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Peds Cardiology > 5. Imaging > Flashcards

5. Imaging Flashcards

1
Q

Equation for Nyquist limit?

A

PRF/2

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2
Q

What is the Nyquist limit?

A

Maximal frequency shift that can be determined by PW Doppler

*Equal to 1/2 the pulse repetition frequency

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3
Q

What can extend the Nyquist limit?

A

Using lower frequency transducers

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4
Q

What does the simplified Bernoulli equation ignore?

A

Flow acceleration

Viscous friction

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5
Q

What is an appropriate use of the simplified Bernoulli equation?

A

Isolated valvar stenosis

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6
Q

Should you use the simplified Bernoulli equation if you have multiple obstructions in series?

A

No… need to account for flow acceleration proximal to and distal to the sites of obstruction

Ex. AS and CoA

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7
Q

Why shouldn’t you use the simplified Bernoulli equation for a PDA or BT shunt?

A

It doesn’t account for viscous friction… the Doppler velocities will be underestimated

*Also difficulties with proper US beam alignment

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8
Q

What is seen on the pulmonary vein Doppler tracing in Grade 1 diastolic dysfunction?

A

Systolic predominance, more prominent a-wave reversal

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9
Q

What grade of diastolic dysfunction do you see E/A reversal?

A

Grade 1

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10
Q

What is the expanded Bernoulli euqation?

A

P1-P2 = 4(V2^2-V1^2)

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11
Q

Coarctation, PW Doppler has a peak velocity of 2M/sec proximal to the coarctation. A CW Doppler across the coarctation reveals a peak Doppler velocity of 4M/sec. What is pressure gradient across coarctation?

A

4(4^2-2^2) = 48mmHg

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12
Q

What does the presence of holodiastolic flow reversal in the abdominal aorta indicate?

A

Severe AR

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13
Q

What is used in echo that passes through the pulmonary circulation to opacify LA/LV?

A

Contrast agents

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14
Q

What size are typical contrast agents?

A

1-10 microns

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15
Q

Which has lower acoustic impedance, blood or contrast?

A

Contrast

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16
Q

How long do contrast agents effects persist?

A

3-5 minutes

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17
Q

When are agitated saline injections used in echo?

A
  1. Unexplained cyanosis

2. Stroke

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18
Q

What size are microbubbles in agitated saline?

A

10-100 microns

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19
Q

How does an agitated saline injection work?

A
  • Don’t pass through the pulmonary capillary bed
  • Microbubbles opacity the RA and RV, but not the left heart structures in the absence of an intracardiac or intrapulmonary shunt
  • Helpful to identify an intracardiac right to left shunt
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20
Q

How many cardiac cycles for microbubbles to appear in the left heart in an intrapulmonary shunt?

A

3-5

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21
Q

How many cardiac cycles for microbubbles to appear in the left heart in an intracardiac shunt?

A

1-2

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22
Q

True or False: A negative bubble study rules out an intracardiac R-L shunt?

A

False- Negative bubble study doesn’t definitively exclude presence of an intermittent R-L shunt

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23
Q

Name 2 quantitative measures to grade AI

A
  1. Width of regurgitant jet (vena contracta)

2. Ratio of vena contracta dimension to aortic annulus dimension

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24
Q

Name a semi-quantitative measure of AI severity?

A

LV dilation

*Consistent with duration of AI and severity of AI

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25
Q

What factors can influence the length of a regurgitant jet into the LV besides the severity of AI?

A
  1. LVEDP

2. Eccentricity of jet

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26
Q

What non-aortic valve measure is an excellent predictor of the regurgitation degree?

A

Degree of Doppler flow reversal in abdominal aorta

*Forward to reverse flow TVI ratio in distal transverse arch

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27
Q

What is the equation for MPI or Tei index?

A

[ICT + IRT] / ET

*Distance between end of A wave and beginning of E wave minus ejection time divided by ejection time

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28
Q

What is the ratio of total time spent in isovolumic activity (isovolumic contraction and isovolumic relaxation times) divided by the time spend in ventricular ejection?

A

Myocardial performance index

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29
Q

What echo window is best for a secundum ASD?

A

Subcostal

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30
Q

Imaging plane should be what in relation to the cardiac structure of interest?

A

Perpendicular

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31
Q

Most common associated cardiac defect with a sinus venosus ASD?

A

Anomalous right pulmonary venous connection

*Either a single right upper pulmonary vein or the right upper and middle pulmonary veins insert anomalously to the SVC or SVC-RA junction

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32
Q

Where are sinus venosus defects most commonly found?

