Cardiac Flashcards
most common congenital heart anomaly
bicuspid aortic valve
ASD #2
most common cause enlarged coronary sinus
persistent left SVC
most common primary cardiac tumor in adults
cardiac myxoma
left atrium, attached to septum, +/- Ca2+
“aortic root”
aortic annulus (basal ring) + sinuses of Valsalva + sinotubular junction
“annuloaortic ectasia”
dilatation of annulus and sinuses of Valsalva with effacement of the sinuotubular junction
tulip bulb sign
anomalous course of coronary arteries
- interarterial (malignant)
- retroaortic
- prepulmonic
- subpulmonic/transseptal
dilated cardiomyopathy causes
- ischemia
- infection
- toxic: alcohol, cocaine
- chemotherapy (doxorubicin)
- idiopathic
- familial
(- peripartum)
(- muscular dystrophies)
valve cusps (aortic, tricuspid, pulmonary, mitral)
- aortic: “learn” - L, R, Noncoronary
- tricuspid: “traps” - Ant, Post, Septal
- pulmonary: “pallor” PALR - Ant, Left, Right
- mitral: MAP - Ant, Post
myocarditis findings
- midmyocardium & epicardium
- wall motion abN
- myocardial edema
LV aneurysm vs pseudoaneurysm
aneurysm: bounded by thin myocardium
- wide neck
- anterior or apical
- less rupture risk
pseudoaneurysm: contained rupture by pericardium
- narrow neck (ratio <1)
- posterolateral or inferior
- risk of rupture
both complic of MI, assoc w thrombus
tamponade
- large or rapidly accumulating
- RA/RV compression
- dilated IVC
- reflux of contrast
- septal flattening
second most common benign heart tumor
lipoma
most common embryologic abnormality of aortic arch
aberrant right subclavian - usually incidental
Glenn shunt
SVC to right pulmonary artery
- classic: end-to-end + prox RPA closed (to reduce RV work)
- bidirectional: end-to-side (RPA left open, blood flow to both lungs)
Blalock Taussig shunt
subclavian artery to pulmonary artery
- classic: opposite side of arch
- modified: gortex shunt, same side as arch
purpose: increase pulm blood flow
Fontan procedure
total cavopulmonary connection to bypass RV & direct systemic circulation into PAs
- for single ventricle physiology (HLH, Ebstein, tricuspid atresia, double inlet ventricle)
Glenn shunt: SVC to right PA
Fontan pathway: IVC to right or left PA
- lateral tunnel or extracardiac
Fontan procedure complications
conduit related: thrombosis, stenosis, calc’n
cardiac: RA enlargement, ventric failure, arrhythmias
vascular: pulm AVM, PE, pHTN, aortopulmonary collaterals (hemoptysis)
liver: congestion, cirrhosis, regen nodules, HCC
lymphatic: chylous effusions, protein losing enteropathy, plastic bronchitis
Blalock Taussig shunt complication
stenosis at shunt’s pulm insertion site
LV papillary muscles: name & blood supply
- anterolateral: shared LAD and LCX
- posteromedial: RCA (in right dominant patients) –> more prone to rupture 2/2 single vascular supply
microvascular obstruction
- infarcted myocardium where obstructed microvasculature doesn’t allow contrast to perfuse the tissue (contrast does not reach interstitium)
- area without reflow → less favourable prognosis, marker of adverse LV remodeling
Imaging: dark signal tissue surrounded by enhancing scar on both sides
vulnerable plaque - 4 main features on CTA
- positive remodeling
- outer vessel diameter at plaque ≥ 1.1x adj uninvolved vessel (on long & short axis) - low attenuation plaque <30 HU
- napkin-ring sign
- peripheral higher attenuation of the noncalcified portion of the plaque - spotty calcium
- small calcified plaque (>130 HU separately visualized from the lumen, diameter <3 mm in any direction, length <1.5x vessel diameter & width <2/3x vessel diameter)
hypertrophic cardiomyopathy - types
- asymmetric
- symmetrical (or concentric)
- apical (spade shape ventricular lumen)
- mid ventricular
- mass-like
hypoplastic left heart
- cyanotic, ↑ pulm vascularity & pulm edema
