Cardiac Flashcards
Right Atrium
Defined by the IVC. The Crista Terminalis is a frequently tested normal
structure (it’s not a clot or a tumor). It is a muscular ridge that runs from the entrance o f the
SVC to that o f the inferior vena cava. Another normal anatomic structure that is frequently
shown (usually on IVC gram) is the IVC valve or Eustachian valve. It looks like a little flap
in the IVC as it hooks up to the atrium. When the tissue o f this valve has a more
trabeculatated appearance it is called a Chiari Network.
Coronary Sinus
The main draining vein o f the myocardium. It runs in the AV groove
on the posterior surface o f the heart and enters the right atrium near the tricuspid valve.
Right Ventricle
Defined by the Moderator Band. Has several characteristics that are
useful for distinguishing it (and make good test questions).
The tricuspid papillary muscles insert on the septum (not the case with the mitral valve). There is no fibrous connection between the AV valve / outflow tract.
The pulmonary valve has three cusps, and is separated from the tricuspid valve by a thick muscle known as the crista supraventricularis . This differs from the left ventricular outflow
tract, where the mitral and aortic valves lie side by side.
Left Atrium
overview
The most posterior chamber. When you think about multiple choice
questions regarding the left atrium, think about the various signs of enlargement.
Left Atrium
double density
(direct sign): Superimposed second contour on the right heart, from
enlargement o f the right side o f the left atrium
Left Atrium
splaying of the carina
(indirect sign): Angle over 90 degrees suggests enlargement
Left Atrium
walking man sign
(indirect sign): Posterior displacement o f the left main stem
bronchus on lateral radiograph. This creates an upside down “V ” shape with the
intersection o f the right bronchus (looks like a man walking).
Left Ventricle
The leaflets o f the mitral valve are connected to the papillary muscles
via cord-like tendons called chordae tendinae. The papillary muscles insert into the lateral
and posterior walls as well as the apex o f the left ventricle (not the septum, as is the case on the right).
Echogenic Focus in Left Ventricle
Relatively common sonographic observation seen on pre-natal ultrasound. It is a calcified papillary muscle that usually goes away by the third trimester. So who gives a shit? Well they are associated with an increased incidence of Downs (13%). Don’t get it twisted, having one means nothing other than you should look for other signs of downs (most of the time it’s normal).
Lipomatous Hypertrophy
of the Interatrial Septum:
This has a very classic look o f a
dumbbell (bilobed) appearance of
fat density in the atrial septum,
sparing the fossa ovalis. This
sparing of the fossa ovalis,
creates a dumbbell appearance
{when it doesn’t spare it think
lipoma). It’s associated with
being fat and old. As a point of
trivia it can cause
supraventricular arrhythmia,
although usually does nothing.
Additional even more high-yield
trivia is that it can be hot on
PET because it’s often made of
brown fat.Lipomatous
Hypertrophy of the
Interatrial Septum
quick
common
ft in the atrial sptum, thicker than 2cm
spares the fossa ovalis
can be PET hot
RAre assoiated with arhythmias (usually asymptomatic)
Interatrial septum lipoma
rare
encapsulated
does not spare fossa ovalis
if multiopl = tuberous sclerosis
is usually PET HOT, T1 birght, drops out on fat sat
rarely associated with arrhythmias (usually asymptomatic)
Normal coronaries origin
There are three coronary cusps; right, left, and non-coronary (posterior).
The left main comes off the left cusp, the right main comes off the right cusp.
With regard to what perfuses what, the following are high yield factoids:
- RCA perfuses SA node 60%
* RCA perfuses AV node 90%
Posterior Descending Artery
PDA
RCA 65%-80%
-(*the other 20% have the PDA
supplied by the left coronary)
Conus
Off of RCA
*About 1/2 the time this
is the first branch.
-It supplies the
ventricle outflow tract.
