Cardiac Flashcards
Crista terminalis
A muscular ridge in the right atrium that runs from the entrance of the SVC to the entrance of the IVC
Note: Do not confuse this right atrial structure with a clot.
Where are pectinate muscles found?
- Right atrium (running from the peak of the crest terminals to the right atrial appendage)
- Left atrial appendage (inner surface only)
Eustachean valve
IVC valve that looks like a little flap in the distal IVC
Note: If this IVC valve appears more trabeculated, then its called a Chair Network.
What defines the right atrium?
The IVC entrance
What defines the right ventricle?
The moderator band
How do the ventricular outflow tracts differ?
The right ventricular outflow tract is muscular
The left ventricular outflow tract is fibrous (and continuous with the mitral valve)
Moderator band
A right ventricular structure that defines the right ventricle and acts as part of the right bundle branch electric system
Which cardiac view allows assessment of both the mitral and tricuspid valves?
The horizontal long axis (4-chamber) view
An AV canal defect is best seen on which view?
The horizontal long axis (4-chamber) view
Note: Most other congenital heart problems are better evaluated on other views.
The LV short axis view is perpendicular to the…
Horizontal long axis (4-chamber) view
The 3 chamber view is best for evaluating the…
Left ventricular outflow tract (e.g. for aortic regurgitation/stenosis)
What is the best MRI view for evaluating for aortic stenosis?
3 chamber view (of the left ventricular outflow tract)
What view is this?
Horizontal long axis (4-chamber) view
What view is this?
3 chamber view (of left ventricular outflow tract)
What view is this?
2-chamber long axis view
Widening of the carinal angle > 90 degrees on chest radiograph suggests…
Left atrial enlargement
Radiographic signs of left atrial enlargement
- Double density sign (2 superimposed right heart borders)
- Widening of the carinal angle > 90 degrees
- Elevation of the left main bronchus
- Walking man sign (splaying of the main bronchi on lateral radiograph making them looks like two legs walking)
Shifting of the right heart border by > 3 cm from midline on chest radiograph…
Suggestive of right atrial enlargement
On pre-natal ultrasound, the tech identifies an echogenic focus within the fetal left ventricle…
Likely a calcified papillary muscle that will resolve by the third trimester, but is associated with an increased risk of Down syndrome (look for other signs of Down syndrome)
Dumbbell appearance of billobed fat density in the atrial septum sparing the fossa ovalis…
Lipomatous hypertrophy of the interatrial septum
Lipomatous hypertrophy of the interatrial septum should spare the…
Fossa ovalis
Note: If the fossa ovalis is not spared, think lipoma.
Fat density in the interatrial septum without dumbbell appearance (i.e. does not spare the fossa ovalis)…
Think lipoma
Note: Lipomatous hypertrophy of the intertribal septum should spare the fossa ovalis.
You are thinking a fat density in the interatrial septum is lipomatous hypertrophy, but it is hot on PET/CT…
Lipomatous hypertrophy of the intertribal septum can be hot on PET (often made of brown fat)
Note: The important factor is whether it spares the fossa ovalis. If it does not, then think lipoma.
Lipomatous hypertrophy of the interatrial septum can cause…
Supraventricular arrythmias, but is otherwise inconsequential
Which coronary artery supplies the SA node?
The right coronary artery
Which coronary artery supplies the AV node?
The right coronary artery
The posterior descending artery is supplied by the…
- Right coronary artery (80%)
- Left coronary artery (20%)
What does the conus branch of the right coronary artery supply?
The ventricular outflow tract
Note: This is the first branch of the right coronary artery 50% of the time.
What are the main branches of the right coronary artery?
- Conus branch
- AV nodal branch
- Acute marginal branch
- Posterior descending artery (80%)
What are the main branches of the left coronary artery?
- Left anterior descending (with diagonal and septal branches)
- Left circumflex (with marginal branches and in 20% of people also the PDA)
Which coronary supplies the cardiac apex?
Left anterior descending
Which coronary supplies the cardiac septum?
LAD and Right coronary
Which coronary supplies the anterior LV wall?
LAD
Which coronary supplies the lateral LV wall?
Left circumflex
Which type of coronary anomaly should always get fixed?
LCA originating from the right coronary sinus
Note: If this doesn’t get fixed there is a high risk of sudden cardiac death.
