.
The message was simple and
consistent. We kept saying, “Here are all
the imaging modalities and clinical solu-tions
we have, and here’s what they can
offer. If you feel they can benefit your
patient, here’s the number to call.” We
also made it very simple for them to re-fer
patients. Everybody in the group had
extensive education about each modality,
appropriate indications as defined by the
guidelines including the scheduler, the
technologists, the nurses and the pro-gram
administrator in addition to being
aware of the unique Siemens technologi-cal
benefits. At first, we turned down
many referring providers who were order-ing
studies that did not meet the appro-priateness
criteria, at the risk of offending
them. However, the initial emphasis was
on letting our referring providers realize
that our program was a credible patient
centric program and if they know we
were being very careful to prevent un-necessary
utilization eventually we
would get more appropriate studies. In
addition, we had a constant line of com-munication
with all the referring provid-ers
with access to an imaging physician
at all times for any question related to
the appropriate use of advanced imag-ing
modalities.
It sounds as if you have to be as good
as a businessman as a physician.
We are fortunate to have an outstanding
administrative leadership team for busi-ness
planning. Therefore the credit goes
to them. From my perspective, what the
doctors and third-party payers really want
to know is: Is this a layered test? Are
you just adding another test to patients
already getting stress tests and MRIs or an
angiogram? Even before we began the
program, we engaged all the parties
involved – all the cardiologists, the pri-mary
care providers and the third-party
payers – and informed them that we are
going to start this program, and shared
our pilot data with them to reassure them
that there would not be layering of tests.
On the contrary, we shared data about
the large cost savings to the system based
on our initial pilot of 250 patients. We
also informed them that every year we
Full cardiac evaluation possible with syngo Circulation which is automatically included in CT
Cardiac and Acute Care Engine.
What were some of the challenges
you anticipated and what did you do
to build market share to the point that
the clinic could work economically?
What was your marketing plan?
Because this is new technology, we real-ized
the biggest hurdle would be aware-ness
and education. Although we are a
tertiary care practice, most physicians
within our practice and in the community
were not aware of the benefits and appro-priate
use of these advanced technolo-gies
and how they can improve clinical
diagnoses, management and treatment
of their patients, as well as decreasing
the overall costs of working up patients.
Members of my group gave about 200
formal and informal talks in the first year
1
1

Business
would come back and show the data to
the third-party payers.
And what happened?
At the end of the first year, we invited all
the major payers to come to our practice.
The data was remarkable. In a study of
more than 1,000 cardiac CT scans, only
15 percent of patients went on to have
angiograms. Normally, if CT was not in
the picture, more than 50 percent of these
patients would go on to have angiograms
based on previous studies of patients with
equivocal or mildly positive stress tests.
However, invasive angiograms carry a
higher procedural risk and are 5 to 10
times more expensive than CT scans.
You are a busy interventional cardiol-ogist.
What is your perspective on
cardiac CT?
Being an interventional cardiologist, I am
very skeptical of anything that is por-trayed
in the media as a replacement to
an invasive angiogram. But I can’t argue
with the fact that for 30 to 40 percent
of patients that are currently referred for
diagnostic angiography, cardiac CT is in
fact a safer and equally effective proce-dure
in addition to being cost effective
for the health system due to its very
high negative predictive value. What
would really help in convincing decision
makers like cardiologists, primary care
“The improved workfl ow means
greater patient throughput and
the non-diagnostic scan rate is
now three percent, less than half
of what it was before.”
Uma Valeti, MD,
Director of Cardiovascular CT/MRI,
St. Paul Heart Clinic, St. Paul, Minnesota, USA.
Further Information
www.siemens.com/
ct-cardiology
physicians and the third-party payers is
data from large multicenter trials, prov-ing
the benefit of the cardiac CT in a
wide patient population.
Your equipment was installed in 2006.
In those three years, your market share
has grown to 90 percent of cardiac MRI
and CT imaging in your region. There
are more than 20 clinics referring to
your center. How do you account for
that rapid growth?
The key has been good, relevant informa-tion
that was immediately conveyed to
the referring providers along with the
outstanding patient experiences during
the process of scheduling, scanning and
follow up. Consequently our program has
been growing steadily for the past three
years with a wide range of clinical pathol-ogy.
Our advanced imaging program sup-ports
several sub-speciality clinics and
helped in their growth (for example: vas-cular
clinic, adult congenital clinic, CHF
clinic, Hypertrophic Cardiomyopathy clin-ic,
Pulmonary Hypertension clinic etc).
We were also very successful in educating
our referring providers about the techno-logical
benefits offered by our CT and MR
imaging equipment. For instance, the low
dose cardiac CT protocols, the high image
quality even in difficult patients, the lack
of a mandatory need for oral beta-block-ers
and lack of a large list of exclusion
criteria was very attractive for them.
We were also able to recruit eight highly
talented physicians in the last three years,
at a time when most practices in the re-gion
had trouble recruiting and retaining
cardiologists. An important reason is be-cause
St. Paul Heart Clinic offered them
advanced imaging modalities that provide
exciting and unique capabilities and ser-vices.
Do you have any advice for other
clinics that are considering investing in
SOMATOM Definition CT technology?
We believed in the technology and
believed that it would inevitably move to
mainstream modality in a few years. You
have to spend a lot of time in educating
the people who will be using it and pay-ing
for it. This is a long-term strategy
and you will need to believe in the para-digm
shifts occurring in cardiac imaging.
That’s why we invested in it.
Ron French is a senior writer and award-winning
journalist for the Detroit News, where
he specializes in coverage of health care and
the economy.

