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Comparative Study
. 2025 Sep 20;9(1):94.
doi: 10.1186/s41747-025-00624-8.

Spectral photon-counting CT in first-pass myocardial perfusion imaging for very high-risk patients: a comparison with dual-energy CT

Guillaume Fahrni  1   2 , Salim Si-Mohamed  2   3 , Rafael Wiemker  4 , David C Rotzinger  1 , Angèle Houmeau  3 , Cyril Prieur  5 , Philippe Douek  2   3 , Sara Boccalini  6   7
Affiliations
Comparative Study

Spectral photon-counting CT in first-pass myocardial perfusion imaging for very high-risk patients: a comparison with dual-energy CT

Guillaume Fahrni et al. Eur Radiol Exp. .

Abstract

Background: Spectral photon-counting computed tomography (SPCCT) outperformed dual-energy computed tomography (DECT) for coronary artery stenosis assessment. However, data about myocardial perfusion imaging (MPI) is lacking. This feasibility study aimed to evaluate and compare the diagnostic performance of SPCCT and DECT for rest MPI in patients with hemodynamically significant coronary stenoses, using invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR) as reference standards.

Materials and methods: Eighteen very-high-risk patients with hemodynamically significant coronary stenoses at ICA underwent both dual-layer DECT and SPCCT coronary CT within three days. The sensitivity, specificity, and accuracy of MPI in detecting myocardial hypoperfusion were assessed. Quantitative attenuation differences between normal and hypoperfused myocardial segments were compared for both modalities. Interobserver variability was assessed with a weighted kappa analysis.

Results: SPCCT demonstrated comparable overall performance to DECT for MPI, with an overall sensitivity, specificity, and accuracy of 73.3%, 79.2%, and 76.9%, respectively, versus 73.3%, 75%, and 74.4% for DECT. SPCCT outperformed DECT in the left anterior descending artery territory, achieving a sensitivity of 87.5%, specificity of 100%, and accuracy of 90%, versus 62.5%, 50%, and 60% for DECT. For each CT system, attenuation analysis revealed differences between normal and hypoperfused segments, with mean differences of 17.9 HU for DECT and 15.8 HU for SPCCT (p < 0.05). Inter-reader agreement was higher for SPCCT (κ = 0.86) compared to DECT (κ = 0.62).

Conclusion: SPCCT and DECT provided similar diagnostic performance for rest MPI in a very-high-risk patient cohort, demonstrating comparable effectiveness in detecting the effects of hemodynamically significant coronary stenosis.

Relevance statement: Hemodynamically significant stenosis in very-high-risk patients results in myocardial hypoperfused areas at rest that can be detected equally well with dual-layer CT and spectral photon counting CT, albeit with better reproducibility for the latter.

Key points: SPCCT and DECT showed comparable performance for MPI at rest in very-high-risk patients. The differences between normal and hypoperfused segments were of 17 HU and 16 HU on conventional images for DECT and SPCCT. SPCCT showed higher interobserver agreement compared to DECT, suggesting improved reproducibility.

Keywords: Computed tomography angiography; Coronary stenosis; Dual energy computed tomography; Fractional flow reserve; Myocardial perfusion imaging.

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Conflict of interest statement

Declarations. Ethics approval: The study was approved by the local ethics committee (approval number: 2019-A02945–52). Written informed consent was provided by all patients. Consent for publication: Consent for publication was given by all patients at the moment of the signature of informed consent. Competing interests: SSM, PD, and SB have nothing to disclose directly related to the content of this article. They have received speaker fees from Philips Healthcare. SSM is a member of the Scientific Editorial Board of European Radiology Experimental (section: Computed Tomography). As such, they have not participated in the selection or review processes for this article. GF, DR, CP, and AH have nothing to disclose related to this article. RW is an employee of Philips Healthcare.

Figures

Fig. 1
Fig. 1
Study flowchart
Fig. 2
Fig. 2
Example of lesion tagging using custom-made software, showing the first-pass myocardial perfusion images in short-axis view without (a) and with (b) an overlay interface, on SPCCT. A hypoperfusion area in the mid-anterior territory is tagged from endocardium to epicardium (blue area)
Fig. 3
Fig. 3
Short-axis view of DECT (A) and SPCCT (B) first-pass MPI images showing hypoperfusion areas (arrows) in a 61-year-old male with severe (> 80%) stenoses (arrowheads) of the LAD, as seen on ICA (C) and SPCCT (D). Perfusion images are displayed at 40 keV monoenergetic reconstruction
Fig. 4
Fig. 4
Performance of DECT and SPCCT in detecting hypoperfused territories, including sensitivity, specificity, and accuracy. Results are shown for the three main coronary arteries and all detected lesions. DECT, Dual-energy CT; SPCCT, Spectral photon-counting CT
See this image and copyright information in PMC

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