Acute marginal
off the RCA, R forms an acute angle
nodal branc
off the RCA
Left main
LAD, circumfles, diagonals, obtuse marginals
obtuse marginals
supply the lateral margin
The 2 Chamber view
This displays the LV and LA (2 chambers). This is
good for a few things (1) Wall motion / Global LV
function , and (2) Mitral valve issues - regurg, etc.
The anatomy trick would be to have you ID the
coronary sinus on this view.
The 3 Chamber view
Some people will call this an “apical long axis
view.” The major plus to this view is that it lets you
see the left ventricular outflow tract (LVOT), - and is
ideal for look at flow through this area (i.e. aortic
regurg). A way a question could be asked is “what
view is best for aortic regurg? / stenosis?” or “which
of the following views” - and make you pick out the
picture of the 3 chamber. Or just straight ask you -
what is this view?
Dominance
Coronary Dominance is determined by what vessel gives rise to the
posterior descending artery and posterior left ventricular branches (most are right-
85%). You can be “co-dominant” if the posterior descending artery arises from the right
coronary artery and the posterior left ventricular branches arise from the left circumflex
coronary artery.
Malignant Origin
Most Common and Most Serious: LCA from the Right Coronary Sinus, coursing between the Aorta and Pulmonary Artery. This guy can get compressed and
cause sudden cardiac death.
Anomalous right off the left cusp
repair is symtomatic
Anomalous left off the right cusp
Always Repair
Malignant coronary artery with origin from the opposite sinus and an interarterial course is the
second most common cause of sudden cardiac death in young patients (most common is hypertrophic cardiomyopathy).
ALCAPA
Anomalous Left Coronary from the Pulmonary Artery. There are two types:
(a) Infantile type (they die early - CHF & dilated cardiomyopathy), and (b) Adult (still at
risk of sudden death). The multiple choice question is going to be “STEAL SYNDROME”
- which describes a reversed (retrograde) flow in the LCA as pressure decreases in the
pulmonary circulation.
Myocardial Bridging
This is an intramyocardial course of a coronary artery (usually
the LAD). The finding may cause symptoms as the diameter decreases with systole, or may
cause an issue for CABG planning. This can be a source o f ischemia.
Coronary Artery Aneurysm
By definition this is a vessel with a diameter greater
than 1.5x the normal lumen. Most common cause is atherosclerosis. Most common cause
in children is Kawasaki (spontaneously resolves in 50%). They can occur from lots of other
vasculitides as well. Last important cause is iatrogenic (cardiac cath).
Coronary Fistula
Defined as a connection between a coronary artery and cardiac
chamber or great vessels. It’s usually the RCA, with drainage into the right cardiac
chambers. They are associated / result in coronary aneurysm. I f you see big crazy dilation o f the coronaries - think about this.
Who is the ideal patient to g et a coronary CT
There are two main groups o f people
getting these. (1) Low risk or atypical chest pain patients. A negative coronary CT will
help stop a stress test or cath from occurring. Why do a procedure with risks on someone
with GERD? (2) Suspected aberrant coronary anatomy.
What is the ideal heart rate
To reduce motion related artifacts a slow heart rate is
preferred. Most books will tell you under 60 beats per min. Beta blockers are used to
lower the heart rate to achieve this ideal rate.
Are there contraindications to beta blockers
Yup. Patients with severe asthma, heart
block, acute chest pain, or recent snorting o f cocaine - should not be given a beta blocker
Are all heart blocks contraindications to beta blockers
2nd and 3rd Degree are contraindications. A 1st degree block is NOT.
What i f I can V give the beta blocker
Can he still have the scan? Yes, you just can’t use a
prospective gating technique. You’ll have to use retrospective gating.