Topic
Business
Chest Pain: Clarity with CT
It’s not an insignifi cant problem, nor a cheap one. With more than six
million patients a year presenting at emergency departments with chest
pain, costing an estimated eight billion dollars, the importance of an
accurate, effi cient and quick way to determine which patients need inter-ventional
treatment and follow-up is hard to ignore. Dual Source CT scan-ners
meet these criteria perfectly. They are enhancing diagnostic capacity
for adult and pediatric patient populations that would have formerly
been excluded from CT scans because of conditions such as obesity, high
heart rates, atrial fi brillation or contra-indications to beta-blockers.
By Louisa Kasdon
“You can do the ‘triple rule-out’
in real time, confi rming three
diagnoses with one scan.”
Udo Hoffmann, MD, MPH,
Director of Cardiac MR PET CT Program,
Massachusetts General Hospital, Boston, MA, USA
“With the new SOMATOM Defi nition
Flash technology, you will be
able to image the entire chest in
less than one second.”
Harold I. Litt, MD, PhD, Assistant Professor of Radiology and Medicine,
Chief, Cardiovascular Imaging Section, Department of Radiology,
University of Pennsylvania Health System, Philadelphia, PA, USA

Topic
“With the CT of the heart
being less than one milliSievert,
radiation will basically no
longer be an issue.”
Gilbert Raff, MD, Director,
Ministrelli Center for Advanced Cardiovascular Imaging,
William Beaumont Hospital, Royal Oak, MI, USA
The “Holy Grail” in the emergency depart-ment,
according to Gilbert Raff, MD, of
William Beaumont Hospital in Royal Oak,
Michigan, USA, is figuring out which
patients to send home, and which to keep
for further observation and treatment.
Raff, a cardiologist with more than thirty
years of clinical experience, says that
misdiagnosing a patient and sending
him or her home with a potentially fatal
heart attack, is the nightmare scenario
for every ER doctor. The tricky part is to
identify the 10 to 20%, out of the patient
cohort, who really do need immediate
treatment.
A Roundtable at the University
of Pennsylvania
A group of prominent American inter-ventional
radiologists and cardiologists,
specialists at the forefront of their pro-fessions,
suggest that immediate triaging
to a CT scan for patients presenting with
chest pain has the potential to radically
streamline the diagnostic process and
speed up the door-to-balloon interval.
SOMATOM Sessions recently met with
three of these experts for a roundtable
discussion at the University of Pennsyl-vania
– Harold I. Litt, MD, PhD, Assistant
Professor of Radiology and Medicine,
Chief, Cardiovascular Imaging Section,
Department of Radiology, University of
Pennsylvania Health System in Philadel-phia;
Udo Hoffmann, MD, MPH, Director
of Cardiac MR PET CT Program at the
Massachusetts General Hospital (MGH)
of Harvard University in Boston; and
Gilbert Raff, MD, Director, Ministrelli Cen-ter
for Advanced Cardiovascular Imag-ing,
William Beaumont Hospital, Royal
Oak, Michigan – and listened in as they
revealed their vision for a new “gold
standard” for the diagnosis of chest pain.
These clinicians believe that scanning
patients with a Dual Source CT (DSCT)
SOMATOM® Definition can save billions
of dollars in healthcare costs annually.
“The work-up of those patients who do
end up not having a heart attack costs us
about eight billion dollars a year. A big
chunk, with the potential for big health-care
savings,” says Hoffmann. Litt con-curs,
“we conducted a large trial, with
more than 640 individuals, about the
actual financial comparison of different
strategies to evaluate patients with
potential acute coronary syndrome.“*
“Herein we compared the CTA group (A)
with the two groups being treated the
standard or current way,” describes Litt.
These two groups are the clinical decision
unit group with serials of biomarkers and
stress test (B) and the usual care group
Business
which was defined as admission with
serial biomarkers and hospital-directed
evaluation (C).
The main outcomes were actual cost
of care (facility direct and indirect fixed,
facility variable direct labor and supply
costs), length of stay, the 30-day read-mission
rate as well as safety measured
in 30-day death or myocardial infarction
rate.
The study showed an overwhelming
result. The standard of care group B and
the usual care group C revealed median
costs of $2,913 – $4,024 per patient
and an average length of stay of 26.2
to 30.2 hours. The rate of myocardial
infarction and death was 0.7 to 3.1%.
The readmission rate was between 2.3
and 12.2% here, which means that addi-tional
cost has to be considered for the
patients coming back for further test
and treatment. Those results were com-pared
with the new CTA strategy. The
cost per patient in the CTA group A were
found to be only $1,240 which was a
57% to 69% saving. Similar results been
revealed for length of stay with eight
hours in CTA group, which was a time
advantage of 69 – 73%. Interestingly the
rate of myocardial infarction or death in
the CTA group (A) was 0%, which can be
explained with the high negative predic-

Business
tive value of almost 100% of the DSCT.
Also the 30 day readmission rate was 0%
which means no patients coming back
for additional testing or treatment,
which saves additional time and money.
Litt and his group found that, using total
facility cost in their analysis, immediate
CTA was the least costly method of eval-uation.
It also resulted in reduced length
of stay, decreased rate of admission,
lower rate of return visits, and at least
equivalent 30-day outcomes. Other
strategies that required inpatient or ob-servation
unit admission were more
costly, had more prolonged length of
stay, and did not detect any more dis-ease
than the immediate CTA strategy.
The subset of patients who received ’usu-al
care’ accompanied by cardiac testing
(stress echo, treadmill testing, or cardiac
catheterization) had a mean cost of
$4,154 compared to $1,239.
A Unique Tool for a Better
Image
Beyond economic and efficiency issues,
any new technology has to support better
patient care. These three doctors feel
strongly that the new generation of Dual
Source CT scanners enables them to iden-tify
cardiac issues with more clarity, and
yields diagnostic information to prevent
future disease. There is a big impact on
patient care. “We now have a unique tool
with the spatial and temporal resolution
that can help us noninvasively visualize
the disease,” Hoffmann explains.
At MGH, Udo Hoffmann is conducting
a randomized trial where both low-risk
and high-risk patients are put into a CT
scanner. For the high-risk patients with
a suspicion of pulmonary embolism,
aortic dissection, or acute coronary syn-drome,
he is finding the Dual Source
scanners high-image-quality, even at
high heart rates or with obese patients,
extremely helpful. “You can do the ‘triple
rule-out’ in real time, confirming three
separate diagnoses with one scan,” says
Hoffmann. For the low-risk patient sub-clinical
disease can be captured also and
treatment can be started that could pre-vent
a heart attack in the future.”
The Heart is a Moving Target
Another advantage of the Dual Source
CT scan seems to be speed. “Because the
heart is moving, in order to get images
of it that don’t have motion artifacts,
you need to be able to scan as quickly
as possible,” says Litt. He enthuses that
a DSCT scanner like the SOMATOM
Definition Flash scanner “can freeze the
heart’s motion twice as fast as other com-peting
technologies. This is a particularly
important benefit for patients who come
to the emergency room and cannot take
a beta-blocker to lower their heart rate
so that the heart beats more slowly. “In
our patient population,” Litt explains,
“we have patients with asthma or suspi-cion
of other lung problems like pulmo-nary
embolism, people who have taken
cocaine recently – and you can’t use
these types of drugs on them. With the
new Dual Source CT, it is possible to do
a thorax scan in a split second without
holding breath. We can scan patients
with higher heart rates and have confi-dence
that we’re going to get good
image quality.”
Obese patients represent another clinical
challenge. Litt says: “With the Dual Source
CT technology, we’re able to get better
image quality at lower radiation doses in
Dual Source scanners deliver high image quality, even at high heart rates.