- hypoplasia of asc aorta, aortic & mitral valves, LV
- PDA dependent (R→L shunt for survival)
- dilated right-sided cardiac chambers & PA
- most severe CHD: CHF, cardiogenic shock, cyanosis
- assoc w coarctation, endocardial fibroelastosis
- palliative repair: Norwood, bidirectional Glenn, Fontan
right aortic arch branching patterns and associations
- right arch w/ aberrant left subclavian - no association
2. right arch w/ mirror image branching - cyanotic heart disease (truncus arteriosus, tetralogy of fallot)
tetralogy of fallot - components
“PROV”
- pulmonic stenosis
- RV hypertrophy
- overriding aorta
- VSD
rib notching patterns
- Bilateral = Past L subclavian (post ductal)
- Right sided = Before L subclavian (pre ductal/infantile)
- Left sided = Proximal to anomalous R subclavian
most common vessel with myocardial bridging
LAD
then LCx and RCA
most common partial anomalous pulmonary venous return (PAPVR)
- right superior pulmonary vein into IVC
- associated w/ sinus venosus ASD
more common side of absent pulmonary artery
which is associated w/ CHD
R > L
2:1
L w/ CHD - Tet of Fallot
embryologic arch to form the pulmonary arteries
6th arch
significant shunt (Qp/Qs - pulmonic/aortic)
> 1.5
artifact resulting from regurgitant flow
dephasing artifact
Ebstein anomaly
- atrialized RV
- apically displaced septal tricuspid leaflet
- tricuspid regurg
def’n of severe stenosis on coronary CT angio
def’n of obstructive CAD
diameter narrowing >70%
except in left main coronary artery where a severe stenosis is >50%
obstructive >50%
enlargement of main and left pulmonary artery with a small right pulmonary artery
pulmonary stenosis
cutoff on CT for pericardial thickening
4 mm
beta blocker contraindications (CT angiography)
sinus bradycardia hypotension asthma, COPD sick sinus syndrome 2nd- & 3rd-degree AV nodal block critical aortic stenosis decompensated heart failure
mid-myocardial delayed gadolinium enhancement
myocarditis sarcoidosis (linear or nodular, RV side of septum is classic) dilated cardiomyopathy (septal) hypertrophic cardiomyopathy (at hinge points) RV pressure overload (at hinge points)
subepicardial delayed gadolinium enhancement
myocarditis
sarcoidosis
diffuse subendocardial delayed gadolinium enhancement
amyloidosis
Loeffler endocarditis
endomyocardial fibrosis
myocardium nulls before blood pool on TI scout sequence
amyloidosis
buzzwords: “difficult to suppress myocardium”
which kind of ASD is most highly associated with partial anomalous draining of the right superior pulmonary vein?
sinus venosus
mitral valve prolapse def’n & associations
2mm displacement of mitral valve leaflets posterior to mitral valve plane during systole
- often assoc w mitral regurg
- can be assoc w papillary muscle or chordae tendineae rupture
- connective tissue disorders, adult PCKD
transposition of the great arteries: types
D-transposition: ventriculoarterial discordance (RV➡aorta, LV➡PA)
- PDA connects 2 systems
- CXR: egg on a string
L-transposition: ventriculoarterial & atrioventricular discordance (SVC/IVC➡RA➡LV➡PA➡pulm veins➡LA➡RV➡aorta)
- congenitally corrected; no PDA required
- Two wrongs (atrioventricular & ventriculoarterial discordance) make a right and L= life
surgical options for D-transposition of the great arteries
- Jatene arterial switch
- atrial inversion using intra-artrial baffle: Senning (uses atrium) or Mustard (pericardium or synthetic material)
- Rastelli procedure (if concomitant VSD & LVOT obstruction)
surgical options for L-transposition of the great arteries
double switch procedure:
- atrial inversion surgery (Senning or Mustard) + Jatene arterial switch OR Rastelli procedure
- to remove systemic pressure load from morphologic RV & prevent tricusp valve dysf’n
