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Flashcards in Cardiac Deck (156):
1

Why would lipomatous hypertrophy of IA septum be hot on PET?

Because it has brown fat.

2

Branches of LCA:

LAD: Diagonal and septal branches
LCx: Obtuse marginal- supply lateral margin.

3

Branches of RCA:

Acute marginal
AV node (90%) and SA node (60%)
PDA- 65-80%

4

What determines the dominance on coronary arteries?

What supplies the PDA and posterior LV branches determines the dominance.

5

What is the treatment in the following disarrangement?
1) RCA arising from the left coronary sinus?
2) LCA arising from the right coronary sinus?

1) RCA arising from the left coronary sinus: REPAIR if symp.
2) LCA arising from the right coronary sinus: ALWAYS REPAIR

6

ALCAPA stands for?

Anomalous LCA from the pulmonary artery.

7

What is a STEAL SYNDROME?

It is reversal of flow in the LCA as pressure decreases in pulmonary circulation.

8

Causes of coronary artery aneurysm?

1. Atherosclerosis
2. Kawasaki- resolves in 50%
3. Iatrogenic by cardiac catheters.

9

Who is the ideal patient to get a coronary CT? (2)

1) Low risk or atypical chest pain
2) Suspected aberrant coronary anatomy.

10

What is the ideal heart rate?

Low heart rate is optimal to reduce artefact.
BB are used to achieve HR<60.

11

# to BB? (4)

Severe asthma
Heart block
Acute chest pain
Cocaine

12

Are all heart blocks # to BB?

NO!
2nd and 3rd are #
A 1st degree block is ok.
If cant give BB: can only do retrospective gating

13

What is the difference between retrograde and prospective gating?

Prospective: Step and Shoot, use RR interval as tigger
+ve: Low radiation dose
-ve: No functional images
Trivia: Always axial and not helical

Retrospective: scan the whole time and the recalculate
+ve: Functional images
-ve: High radiation dose, use low pitch= high dose
Trivia: Helica.

14

Any other drugs than BB given for coronary CT?

GTN to dilate the coronaries.

15

# to GTN? (4)

Hypotension: SBP<100
Severe aortic stenosis
HOCM
Phosphodiesterase (viagra Sildenafil) use

16

Name the sequence used for quantifying the velocity of flowing blood;

Velocity encoded cine MR imaging (VENC) also known as velocity mapping or phase contrast imaging.

17

Name the causes of ascending aortic dilatation: (3)

1. Supravalvular: Williams syndrome
2. Valvular 90%
3. Subvalvular

18

Supravalvular aortic stenosis...

William's syndrome

19

Bicuspid aortic valve and coarctation...

Turner's syndrome

20

Most common congenital heart disease:

Bicuspid aortic valve and VSD

21

What are the associations with bicuspid aortic valve: (3)

Polycystic kidney disease
CMN: cystic medial necrosis
Turner's syndrome and coarctation.

Increases the risk of aortic aneurysm.

22

Causes of aortic regurgitation: (5)

1. Bicuspid aortic valve
2. Bacterial endocarditis
3. Marfans
4. Aortic root dilation secondary to HTN
5. Aortic dissection

23

Most common cause of mitral regurgitation:

Rheumatic heart disease

24

What are the signs of MR on CXR:

LA enlargement:
- Double density sign
- Splaying of the carina
- Posterior oesophageal displacement

25

What causes mitral regurgitation?

Acute:
- Endocarditis
- Papillary muscle/chordae rupture post MI

Chronic:
- Primary: Myxomatous degeneration
- Secondary: Dilated cardiomyopathy

26

Isolated RUL pulmonary oedema is associated with...

Mitral regurgitation.

27

Pulmonary stenosis syndrome:

1. uSpravalvular: Williams syndrome
2. Valvular: Noonan's syndrome (male version of Turner's)
3. Subvalvular- TOF

28

Peripheral pulmonary stenosis is seen with...

Alagille syndrome: Absent bile ducts

29

Most common cause of PR

TOF patients with repair.

30

Which valves most commonly affected by rheumatic heart disease?

MV and AV

Multivalve disease, think of rheumatic fever.

31

Rh heart disease is immune modulated response to which group of infection?

Group A beta haemolytic strep.