Treatment for left coronary artery arising from the right coronary cusp
Surgical repair (to decrease risk of sudden cardiac death)
Treatment for right coronary artery arising from the left coronary cusp
Surgical repair only if symptomatic
What are the two most common causes of sudden cardiac death in young pts?
- Hypertrophic obstructive cardiomyopathy
- Malignant coronary artery with origin from the opposite sinus
ALCAPA
Anomalous left coronary from the pulmonary artery
What are the two types of ALCAPA
- Infantile (these pts die early from CHF and dilated cardiomyopathy)
- Adult (increased risk of sudden cardiac death)
Transient reversal of flow in the left coronary artery…
Think steal syndrome in the setting of ALCAPA (anomalous left coronary from the pulmonary artery)
Note: Flow reverses in the left coronary artery when pressure decreases in the pulmonary circulation.
Myocardial bridging
When a coronary artery dives into and courses through the myocardium
Note: This can complicate CABG planning.
Definition of coronary artery aneurysm
Dilatation of a coronary artery to 1.5x its normal diameter
Most common cause of coronary artery aneurysm in adults and children
- Atherosclerosis (adults)
- Kawasaki syndrome (children)
Coronary fistula
A connection between a coronary artery and cardiac chamber or great vessel (usually the RCA draining into the right cardiac chambers)
Note: This is associated with coronary aneurysms.
If you see crazy dilatation of coronary arteries…
Think coronary fistula with secondary formation of coronary artery aneurysms
What are the ideal indications for a coronary CTA?
- Intermediate risk for MI and/or atypical chest pain (to avoid unnecessary cardiac catheterization)
- Suspected aberrant coronary anatomy
- Evaluating stents >3 mm or CABG patency
- Preoperative assessment prior to TAVI/TAVR
Definition of intermediate risk for MI
Framingham risk score 10-20%
What coronary CTA findings suggest an increased risk for a major adverse cardiac event?
High Agatson score > 160 (means there’s a ton of calcium in the vessels)
What is the ideal heart rate for a coronary CTA?
Under 60 bpm (beta blockers should be used to achieve this if no contraindications)
Contraindications to beta blockers
- Severe asthma
- Heart block (2nd or 3rd degree)
- Acute chest pain
Can you still perform a coronary CTA if a pts HR > 60 bpm and they have contraindications to beta blockers?
Yes, but you will have to use retrospective gating (rather than the better prospective gating that can be used if HR < 60 bpm)
What are the pros and cons of prospective cardiac gating?
- Reduced radiation (because the scanner is only on during the R wave)
- Can’t do functional imaging
- More sensitive to heart rate variability
- Can’t do helical acquisitions
What are the pros and cons of retrospective cardiac gating?
- Can do functional imaging
- Less sensitive to heart rate variability
- Higher radiation (data is acquired continuously, not only during the R wave)
- Helical acquisition
What triggers imaging acquisition during a cardiac gated CT?
The R wave (if prospectively gated)
Note: If retrospectively gated, nothing triggers acquisition because images are being acquired throughout the cardiac cycle.
Which type of cardiac gating is best for valvular evaluation?
Retrospective
What medications are given for a coronary CTA?
- Beta blockers (to achieve HR < 60)
- Nitroglycerine (to maximally dilate the coronary arteries)
Contraindications to nitroglycerine
- Hypotension (SBP < 100)
- Severe aortic stenosis
- Hypertrophic obstructive cardiomyopathy
- Viagra/sildenafil/tadalafil use
What is the sequence used to look for valve stenosis/regurgitation?
Velocity-encoded cine MR imaging (a type of phase contrast imaging used to quantify the velocity of flowing blood)
What is the most common artifact with velocity-encoded MR imaging?
Aliasing, which occurs if the velocity range is too low
Note: The velocity range should be set to 20-25% higher than the maximum expected velocity. If there are still white aliasing areas, then increase the range further.
Whoa cardiac valve is the most superior?
Pulmonic
Which cardiac valve is the most anterior?
Tricuspid
If a cardiac pacing lead is seen traveling through a valve replacement, which valve is it?
Tricuspid (allowing the lead to terminate in the right ventricle)
How can you differentiate mitral from aortic valve replacements on chest radiograph?
On frontal view, draw a line from the left hilar angle to the right cardiophrenic angle (Aortic valve Above and mitral valve below)
On lateral view, draw a line from the carina to the anterior costophrenic angle (Aortic valve Above and mitral valve below)
How can you tell the direction of blood flow through a valve on chest radiograph?