A

Superior portion of the atrial septum creating a “biatrial” insertion of the SVC

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33
Q

What is characterized by increased respiratory variation in mitral inflow Doppler velocities by >25%

A

Constrictive pericarditis

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34
Q

What is seen in the transmitral Doppler in constrictive pericarditis?

A

Increased E:A ratio and a shortened E-wave deceleration time

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35
Q

True or False: The lateral mitral TDI velocities are usually normal in constrictive pericarditis?

A

True

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36
Q

What is seen in the hepatic venous Doppler in constrictive pericarditis?

A

Increased atrial systolic flow reversal during expiration

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37
Q

List the echo hallmarks of restrictive LV physiology in adults

A
  1. Increased mitral inflow Doppler E:A ratio > 2.0
  2. Shortened mitral E-wave deceleration time <160msec
  3. Decreased lateral mitral Ea velocity
  4. Increased E/E’ ratio >15
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38
Q

What does the pulmonary venous Doppler show in restrictive LV physiology?

A

Decreased systolic to diastolic pulmonary venous filling wave ratio with significant increased atrial reversal wave velocity and duration

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39
Q

What associated congenital heart lesion most common in patient with Down syndrome and AVSD?

A

ToF

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40
Q

What is % incidence of CHD in T21?

A

50%

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41
Q

Most common cardiac anomaly in T21?

A

AVSD

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42
Q

Most common constellation of cardiac anomalies in Down?

A

AVSD + ToF

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43
Q

Most common anatomic finding in complete AVSD?

A

LVOT “sprung” anteriorly

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44
Q

Anatomic hallmarks of AVSD?

A
  1. Cleft in anterior leaflet of left AV valve
  2. Lateral rotation of left ventricular papillary muscles
  3. Attachments of left and right AV valves at the same level as cardiac crux
  4. LVOT “sprung” anteriorly
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45
Q

Goose-neck deformity?

A
  • AVSD
  • Absence of AV septum, LV inflow is shortened and LV outflow is elongated
  • Creates a ratio of LV inlet to LV outlet <1
  • Common AV valve, aortic valve is no longer “wedged” between tricuspid and mitral valves and is pushed anteriorly (“sprung”)
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46
Q

What imaging modality had excellent temporal resolution and a high fixed PRF?

A

M-mode

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47
Q

What is on X and Y axis for M-mode?

A

X-axis: Time

Y-axis: Distance from transducer

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48
Q

What is used in M-mode?

A

Single imaging crystal

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49
Q

What is the smallest distance between 2 points distinguishable as separate points?

A

Spatial resolution

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50
Q

What is axial resolution?

A
  • Ability to differentiate points along the US beam

- Equal to wavelength

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51
Q

What is lateral resolution?

A
  • Ability to resolve points perpendicular to the US beam

- Dependent on beam width (best resolution found where beam narrowest)

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52
Q

What is better, axial or lateral resolution?

A

Axial

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53
Q

What is the most likely source of error in calculation of Doppler flow velocity?

A

Angle of incidence of US beam

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54
Q

[c(fd)]/[2focostheta]

A

Doppler velocity

  • Speed of sound (c)
  • Transmitted US frequency (fo)
  • Frequency shift (fd)
  • Angle of incidence (theta)
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55
Q

Under what angle of incidence will Doppler velocity not be significantly underestimated?

A

<20 degrees

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56
Q

What type of Doppler has no limit to max velocity measured?

A

CW

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57
Q

How does CW Doppler work?

A
  • Utilizes 2 crystals

* One is continuously transmitting and one is continuously receiving

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58
Q

What is a disadvantage of CW Doppler?

A

No range gating leads to lack of range resolution… the max velocity can be anywhere along the US beam path

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59
Q

True or False: CW and PW are equally dependent on the angle of incidence for accurate velocity determination

A

True

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60
Q

How does PW Doppler work?

A

Utilizes 1 crystal that intermittently transmits and receives

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61
Q

True or False: PW has excellent range resolution?

A

True…1 crystal transmits and receives and the time between transmission and reception allows determination of depth of signal which provides excellent range resolution

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62
Q

Why does PW have a lower Nyquist limit than CW?

A

The max detectable frequency shift is limited

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63
Q

Which has higher PRF, Color or Spectral Doppler?

A

Spectral

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64
Q

What does PRF vary with in PW Doppler?

A

Depth of sample volume

*Higher PRF with shallower sample volume

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65
Q

What represents the highest frequency shift that can be unambiguously detected and displayed?

A

Nyquist limit

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66
Q

What is the maximal frequency shift detectable by PW Doppler?

