Synthetic hematocrit from virtual non-contrast images for myocardial extracellular volume evaluation with photon-counting detector CT

To assess the accuracy of a synthetic hematocrit derived from virtual non-contrast (VNC) and virtual non-iodine images (VNI) for myocardial extracellular volume (ECV) computation with photon-counting detector computed tomography (PCD-CT). Consecutive patients undergoing PCD-CT including a coronary CT angiography (CCTA) and a late enhancement (LE) scan and having a blood hematocrit were retrospectively included. In the first 75 patients (derivation cohort), CCTA and LE scans were reconstructed as VNI at 60, 70, and 80 keV and as VNC with quantum iterative reconstruction (QIR) strengths 2, 3, and 4. Blood pool attenuation (BP${}_{mean}$) was correlated to blood hematocrit. In the next 50 patients (validation cohort), synthetic hematocrit was calculated using BP${}_{mean}$. Myocardial ECV was computed using the synthetic hematocrit and compared with the ECV using the blood hematocrit as a reference. In the derivation cohort (49 men, mean age 79 ± 8 years), a correlation between BP${}_{mean}$ and blood hematocrit ranged from poor for VNI of CCTA at 80 keV, QIR2 (R${}^2$ = 0.12) to moderate for VNI of LE at 60 keV, QIR4; 70 keV, QIR3 and 4; and VNC of LE, QIR3 and 4 (all, R${}^2$ = 0.58). In the validation cohort (29 men, age 75 ± 14 years), synthetic hematocrit was calculated from VNC of the LE scan, QIR3. Median ECV was 26.9% (interquartile range (IQR), 25.5%, 28.8%) using the blood hematocrit and 26.8% (IQR, 25.4%, 29.7%) using synthetic hematocrit (VNC, QIR3; mean difference, -0.2%; limits of agreement, -2.4%, 2.0%; p = 0.33). Synthetic hematocrit calculated from VNC images enables an accurate computation of myocardial ECV with PCD-CT. Virtual non-contrast images from cardiac late enhancement scans with photon-counting detector CT allow the calculation of a synthetic hematocrit, which enables accurate computation of myocardial extracellular volume.