32

Causes of Tricuspid regurgitation:

1. Endocarditis (IVDU)
2. P HTN
3. Carcinoid ( Serotonin degrades the valve)

33

What happens to RV in TR?

RV dilation and NOT hypertrophy.

34

Which children are at increased risk of Ebstein anomaly?

Children whose mums used Lithium

35

What happens in Ebstein anomaly?

The TV is hypoplastic , the posterior leaf is displaced apically (downwards) --> Enlarged RA, decreased RV(atrialised) and TR.

Massive box shaped heart on CXR

36

When would tricuspid atresia happens?

It happens with RV hypoplasia

37

Associated findings with TA (tricuspid atresia)

- ASD and PFO
- Right sided arch (think of truncus and TOF)
- Asplenia

38

TA and PS?

TA + PS = reduced vascularity
TA alone = increased vascularity

39

Which side of the heart gets affected by carcinoid syndrome?

Right side of the heart: Tricuspid and pulmonary

Left side is super rare.

40

How would carcinoid syndrome affects the valves?

The serotonin degrades the valve- usu the right side

41

What does it mean if you see a left sided valvular disease with carcinoid syndrome? (2)

1. Primary bronchial carcinoid
2. Right to left shunt

42

The terminology right arch/left arch is based on relationship of aortic arch to which structure?

Trachea

43

When I say right arch with mirror branching, you say...

Congenital heart

44

What is a Bovine arch?

This is when the BCA and LCCA arise from a common origin.

45

If there is mirror image right arch, then 90% will have...

TOF
6% truncus

46

If a person has truncus , then they have a mirror image right arch...

33%
TOF 25%

47

What symptoms patients with aberrant RSCA most likely to present with?

Dysphagia lusoria
As the RSCA passes posterior to oesophagus

48

What is a Kommerell diverticulum?

It refers to the bulbous configuration of the origin of an aberrant left subclavian artery in the setting of a right sided aortic arch.

49

What are the symptoms of double arch?
Location?

Tracheal compression and dysphagia.
Arches are posterior to esophagus and anterior to trachea- encircling them both.

50

Subclavian Steel Phenomenon?

Stenosis and/or occlusion of the proximal subclavian with retrograde flow in the ipsilateral vertebral artery.

51

Subclavian Steel Syndrome?

Stenosis and/or occlusion of the proximal subclavian artery with retrograde flow in the ipsilateral vertebral artery AND associated cerebral ischaemic symptoms (syncope, dizziness etc).

52

What are the causes of SSS? (5)

1. Atherosclerosis
2. Takayasu arteritis
3. Radiation
4. Preductal aortic coarctation
5. Blalock Taussig shunt

53

What are the causes of cyanosis in paediatric patients? (5)

1. Truncus
2. TOF
3. Transposition
4. Tricuspid atresia
5. TAPVR

54

Come up with the diagnosis:

Cyanosis, Right sided arch with increased blood flow.

Truncus

55

Come up with the diagnosis:

Cyanosis, right sided arch with reduced blood flow.

TOF

56

Come up with the diagnosis:

Cyanosis, left sided arch with massive heart size

Ebstein

57

Come up with the diagnosis:

Cyanosis, left sided arch with increased blood flow

TAPVR
Transposition
Tingle ventricle.

58

Come up with the diagnosis:

Cyanosis, left sided arch with decreased blood flow

Ebstein
Tricuspid atresia

59

What are the causes of non cyanotic peadiatric patient with CHD (5)

1. ASD
2. VSD
3 PDS
4. PAPVR
5. Aortic coarctation- adult type

60

What are the DDx for small heart? (3)

1. Adrenal insufficiency - Addison's
2. Cachectic state
3. Constrictive pericarditis

61

Re VSD:
- Most common types
- Which type must be repaired?
- CXR findings?

- Most common congenital heart disease
- Membranous type most common.
- The outlet subtypes (infundibulum) must be repaired as the right coronary cusp prolapses into the defect.
- Non specific: Cardiomegaly, increased vasculature, small aortic knob) or LA enlargement.

62

When does PDA close?

Usually closes after 24 hours after birth (functionally) and anatomically around 1 month.

Can close it or keep it open with medication.

63

PDA is associated with... ? (3)

1. Prematurity
2. Maternal rubella
3. Acyanotic heart disease

64

When I say hand/thumb defect + ASD, you say...

Holt Oram

65

When I say ostium primum ASD, you say...

