Glossary of cardiac review

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Group Ia criteria
Acyanotic with normal vascularity
Group Ia lesions
Aortic stenosis, aortic coarctation, interrrupted aortic arch (pulmonic stenosis without septal defect)
Most common group IV lesion
Group IV lesion with narrow mediastinum
transposition, also has egg shaped heart (different appearance in corrected transpo)
Appearance of Transposition
on AP view, looks egg shaped, with very narrow mediastinum = egg on a string appearance.
Group IV lesion with right aortic arch
truncus arteriosus, usually type I.
group IV lesion with widened mediastinum
supra cardiac type of total anomalous pulmonary venous connection.
AP radiograph of the chest demonstrates mild dextroposition of the heart and a linear structure which enlarges as it travels inferiorly towards the diaphragm
scimitar syndrome. Dextroposition of heart due to hypogenetic right lung. Linear structure is anomalous venous connection training right lung through scimitar vein.
Prominent convexity along upper left cardiac border
corrected transposition. Prominent convexity is ascending aorta, and there is absence of the ascending aorta in the normal position at the right cardiac border.
Large main pulmonary artery segment, and enlarged left pulmonary artery on plain film
pulmonic stenosis with poststenotic dilatation.
Long segment aortic Coarctation with enlarged proximal aorta
think of acquired pathology in adults, such as from Takayasu's.
Most common form of partial anomalous pulmonary venous connection
R upper lobe pulm vein to SVC
Another common form of PAPVC
Both upper lobe pulmonary veins drain into the SVC. The right is the same as the most common form, but on the left, the upper lobe pulmonary vein drains via a vertical vein, to enter the left brachiocephalic vein, and then into the superior vena cava. Very similar in appearance to supra cardiac total anomalous pulmonary venous return, however, this is partial so it only involves the upper lobe pulmonary veins.
Most likely lesion to be seen on MRI in cardiac section
tetralogy of fallot.
Components of tetralogy of fallot
unrestrictive membranous (high) ventricular septal defect, overriding aorta, infundibular pulmonary stenosis (always infundibular stenosis, sometimes narrowing at the annulus) , and right ventricular hypertrophy.
25% of tetralogy of fallot
right aortic arch
axial image of the heart demonstrating only one great vessel coming out of the heart
either pulmonary atresia or truncus arteriosus. In hypoplastic left heart with a atretic aorta, usually will see some remnant.
Patient with tetralogy of fallot and severe pulmonary atresia: how does the lung get perfused
ductus arteriosus doesn't help so much with severe atresia. Patient develops systemic to pulmonary collaterals to feed the pulmonary arteries past the atresia. They are not really bronchial arteries that are enlarged, because not all of them are bronchial arteries. The proper terminology is systemic to pulmonary collaterals. Now I see why we call it pseudo truncus, because when there's severe pulmonary atresia, it does look like a single vessel emerging from the heart.
Diagnostic of transposition
aorta in front of pulmonary artery. Only other thing-- double outlet right ventricle, not likely to be seen on boards.
Normal positions of great vessels
pulmonary valve is normally left, superior, and anterior to aortic.
Malignant coronary artery anomaly
anomalous coronary artery which passes inter arterial (between pulmonary artery and aorta). Outcome is sudden death during exercise.
how is acquired cardiac disease categorized
small heart and big heart heart disease
small heart heart disease
cardiothoracic ratio of less than 0.55
small heart heart disease lesions
pressure overload lesions and lesions which reduce ventricular compliance
big heart heart disease
cardiothoracic ratio greater than 0.55
big heart heart disease lesions
volume overload lesions or lesions in which early in the course of disease there is myocardial failure (i.e. cardiomyopathy)
cardiac disease with small heart
is there left atrial enlargement? if yes, that points to mitral valve disease. In small heart heart disease, suspect mitral stenosis. If no LAE , go to next signpost.