Prospective gating
“Step and Shoot” - R-R interval * data acquisition triggered by R Wave
Pro: There is reduced radiation b/c the scanner isn’t on the whole time
• Con: No functional imaging
• Trivia: Always axial, not helical
retrospective gating
Scans the whole time, then back calculates
Pro: Can do functional imaging
Con: Higher radiation (use of low pitch - increases dose)
Trivia: this is helical
Other than beta blockers, are any other drugs given fo r coronary CT
Yup. Nitroglycerine is given to dilate the coronaries (so you can see them better).
Are there contraindications to nitroglycerine
Yup. Hypotension (SBP < 100), severe
aortic stenosis, hypertrophic obstructive cardiomyopathy, and Phosphodiesterase (Viagra- Sildenafil, “boner pills”) use.
Velocity-encoded cine MR imaging (VENC), also known as velocity mapping or phase-contrast
imaging, is a technique for
quantifying the velocity of flowing blood.
Aortic Stenosis
This may be congenital (bicuspid) or Acquired (Degenerative or Rheumatic
Heart). Increased afterload can lead to concentric LV hypertrophy. Peak velocity through the valve
can be used to grade the severity. Velocity-encoded cine MR imaging (VENC), which also answers
to the name “velocity mapping” or “phase-contrast imaging”, is an MRI technique for quantifying the
velocity of flowing blood (if anyone would happen to ask). Dilation of ascending aorta is due to jet
phenomenon related to a stenotic valve. Aortic Stenosis comes in three flavors: (a) valvular, (b)
subvalvular, (c) and supravalvular. Valvular is the most common (90%).
When I say “Supra-valvular Aortic Stenosis ’’you say
williams syndtome
When I say “Bicuspid Aortic Valve and Coarctation ” you say
Turner syndrome
Bicuspid Aortic Valve
overview
This is very common, some
sources will say nearly 2% of the general population. As a
result, it becomes the source of significant fuckery with
regard to one particular multiple choice question - “what is
the most common congenital heart disease?” The answer is
probably bicuspid aortic valve, but because it’s often
asymptomatic and not a problem till later in life when it gets
stenotic and causes syncope - 1 think it messes with peoples’
math. How do you handle this question? Well… if they list
bicuspid aortic valve then you have to pick it. If they don’t
list it then the answer is VSD.
Bicuspid Aortic Valve
things to know
• Aortic Stenosis is the most common complication
• Bicuspid aortic valve (even in absence of stenosis) is an
independent risk factor for aortic aneurysm. Severity of
valve dysfunction does not predict aneurysm formation.
• Association with Cystic Medial Necrosis (CMN)
• Association with Turners Syndrome, and Coarctation
• Association with AD Polycystic kidney disease
Aortic Regurgitation
Seen with bicuspid aortic valves, bacterial endocarditis, Marfan’s, aortic
root dilation from HTN, and aortic dissection. How rapid the regurgitation onsets determines the
hemodynamic impact (acute onset doesn’t allow for adaptation). Step 1 question was “Austin Flint
Murmur.”
Mitral Stenosis
Rheumatic heart disease = most
common cause. Could be shown as a CXR with left atrial
enlargement (double density sign, splaying of the carina,
posterior esophageal displacement).
Ortner’s Syndrome
Cardio Vocal Hoarseness
Hoarseness caused by
compression o f the left recurrent
laryngeal nerve by an enlarged
left atrium
Mitral Regurgitation
The most common acute causes are endocarditis or papillary muscle /
chordal rupture post MI. The chronic causes can be primary (myxomatous degeneration) or
secondary (dilated cardiomyopathy leading to mitral annular dilation). Remember the isolated Right
Upper Lobe pulmonary edema is associated with mitral regurgitation
Pulmonary Stenosis
Just like in the Aortic Valve, comes in three flavors: (a) valvular, (b) subvalvular, (c) and supravalvular. Valvular is the most common, and can lead to ventricular hypertrophy. Associated with Noonan Syndrome (male version of turners). “Peripheral Pulmonary Stenosis” is seen with Alagille syndrome (kids with absent bile ducts). Williams can give you supra-valvular aortic stenosis (and pulmonic).