Business
With sub-milliSievert heart scanning, the SOMATOM Definition Flash raises the bar
higher in terms of cardiac dose saving.
Louisa Kasdon is a Cambridge, Massachusetts-based
writer who specializes in health, medi-cine,
nutrition, food and business. She writes
about health issues for Fortune magazine, the
Boston Globe and the Christian Science Monitor.
* Chang AM, Litt HI et al.: Actual Financial Comparison
of Four Strategies to Evaluate Patients with Potential
Acute Coronary Syndromes. ACADEMIC EMERGENCY
MEDICINE. 2008; 15: 649-655.
obese patients, even those who weigh
more than 350 pounds.” At Raff’s hospi-tal
in Michigan, using a new software
package, that he terms the cardio obese
model, in combination with the Dual
Source CT allows him to scan 90% of
obese patients and get a diagnostic
image.
Next Steps for CT Scanners?
As the technology continues to improve,
the doctors look ahead to a new era of
even greater clinical utility as equipment
like the Flash scanner comes into clinical
use. When they see that one could now
image at 83 milliseconds, they understand
immediately that this is a tremendous
improvement, really a quantum leap
from the 64-slice CT. It opens up their
patient population to patients who were
previously considered not suitable – for
example, those with calcification – and
lets a diagnosis become even more quan-titative.
Litt concurs, that with SOMATOM
Definition Flash it is possible to image
very quickly. “Typically a chest CT on an
average high-end scanner might take five
to ten, perhaps twenty seconds. With
the new technology, you will be able to
image the entire chest in less than one
second. That will allow us to get very
clear images of the heart, the pulmonary
arteries, and the aorta without the patient
needing to hold his breath. Similarly, in
children and infants who can’t understand
the direction to take a deep breath and
hold it, you will be able to get motion-free
images of the entire chest or the
body in a time frame where the patient
can remain still.”
With sub-milliSievert heart scanning,
the SOMATOM Definition Flash raises
the bar even higher in terms of cardiac
dose saving. Raff pronounces, “that
with the CT of the heart being below
1 milliSievert, radiation will basically no
longer be an issue.” Hoffmann says that,
due to its low dose, it is even conceiv-able
that, in the future, this technology
could be used for early detection and
prevention of acute myocardial infarc-tion.
Another priority for the future is collect-ing
better clinical data. The physicians
are working together to launch several,
large, multi-center trials to get demon-strable
data and validation of the new
triage pattern for their colleagues, for the
NIH, and for the large public and private
insurers such as Medicare in the USA, all
of whom will have to be convinced of the
CT scanner’s superiority as a diagnostic
tool as well as its ability to increase work-flow
and efficiency in emergency depart-ments
all across the country. Other pri-orities
for the doctors are education and
training. Unless young physicians and
radiological technicians are trained to
use and interpret CT scans, the benefits
of the technological advances will be
limited to the most sophisticated medi-cal
centers.
Further Information
www.siemens.com/
somatom-definition

Topic
“We are very pleased with the performance
of the SOMATOM Emotion 16. The system
reliability has been excellent.”
Holly Klein, RT(R)(M), Director of Imaging/Cardiolab Services,
Shannon Clinic, San Angelo, Texas, USA
SOMATOM Emotion Around the Globe
Worldwide sales of the SOMATOM Emotion CT system recently
exceeded 6,500 units, making it globally the most popular CT system.
SOMATOM Sessions asked eight clinics why they chose the Emotion
system and how it has been put to use in their clinical environments.
By Steven Bell, Business Unit CT, Siemens Healthcare, Forchheim, Germany
6
“We were looking for a workhorse scanner,
and the SOMATOM Emotion has proven
to be that. We’ve never had any problems
with the system – it’s great!”
Reginald Moultrie, MD, Radiology Supervisor,
Northside Hospital, Atlanta, Georgia, USA
“The system has an extraordinary
image quality – in fact, we have the
best images in the entire city!”
Ramírez Calderón, MD, Centro Médico de Diagnóstico Hermanos
Ramírez Calderón, San Cristóbal, Táchira, Venezuela
5
7
Business

Topic
Business
“The image quality is excep-tional.
The SOMATOM® Emotion has proven itself
over and over again as a leading work-horse
CT in almost all global CT markets.
The SOMATOM Emotion has achieved
this outstanding success through a com-bination
of excellent image quality, lead-ing-
edge clinical applications, efficient CT
workflow and Siemens’ continued focus
on system uptime. These factors offer
Siemens customers enhanced clinical
capabilities that translate into better clini-cal
and financial outcomes. The success
of this philosophy is easily recognized
with over 6,500 satisfied and knowledge-able
customers worldwide.
On these pages, SOMATOM Sessions has
put together a selection of quotes and
stories from many successful SOMATOM
Emotion installations from all corners of
the globe. These sites are varied in nature,
from outpatient clinics, to comprehen-sive
trauma hospitals, and offer superb
examples of why the SOMATOM Emotion
is the world’s most popular CT system and
The system enables us
to scan and process patients’
images very fast. For emer-gency
cases at night, we use
only this system.”
Yu Kang Chang, MD, CT Section Chief,
Chie Mei Medical Center, Luiying, Tainan, Taiwan
2
“We examine practically the complete
non-cardiac spectrum of patients
on our SOMATOM Emotion 6 – from
patients with diffuse lung disease to
those with cerebral ischemia.”
Pavel Elias, MD, PhD, Professor of Radiology,
University Hospital Hradec Králové, Czech Republic
“All examinations – head, whole
body, thorax, abdomen and
pelvis – are performed with the
SOMATOM Emotion 16. The
postprocessing is extremely
fast.”
Prof. Kunihiko Fukuda, MD,
Tokyo Jikei University Hospital, Japan
why it is the right choice for CT service
installation.
1 Tokyo Jikei University Hospital,
Japan.
The Tokyo Jikei University Hospital is
one of four hospitals associated with the
Jikei School of Medicine. The hospital is
large, with over 1,050 beds and 3,000
outpatient visits per day, six days a week.
It has four CT systems to service both
in- and outpatients. In 2006, the hospital
1
Business
8
3
4