Cardiac disease with small heart, no left atrial enlargement
Look FIRST at ascending aorta for enlargement, then use knob as confirmation. Great if knob is also enlarged, but ascending aortic enlargement is what counts. If yes, suspect aortic stenosis. If no, there are no signposts.
Cardiac disease with small heart, no left atrial enlargement or aortic enlargement
differential includes myocardial and pericardial disease: AMI, restrictive or hypertrophic cardiomyopathy, or constrictive pericarditis. Ask for history. If not ruling out AMI, now you must request MRI to differentiate constrictive pericarditis from restrictive cardiomyopathy.
Cardiac MRI in patient with small heart heart dz
Is pericardium thickened? yes = Pericardium 4mm or greater in thickness. (normal 1-2 mm). Basically if you can see it, its abnorma = Constrictive pericarditis. No? If they are showing you a case that did not have thickened pericardium, then they are probably going to show you hypertrophic. Restrictive cardiomyopathy is diagnosed by Echo. The only time patients with thickened myocardium get scanned is when they have asymmetric hypertrophy. Diagnose hypertrophic when interventricular septum is 1.5 times thicker than the posterior or lateral left ventricular wall.
Associated MRI findings in constrictive pericarditis
IVC or RA enlarged. RV normal in size or narrowed (tunnel shape). Ascites or pleural effusion. SEPTAL BOUNCE: When the tricuspid valve opens, the septum suddenly moves toward the left ventricle as the blood enters into the RV, narrowing the lumen of the LV. But all this is just icing on the cake. The primary diagnosis is established once you see pericardial thickening.
Thickened pericardium separated into parietal and visceral layer is by pericardial effusion
effusive constrictive pericarditis.
most common causes of constrictive pericarditis
cardiac surgery, radiation, viral/uremic pericarditis. TB is still the most common worldwide.
cardiac disease with large heart
is there left atrial enlargement? if yes, that again points to mitral valve disease, which in big heart heart disease implies mitral regurgitation. If no LAE, go to next signpost.
Cardiac disease with large heart, no left atrial enlargement
is there ascending aorta or thoracic aortic enlargement? If yes, that again points to the aortic valve, but in big heart heart disease implies aortic regurgitation.
Cardiac disease with large heart, no obvious LAE, no obvious AscAo enlargement
Is the right atrium enlarged. If yes, that points to tricuspid regurgitation or RV failure. If no, there are no signposts.
Cardiac disease with large heart, no signposts
again points to myocardial or pericardial disease, but this time things that make the myocardium floppy such as dilated cardiomyopathy, ischemic cardiomyopathy, or pericardial effusion.
Determining left atrial enlargement
left atrial double density OR lack of concavity underneath main pulmonary artery, representing dilated left atrial appendage
dilated left atrial appendage
you see this, it implies a specific type of mitral valve disease, that caused by rheumatic heart disease. There are many causes of enlargement of the left atrium, but it is rheumatic heart disease that is specific for enlargement of the left atrial appendage.
Convexity of superolateral surface of left heart border
LV aneurysm or pseudoaneurysm (less likely pericardial cyst or pericardial mass). You must differentiate between LV aneurysm and pseudoaneurym. In order to do this, look at the lateral view. If there is a double density overlying the heart anteriorly, that is a true aneurysm. If there is a double density arising from the posteroinferior aspect of the heart, in contiguity with the diaphragmatic surface, that is a pseudoaneurysm. Actually, on the AP view, the pseudoaneurysm is sometimes also seen in contact with the diaphragm. After you have tried to diagnose it archaically, ask for MRI.
MRI of heart, ?Aneurysm/pseudoaneurysm
LOOK FOR THE ENTRY INTO THE SAC. NARROW = PSEUDOANEURYSM. WIDE = TRUE ANEURYSM. True aneurysm occurs at apex or anterolateral wall. Pseudoaneurysm occurs posterolaterally, abutting the diaphragmatic surface. Look for low-density clot in a true aneurysm.
Flattened/straightened right heart border
pathognomonic constrictive pericarditis.
Heart with peripheral calcification
Also constrictive pericarditis. Circular on the lateral view.