The pointy parts of the valve replacement point in the direction of blood flow
How can you measure regurgitant volume of a valve on MRI?
Measure during diastole on transverse slices placed at the valve or slightly below
Why is there dilatation of the ascending aorta in aortic stenosis?
Jet phenomenon of the stenotic valve (high-velocity narrow jet through the stenotic valve)
What are the types of aortic stenosis?
- Valvular (90% of cases)
- Subvalvular
- Supravalvular
Supravalvular aortic stenosis…
Think Williams syndrome
Bicuspid aortic valve and coarctation…
Turners syndrome
What is the most common congenital heart disease?
Bicuspid aortic valve
Note: Followed by ventricular septal defects.
What is the most common complication of a bicuspid aortic valve?
Aortic stenosis
Bicuspid aortic valve is an independent risk factor for_____ (even without aortic stenosis)
Aortic aneurysm
Note: Severity of valve dysfunction does not predict aneurysm formation.
Bicuspid aortic valves are associated with…
- Cystic medial necrosis (CMN)
- Turners syndrome (and coarctation)
- Autosomal dominant polycystic kidney disease
Common causes of aortic regurgitation
- Bicuspid aortic valve
- Bacterial endocarditis
- Marfan’s syndrome
- Aortic root dilatation secondary to hypertension
- aortic dissection
Most common cause of mitral stenosis
Rheumatic heart disease
Ortner’s syndrome
Cardio-vocal hoarseness, symptomatic hoarse voice secondary to compression of the left recurrent laryngeal nerve by an enlarged left atrium
Common causes of acute mitral regurgitation
- Endocarditis
- Papillary muscle/chordal rupture s/p myocardial infarction
common causes of chronic mitral regurgitation
- Myxomatous degeneration (primary)
- dilated cardiomyopathy (secondary)
Isolated right upper lobe pulmonary edema…
Think mitral regurgitation
What are the types of pulmonary stenosis?
- Valvular (most common)
- Subvalvular
- Supravalvular
Valvular pulmonary stenosis is associated with…
Noonan syndrome
Peripheral pulmonary stenosis is seen in…
Alagille syndrome (kids with absent bile ducts)
Supravalvular pulmonary stenosis can be seen in…
Williams syndrome
What is the primary complication of tetralogy of Fallot repair?
Pulmonary regurgitation
Note: The pulmonary valve is disrupted to fix the right ventricle obstruction.
Common cause of pulmonary regurgitation
Tetralogy of Fallot repair
When should pulmonary regurgitation be fixed?
Before the right ventricle is severely dilated (after this, it won’t return to normal)
Common cause of tricuspid regurgitation
- Pulmonary arterial hypertension (most common)
- Endocarditis (IV drug use)
- Carcinoid syndrome
How does tricuspid regurgitation affect the right ventricle?
Tricuspid regurgitation causes right ventricular dilatation (NOT hypertrophy)
Pt with mitral and aortic valve disease…
Think rheumatic fever anytime there is multivalve disease (mitral and aortic valves are the most likely to be affected)
Kid with a massive “box shaped” heart on radiographs with a mom who took lithium during pregnancy…
Ebstein anomaly
Ebstein anomaly
Hypoplastic tricuspid valve with the posterior leaf displaced apically (downward), resulting in tricuspid regurgitation, right atrial enlargement, and atrialization of the right ventricle
Note: Most cases are sporadic, but there is also an association with lithium use during pregnancy.
Tricuspid atresia is associated with…
Asplenia
Note: There is also going to be an ASD or PFO.
Left-sided heart disease in a pt with carcinoid syndrome…
Think primary bronchial carcinoid (rather than GI carcinoid which would cause right-sided heart disease) OR a right-to-left shunt
What is the most common great vessel variant anatomy?
Common origin of the left common carotid and brachicephalic arteries (Bovine configuration)
What defines whether the aortic arch is right or left?
Which side of the trachea it descends on (the normal left arch has the aorta to the left of the trachea)
If you see right arch with mirror branching, think…
Congenital heart disease (mostly tetralogy of Fallot)
How can you tell right arch with mirror branching and right arch with aberrant subclavian apart?