- may 1st need pulmonary artery banding to train morphologic LV to receive higher systemic load
- modified BT shunt if severe pulmonary stenosis or atresia
most common type of TAPVR
type 1: supracardiac
types of coarctation
infantile: preductal
adult: juxta-ductal, post-ductal or middle aortic
coarctation associations
bicuspid aortic valve PDA VSD transposition of great vessels truncus arteriosus intracranial berry aneurysms spinal scoliosis PHACE & Turner syndromes
pseudocoarctation
- elongation, kinking or buckling of descending aorta at level of ligamentum arteriosum
- no pressure gradient across lesion
- benign entity with no specific intervention
complications of Senning & Mustard procedures
Stenosis of the baffle Arrhythmias - sinoatrial node may be injured in Senning - intra-atrial conduction delays Right heart failure - d/t RV supplying system circulation
pulmonary sling: course of LPA
left PA courses between esophagus and trachea
Ortner’s syndrome
cardiovocal hoarseness
2/2 compression of left recurrent laryngeal nerve by enlarged left atrium
CXR appearance of mitral stenosis
left atrial enlargement:
- right double density sign
- splaying of carina (superior displacement of left mainstem bronchus)
- posterior esophageal displacement
- walking man sign on lateral
heterotaxy associated with polysplenia
LEFT pulmonary isomerism
- polysplenia
- bilateral left lung lobation
- azygos or hemiazygos continuation of the inferior vena cava
pathognomonic for pulmonary sling
anterior indentation on esophagus
high risk plaque features
positive remodeling
low attenuation plaque
spotty Ca2+
napkin ring
ECG finding in ARVD
epsilon waves
other name for apical HoCM
Yamaguchi
T1 black blood phase
spin echo sequence
LV myocardial thickening cutoff
diastolic LV wall ≥ 15 mm
echo: ≥ 12 mm
dilated cardiomyopathy cutoff
LV end diastolic dimension of 60 mm
measured from anteroseptal wall to inferolateral wall at mid chamber of LV
Loeffler endocarditis
aka eosinophilic endocarditis, cardiac manifestation of hypereosinophilic syndrome
- eosinophils deposit in the subendocardium with necrosis & fibrosis of endocardium, thrombus formation
- over time, thrombus epithelializes into subendocardium -> reduced chamber -> restrictive CM
Crack: biventricular thrombus
Most common valve neoplasm
Fibroelastoma
MR features of noncompaction
hypertrabeculated LV myocardium
noncompacted end-diastolic myocardium to compacted end-diastolic myocardium ratio of >2.3:1
cyanotic heart disease (5) & non cyanotic (5)
cyanotic (5 T’s): TOF, TAPVR, transposition, truncus, tricuspid atresia
noncyanotic: ASD, VSD, PSA, PAPVR, aortic coarctation (adult, post ductal)
what defines the RV
moderator band (important for congenital heart)
congenital heart disease relying on admixture (5)
- TAPVR (has PFO)
- transposition
- TOF (has VSD)
- tricuspid atresia (has VSD)
- hypoplastic left
microvascular obstruction independent predictor of:
- death
- adverse LV remodeling
causes restrictive cardiomyopathy
things decreasing diastolic function
- amyloidosis
- loeffler/eosinophilic cardiomyopathy
- endocardial fibroelastosis
- hemochromatosis
systolic anterior motion in hypertrophic cardiomyopathy independent risk factor for…
sudden death
ratio for LV noncompaction
≥ 2.3 : 1
telediastolic noncompated myocardium: compacted
most common primary malignant tumor of heart
angiosarcoma
right atrium
What perfusés SA and AV nodes?
RCA SA node 60%
RCA AV node 90%
Cardiac CT drugs and contraindications
Beta blocker - 2nd/3rd degree heart block, asthma, acute chest pain, cocaine
Nitroglycérine - hypotension SBP<100, severe aortic stenosis, hypertrophic obstructive cardiomyopathy, phosphodiesterase
most common cause malignant pericardial effusion
lung cancer
critical aortic stenosis valve area
1 cm^2