Pulmonary stenosis
williams syndrom
supra=valbular stenosis
Pulmonary stenosis
Noonans syntdrome
valvular stenosis
Pulmonary stenosis
TOF
sub-valvular stenosis
Pulmonary Regurgitation
The classic scenario is actually TOF patient who has been repaired.
TOF repair involves patch repair of the VSD and relief of the RV outlet obstruction. To fix the RV
obstruction the pulmonary valve integrity must be disrupted. Eventual failure of the valve (regurgitation)
is the primary complication of tis procedure.
Pulm regurg repair
Cardiac MRI is used to guide the timing of pulmonary regurg repair. If the valve is repaired before the
RV is severely dilated (150 ml end diastolic volume) the outcomes are good. If the RV reaches a certain
degree of dilation- it typically won’t return to normal and the patient is pretty much fucked.
Tricuspid Regurgitation
Most common form of tricuspid disease, due to the relatively weak
annulus (compared to the mitral). May occur in the
setting of endocarditis (IV drug use), or carcinoid
syndrome (serotonin degrades the valve). The most
common cause in adults is pulmonary arterial
hypertension. A testable pearl is that TR causes RV
dilation (NOT RV Hypertrophy).
valves gamesmanship
Rheumatic heart
disease most commonly involves the mitral
and aortic valves. Anytime there is multivalve
disease, think Rheumatic Fever!
Valves step 1 trivia
Rheumatic heart disease is
an immune modulated response to Group ABeta
hemolytic strep.
Ebstein Anomaly
Seen in children whose moms used Lithium (most cases are actually
sporadic). The tricuspid valve is hypoplastic and the posterior leaf is displaced apically (downward).
The result is enlarged RA , decreased RV (“atrialized”), and tricuspid regurgitation. They have the
massive “box shaped” heart on CXR.
Tricuspid Atresia
Congenital anomaly that occurs with RV hypoplasia. Almost always has an
ASD or PFO. Recognized association with asplenia. Can have a right arch (although you should
think Truncus and TOF first). As a point of confusing trivia; tricuspid atresia usually has pulmonary
stenosis and therefore will have decreased vascularity. If no PS is present, there will be increased
vascularity.
Carcinoid Syndrome
This can result in valvular disease, but only after the tumor has met’d to
the liver. The serotonin actually degrades heart valves, typically both the tricuspid and pulmonic
valves. Left sided valvular disease is super rare since the lungs degrade the vasoactive substances.
When you see left sided disease you should think of two scenarios:
(1) primary bronchial carcinoid, or (2) right-to-lcft shunts.
The most common variant in branching
is the “bovine arch” in which the brachiocephalic artery and left common carotid artery arise from a common origin.
The terminology right arch / left arch is
described based on
the aortic arch’s
relationship to the trachea.
When I say Right Arch with Mirror
Branching
You say congenital heart
There are 5 types of right arches, but only two are worth knowing
(Aberrant Left, and
Mirror Branching^. The trick to tell these
two apart is to look fo r the origin o f the left subclavian.
originating fromt he front of the arch=mirror image (bad one lots of congenital heart)
originating from the back of the arch = aberrant left subclavian
Right Arch with Mirror Branching
Although these are often asymptomatic they
are strongly associated with congenital heart disease. Most commonly they are associated
with TOF. However, they are most closely associated with Truncus. Obviously, this tricky
wording lends itself nicely to a trick question.
f there is a mirror image right arch
then 90% will have TOF (6% Truncus).
I f the person has Truncus, then they have a mirror image right arch
33% (TOF 25%).
Right Arch with Aberrant Left Subclavian
The last branch is the aberrant left subclavian artery. This is a vascular ring
because the ligamentum arteriosum (on the left) completes the “ring’
encircling the trachea.
