1. Cardiac p10-20 (Chambers, coronaries, valves, great vessels) Flashcards
Right atrium defined by…
IVC
Crista Terminalis
Muscular ridge running from entrance of IVC to entrance of SVC (normal)
Eustachian valve
Flap in the IVC as it joins right atrium
Chairi network
Trabeculated appearance of eustachian valve
Coronary sinus (purpose+anatomy)
Main draining vein of myocardium.
Runs in AV groove (posterior surface) and enters right atrium near tricuspid valve
Right ventricle defined by
Moderator Band
Tricuspid vs mitral papillary muscles
Tricuspid insert on septum, mitral don’t
Right vs Left Valves
Right valves searated by thick muscle (crista superventricularis)
left valves sit side-by-side
Most posterior chamber
Left atrium
Double density sign
CXR: Superimposed 2nd contour of the right heart from the right side of enlarged left atrium
Indirect signs of left atrial enlargement (2)
Splaying of carina (>90 degrees),
Walking man sign: posterior displacement of left main bronchus, upside-down V shape with intersection of right main bronchus on lateral CXR
Left papillary muscle insertion
Lateral, posterior walls and apex of left ventricle
Chordae tendonae
Connect mitral valve leaflets to papillary muscle
Echogenic focus in left ventricle (pre-natal)
Calcified papillary muscle, usually goes away by 3rd trimester, associated with Downs.
Lipomatous hypertrophy of the intra-atrial septum (Appearance) (2)
Dumbbell fat density in the atrial septum, sparing fossa ovale.
Can be hot on pet (brown fat).
Lipomatous hypertrophy of the intra-atrial septum (Associations) (2)
Can cause supraventricular arrhythmia.
Associated with being old and fat.
Coronary cusps & associated arteries (3)
Right coronary cusp –> RCA
Left coronary cusp –> LCA
Non-coronary cusp (posterior) –> none
Left main coronary artery branches
LCX (circumflex) –> Obtuse marginals
LAD –> Septal branches & Diagonals
Right main coronary artery branches
Acute marginals
AV node branch
Posterior descending (PDA)
Dominance determined by
Which artery supplies the PDA (RCA in 65-80%)
Which artery perfuses SA node?
RCA (60%)
Which artery perfuses AV node?
RCA (90%)
Co-dominance defined as
PDA arises from RCA & posterior left ventricular branches arise from LCX
Malignant origin of coronary artery (types (+Rx)) (2)
Anomalous LCA from Right coronary sinus (most serious, always repair).
Anomalous RCA from Left coronary sinus (repair if symptomatic).
Malignant origin of coronary artery (Clinical significance)
Courses between pulmonary artery and aorta, can get compressed –> sudden cardiac death.
ALCAPA syndrome - definition
Anomalous Left Coronary Artery from Pulmonary Artery
ALCAPA syndrome - types (2)
Infantyle type –> die early
Adult type –> risk of sudden death
Associated with STEAL syndrome: Reversal of LCA flow as pressure decreases in pulmonary circulation
ALCAPA syndrome - Association
Associated with STEAL syndrome: Reversal of LCA flow as pressure decreases in pulmonary circulation
Myocardial bridging - Definition
Intramyocardiac course of coronary artery, usually LAD.
Myocardial bridging - Sequelae (2)
Symptoms in systole as diameter decreases. Can cause ischaemia.
Can be issue for CABG planning.
Coronary artery aneurysm - definition
Coronary vessel diameter 1.5x normal.
Coronary artery aneurysm - causes (3)
Adults commonest cause: Atherosclerosis
Kids commonest cause: Kawasaki
Iatrogenic (Cardiac catheter) can also cause
Coronary fistula - definition and distribution
Connection between coronary artery and great vessel or chamber.
Usually RCA and right chambers.
Coronary fistula - Association
Associated with coronary aneurysms
Ideal patients for coronary CT (2)
Low risk/atypical chest pain (prevents risky cath angio for e.g. GORD)
Suspected aberrant coronary artery
Ideal HR for coronary CT (2)
Ideally <60. Slower is better. Beta blockers used to help
Contraindications to beta blockers (4)
Severe asthma,
Heart block (2nd or 3rd degree),
Acute chest pain,
Recent cocaine use
Can’t give beta blockers for coronary CT?