Down's syndrome

66

When I say sinus venosus ASD, you say...

PAPVR

67

What does AV canal refer to?

Endocardial cushion defect

68

What causes the development of the AV canal?

Secondary to deficient development of a portion of atrial septum, a portion of IV septum and AV valve.

69

What is the strong association of AV canal?

Down's syndrome

70

What is an unroofed coronary sinus?
Most common clinical findings?

Rare ASD which occurs secondary to a fenestrated or totally unroofed coronary sinus.

Paradoxical emboli and chronic right heart volume overload.

71

What is the strong association of unroofed coronary sinus?

Persistent left sided SVC.

72

What is a TAPVR?

What is needed for survival?

This is when the pulmonary venous system drains to the right side of the heart.

PFO or ASD is required.

73

What are the different types of TAPVR? (3)

Type 1: Supracardiac: Most common type
Veins drain above the heart = snow man appearance

Type 2: Cardiac: Second most common type

Type 3: Infracardiac: Veins drain below the diaphragm: Hepatic veins or IVC. Obstruction on the way back is common and causes a full on pulmonary oedema look.

74

What are the congenital heart disease associated with asplenia?

50% would have CHD: 100% would have TAPVR and 85% have additional endocardial cushion defect.

75

What is PAPVR?

What is it associated with?

Partial Anomalous Pulmonary Venous Return.

This is when one or more of the 4 Pulmonary veins drain into the right atrium.

It is associated with ASD.

76

When I say right sided PAPVR, you say..

Sinus venous ASD

RUL: SVC association with sinus venous type ASD

77

When I say Right sided PAPVR and pulmonary hypoplasia , you say..

Scimitar syndrome

78

What is the main RF for transposition

Maternal diabetes

79

How can you tell which chamber is the RV?

The one with the moderator band is the right ventricle.

80

What are the different types of transposition?
Which one needs correction?

D type- You need patent PDA. Intra-atrial baffle (Mustard or Senning procedure) is performed to fix them

L type- L type is Lucky enough to be congenitally corrected. There is inversion of the ventricles - No PDA is needed.

81

What happens in L type transposition?

Aorta --> Systemic--> RA--> LV--> PA--> Lungs--> LA--> RV--> Aorta

82

What happens in D type transposition?

Aorta--> systemic--> RA--> RV--> Aorta
{
PDA
{
PA--> lungs--> LA--> LV--> PA

83

What is a corrected D transposition?

This is when the PA is draped over the aorta which occurs after a surgeon has performed " LeCompte Maneuver"

84

What is the tetralogy of Fallot?

1. VSD
2. RVOTO (Right Ventricular Outflow Tract Obstruction)
3. Overriding aorta
4. RV hypertrophy

If there is ASD- Pentalogy of Fallot- likely to have Right arch

85

What is the most common complication post TOF repair?

Pulmonary regurgitation.

86

What is a truncus arteriosus?

This is when single trunk supplies the systemic and pulmonary circulation.

Almost always has a VSD. Associated with Right arch.

87

What is truncus associated with?

CATCH 22 genetics (Di George syndrome)

88

Define coarctation?

What are the types?

CXR sign?

This is narrowing of the aortic lumen.

Two flavours:
1. Infantile (preductal)- pulmonary oedema
2. Adult (ductal)

Figure 3 sign and rib nortching (4th - 8th ribs) on CXR.
It does not involve the 1/2 rib because they are fed by costocervical trunk.

89

What are the associations with coarctation?

1. Turner's syndrome
2. Bicuspid aortic valve- 80%
3. Berry aneurysm
4.

90

Re Hypoplastic left heart:

What is it?

This is when the LV and aorta are hypoplastic. They present with pulmonary oedema.

Must have ASD/PFO or a large PDA

91

What is hypoplastic left heart associated with? (2)

1. Aortic coarctation
2. Endocardial fibroelastosis.

92

Cor Triatriatum Sinistrum

This is when an abnormal pulmonary vein drains into the LA (sinistrum means left) with unnecessary fibromuscular membrane that causes a subdivision of the LA creating the appearance of a tri-atrium heart.

93

What is the main signs and symptoms of Triatriatum Sinistrum

1. Unexplained pulmonary hypertenion in paeds
2. Acts like MS - Pulmonary oedema

Prognosis is bad, fatal within 2 years.