Left Arch Aberrant Right
Subclavian
The most common arch
anomaly. Although it is usually
asymptomatic it can sometimes be
associated with dysphagia lusoria, as the
RSCA passes posterior to the esophagus. The
last branch is the aberrant right subclavian
artery. The origin of the RSCA may be
dilated = Diverticulum of Kommerell.
Double Aortic Arch
The most common vascular ring. As a point o f trivia, symptoms may begin at birth and include tracheal compression and/or
difficulty swallowing. The right arch is
larger and higher, and the left arch is
smaller and lower. Arches are posterior to the esophagus and anterior to the trachea
(encircling them both).
Subclavian Steal Syndrome/Phenomenon
phenomenon
Stenosis and/or occlusion o f the proximal subclavian with
retrograde flow in the ipsilateral vertebral artery.
Subclavian Steal Syndrome/Phenomenon
syndrome
Stenosis and/or occlusion o f the proximal subclavian artery with
retrograde flow in the ipsilateral vertebral artery AND associated cerebral ischemic
symptoms.
Subclavian Steal Syndrome/Phenomenon
If the level o f stenosis and/or occlusion is proximal to the vertebral artery, reversal o f flow
in the vertebral artery can occur, resulting in the theft o f blood from the posterior
circulation. When the upper limb is exercised, blood is diverted away from the brain to the
arm. Cerebral symptoms (dizziness, syncope, etc…) depend on the integrity o f collateral
intracranial flow (PCOMs).
Subclavian Steal is almost always caused by atherosclerosis (98%), but other very testable
causes include Takayasu Arteritis, Radiation, Preductal Aortic Coarctation, and Blalock-
Taussig Shunt. In an adult they will show atherosclerosis. If they show a teenager / 20 year
old it’s gonna be Takayasu. Case books love to show this as an angiogram, and I think
that’s the most likely way the test will show it. They could also show a CTA or MRA
although I’d say that is less likely.
My thoughts on multiple choice questions regarding congenital heart is that they will come in 3
flavors
(A) Aunt Minnie, (B) Differentials with crappy distractors, and (C) Associations / Trivia.
Congenital heart CXR
egg on a string
transposition
Congenital heart CXR
snow man
TAPVR (supracardiac)
Congenital heart CXR
boot shaped
TOF
Congenital heart CXR
Figure 3
Coarctation
Congenital heart CXR
box shaped
Ebstein
Congenital heart CXR
scimitar sword
PAPVR with hypoplasia
Another classic trick with regard to the
big box heart
non-cardiac causes o f high output failure (Infantile Hemangioendothelioma
and Vein of Galen Malformation).
Cyanotic
right sided arch
TOF or truncus (types 1-3)
Cyanotic left sided arch, massive heart size
Ebsteins or
Pulmonary Atresia without VSD
Non-Cardiac (won’t be cyanotic)
- Infantile Hemangioendothelioma
- Vein of Galen Malformation
cyanotic, left sided arch, normal heart size, increased pulmonary blood flow
- TAPVR (especially type 3)
- D-Transposition
- Truncus (look for R Arch)
- “Tingle Ventricle”
cyanotic, left sided arch, normal heart size, decreased or normal pulmonary blood flow
TOF
Ebsteins
tricuspid atresia
Cyanotic congenital heart ddx
TOF TAPVR Transposition Truncus Tricuspid Atresia
not-cyanotic congenital heart ddx
ASD VSD PDA PAPVR Aortic coarctation (adult type-postductal)
CHF in Newborn
ddx
TAPVR (Infracardiac type “III”) Congenital Aortic or Mitral Stenosis Left Sided Hypoplastic Heart Cor Triatriatum Infantile (pre-ductal) Coarctation
Survival dependent on admixture - Cyanotics
ddx
TAPVR (has PFO) Transposition TOF (has VSD) Tricuspid Atresia (has VSD) Hypoplastic Left
Small heart DDx
Adrenal Insufficiency (Addisons)
Cachectic State
Constrictive Pericarditis