A

Nyquist limit

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67
Q

What is the Nyquist limit equal to?

A

1/2 PRF

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68
Q

Is the Nyquist limit lower or higher with PW Doppler?

A

Lower

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69
Q

Is the Nyquist limit lower or higher with a lower frequency transducer at a shallower depth of interrogation?

A

Lower

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70
Q

What does color Doppler represent?

A

Mean velocity of blood flow

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71
Q

How does color Doppler work?

A

Utilizes multiple sampling sites along multiple US beams to generate frequency shifts that are converted into a digital format and autocorrelated into a color scheme

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72
Q

What does the intensity of color represent in color Doppler?

A

Mean Doppler flow velocities

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73
Q

The nyquist limit is lower with what compared to spectral Doppler?

A

Color Doppler

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74
Q

What happens to the 2D images color Doppler is superimposed onto?

A

Less resolution

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75
Q

What is the optimal echo view to show a subpulmonary VSD?

A

PSSA

*Can also see in subcostal/apical views angled into RVOT

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76
Q

Where are subpulmonary VSDs located?

A

Adjacent to the PV and AV

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77
Q

What are other names for a subpulmonary VSD?

A
  • Supracristal

- Doubly committed defect

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78
Q

What is most characteristic acquired cardiac lesion resulting from a subpulmonary VSD?

A

AI

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79
Q

What causes AI in a subpulmonary VSD?

A

Prolapse of the aortic cusp into the VSD

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80
Q

What is an indication for surgical closure of subpulmonary VSd with a trivial-small L-R shunt?

A
  • Significant or progressive AI
  • Prolapse of aortic tissue may limit size of VSD and lessen L-R shunt, but progression of AI due to distortion of AV seen
  • In this case, close VSD regardless of size of L-R shunt
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81
Q

What is the most characteristic physiologic effect of a large VSD?

A

Equal RV/LV pressures

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82
Q

A large VSD results in what change in ventricular pressure?

A
  • Equalized RV/LV pressures

- Also elevated PASP

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83
Q

Which chambers become volume overloaded with a large VSD?

A

LA/LV

-L-R ventricular shunting causes increase in PBF and return to left heart

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84
Q

True or False: Overall systemic blood flow isn’t significantly increased in a large VSD?

A

True

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85
Q

What is the best morphologic marker of RA?

A

Broad based triangular appendage

*Also connections of IVC and CS (SVC connections can have anatomic variability)

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86
Q

The valve of the fossa ovalis (septum primum) is a structure in which atria?

A

LA

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87
Q

AV valves are a hallmark of what?

A

Ventricular morphology

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88
Q

The atrial septum is best imaged in which scan plane?

A

Subcostal

-This is perpendicular to septum… can get false dropout in imaging planes more parallel

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89
Q

What is the best anatomic hallmark of the morphologic RV?

A

Connection of the tricuspid valve with a more apical insertion at the cardiac crux as compared to the morphologic MV

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90
Q

List some anatomic features of a morphologic RV

A
  • More apical insertion point of AV valve
  • Septophilic (tricuspid valve attachments to the ventricular septum)
  • Crescent shaped
  • Prominent trabeculations
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91
Q

What is a typical feature of the morphologic LV?

A

Lack of AV valve septal chordal attachments

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92
Q

List some anatomic features of a morphologic LV?

A
  • Lack of AV valve septal chordal attachments (septophobic)
  • Higher insertion of morphologic MV at cardiac crux
  • Ellipsoid
  • Fine trabeculations (mainly towards apex
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93
Q

Modified Bernoulli equation?

A

Velocity^2 * 4

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94
Q

What estimate does the modified Bernoulli equation give?

A

Max instantaneous Doppler gradient

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95
Q

What is the most common anatomic type of subaortic stenosis?

A

Discrete membrane proximal to AV within LVOT

*Most often circumferential and can be adherent to AV and anterior leaflet of MV

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96
Q

LVOT obstruction in HCM is related to what?

A
  • Asymmetric septal hypertrophy

- SAM of MV chordal/leaflet tissue

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97
Q

What issue with the mitral valve can cause LVOT?

A

Anomalous chordal insertions in the LVOT

*Can be isolated or found in association with CHD

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98
Q

What is the most common associated cardiac abnormality in someone with CoA?

A

Bicuspid AoV

*As high as 80% occurrence in patients with CoA

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99
Q

In patients with CoA, systemic arterial pressure begins to be significantly affected when the overall aortic lumen is narrowed by how much?