Wall to Wall heart
pathognomonic for severe, long-standing tricuspid regurgitation. It has a positive signpost for RA enlargement, but wall to wall means you can toss RV failure out, as its pathognomonic of the other.
Fat in RV myocardium on MRI
RV dysplasia. Diagnostic when Transmural fat. May also see focal fat, and if you see focal wall thinning or aneurysm, that makes the diagnosis very likely. To be sure of diagnosis must see contractile abnormality on Cine MR. Sudden death during exercise. All need defibrillator.
Heart shifted towards left on AP chest, no atelectasis, normal right lung
make sure trachea is midline. Most common cause for this appearance is pectus deformity. Ask for lateral view. If no pectus deformity, most likely absence of pericardium. Ask for CT at the level of the AP window to look for lung insinuating into the AP window. Normally, pericardium prevents this from occurring.
MR eval ischemic heart disease
0.3 mmol/kg bodywt of gado in patients with ischemic heart disease. Do first pass imaging. Goes into RV, then LV, then enhances myocardium. Can see ischemic area as area of non or delayed perfusion. LOOK FOR LOCALIZED SUBENDOCARDIAL ISCHEMIA. Or do 1.5 mmol/kg for delayed imaging. It stays for a long period of time in areas of nonviable myocardium/scar. Transmurality is important. If 100%, its dead. If greater than 50%, not worth trying. If less than 50%, good chance that revasc will help.
Cardiac mass
most likely to be thrombus. Don't look for any specific size or shape. Can have all kinds of appearances and differing signal intensities in different parts as it organizes. Can be calcified. Can look like absolutely anything. therefore, RULE OUT THROMBUS IN EVERY CASE. Regardless of appearance. Assume its a thrombus until proven otherwise.
Rule out thrombus
Check for enhancement. Can also look for appearance on gradient echo or SSFP images.
Thrombus appearance on gradient echo images
dark, just like hemosiderin in DAI. Tumors are intermediate.
40 times more likely to be metastatic (incl lymphoma) or direct extension from mediastinal disease than primary cardiac tumor.
No history of mediastinal, thoracic, or extrathoracic malignancy
benign tumors include Lipoma (fat saturation), Myxoma. Most common malignant tumor in adult is angiosarcoma. In child, rhabdomyosarcoma.
Features suggesting malignant cardiac tumor
irregular margins. Involvement of more than one cardiac chamber. Areas of necrosis. Pericardial effusions. Gross invasion outside of the heart. Visible pulmonary Mets.
Calcified cardiac mass
thrombus, Myxoma.
Calcified valve
role of MRI in valvular disease
quantitation of disease. Not to make diagnosis.
MRI cardiac
look for pericardial thickening. Look for wall thickness abnormalities. Look for cardiac masses. Look for flow voids at regurgitant or stenotic valves (find valve first, then decide if Jet is proximal or distal)
phase contrast MRI
looking to quantify and/or diagnose stenosis or regurgitation. Normal aortic valve will be white during systole , depicting flow, then turned gray during diastole , when the aortic valve is close, depicting stasis. regurgitant aortic valve is dark during diastole, depicting reversal of flow.
Thoracic aortic aneurysm sizing
greater than 4 cm is dilated, greater than 5 cm is aneurysmal, and greater then 6 centimeters goes to surgery. Exception to this rule is annuloaortic ectasia, which has a high risk of rupture, and goes to surgery at 5 cm.
enlarged ascending aorta
look at the annulus. If it is dilated as well, it's annuloaortic ectasia.
annuloaortic ectasia
the aortic annulus dilates along with the ascending aorta. Can involve the entire ascending aorta, or stop the sinotubular junction. Associated with Marfans and Ehlers-Danlos. Can also be degenerative. THREE IMPORTANT COMPLICATIONS: AORTIC REGURGITATION, DISSECTION, AND RUPTURE.
Hugely dilated aorta
rupture, penetrating ulcer, or dissection.