Business
installed a SOMATOM Emotion 16 to ser-vice
all routine examinations and emer-gency
cases. Professor Kunihiko Fukuda
says that up to 70 patients are examined
with the Emotion 16 per day: “All exam-inations
– head, whole body, thorax,
abdomen and pelvis – are performed
with the SOMATOM Emotion 16 at our
hospital. The postprocessing is extremely
fast. The techs create MPR, MIP and 3D
images in no time at all.”
2 University Hospital Hradec
Králové Czech Republic.
The Department of Radiology at the Uni-versity
Hospital Hradec Králové is associ-ated
with the Charles University in
Prague. This facility ranks among the
most significant healthcare facilities in
the Czech Republic. The hospital serves a
population of approximately 1,000,000
residents and many departments attract
patients from the entire Czech Republic.
The hospital is an important training cen-ter
for physicians and secondary school
educated medical workers. Every year,
about 42,000 patients are admitted to 21
clinics with about 1,500 beds, and ap-proximately
660,000 patients are treated
as outpatients. Since 2004, the lead CT
system has been a SOMATOM Emotion.
Pavel Elias, MD, PhD, from the University
Hospital Hradec Králové says: “There are
two CT scanners working in our facility.
We examine practically the complete
non-cardiac spectrum of patients on our
SOMATOM Emotion 6 – from patients
with diffuse lung disease to those with
The SOMATOM Emotion has proven itself as a leading workhorse CT.
cerebral ischemia. Perfusion studies or CT
angiography are crucial for treatment pa-tients
with cerebral ischemia, subarach-noid
hemorrhage, or for patients with an-eurysmal
dilation of aorta. We exam up
to 50 patients per day.”
3 Chi Mei Medical Center,
Luiying, Tainan, Taiwan.
The Chi Mei Medical Center in Luiying,
Taiwan, installed the SOMATOM
Emotion 6 in mid-2004. Initially, the
system was used to examine over 1,400
patients per month until a second CT
system was installed. The SOMATOM
Emotion system provides 24-hour ser-vices
for all routine and emergency cases.
“The image quality of the SOMATOM
Emotion is exceptional, even when com-pared
to the 64-slice systems in our
department,” says CT Section Chief
Yu-Kang Chang, MD. “The workflow of
the SOMATOM Emotion 6 enables us to
scan and process patients’ images very
fast. It’s the reason why we only use
SOMATOM Emotion 6 for emergency
cases at night instead of the other CT
systems in the department.”
4 Treviso Santa Maria Cà Foncello
Hospital, Italy.
The workload at the Neuroradiology
Department of Treviso Santa Maria Cà
Foncello Hospital can be very heavy. Over
13,000 CT procedures were performed
on the SOMATOM Emotion 6 during 2008.
“The Emotion 6 performance in neuro-radiology
is without any doubt satisfying
as far as image quality and scanning
speed are concerned,” says the chairman
of the department, Francesco Di Paola,
MD. Moreover, he praises the versatility
of the system. At his hospital, the
“The SOMATOM Emotion 6
performance in neuroradiology is
without any doubt satisfying.
It offers the quality-to-price ratio
the hospital was looking for.”
Francesco Di Paola, MD, Chairman Neuroradiology Department,
Treviso, Santa Maria Cà, Italy

Business
SOMATOM Emotion is used not only for
neurological-related exams (brain, head,
maxillo-facial, CT angiography of the
carotids and intracranic vessels) but also
for general radiology (thorax and abdo-men).
“The SOMATOM Emotion,” says
Di Paola, “offers the quality-to-price ratio
the hospital was looking for.”
5 Centro Médico de Diagnóstico
Hermanos Ramírez Calderón,
San Cristóbal, Táchira, Venezuela.
Since the opening of the Centro Médico
de Diagnóstico Hermanos Ramírez
Calderón in 2007, the CT department’s
patient traffic has grown to around 35
examinations per day. “We are a family
of physicians and decided to build this
center for the benefit of the city of San
Cristóbal. Since I have four children who
are radiologists, we decided on the field
of diagnostics,” says Ramírez Calderón,
MD. From the onset, the team of doctors
was convinced that this center should
offer the highest technology with state-of-
the-art equipment. “When we started,
we decided to work only with the best
systems available on the market,” says
Ramírez Calderón. “The Emotion is a very
good CT system, it has extraordinary
images – in fact, we have the best images
in the entire city!”
6 Shannon Clinic, San Angelo,
Texas, USA.
Shannon Clinic is a large, multi-speciality
outpatient clinic with around 120 physi-cians.
In 2000, the hospital purchased a
Siemens SOMATOM Emotion single slice
system. “The system was easy to use and
very reliable,” says Holly Klein, RT(R)(M),
Director of Imaging/Cardiolab Services.
“Our technologists loved it. Due to the
higher quality and performance, Shannon
Clinic decided to upgrade to the Siemens
SOMATOM Emotion 6 in 2004.” Then, in
2008, a decision was taken to upgrade
the Emotion 6 scanner to the SOMATOM
Emotion 16. Since the decision the num-ber
of CT examinations has steadily been
growing from a base of around 300 cases
per month. “We are very pleased with the
performance of the SOMATOM Emotion
16. The system reliability has been excel-lent.
We use the scanner to perform
high-quality routine examinations such
as abdomen, pelvis, head, and chest,” says
Holly Klein. “Feedback from our radiology
staff has been very positive about the
image quality of the SOMATOM Emotion
16,” Klein continues. “Furthermore, our
patients are particularly happy with the
shorter scan times.”
7 Northside Hospital, Atlanta,
Georgia, USA.
With imaging facilities spread across
a large metropolitan area, Northside
Hospital in Atlanta, Georgia, needed a
CT solution that would reliably and effi-of
CT procedures. In 2007 alone, North-side
performed more than 78,000 CT
exams. The SOMATOM Emotion was built
with reliability in mind and has not dis-appointed
the staff at Northside. “We’ve
never had any problems with it since
we’ve had it here,” says radiology super-visor
Reginald Moultrie. “It’s great.”
8 Yunus Emre State Hospital,
Eskisehir, Turkey.
The Yunus Emre State Hospital was first
opened under the name Eskis˛ehir SSK
District Hospital on the 4th of April 1963.
In early 2005, the hospital has been
handed over to the Ministry of Health.
“We have optimized our hospital
workfl ow with the fast scan protocols
of the SOMATOM Emotion.”
Alper Yurdasiper, MD, Yunus Emre State Hospital,
Eskisehir, Turkey
Further Information
www.siemens.com/
somatom-emotion
ciently allow its staff to image a large
volume of patients with a broad range
of medical needs. “Our goal is to make
sure that our care is convenient and
patient-centric while also providing our
referring physicians with high-quality
imaging – regardless of location,” says
director of Radiology Services, Deidre
Dixon. In January 2008, Northside chose
to install five Siemens SOMATOM Emotion
CT scanners across their network. As a
result, Northside has been able to expand
its imaging services while gaining effi-ciencies
and measurable financial bene-fits
from faster workflow. “We were
looking for a workhorse scanner,” says
radiologist Carolyn J. Weaver, MD, “and
the SOMATOM Emotion has proven to
be that.” In addition to superb image
quality, Northside wanted a system that
would efficiently handle its large volume
The SOMATOM Emotion 16 was installed
in February 2008. “With the SOMATOM
Emotion CT, we are able to scan 90
patients per day on average,” says Alper
Yurdasiper, MD. “Especially in periphal
angiography studies, the diagnostic
sharpness has increased due to the great
image quality of our SOMATOM Emotion.
Radiologists in our hospital are grateful
to achieve such high-quality CT images.
Moreover, we optimized our hospital
workflow with the fast scan protocols of
the SOMATOM Emotion.’’