A

50%

*Lumen must be narrowed by at least 50% to significant affect systemic arterial pressure… 50% narrowing = 10mmHg gradient

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100
Q

What is the most diagnostic echo finding in pericardial effusion with cardiac tamponade?

A

Diastolic RV wall collapse

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101
Q

When does cardiac tamponade occur?

A

When increasing fluid in the pericardial space causes a rise in intrapericardial pressure (typically > intracardiac pressure) compromising systemic venous return to RA

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102
Q

When does diastolic RA/RV collapse occur in tamponade?

A

When intrapericardial pressure exceeds intracardiac pressure

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103
Q

What is most sensitive to identify tamponade physiology on echo?

A

Diastolic RV collapse

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104
Q

How can pulse-wave Doppler help identify cardiac tamponade?

A

> 30% change in Doppler flow across the tricuspid valve or >25% change in Doppler flow across the mitral valve with respiratory cycle

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105
Q

What causes the inflow variation seen across the AV valves in tamponade physiology?

A

Ventricular interdependence

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106
Q

What has the most effect on intrapericardial pressure in the setting of tamponade?

A

How quickly the fluid accumulates (versus overall size of effusion)

*Due to relative compliance of pericardium in acute/chronic setting

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107
Q

Which method of assessing LV systolic function is most independent of loading conditions?

A

Stress-velocity index

*EF, SF and MPI are all impacted by preload/afterload

108
Q

True or False: The relationship between velocity of circumferential fiber shortening and end systolic wall stress (Stress-velocity index) is independent of HR and preload

A

True

*Also incorporates afterload making it a quantitative measure of ventricular contractility

109
Q

Normal LV shortening fraction is maximal at what age?

A

2 weeks

*Maximal during 1st month of life (35-45)

110
Q

Equation for SF?

A

(LVEDD-LVESD) / LVEDD

111
Q

The mean LV shortening fraction in children is what?

A

36% (ranges 28-40%)

112
Q

The presence of holodiastolic Doppler flow reversal is consistent with what?

A

Significant runoff from teh descending Ao

113
Q

What could cause holodiastolic Doppler flow reversal?

A
  1. Large PDA
  2. Severe AI
  3. Systemic-PA shunts
  4. Large AV fistula
114
Q

What is the most common type of VSD associated with CoA?

A

Perimembranous

  • Can see possterior malalignment with severe CoA or IAA
  • Can see muscular or inlet (unbalanced RV dominant AVSD)
115
Q

Although less common than perimembranous, what type of VSD can result in severe CoA or IAA?

A

Posterior malalignment

116
Q

What is the Coanda effect?

A
  • Doppler finding often seen in patients with supravalvar AS
  • High-velocity post-stenotic jet that hugs the aortic wall and preferentially transfers kinetic energy into the right innominate artery
  • Marked discrepancy in arm BP (Right arm > Left arm)
117
Q

What should you consider with a upper extremity BP gradient (R > L) in a patient with supravalvar AS?

A

Coanda effect

*The systolic jet in patients with supravalvar AS propagates further than the jet originating with aortic valvar stenosis and has a tendency to be entrained along the aortic wall thereby transferring its kinetic energy into the right innominate artery

118
Q

What component of the complete Bernoulli equation isn’t ignored in the simplified version?

A

Convective acceleration

119
Q

What component of the complete Bernoulli equation is ignored in the simplified version?

A

Flow acceleration

Viscous friction

120
Q

To utilize the simplified Bernoulli equation, what must be negligible?

A

Proximal Doppler velocity

121
Q

How do you determine which ventricle an overriding AV valve is committed to?

A

Whichever ventricle that >50% of the orifice is directed

122
Q

What is the definition of an overriding AV valve?

A

Empties into 2 ventricles

123
Q

An overriding AV valve is always associated with what?

A

Malalignment VSD

124
Q

True or False: Valves that override can also straddle?

A

True- Can straddle by having chordal attachments to the contralateral ventricle

125
Q

What type of AV valve has anomalous chordal insertions or papillary muscles in the contralateral ventricle?

A

Straddling

126
Q

True or False: Straddling and overriding AV valves can coexist?

A

True

127
Q

What is a straddling AV valve associated with?

A

VSD

*Doesn’t have to be malalignment

128
Q

Interruption of the intrahepatic portion of the IVC with azygous vein continuation to the SVC is a common feature of what?

A

Polysplenia (LA isomerism)

129
Q

Describe abdominal anatomy in polysplenia (LA isomerism)?

A

Variable- Can be ambiguous, inversus or solitus

  • Usually multiple spleens that are on the same side
  • Single gallbladder (can occasionally get biliary atresia though)
130
Q

How are the great arteries positioned in a levocardia (normal) heart?

