Cardiac

Question 1

Most common malignant cardiac tumor?

Answer 1

Angiosarcoma

Question 2

Most common pericardial tumor?

Answer 2

Mesothelioma

Question 3

AICD lead placement

Answer 3

Proximal coil SVC distal coild RV

Question 4

ASDs

Answer 4

Ostium primum defects are the second most common atrial septal defects (ASD),accounting for about 15 percent of all ASDs. The primum portion of the atrial septum is located inferiorly at the level of the mitral and tricuspid valves. Ostium primum defects are often associated with atrioventricular defects. The abnormality on the image is not in this location.

Ostium secundum defects are the most common ASD, accounting for approximately 75 percent of all ASDs, and are located near the fossa ovalis, in the middle of the atrial septum. The abnormality on the image is not in this location.

Sinus venosus defects are the third most common ASD accounting for approximately 10 percent of all cases. The sinus venosus portion of the atrial septum separates the left atrium from the superior vena cava. The defect in this case is located in the superolateral aspect of the atrial septum at the junction of the superior vena cava and right atrium, near the insertion of the right pulmonary veins, consistent with a sinus venosus ASD.

Patent foramen ovale occurs in up to 25 percent of adults. The flap of tissue covering the
foramen ovale typically closes the defect since the left atrial pressure is higher than the right atrial
pressure. Normally, this flap of tissue fuses with the septum after the first year of life. The abnormality
on the image is not in the location of the foramen ovale.

Question 5

Which septal defects is MOST commonly associated with partial anomalous pulmonary venous drainage?

Answer 5

Drainage of the pulmonary veins should be assessed in all patients with congenital anomalies. Nearly all patients with sinus venosus atrial septal defect have anomalous pulmonary venous drainage, most commonly drainage of the right upper lobe to the superior vena cava. Approximately 10 percent of patients with an ostium secundum atrial septal defect will have anomalous pulmonary venous drainage.

Question 6

AV node coronary artery supply

Answer 6

The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery. Infarct will cause severe bradycardia.

Question 7

Tricuspid regurgitation in adults

Answer 7

The majority of cases of tricuspid regurgitation in adults result from high right sided pressures with or without right ventricular failure (right ventricular hypertension).

Question 8

Which of the following findings is the MOST reliable sign of elevated right ventricular pressure on a
contrast-enhanced CT scan of the chest?

Answer 8

Abnormal curvature of the ventricular septum toward the left ventricle indicates elevated right ventricular pressure. Enlargement of right ventricle indicates a volume overload, such as tricuspid regurgitation
or a left to right shunt, or the presence of right ventricular failure. Elevated right ventricular pressure
alone will not generally enlarge the chamber.

Question 9

What is the MOST common anomaly associated with partial anomalous pulmonary venous drainage of
the left lung?

Answer 9

Anomalous pulmonary venous drainage on the left is usually from the left upper lobe to a left vertical vein, which then drains into the left brachiocephalic vein.

Question 10

Valvular heart disease

Answer 10

Rheumatic heart disease is the most common etiology of mitral stenosis.

Rheumatic valvular heart disease affects the mitral valve in almost all cases and concomitantly
affects the aortic valve in approximately 50% of cases. Rheumatic heart disease rarely destroys only the aortic
valve. Isolated aortic valve disease is typical of a bicuspid aortic valve.

Valvular calcification typically reflects valvular stenosis. A primarily insufficient valve rarely calcifies.

The congenitally deformed bicuspid aortic valve faces abnormal stress and pressure, which cause
fibrosis, calcification, and stenosis.

Question 11

Ross Procedure

Answer 11

The Ross procedure is performed to correct aortic valve disease. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Follow-up studies have shown interval growth of the aortic valve graft (as the child grows) in children and infants. Because a homograft is used, anticoagulation is not necessary.

Question 12

Coronary artery dominance

Answer 12

Dominance is determined by which artery supplies the posterior descending artery (PDA). Right dominant circulation is seen in 85% of individuals. The coronary circulation is left dominant in only 8% of individuals. In left dominant circulation, the posterior descending artery and posterior left ventricular branches arise from the left circumflex artery. In the remaining 7% there is a co-dominant system in which the posterior descending artery arises from the right coronary artery and the posterior left ventricular branches arise from the left circumflex coronary artery

Question 13

SA nodal supply

Answer 13

The right coronary artery supplies the sinoatrial node in 60% of individuals. The sinus node artery arises
from the proximal right coronary artery. In 40% of individuals, the sinus node artery arises from the proximal left circumflex artery.

Question 14

Regarding atrial morphology, which one of the following is the MOST reliable indicator of the morphologic right atrium?

Answer 14

Connection with the inferior vena cava is a reliable indicator of right atrial morphology. This can be a
useful tool to establish the cardiac anatomy in cases of situs abnormalities and atrioventricular discordance. In cases of atrioventricular discordance, the atrioventricular valves follow the morphologic
ventricles, not the morphologic atria.

Question 15

Appendage morphology

Answer 15

A thin appendage with a narrow neck is characteristic of the morphologic left atrium. The right atrial appendage is triangular in shape with a broad neck. The characteristic appearance of the right atrial
appendage is also a reliable indicator of the morphologic right atrium.

Question 16

Constrictive pericarditis

Answer 16

Constrictive pericarditis alters the morphology of the heart causing cone-like compressed ventricles or waist-like deformity at the atrioventricular groove.

The atria are typically dilated in patients with constrictive pericarditis due to high ventricular filling pressures.

The superior and inferior vena cava are typically dilated in the setting of constrictive
pericarditis due to elevated intracardiac filling pressures.

Question 17

Pulmonary valve stenosis

Answer 17

Pulmonary valve stenosis typically results in dilatation of the main pulmonary artery and the left pulmonary artery, which is thought to be due to post-stenotic dilation.