Topic
Business
Emilio Vega, Manager, Image Processing Lab at NYU Langone Medical Center, integrated syngo WebSpace, Siemens’ thin-client server technology,
into clinical workflow.
Economical Benefi ts Drive Thin-Client
Server Technology
By Joachim Buck, PhD
Business Unit CT, Siemens Healthcare, Forchheim, Germany
CT is making 3D post-processing and
advanced clinical applications a necessity
for daily routine in radiology depart-ments.
Large volumes of data with thou-sands
of images per study require 3D
imaging for faster diagnosis. 3D as diag-nostic
tool increases reading efficiency
and saves time. Due to the CT data explo-sion
and the increasing spectrum of
clinical applications, hospitals and other
clinical enterprises are searching for
technologically and economically feasible
solutions to access and utilize CT volume
data. Consequently, in recent years,
Siemens has developed more powerful
clinical applications for cardiac, oncology,
neuro, and acute care CT. The availability
of high quality CT volume data and the
development of new clinical applications
deliver more and better information to
clinicians for their treatment choices.
However, the delivery of huge CT volume
data sets to the individual workstations
of the involved physicians is a heavy bur-den
for the IT system and performance
can, and often does, slow down con-siderably.
In addition, the purchase of
several stand-alone workstations, each
fully packed with clinical applications,
puts heavy pressure on the hospital’s

Business
budget. In view of the increased aware-ness
of IT infrastructure, and its potential
impact on the organization’s business
success, the strong trend from stand-alone
workplaces to thin-client, server-based
solutions, such as Siemens’ syngo
WebSpace, is very natural and driven
primarily by the following economic
benefits:
3D reconstructions immediately
available anywhere: Several thousand
images per CT exam are no longer an
exception. Referring physicians, neuro
and orthopedic surgeons, oncologists
etc., cannot view and diagnose all these
images. They need 3D reconstructions
and the functionality to interactively
modify the 3D representations according
to the specific details they are interested
in. A thin-client, server-based system
centralizes the complete 3D volume pro-cessing
at the server. The 3D results are
immediately available to the physicians
on their personal viewing stations. They
can make use of basic viewing features
such as MPR, MIP or VRT and advanced
clinical applications for cardiac, oncology,
neuro, and acute care CT.
Usage of existing IT infrastructure: For
image processing, volume data sets are
sent from the CT scanner to the central
server where all the image processing
software (e.g. vessel analysis) is up and
running. From each unit (e.g. PACS view-ing
station) connected to the server via
the IT network, the clinician can start the
processing of a CT volume data set. Thus
thin-client server technology does not
place any additional burden on the local
hospital’s IT infrastructure. Large amounts
of CT data are no longer distributed across
the entire IT network to several work-stations.
Therefore, 3D image processing
does not slow down the system for other
image transfer purposes. Expensive
upgrades of the whole IT infrastructure
are avoided.
Cost-effective maintenance: A thin-client,
server-based solution reduces
time and cost of keeping data and soft-ware
up-to-date and consistent across
the healthcare enterprise. It saves a lot
of technical man-hours required for both
the installation and maintenance.
Faster workflow and patient through-put:
Within the radiology department,
thin-client server technology significantly
increases productivity. Technologists
no longer need to run pre-processing
at the scanner’s acquisition console.
Radiology departments are able to shift
higher salaried personnel from time-consuming,
routine tasks to more com-plex
and demanding duties, resulting
in faster and better diagnosis for the
patient.
Increased revenue: Thin-client, server-based
technology makes 3D post-pro-cessing
and advanced clinical applications
available to other departments within
the hospital or to referring physicians.
Therefore hospitals can significantly
increase reimbursement and revenue.
Shorter reading times: 3D reading soft-ware
provides significant added value
for the patient’s diagnosis. Compared
to stand-alone workplaces, thin-client,
server-based solutions are capable of
speeding up the 3D reading process by
easily integrating into existing PACS
installations. The end result of being
able to access the very same case in 3D
applications with just one click, can
lead to an earlier therapy decision for
the patient.
Competitive edge for the hospital/
department: Ongoing cost pressure due
to shrinking healthcare budgets is com-mon
to all healthcare facilities. As this
fact drives the competition among hos-pitals
and healthcare providers, thin-client
server technology can provide a
competitive edge in attracting referring
physicians and patients as well as
recruiting qualified medical staff to join
the hospital or department.
Significant cost reduction: 3D thin-client
images are instantaneously avail-able
on virtually any clinical-quality
PC, PACS workstation etc. Hospitals no
longer have to incur additional costs of
adding hardware for 3D post-processing
throughout the hospital or in remote
locations.
Investment protection and flexibility:
Investment into thin-client server
technology enables hospitals and other
healthcare enterprises to gradually
invest, depending on varying needs, and
thus spread costs over several budget
cycles. Investment protection programs,
such as Siemens’ exclusive e-Tune, are
the key to keeping hospitals and other
healthcare enterprises economically on
the safe side.
“syngo WebSpace allows our
clinicians to access advanced post-processing
tools from any computer
at the offi ce or even at home.
This has given us fl exibility thus
becoming more effi cient.”
Emilio Vega, Manager, Image Processing Lab at NYU Langone Medical Center