A

Aorta is rightward and posterior relative to the PA

131
Q

How are the great arteries positioned in a d-TGA heart?

A

Aorta is typically anterior and rightward relative to PA

132
Q

How are the great arteries positioned in a l-TGA heart?

A

Aorta is typically anterior and leftward relative to PA

133
Q

How are the great arteries positioned in DILV?

A

Aorta is most commonly anterior and leftward relative to PA

134
Q

What is an example of a single inlet atrioventricular valve connection?

A

Tricuspid atresia

135
Q

Where does a Type A interrupted aortic arch occur?

A

Distal to the origin of the left subclavian artery

136
Q

Where does a Type B interrupted aortic arch occur?

A

Between the left common carotid and left subclavian arteries

137
Q

Where does a Type C interrupted aortic arch occur?

A

Between the right innominate and left common carotid arteries

138
Q

When a persistent left SVC drains to the CS, the size of the CS is inversely proportional to what?

A

Size of the bridging innominate vein

139
Q

Describe the innominate or brachiocephalic vein when the CS is severely dilated?

A

Very small or absent

140
Q

When the IVC is interrupted, how does venous return get to the heart?

A

From the azygous vein to the SVC

141
Q

Interrupted IVC is more common in polysplenia or asplenia?

A

Polysplenia

142
Q

True or False: The SVC connection is an anatomic hallmark of the morphologic RA?

A

True

143
Q

Which sided pulmonary veins more commonly merge as they connect to the LA?

A

Left

144
Q

What is the most reliable feature that distinguishes a mitral valve from a tricuspid valve?

A

Level of attachment to the AV valve at the cardiac crux

145
Q

True or False: The AV valves are invariably associated with their appropriate morphologic ventricle (tricuspid to RV and mitral to LV) and are the best marker for atrioventricular connection and ventricular morphology

A

True

146
Q

What are some features that distinguish the AV valves from each other?

A
  1. Shape of the orifice
  2. Atrioventricular valve-semilunar valve continuity
  3. Presence of septal chordal attachments
  4. Level of attachment of the atrioventricular valve at cardiac crux
  5. # of leaflets
  6. Which morphologic ventricle it is associated with
147
Q

What organ systems are characterized by situs or sidedness?

A

Cardiac, Pulmonary GI

148
Q

Cardiac sidedness is determined by what?

A

Position of RA

149
Q

Pulmonary situs is determined by what?

A

Positions of morphologic right and left lungs

150
Q

Abdominal situs is characterized by what?

A

Location of liver and stomach

151
Q

Where is the defect in a sinus venosus ASD?

A

Superior/posterior portion of the atrial septum adjacent to the SVC

152
Q

Which veins are often anomalous in a sinus venosus ASD?

A

Right upper and middle pulmonary veins

153
Q

Where do the right upper and middle pulmonary veins connect to most often in a sinus venosus ASD?

A

SVC

154
Q

Large primum septum, AV valves inset at same level at the cardiac crux, inlet ventricular septum intact, MR from cleft mitral valve?

A

Partial AVSD

155
Q

What defects could be present if you see a large anterior malalignment VSD with 50% aortic override of the VSD?

A

ToF, PA-VSD, Truncus

156
Q

Significant aortic root dilation and MVP should make you think of…?

A

Marfan

157
Q

AVSD and VSD should make you think of…?

A

Down

158
Q

Aortic arch anomalies and conotruncal defects should make you think of…?

A

DiGeorge

159
Q

RVOT/PA anomalies, ASD and HCM should make you think of…?

A

Noonan

160
Q

Supravalvar AS and supravalvar/branch PS should make you think of…?

A

Williams

161
Q

What is the most common adult cardiac tumor?

A

Myxoma

162
Q

What is the 2nd most common childhood cardiac tumor?

A

Myxoma

163
Q

Where are myxomas typically located?

A

LA (75%) often attached to the fossa ovalis

164
Q

What can happen if a myxoma in the LA is very large?

A

Can obstruct AV valve inflow leading to positional dyspnea, syncope, death

165
Q

Name some symptoms associated with a myxoma

A
  • Weight loss
  • Malaise
  • Arthralgias
  • Myalgias
  • Positional dyspnea
  • Syncope
  • Death
166
Q

What is a familial form of myxoma that is associated with lentigines and endocrine abnormalities?

A

Carney syndrome

167
Q

What should you consider with a large homogenous echogenic mass in the posterior wall of the LV?

A

Fibroma

168
Q

Describe a fibroma

A

Firm, white, non-encapsulated tumor

169
Q

Where are fibromas typically found?