Definition of pseudoaneurysm
one or more of the walls of the vessel has ruptured.
Where do penetrating ulcers occur?
Near a lot of atherosclerotic plaque. They break through the plaque into the wall.
Aneurysmal dilatation of aorta
figure out if it is true aneurysm or pseudoaneurysm. Best way to do this is to look at the Ostium for the aneurysm. It is larger than 50% of the diameter of the sac, is most likely a true aneurysm. A small Ostium is much more suggestive of a false aneurysm. Just like in the left ventricle
bump on the inferior surface of distal aortic arch
is large and has acute margins, traumatic pseudoaneurysm. Even if chronic, many years later discovered, these are still treated surgically. Ductus bump gives you obtuse margins.
No mediastinal hematoma seen on CT
no chance of acute aortic injury. In fact, if there is mediastinal hematoma, it has to be contiguous with the aortic, otherwise, still no chance of acute traumatic aortic injury.
Mediastinal hematoma adjacent to aorta. Small aortic flap
100% positive predictive value for aortic injury.
trauma CT
is there mediastinal hematoma contiguous with the aorta.
no acute traumatic aortic injury.
is there evidence of aortic injury. If yes, go to surgery. If no, go to thin section multiplanar reformatted CT or catheter aortogram.
aortic dissection etiologies
annuloaortic ectasia, hypertension, vasculitis.
High-density rim of aortic wall on noncontrast CT
intramural hematoma. Causes are vasculitis due to bleeding of vaso vasorum or penetrating ulcer.
vascular rings
double aortic arch, right aortic arch with aberrant left subclavian artery, pulmonary sling. Left arch with aberrant right subclavian artery is not a vascular ring.
right aortic arch
must identify type. If mirror image branching, strongly associate with Cyanotic heart disease, namely Tetralogy of flow and truncus arteriosus. Other type is right aortic arch with aberrant left subclavian artery, which is a vascular rank. So if you have a right aortic arch, either have Cyanotic heart disease or a vascular ring one or the other. Differentiate the two by looking for the large vessel coming off the aortic arch going behind the esophagus.
Pulmonary sling
main pulmonary goes directly into the right pulmonary artery. There is no pulmonary artery bifurcation. So the left pulmonary artery comes off of the right pulmonary artery, and goes behind the trachea.
Vessel lateral to aortic arch
either the vertical vein of partial anomalous pulmonary venous connection of the left upper lobe, or persistent left superior vena cava. Differentiate the two by looking for branching of the vertical vein inferiorly. If it branches and ramifies into pulmonary vein branches feeding it, it is the vertical vein of a partial anomalous pulmonary venous connection.
Coronary artery passing posterior to aorta
normal variant. Not a problem. PROBLEM occurs when vessel passes IN BETWEEN pulmonary artery and aorta = interarterial course = surgery.
C. T. in the region of the aortic annulus
look at the coronary arteries. They may be showing you a stenosis of either the right main, LAD, left circumflex, or left main.
Classification of intramural hematoma
classified at the same way as you do a dissection. Type A involves ascending aorta, while type B is descending only. Type A is treated surgically.
Right aortic arch and Cyanotic child
Tetralogy or truncus. Differentiate by vascularity
given the history of tachycardia or arrhythmia and then a cardiac MR
don't even have to look at the images. Diagnosis will be right ventricular dysplasia.
Linear structure at anterior aspect of right ventricle on axial images
moderator band. Extends from septum towards anterior right ventricular wall
stenoses of aortic arch vessels
Takayasu if young patient.
Differentiate Takayasu from atherosclerosis
Takayasu stenoses are not right at the vessel origins.
Shown coronary arteries, don't know what you are looking at. Don't see an anomalous vessel passing between aorta and pulmonary artery
look for a stenosis.
Vascular structure posterior to ascending aorta
look to see if it's connected to a coronary artery. It might be a coronary artery aneurysm.
Connection between left pulmonary artery and very proximal portion of descending aorta
cine image
SSFP (steady state free precession)
Delayed enhanced myocardial image
May only see a tiny bit of residual enhancement on delayed images, but that is enough to call it dead.
