Heavily calcified coronary arteries advanced calcium subtraction improves luminal visualization and diagnostic confidence in dual-energy coronary computed tomography angiography

Objectives: The aim of this study was to evaluate a prototype dual-energy computed tomography calcium subtraction algorithm and its impact on luminal visualization in patients with heavily calcified coronary arteries. Materials and Methods: Twenty-nine patients (62% male; mean age, 64 ± 7 years) who had undergone dual-energy coronary computed tomography angiography were retrospectively included in this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant study. Linearly blended (M0.6) and calcium-subtracted images were reconstructed. Two independent observers assessed luminal visualization of the coronary arteries in a segmentbased analysis, subjective image quality, and diagnostic confidence using 5-point Likert scales. Contrast-to-noise ratios for both data sets were calculated. Wilcoxon testing and Cohen's? were used for statistical comparisons. Results: Calcium-subtracted image series showed improved lumen visualization of the coronary arteries (P = 0.008), with excellent interreader agreement (mean score, 3.3; = 0.82), compared with M-0.6 series (mean score, 2.9; = 0.77). The calcium subtraction algorithm improved diagnostic confidence compared with the M-0.6 reconstructions (mean scores, 4.0 and 3.1, respectively; all P = 0.002). The image quality analysis showed no significant differences between calcium-subtracted and M-0.6 data sets (subjectively: mean scores, 4.1 and 4.2, respectively, P = 0.442; objectively: mean contrast-to-noise ratio, 37.0 and 38.2, respectively, P = 0.733). Conclusions: A prototype algorithm for calcium subtraction improves coronary lumen visualization and diagnostic confidence in patients with heavy coronary calcifications without differences in conventional subjective and objective measures of image quality.