A

LV within posterior wall or septum and commonly at apex

170
Q

What is the problem with fibromas?

A
  • Often large and can result in cavitary obstruction or impair AV valve function
  • Risk of SCD due to ventricular arrhythmias
171
Q

Doppler flow studies in human fetus have shown that the ratio of R-L ventricular combined output is about what?

A

RV: 50-55%
LV: 40-45%

*CO increases during gestation, but relative amounts from 2 parallel circulations stay same

172
Q

What is the best management for a fetus with tachycardia and hydrops?

A

Sotalol

*Dig has poor maternal fetal transfer for a hydropic fetus (isn’t 1st line)

173
Q

What is maternal lupus associated with?

A

Fetal heart block and bradycardia

174
Q

A fetal 4C view is inadequate to exclude which lesion?

A

D-TGA

*Need to look at outflow tracks… 4C view often normal in these babies

175
Q

True or False: HLHS, tricuspid atresia, AVSD and Ebstein can all be diagnosed by a 4C view on fetal echo?

A

True

176
Q

What is the normal range for fetal CT area ratio?

A

25-35% (about 1/3)

177
Q

What is the most common fetal arrhythmia?

A

PACs

*Next is PVC

178
Q

Fetal arrhythmias occur in what % of pregnancies?

A

1-3%

179
Q

Fetal SVT, atrial flutter and complete heart block account for what % of reported fetal arrhythmias?

A

<10%

180
Q

How do you measure a mechanical PR interval on echo?

A

Measure from beginning of atrial inflow (mitral A-wave) to beginning of ventricular ejection

181
Q

What change in ductal flow would you see in PA + IVS?

A

Flow reversal in the ductus arteriosus

*No antegrade flow across atretic pulmonary valve, so flow reversal into hypoplastic MPA/branch PAs

182
Q

What lesion would you expect to see flow retrograde flow into the aortic arch?

A

Critical AS

*Have limited antegrade blood flow across the critically stenotic aortic valve, so arch is supplied retrograde via duct

183
Q

Normal fetal HR ranges?

A

120-180bpm

184
Q

Normal fetal cardiac axis?

A

30-60 degrees

*Left axis of fetal heart relative to midline

185
Q

What % of fetal CO at term perfuses the lungs?

A

10%

*Remainder of deoxygenated blood is directed through ductus to descending Ao/Placenta for oxygenation

186
Q

Fetal CHD with indomethacin?

A

Ductal constriction

187
Q

Fetal CHD with fetal alcohol syndrome?

A

VSD

*Septal defects (ASD/VSD), less common CoA and conotruncal

188
Q

Fetal CHD with fetal hydantoin syndrome?

A

CoA

*Also LVOTO

189
Q

Fetal CHD with lithium?

A

Ebstein

*Also ASD and AV valve atresia

190
Q

Fetal CHD with isotretinoin?

A

d-TGA

*Also septal defects and conotruncal anomalies

191
Q

CHD with Turner (XO)?

A

CoA

  • Most common CoA/AS with bicuspid AoV
  • Less common ASD/VSD
192
Q

CHD with DiGeorge (22q11)?

A

IAA, conotruncal defects (Truncus arteriosus)

193
Q

CHD with T21?

A

AVSD

*Also secundum ASD, VSD, ToF and arch obstruction

194
Q

CHD with T13?

A

VSD

*Also HLHS, ToF, AVSD

195
Q

CHD with Williams Syndrome?

A

Supravalvar AS

*Supravalvar AS and branch PS, septal defects, arch anomalies

196
Q

Maternal SLE, umbilical cord compression, heterotaxy and L-TGA can all cause what in a fetus?

A

Bradycardia

  • SLE: Complete heart block
  • Umbilical cord compression: Transient bradycardia or brief asystole
  • Heterotaxy/L-TGA: Heart block, bradycardia
197
Q

What congenital heart lesion should be excluded in a fetus with SVT?

A

Ebstein

198
Q

Ebstein is associated what % incidence of rhythm abnormalities?

A

15-20%

199
Q

What rhythm issues are associated with Ebstein?

A

WPW/SVT

200
Q

How do you calculate pulsatility index in the umbilical artery?

A

(Peak systolic velocity-End Diastolic velocity)/Mean Velocity

*(s-d)/mean

201
Q

What do Doppler velocities within the umbilical artery reflect?

A

Downstream resistance within the placenta

202
Q

Peak systolic velocity minus end diastolic velocity divided by mean velocity

A

Pulsatility index

203
Q

List some findings associated with heart failure in a fetus?