Pulmonary angiogram demonstrating vessel connecting to IVC
scimitar vein on right side. Partial anomalous pulmonary venous connection from the right lower lobe pulmonary veins directly to the IVC. Blood is flowing into the IVC. This is a left to right shunt.
Middle mediastinal mass
LYMPHOMA, thrombus, bronchogenic CA, spread from esophageal CA
pulmonary hypertension in an adult, cardiac cause
if patient has made it to adulthood and is only now being diagnosed, either atrial septal defect or partial long-lost pulmonary penis connection
1st branch off of the LAD
1st diagonal
calcification in the heart on plain film
constrictive pericarditis if peripheral. Valvular if focal. Or aneurysm if in region of LV.
Calcific pericarditis
TB. Constrictive pericarditis may be calcific, in which case TB is the most likely entity, or noncalcific, which is more common, in which case surgery, radiation, uremic are the common causes.
Cardiac case, don't know what's going on on plain film
look on lateral view for calcification in the aortic valve, consistent with aortic stenosis.
Concentric hypertrophy of left ventricular myocardium
most common is hypertension. Then aortic stenosis. Then the 10% of hypertrophic cardiomyopathy which is symmetric.
Proximal descending aorta bulges laterally on plain film
typical degenerative changes in an adult. However, if pediatric patient, this is Coarctation. Look for three sign, rib notching, and large left subclavian on MRI. Juxtaductal is most common.
doesn't have pressure gradient across the kink.
Given Cardiac MR
Go through the steps like above. LOOK FIRST AT THE PERICARDIUM because otherwise you will not. MAKE SURE IT IS NOT THICKENED OR THERE IS NOT AN EFFUSION. THE SECOND THING YOU DO IS LOOK AT THE CORONARY ARTERIES. Then look at the other things.
Contrast filled structure lateral to upper portion of left atrium
left atrial appendage
LA thrombus
A-fib or mitral stenosis. BOTH CAUSE STASIS in LA. But mitral stenosis will cause LA to be enlarged, so LOOK FOR LAE.
calcified mass in heart
THROMBUS or myxoma.
DDx for appearance of left ventricular aneurysm on plain film
besides left ventricular aneurysm, pericardial cyst
most common cause for true aneurysm of left ventricle
myocardial infarction, transmural
most common cause for pseudoaneurysm of left ventricle
same thing. Myocardial infarction , transmural.
Mass in interatrial septum
ASK FOR FAT SUPPRESSED IMAGE. lipomatous hypertrophy of the interatrial septum. Can be diagnosed by echocardiography as a mass, and sent for MRI to exclude mass. Do not recommend surgery.
Thickening and enhancement of arch vessels
Takayasu arteritis.
Heart shifted toward left
Barring masses or lung collapse/loss, Pectus vs. absence of pericardium. LOOK FOR LUNG INSINUATING in AP window. Can see it on plain film.
Axial CT of the heart
Four month old with Interventricular septal thickening
don't let the age for you. Happens in these little tykes too. Hypertrophic cardiomyopathy. Don't go down the road of cardiac mass when it's just a smoothe hypertrophy of the septum.
Real ddx for increased pulm vascularity with cyanosis
(increased pulm bloodflow because these are the admixture lesions) Transposition, truncus, TAPVC. These are the 3 you need to know. Transpo = egg on string. Truncus = R arch. TAPVC = big superior mediastinum due to snowman appearance of vertical vein crossing over.
Vessel passing posterior to aorta
circumflex originating from the right sinus of valsalva , passing posterior to the aorta in order to serve its territory
R aortic arch
I would like to see cross sectional imaging to determine whether they branch pattern is non-mirror image with aberrant left subclavian or mirror image.
Both great vessels have muscle surrounding them
great vessel with muscle around it is by definition coming out of the right ventricle. If both great vessels have also around them, they are both coming out to right center, and this is a double outlet right ventricle.

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