Question 18

ASDs and VSDs

Answer 18

ASD is four times as common in women as in men.

VSD is most common congenital heart disease but no sex predilection.

Question 19

Cardiac MRI Safety/Contraindications

Answer 19

In general it is recommended to wait six weeks after stent placement before performing MRI. This is to
allow endothelialization which, in theory, prevents stent dislodgement. risk of thrombosis. However, there are many studies in the literature which demonstrate Stent migration is thought to allow increased exposure of the stent metal to platelets and increase the no adverse effects in patients who had MR imaging at a shorter interval
after stent placement.

Studies have demonstrated the safety of occluder devices used to repair atrial septal defects or patent
foramen ovale in MR fields up to 3T in vivo. However, artifacts for the septal repair implants may present problems if the anatomical region of interest is in or near the area where these implants are located.

Provided these are not comprised of steel and are not located near vital structures, MR imaging can be
performed. It should be noted that there may be artifact in the region of the metal, however.
D. Non pacemaker dependent patients may undergo cardiac and non-cardiac MR imaging provided certain
precautions are taken. The duration of radiofrequency pulse should be minimized as much as possible to avoid radiofrequency related thermal myocardial injury by limiting scan time and specific absorption rate values. The pacemaker should be reprogrammed to a sense-only mode or to asynchronous pacing, depending on the individual’s heart rate, to avoid competitive rhythms in patients with high intrinsic heart rate, and gradient field-induced inhibition in patients with low intrinsic heart rates. Patients should undergo continuous electrocardiographic monitoring throughout the procedure and an electrophysiologist and full resuscitation facilities should be available in the MRI suite.

Question 20

Endoleaks

Answer 20

Type II endoleaks are the most common and occur when blood flows into the aneurysm sac in a
retrograde direction through normal branches of the excluded aortic segment. This occurs most
commonly with the inferior mesenteric artery or a lumbar artery. Accessory renal arteries can also lead
to type II endoleaks. Type II endoleaks have not been reported in association with aortic rupture.

Type I and III endoleaks have been reported in association with aortic rupture.

Type IV endoleaks are due to graft porosity. Type III endoleaks are due to a structural failure of the endovascular device. Type III endoleaks can be subdivided into three groups: type IIIA endoleaks are
due to disruptions or holes in the fabric of the device, type IIIB endoleaks arise from separation of modular devices and junctions, and type IIIC endoleaks are due to suture holes in the fabric.

Type I leaks are subdivided into Type IA, which occur at the aortic neck attachment site and
Type IB, which occur at the distal iliac attachment site.

Question 21

Snowman sign

Answer 21

The “snowman sign,” which is formed by the combination of an anomalous left vertical vein and an
enlarged right SVC atop the cardiac silhouette is characteristic of supracardiac total anomalous pulmonary venous return

Question 22

Concerning the morphologic right ventricle, which of the following is the MOST reliable indicator?

Answer 22

Normally, the right ventricle receives blood from the right atrium, lies anterior to and is more trabeculated than the left ventricle. The inflow and outflow valves of the right ventricle are separated by the muscular infundibulum in contrast to the left ventricle where the valves are contiguous. In complex congenital
cardiac anomalies, the separation of the inflow and outflow valves is the most reliable indicator of the morphologic right ventricle.

Question 23

Concerning pulmonary vein ablation?

Answer 23

Accessory pulmonary veins are more common on the right.

Myocardium extends 2-17 mm into the pulmonary veins and is called the myocardial sleeve. The myocardial sleeve is thickest at the atriopulmonary venous junction of the left superior vein. The myocardial
sleeves are longer in the superior pulmonary veins than in the inferior pulmonary veins.

Due to the risk of stroke following manipulation of the left atrium, the presence of left atrial thrombus is a contraindication to pulmonary vein ablation.

Question 24

Blalock-Taussig shunt

Answer 24

The Blalock-Taussig shunt creates a connection between the systemic and arterial systems and is
a palliative procedure that increases systemic arterial oxygenation by increasing blood flow to the pulmonary
artery.

Question 25

Cardiac Transplantation

Answer 25

Accelerated atherosclerosis is a late complication and can be detected by coronary angiography.

Infection, especially pulmonary infection, is the most common indication for imaging following
cardiac transplantation.

Ventricular hypertrophy can be caused by cyclosporine immunosuppressive therapy.

Bacteria are the most common cause of early post-operative infection following cardiac
transplant. Aspergillus and cytomegalovirus infections occur 2-6 months following transplantation.

Question 26

Acute Mitral Regurgitation

Answer 26

In the setting of acute mitral regurgitation, the regurgitant jet from the mitral valve is directed toward the ostium of the right superior pulmonary vein. In patients with acute myocardial infarction that affects the mechanics of the papillary muscles or in the setting of acute papillary muscle or chordae tendinae rupture, the acute onset of mitral regurgitation may present as lobar edema localized to the right upper lobe.

Question 27

Atrial Myxomas

Answer 27

Approximately 85% of myxomas are located in the left atrium attached to the atrial septum, usually at the fossa ovalis. Myxomas that prolapse through the mitral valve can mimic symptoms associated with mitral stenosis.

Question 28

Coronary artery aneurysms

Answer 28

Atherosclerosis most common cause (50%)&raquo_space; congenital, Kawasaki, infectious

Question 29

Cardiac Neoplasms

Answer 29

Myxoma is the most common PRIMARY benign cardiac neoplasm. They account for approximately 25% of all
primary cardiac neoplasms.

Rhabdomyoma is the most common primary cardiac neoplasm in children.

Metastases occur far more frequently than primary cardiac neoplasms.

Primary cardiac lymphoma is uncommon.