A
  • Decreased pulsatility index in MCA
  • Increase in pulsatility index in UA
  • Pulsations within umbilical vein
  • Flow reversal in ductus venosus
  • AVVR
204
Q

Why do you see decreased pulsatility index in the MCA in fetuses with CHF?

A

Cerebral resistance falls (“brain-sparing” effect)

205
Q

What finding would be common to a fetus in the following circumstances:

  • Recipient twin in twin-twin transfusion
  • Poorly controlled maternal DM
  • Fetal HCM
  • Noonan
A

Ventricular hypertrophy

206
Q

True or False: Fetuses with ToF will have RVH on echo?

A

False- RVH develops secondary to RVOT obstruction and develops post-natally

207
Q

What is the incidence of CHD in maternal DM?

A

4-10%

208
Q

What is the incidence of CHD in FHx of CHD?

A

2-4%

209
Q

Which has a higher incidence of CHD… Maternal DM history or FHx of CHD?

A

Maternal DM (4-10%)

FHx 2-4%

210
Q

What are the most common cardiac lesions in fetuses of diabetic mothers?

A
  • D-TGA
  • Truncus arteriosus
  • ToF
211
Q

What is the risk of CHD in a fetus of a diabetic mother directly associated with?

A

Maternal Hgb A1C levels during early gestation

212
Q

True or False: HCM associated with poor maternal glucose control is most often reversible within weeks or months post-delivery?

A

True

213
Q

What cardiac devices are a relative contraindication for CMR?

A

AICD

  • Most implanted metallic objects, coils, clips, pacemaker leads, occluder devices, are weakly ferromegnetic and relatively immobile after implantation
  • Now, many pacemakers/AICDs are CMR compatibile
214
Q

What type of objects cause the most prominent imaging artifact with CMR?

A

Stainless steel (like a PDA coil)

  • Occluder devices including the Amplatzer ASD device also cause significant imaging artifact
  • Pacemaker leads, PDA vascular clip and nonferromagnetic stents cause less artifact with MRI
215
Q

Blood appears black in which CMR techqniue?

A

Spin echo

216
Q

Describe spin echo sequencing on CMR

A
  • Relatively long time period between spin excitation and data sampling resulting in blood flow leaving the imaging plane when the signal is sampled
  • Produces an image where blood appears black and surrounding cardiac tissue is encoded in shades of gray or white
217
Q

What type of images to spin echo sequences provide on CMR?

A

Still images for anatomy and tissue characterization

218
Q

Blood appears bright in what types of CMR images?

A
  • Gradient echo
  • Steady-state free precession
  • Contrast-enhanced images
219
Q

What is the optimal technique to calculate Qp:Qs by CMR in someone with a large ASD?

A

Velocity-encoded cine (VEC) images

220
Q

What is VEC MRI?

A
  • Velocity-encoded cine images

- Gradient echo sequence that can measure blood flow velocity and quantify blood flow

221
Q

True or False: SPAMM, contrast-enhanced MRA, myocardial perfusion study and spin echo don’t provide any quantifiable flow or velocity information?

A

True

222
Q

What CMR technique produces an image where the blood pool is black and surrounding cardiac tissue is gray or white?

A

Spin echo

223
Q

What are some spin-echo applications?

A
  • Myocardial and blood vessel walls
  • Cardiac masses and tumors
  • Pericardium
224
Q

What sequences in spin echo imaging can help with tissue characterization?

A

T1/T2 weighted sequences

225
Q

How is signal acquisition performed in CMR?

A

Over several cardiac cycles

226
Q

True or False: Spin echo CMR produces high tissue contrast and has less imaging artifact with metallic implants compared to other CMR techniques?

A

True

227
Q

What kind of images does gradient echo CMR produce?

A

Bright blood

228
Q

Describe gradient echo sequences in CMR

A
  • Gradient echo sequences have less time between spin excitation and signal detection resulting in a faster acquisition than spin echo sequences
  • Gradient echo technique results in high imaging speed with multiple images acquired during each cardiac cycle
229
Q

Describe CMR signal from slower moving tissue?

A

Gray with less contrast (compared to spin echo images)

230
Q

What type of CMR images are more susceptible to imaging artifact?

A

Signal from slower moving tissue

231
Q

Faster moving blood has a stronger signal which results in what?

A

Bright blood images

232
Q

What is the best cardiac MRI technique to assess myocardial viability?