Retrograde gated study rather than prospective
Prospective vs retrospective gating (definition, pros/cons)
Prospective: acquisition triggered by R wave. Always axial.
+: Reduced radiation (scanner isn’t always on)
-: no functional info.
Retrospective: Scans whole time, then back calculates. Helical.
+: Provides functional information
-: higher dose.
Nitroglycerine in coronary CT (purpose)
Dilates coronary arteries
Contraindications to nitroglycerine (4)
Hypotension(SBP<100)
Severe AS
HOCM
Sildenafil use
VENC (definition)
Velocity ENcoded Cine MR Imaging - used to quantify velocity of flowing blood
Aortic stenosis (Types) (3)
Congenital (bicuspid)
Acquired (degenerative or rheumatic heart)
Aortic stenosis severity grading
Based on velocity of blood flow (VENC)
Aortic stenosis appearance (2)
Concentric LV Hypertrophy
Dilatation of the ascending aorta (Valvular (90%), subvalvular or supravalvular)
Supravalvular aortic stenosis associated with
Williams syndrome
Bicuspid aortic valve & coarctation associated with
Turners syndrome
Commonest congenital heart disease
Bicuspid aortic valve
Bicuspid aortic valve associations (4)
Aortic aneurysm (even in absence of stenosis)
Cystic Medial Necrosis
Turners and coarctation
Polycystic kidney disease
Aortic regurg associated with (4)
Bicuspid valve
Marfans
Aortic root dilatation (HTN)
Bacterial endocarditis
Haemodynamic impact of aortic regurg determined by
Rapidness of onset (less time for adaptation)
Mitral stenosis - commonest cause
Commonest cause is Rheumatic Heart Disease
Mitral stenosis - CXR appearance
CXR shows left atrial enlargement
Mitral regurg - acute causes (2)
Endocarditis
Papillary muscle or chordae rupture post MI
Mitral regurg - chronic causes (2)
Primary: myxomatous degeneration
Secondary: Dilated cardiomyopathy leading to mitral annular dilatation
Mitral regurg causes
Isolated right upper lobe oedema
Pulmonary stenosis - associations (4)
Supravalvular - Williams syndrome
Valvular - Noonan’s syndrome
Subvalvular - TOF
Peripheral pulmonary stenosis - Alagille syndrome
Pulmonary regurg - cause
Commonly congenital valve disease, post op (commonly TOF post repair)
Multivalve disease, think…
Rheumatic fever (immune response to group A beta-haemolytic strep)
Tricuspid regurg associations (3)
Commonest cause in adults: Pulmonary HTN
Others:
Endocarditis (IVDU)
Carcinoid syndrome (serotonin degrades valve)
Cherub syndrome
Sami-Good-Heart-Balasmeh
Tricuspid regurg - pathophysiology (2)
More common than stenosis due to weaker annulus
Causes RV dilatation, not hypertrophy
Epstein anomaly - association
Associated with maternal lithium use, can be sporadic
Epstein anomaly, appearance (3)
Tricuspid valve is hypoplastic, posterior leaf displaced apically.
Tricuspid regurg
Enlarged RA, Smaller RV, Box shaped heart on CXR
Tricuspid atresia associations (3)
Almost always ASD or PFO
Asplenia
Right arch
Tricuspid atresia - pathophysiology (2)
Occurs with RV hypoplasia
Usually has pulmonary stenosis and therefore decreased vascularity (increased vascularity if no pulmonary stenosis)
Carcinoid syndrome - sequelae (2)
Valvular disease only after tumour has metastasized to liver.
Serotonin usually degrades tricuspid and pulmonary valves.
Carcinoid syndrome - distribution (3)
Rare to affect left valves, lungs degrade vasoactive substances.
If left sided disease, think either:
- Primary bronchial carcinoid
- Right to left shunts