Clinical Results Cardiovascular
Case 1
Dual Source CT Unveils Several
High-Grade Stenoses of Coronary Arteries
By Evgeny Egin, MD* and Andreas Blaha**
* Department of Radiology, Cardio Center, Volgograd, Russia
** Business Unit CT, Siemens Healthcare, Forchheim, Germany
VRT of the LM, CX and RCA revealed calcified lesions in LAD (arrow, Fig. 1A). Lateral VRT shows the entire course of the RCA (arrow, Fig. 1B).
approximately 8 mm from the
ostium. Significant calcified plaques in
the proximal part of the right coronary
artery (RCA) and the left coronary artery
descending (LAD) causing high-grade
stenoses with hemodynamic relevance
were observed. An additional high-grade
stenosis was found in D1.
COMMENTS
With the high temporal resolution of
the Dual Source CT, it was possible to
perform a reliable and quick diagnosis
even with this extreme arrhythmic
heart rate.
HISTORY
A 77-year-old male patient presented
with chest pain at the radiology depart-ment
of the Cardio Center, Volgograd,
Russia, in preparation for aortic femoral
bypass surgery. The patient had a known
history of several atherosclerotic arteries,
without hemodynamic relevant stenoses
and atrial fibrillation. The patient also
suffered from chronic iron deficiency,
cerebral atherosclerosis with temperate
Parkinson’s Syndrome and inter-vertebral
osteochondrosis with neurovascular dis-orders.
DIAGNOSIS
Prior to the contrast enhanced scan,
a calcium scoring native cardiac scan
was performed. Almost every segment
showed coronary artery calcifications.
The coronary CTA was performed with
an arrhythmic heart rate of 65–181 bpm,
on average 94 bpm. Aorta and pulmo-nary
artery trunk and branches were
not dilated.
The scan revealed a right dominant heart,
wide left main coronary artery (LM), left
circumflex artery (CX) and its marginal
branch as well as the right ventricular
branch, all without hemodynamic rele-vant
stenoses. A high-grade stenosis was
detected in first diagonal branch (D1),
1B
1
1A
CX
LAD
RCA

Cardiovascular Clinical Results
Curved Planar Reformats of RCA including plaque analysis (Fig. 2A); curved LAD, with syngo Circulation plaque
EXAMINATION PROTOCOL
Scanner SOMATOM Definition
Scan mode Spiral Spatial resolution 0.33 mm
Scan area Heart HR Independent Temporal
Scan length 149 mm Resolution 83 ms
Scan direction Cranio-caudal Slice collimation 0.6 mm
Scan time 13 s Slice width 0.75 mm
Heart rate 65 – 181 bpm, 94 avrg. Reconstruction increment 0.6 mm
Tube voltage 120/120 kV Reconstruction kernel B26f
Tube current 198 mAs/rot. Postprocessing CT Cardiac Engine
Rotation time 0.33 s
2B
3B
2A
analysis (Fig. 2B).
Crossectional cut of LAD (Fig. 3A); Curved Planar Reformats of RCA, with syngo Circulation QCA (Fig. 3B).
3A
2
3

Case 2
SOMATOM Defi nition Flash:
The Entire Heart Scanned in Just 270 ms
with 0.95 mSv
By Stephan Achenbach, MD* and Andreas Blaha**
** Department of Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany
** Business Unit CT, Siemens Healthcare, Forchheim, Germany
HISTORY
A 70-year-old female patient was referred
to the cardiology department because
of recurrent episodes of atrial fibrillation
accompanied by typical chest pain. Prior
to catheter ablation, coronary CT angiog-raphy
was scheduled to assess pulmo-nary
vein anatomy and to rule out coro-nary
artery stenoses.
DIAGNOSIS
During coronary CT angiography, which
was performed using a SOMATOM®
Definition Flash Dual Source CT system,
the patient was in sinus rhythm (52 bpm).
In order to achieve accurate contrast
timing, contrast agent transit time was
determined using a test bolus approach
after injection of 10 ml contrast agent
(Ultravist 370), followed by 60 ml of
saline solution. Coronary CT angiography
was performed in Flash Spiral mode
(prospectively ECG-triggered spiral acqui-sition,
0.28 ms rotation time, pitch 3.2),
with a 270 ms scan in cranio-caudal
direction, triggered at 55% of the RR
interval. 60 ml of contrast agent was
followed by 60 ml saline chaser, both
injected with 6 ml/s flow to keep the
bolus as compact as possible.
CT angiography was able to clearly
demonstrate the absence of coronary
artery stenoses as well as the absence
of calcified and non-calcified plaques.
A minor calcified lesion was located at
the aortic valve. Anatomy of the left atri-um
and pulmonary veins was normal.
For coronary CT angiography, using the
prospectively ECG-triggered Flash Spiral
mode, the dose length product was 68
mGy/cm, corresponding to an estimated
effective dose of 0.95 mSv.
COMMENTS
With a fast rotation time of 0.28 seconds
and two X-ray tubes, the SOMATOM
Definition Flash system allows a new,
prospectively ECG-triggered spiral scan
mode that uses a very high pitch value.
This fast scan mode requires only
270 ms of data acquisition time within
one single cardiac cycle and provides a
temporal resolution of 75 ms. It there-fore
allows ultra-low dose, artifact free
visualization of the heart and coronary
arteries.
Scanner SOMATOM Definition Flash
Scan mode Flash Spiral Cardio Pitch 3.2
Scan area Heart DLP 68 mGy/cm
Scan length 120 mm Slice collimation 128 x 0.6 mm
Scan direction Cranio-caudal Slice width 0.75 mm
Scan time 270 ms Spatial resolution 0.33 mm
Tube voltage 100/100 kV Reconstruction increment 0.4 mm
Tube current 320 mAs/rot Reconstruction kernel B26f
CTDIvol 3.29 mGy Volume 60 ml contrast
Effective Dose 0.95 mSv Start delay 24 s
Rotation time 0.28 s Postprocessing CT Cardiac Engine