A

Myocardial delayed enhancement

233
Q

Describe myocardial delayed enhancement

A
  • Washout of gadolinium contrast agents is delayed in necrotic myocardium and areas of fibrotic tissue
  • Nonviable myocardium appears bright when compared to viable myocardium
234
Q

What is effective in determining presence, size and transmurality of MI as well as identification of presence and extent of myocardial fibrosis in patients with HCM?

A

Myocardial delayed enhancement

235
Q

What CMR sequences can be done without IV contrast?

A

Phase-contrast (velocity-encoded) cine images

236
Q

What is phase-contrast (or velocity encoded) cine imaging used for?

A

Flow quantification

*Doesn’t require contrast administration

237
Q

True or False: IV contrast is needed in CMR for myocardial perfusion, delayed enhancement and TRICKS?

A

True

238
Q

What CMR sequence allows the best assessment of myocardial edema?

A

T2 weighted black blood imaging

239
Q

What sequences are fluid sensitive and can best detect myocardial edema (like in myocarditis)?

A

T2 weighted sequences

240
Q

True or False: First pass perfusion imaging may or may not show a hypo-attenuated filling defect in the area of myocardial edema?

A

True

241
Q

What test is best to establish a diagnosis of anomalous origin of the LCA from right sinus of Valsalva with intramural course?

A

CTA with ECG gating

  • MRI doesn’t have the spatial resolution needed
  • CTA without ECG gating doesn’t allow assessment of coronaries
  • Coronary angiography can’t assess the intramural course
  • Thallium scan can only show myocardial areas of hypoperfusion
242
Q

What advanced imaging modality is best to assess CoA?

A

MRA or CTA (don’t need ECG gating)

243
Q

What kind of CTA has the highest dose of radiation?

A

Retrospective ECG-gated

244
Q

True or False: The CMR magnet is always on

A

TRUE

Ferromagnetic objects brought into room can act as projectiles

245
Q

True or False: Distribution of delayed myocardial enhancement can help distinguish infarction from myocarditis?

A

True

246
Q

Where is delayed myocardial enhancement seen in myocarditis?

A
  • Subepicardial or midmyocardial

- Patchy

247
Q

Where is delayed myocardial enhancement seen in infarction?

A

-Subendocardial or transmural

248
Q

Myocardial edema is best seen on what type of imaging?

A

T2-weighted black blood images

249
Q

Fatty infiltrates can be seen on what type of imaging?

A

T1 weighted images

250
Q

In myocarditis, what is early myocardial enhancement due to?

A

Hyperemia of inflamed areas

251
Q

What is the best test to assess pericardial calcification in someone with pericardial construction?

A

Non-contrast CT

*Don’t need contrast or ECG gating

252
Q

What CMR sequences allows assessment of myocardial iron overload in patients with thalassemia or other chronic blood transfusion recipients?

A

Myocardial T2* quantification

253
Q

What is seen on CMR for a patient with pericarditis?

A
  • Thickened pericardium on T1 weighted double inversion recovery sequence
  • Pericardia edema and effusion on T2-weighted sequence
  • Diffuse post-contrast delayed enhancement
254
Q

What type of surgery was done if you see the MPA anterior to the aorta with the branch PAs draped over the aorta?

A

ASO- LeCompte maneuver

255
Q

Why is it so important to delineate coronary arteries in a ToF patient?

A

If there is a single coronary or other anomaly where a branch crosses anterior to the pulmonary valve, may need a RV-PA conduit to avoid damage to the coronary artery

256
Q

Surgical shunt from right subclavian to PA?

A

Modified BTT

257
Q

Surgical shunt with direct end-to-side anastomosis of subclavian artery to PA?

A

Classic BTT

258
Q

Surgical shunt with direct side-to-side anatomosis of ascending aorta to RPA?

A

Waterston shunt

259
Q

Surgical shunt with direct side-to-side anatomosis of descending aorta to LPA?

A

Potts shunt

260
Q

Small conduit from aorta to PA?

A

Central shunt

261
Q

Aortic arches on both sides of trachea?

A

Double aortic arch

262
Q

What is the typical branching pattern for a double aortic arch?

A

Separate origin of 4 arch branches

  • Right common carotid and right subclavian from right arch
  • Left common carotid and left subclavian from left arch
263
Q

What happens with time to the coronary arteries in anomalous origin of the LCA from PA?

A

They become dilated due to increased flow from RCA to LCA via collaterals + Chronic run-off of blood from the LCA to PA

264
Q

What is common in Fontan patients who received a conduit made of biologic material (like an aortic homograft)?

A

Fontan conduit stenosis

265
Q

What are the 2 most common coexisting diagnoses in patients with CoA?

A

VSD and Bicuspid AoV

Peds Cardiology (20 decks)

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