Look at the origin of the left subclavian artery (originating from the front of the arch in mirror branching and from the back of the arch in aberrant subclavian)
What is the most common great vessel variant anatomy in pts with truncus arteriosus?
Right arch with mirror branching (33% of cases)
Is a right arch with aberrant left subclavian a vascular ring?
Yes, because the ligamentum arteriosum completes the ring on the left
What is the most common arch anomaly (not just variant anatomy)?
Left arch with aberrant right subclavian
Dilated origin of the right subclavian artery in a pt with a left arch with aberrant right subclavian artery…
Diverticulum of Kommerell
Is a left arch with aberrant right subclavian artery usually symptomatic?
No, but it can cause dysphagia lusoria (compression of the esophagus by the aberrant subclavian)
What is the most distal great vessel when there is a left arch with aberrant right subclavian?
The aberrant right subclavian
What is the most common vascular ring?
Double aortic arch
What is encircled by a vascular ring?
The esophagus and trachea
Note: Symptoms include tracheal compression and difficulty swallowing.
Subclavian steal phenomenon
Reversal of flow in the ipsilateral vertebral artery secondary to stenosis of the proximal subclavian artery
Note: This “steals” blood from the posterior cerebral circulation and can result in symptoms of cerebral ischemia, which is then known as subclavian steal syndrome.
Subclavian steal syndrome
Symptoms of cerebral ischemia in the setting of subclavian steal phenomenon
What symptoms might you expect for a pt exercising their left arm if they have left-sided subclavian steal syndrome?
- Dizziness
- Syncope
Note: In subclavian steal phenomenon, blood flow is being “stolen” from the posterior cerebral circulation.
What is the most common cause of subclavian steal phenomenon?
Atherosclerosis (98%)
Note: Other causes include Takayasu arteritis, radiation changes, preductal aortic coarctation, and Blalock-Taussig shunt.
18 y/o pt with subclavian steal phenomenon…
Think Takayasu arteritis (pt is too young for atherosclerotic disease)
Which congenital heart disease is most likely?
Transposition of the great arteries
Note: This is the “egg-on-a-string” sign.
Which congenital heart disease is most likely?
Total anomalous pulmonary venous return
Note: This is the “snowman” sign.
Which congenital heart disease is most likely?
Tetralogy of Fallot
Note: This is the “boot-shaped heart” sign.
Which congenital heart disease is most likely?
Aortic coarctation
Note: This is the “figure 3” sign, where the middle of the “3” is the coarctation.
Which congenital heart disease is most likely?
Ebstein anomaly (classically, but can also be due to non-cardiac causes of high output failure, such as infantile hemangioendothelioma or vein of Galen malformation)
Note: This is the “box-shaped heart” sign, due to massively enlarged right atrium.
Which congenital heart disease is most likely?
Scimitar syndrome (partial anomalous pulmonary venous return with pulmonary hypoplasia)
What are the major cyanotic congenital heart diseases?
5 T’s
- Tetralogy of Fallot
- Total anonymous pulmonary venous return
- Transposition of the great arteries
- Truncus arteriosus
- Tricuspid atresia
What are the major non-cyanotic congenital heart diseases?
- ASD
- VSD
- PDA
- PAPVR (partial anomylous pulmonary venous return)
- Aortic coarctation (adult type, post ductal)
Which cyanotic heart disease if right-sided arch and increased pulmonary vasculature?
Think truncus arteriosus (types 1-3)
Which cyanotic heart disease if right-sided arch and decreased/normal pulmonary vasculature?
Think tetralogy of Fallot
Which diagnoses should you think about if you see CHF in a newborn?
- Total anomylous pulmonary venous return (infracardiac, type III)
- Congenital aortic or mitral stenosis
- Left sided hypoplastic heart
- Cor triatriatum
- Infantile (pre-ductal) coarctation
Which diagnoses should you think about if you see a small heart in a newborn?
- Adrenal insufficiency (e.g. Addisons disease)
- Cachectic state
- Constrictive pericarditis
Which congenital heart diseases would result in death unless there is a coexistant shunt allowing admixture?
- Total anomylous pulmonary venous return (must have a PFO)
- Transposition of the great arteries
- Tetralogy of Fallot (must have VSD)
- Tricuspid atresia (must have VSD)
- Hypoplastic left heart
What is the most common congenital heart disease?
VSD
Note: 70% of small ones close spontaneously.