Volume
1A 1B 1
rendered image
of the heart,
highlighting the
coronary arteries
in the foreground
as well as the
left atrium in the
background
(LA in red).
Curved planar
reformation in
MIP technique
depicts the entire
course of the RCA
(Fig. 2A). The
“angio like view”
in MIP from ante-rior
oblique direc-tion
shows the
entire coronary
tree (Fig. 2B);
image processing
with syngo Circu-lation.
Volume
rendered image of
the heart show-ing
the right coro-nary
artery (RCA,
arrow) and right
ventricular branch
(RVB, arrowhead,
Fig. 3A). Volume
rendered image
of the posterior
descending artery
(PDA, arrowhead)
and the left artery
descending (LAD,
arrow, Fig. 3B).
Curved planar
reformation with
syngo Circulation
in MIP technique
shows the entire
course of the LCX
(Fig. 4A) and the
LAD (Fig. 4B) for
interactive lesion
evaluation.
2A 2B
3A 3B
4A 4B
2
3
4

Case 3
Low Dose 3D Evaluation of a Child’s
Heart with Anomalous Venous Return
with the SOMATOM Sensation
By Robert Gilkeson, MD
University Hospital, Case Medical Center, Cleveland, Ohio, USA
HISTORY
A 19-month-old male patient presented
with failure to thrive. An echocardiogram
demonstrated a markedly enlarged right
ventricle and findings consistent with
total anomalous venous return. A mark-edly
enlarged common draining vein
entering the superior vena cava (SVC)
was identified. The echocardiogram was
limited in delineating the full course of
this anomalous vein. For pre-surgical eval-uation,
a three dimensional evaluation
was needed. A CT scan was requested by
the surgical team. The patient’s weight
was 14 kg (31lbs) with a heart rate of
132 bpm. A “feed and bundle” technique
was performed, where the performance
of the CT was coordinated with the last
bottle-feeding. There was no need for
patient sedation, the IV contrast was
hand injected at a dose of 2cc/kg. A low-dose
CT angiographic technique was
performed with a protocol used to evalu-ate
infants with congenital heart dis-ease.
The X-ray dose that had to be ap-plied
was 0.102 mSv with DLP 6 mGycm.
DIAGNOSIS
Volumetric and MIP reconstructions
demonstrate a markedly enlarged anom-alous
Scanner SOMATOM Sensation 40-slice configuration
Scan mode Spiral, Care Dose4D, MinDose Spatial resolution 0.33 mm
Scan area Chest Reconstruction increment 0.4 mm
Scan length 130 mm Reconstruction kernel B20f
Scan direction Cranio-caudal Volume 28 ml
Scan time 5 s Start delay No actual “scan delay”.
Heart rate 132 bpm Because of the small size of
Tube voltage 80 kV these patients, a pressure
Tube current 10 mAs/rot. injector was not used. Begin of
Dose modulation Retrospective ECG gating with imaging as soon as approxi-
MinDose technique mately ¾ of the contrast medium
Rotation time 0.33 s has been infused.
Slice collimation 0.6 mm Postprocessing syngo 3D
Slice width 0.75 mm
common draining vein emptying
into the SVC. The right ventricle was
markedly dilated.
COMMENTS
Due to the 0.33 s fast rotation time and
corresponding high temporal resolution,
the pediatric patient’s heart could be vi-sualized
without motion artifacts despite
the high heart rate of 132 bpm. These
images were important in the surgical
planning, and surgical redirection of the
large anomalous vein into the left atri-um
has been successfully performed.

Cardiovascular Clinical Results
1A 1B
Low dose (0.1 mSv) axial image demonstrates the anomalous common vein draining into the SVC (white arrows).
Axial image demonstrates anomalous drainage of pulmonary
1
veins (orange arrows) into common draining vein (white arrow).
Coronal MIP image demonstrates large anomalous draining
vein emptying into SVC (white arrows). Marked enlargement of right
ventricle (RV) is clearly visible.
2 3
2 3
RV

Case 4
Cardiac Scan Prior to Bariatric Surgery
By Uma Valeti, MD
Department of Cardiology, St. Paul Heart Clinic, Saint Paul, Minnesota, USA
HISTORY
A 57-year-old obese female patient with
a body mass index (BMI) of 52, weight
305 lbs (138.6 kg), presented for a pre-operative
evaluation to undergo a bar-iatric
surgery. The patient had cardiac
risk factors of hypertension (HTN), hyper-lipidemia
and diabetes mellitus. An exer-cise
cardiolite stress test was performed
with equivocal results due to the pres-ence
of attenuation and splanchnic arti-facts
due to the large body habitus.
DIAGNOSIS
The patient, presented with a heart rate
of 78 beats per minute, was given 0.4
sublingual nitroglycerin (NTG) prior to the
scan. The contrast flow rate was increased
to 7 ml/s for improved contrast to noise
ratio, total volume of contrast was set
to 100 ml.
The start of the coronary CTA was trig-gered
by the Bolus Tracking approach,
placing a region of interest in the aorta
ascending.
During the fast scan time of only eight
seconds the scan revealed mild to moder-ate
stenoses associated with mixed plaque
in the proximal left artery descending
(LAD, Figs. 4–5).
COMMENTS
The cardiac obese protocol done with
combining information in 165 ms of the
cardiac circle shows improvement in the
signal to noise ratio compared to the
standard of using 82 ms (Figs. 3A–3B).
1
Colored
volume rendered
image of the
heart (VRT)
embedded in
thoracic cage.
VRT of the
heart showing
the entire course
of LAD and first
diagonal (D1)
branch lesion
marked with
arrow.
2
1
2

5
3A
3B
Improved signal to noise ratio using 165 ms data acquisition (Fig. 3A) versus 82 ms data acquisition (Fig. 3B).
4
Moderate stenosis in proximal segment of LAD
3
4
(mixed plaque).
Cross-sectional cut of the stenotic area perpendicular
to the centerline of curved LAD path.
5
Scan mode Obese Cardio Protocol Pitch 0.32
Scan area Heart Spatial resolution 0.33 mm
Scan length 124 mm Slice collimation 64 x 0.6 mm
Scan direction Cranio-caudal Slice width 0.75 mm
Scan time 8 s Reconstruction increment 0.4 mm
Heart rate 78 bpm Reconstruction kernel B26f
Tube voltage 120 kV Volume 100 ml
Tube current 205 mAs/rot. Flow rate 7 ml/s
Start delay Bolus Tracking Effective dose 6.2 mSv
Rotation time 0.33 s Postprocessing CT Cardiac Engine

Case 5
Detection of Unusual Case
of Aorto-Leftventricular Tunnel
with Dual Source CT
By Wolfgang Eicher, MD, Thomas Kau, MD, Klaus Armin Hausegger, MD
Department of Radiology, Landeskrankenhaus Klagenfurt, Klagenfurt am Wörthersee, Austria
HISTORY
A 16-year-old patient appeared at the
department of radiology suffering with
fever for the past week. A Magnetic
Resonance Tomography (MRT) and an
echocardiographic investigation showed
a thickened bicuspid aortic valve and
a perfused tissue structure, seeming to
arise from left-ventricular outflow tract.
A coronary fistula could not be diagnos-tically
excluded with these methods
due to the extreme adjacency to left cir-cumflex
coronary artery (LCX) and left
main coronary artery (LMCA).
To clarify whether or not there was a
coronary aneurysm or an endocarditic
based paravalvular aneurysmatic aorto-leftventricular
tunnel (ALVT), a Dual
Source CT was conducted under the fol-lowing
conditions: DLP 120, 2.04 mSv,
slice 7 x 0,6 x 32 x 2 mm, RECON,
Saline flush mix 5 ml KM and 40 ml NaCl,
flow 6 ml/s. The heart rate during the
examination was 75 bpm.
DIAGNOSIS
In the cardio CT, a close relation between
the inflammatory ALVT and the LM could
be observed (distance 1–2 mm), whereas
the LM itself and their lumen were not
affected.
Additionally, a small left ventricular
perforation adjoining the bicuspid aortic
valve was visible. The tiny hole in the
aortic root could be only supposed. These
findings seemed to be accordable with
Scan mode Adaptive Cardio Sequence Rotation time 0.33 s
Scan area Heart Slice collimation 0.4 mm
Scan length 175 mm Slice width 0.6 mm
Scan direction Cranio-caudal Spatial resolution 0.33 mm
Scan time 8 s Reconstruction increment 0.4 mm
Heart rate 75 bpm Reconstruction kernel B26f
Tube voltage 100 kV Volume 80 ml
Tube current 190 mAs/rot. Flow rate 6 ml/s
Dose modulation ECG-pulsing on, Start delay 2 s
from 70–74%, MinDose off Postprocessing CT Cardiac Engine
CTDIvol 7.09 mGy
an inflammatory ALVT, based on endo-carditis
of the bicuspid aortic valve, which
could be confirmed by thorax surgery
and histological findings.
COMMENTS
Afterwards, the etiopathology was
controlled by transoesophageal echo-cardiography.
The patient was treated
by a two-step surgery. After closure of
the left ventricular defect, the sac of the
tunnel was growing and compressed
the LCA leading to significant ischemic
ECG abnormalities and elevated CK-MB.
In a second step, the aortic hole was
closed by a patch-plastic and the ALVT
was obliterated by using fibrin adhesive.

1A 1B
Cross-sectional cut in left ventricle and ALTV above aortic valve showing inverted VRT. Arrows indicate relevant
1
region on each image.
2 3
4A 4B
Cross-sectional cut in left ventricle and ALTV above
aortic valve (arrow).
With VRT calculation (yellow) the size of the lesion
(arrow) can be measured.
2 3
Extraction of left coronary artery (LM) and circumflex coronary artery left neighboured by the ALTV visualized
4
with syngo Circulation (Fig. 4A). The ALTV is nicely visible in the cross-sectional axial slice (Fig. 4B).

Clinical Results Oncology
Case 6
Dual Source CT
Kidney Tumor Imaging with Virtual
Non-Contrast Dual Energy
By Jiri Ferda, MD, PhD and Boris Kreuzberg, MD, PhD
Clinic of Radiodiagnostics, University Hospital Pilsen, Pilsen, Czech Republic
HISTORY
A 56-year-old male patient was referred
to the University Hospital Pilsen with
abdominal pressure pain near the right
kidney region. The patient also experi-enced
fever and weight loss. A hematuria
exists and has been proven by the gen-eral
practitioner. The proximate ultra-sound
showed a right kidney infiltration.
DIAGNOSIS
After a Dual Energy scan performed on
the SOMATOM® Definition, the post pro-cessing
of the images in VNC (Virtual Non-
Conrast) displayed a color-coded iodine
distribution map. The Dual Energy iodine
assignment confirmed a tumor infiltra-tion
of the right kidney and, emphasized
by color-coding, the hypervascularized
tumor tissue with involvement of the renal
vein. The same SOMATOM Definition scan
verified metastases in retroperitoneal
lymph nodes.
COMMENTS
In the Dual Energy mode, two X-ray
sources can be operated simultaneously
at different kV levels. The results are
two spiral data sets, acquired in a single
scan, providing diverse information that
allows one to differentiate, characterize,
isolate, and distinguish the imaged tissue
and material. Enhancement patterns of
kidney regions can be clearly visualized
with the Dual Energy VNC application.
Scan mode Spiral
Scan area Abdomen
Scan length 500 mm
Scan direction Cranio-caudal
Scan time 17 s
Tube voltage A/B 140/80 kV
Tube current A/B 60/360 Eff. mAs
Rotation time 0.5 s
Spatial resolution 0.33 mm
Slice collimation 0.6 mm
Slice width 0.6 mm
Reconstruction increment 0.4 mm
Reconstruction kernel D20f
Postprocessing syngo DE Virtual Unenhanced (VNC)

2
1 2
1
Dual Energy Virtual Non-Contrast (VNC) scan. Dual Energy scan shows vascularisation of tumor,
composed data with contrast (arrows).
Mixed visualization of VNC and iodine concentration. Dual Energy application highlights iodine concentration.
5 6
VRT with Bone Removal shows vascular status of the
tumor (arrow).
Coronal reformation of the right kidney using
Optimum Contrast.
3 4
3 4
5 6

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