94

Where does the wave front of necrosis start?

The wave front of necrosis always starts sunendocardial and progresses to subepicardium.

Delayed enhancement follows a vascular distribution.

95

How would acute/subacute MI look like on MR?

Micovascular obstruction: destruction of small capillaries will not allow contrast to area of injury = islands of dark signal in ocean of delayed enhancement. Best seen on first pass imaging (25sec)

Independent factor of death and adverse LV remodelling.

Zone of enhancement that extends from subendocardium toward the epicardium in a vascular distribution.

96

Stunned myocardium:

Define it:
perfusion study? contractility?

This is after an acute injury (ischaemia or reperfusion injury), dysfunction of myocardium persists even after restoration of the blood flow- can last days- weeks.

Perfusion study will be normal but contractility is crap.

97

Hibernating myocardium

Perfusion? contractility?

Chronic process , the result of severe CAD causing chronic hypoperfusion.

Decreased perfusion and decreased contractitility even when resting. It is NOT an infarct.

It is reversible with revascularisation.

98

Scar:

This is DEAD myocardium. Will not squeeze normally and will have abnormal wall motion.

Revascularisation - NOT helpful.

99

Hibernating myocardium on FDG PET?

On a FDG PET, this tissue will take up tracer more intensely than normal myocardium and will also show redistribution of thallium.

100

Stunned vs hibernating vs scar:

Stunned: Associated with acute MI.
- Normal perfusion.
- Abnormal wall motion.

Hibernating: Associated with high grade CAD.
- Abnormal perfusion.
- Abnormal wall motion.
- Will take up FDG and delayed thallium.

Scar: Associated with chronic prior MI.
- Abnormal fixed perfusion
- Abnormal wall motion.
- No uptake with FDG or Thallium.

101

How does delayed imaging work?

1. Increased volume of contrast material distribution in acute MI

2. Scarred myocardium washes out more slowly.

102

How is delayed imaging performed?

By using IR to null normal myocardium followed by Gradient echo. T1 shortening from Gd looks bright. (Bright is Dead)

103

What medications are used in stress imaging?

- Dobutamine- inotropic stress agent for wall motion
- Adenosine - vasodilator for perfusion analysis.

104

Is microvascular obstruction seen in chronic MI?

Microvascular obstruction is NOT seen in chronic MI as these will turn to scars eventually.

In acute settings: injured myocardium will have increased T2 signal which can be used to to estimate the area at increased risk, which can be used to estimate the area at risk (T2 bright enhanced = salvageable tissue)

105

Acute vs chronic MI on MRI

- Both have delayed enhancement
- Acute will have normal thickness
- T2 signal from oedema may be increased in teh acute setting.
- NO microvascular obstruction in chronic
- ACUTE is T2 bright and CHRONIC (scar) is T2 Dark.

106

Types of ventricular aneurysm:

- True: Mouth is wider than body. Myoardium is intact. Usually on the anteriolateral wall.

- False: Mouth is narrower than body. Myocardium is NOT intact (pericardial adhesions contain the rupture).
Usually posteriolateral wall. Higher risk of rupture.

107

How would you grade viability?

Prognosis?

Based on % of transmural thickness involved in the thickness.

- <25%: likely to improve with PCI
- 25-50%: may improve
- 50-100%: unlikely to recover function.

108

What is the timing on the bad sequelae of an MI:

DRESSLER SYNDROME

4-6 weeks

109

What is the timing on the bad sequelae of an MI:

Papillary muscle rupture

2-7 days

110

What is the timing on the bad sequelae of an MI:

Ventricular pseudoaneurysm

3-7 days

111

What is the timing on the bad sequelae of an MI:

Ventricular aneurysm

months- requires remodelling and thinning

112

What is the timing on the bad sequelae of an MI:

Myocardial rupture

Within 3 days (50% of the time).

113

Where is the most common site affected by mets in the heart?

Pericardium. Pericardial effusion and pericardial lymph nodes

Melanoma may involve the myocardium

Lung cancer: epi/myocardium

114

Most common primary malignant tumour of the heart:

Angiosarcoma

115

Where does angiosarcoma affect?

RA and pericardium. They cause right sided heart failure and /or tamponade.

116

Angiosarcoma appearance?

Bulky and heterogenous

BUZZWORD: SUNRAY

117

What are the left atrial myxoma associated with?

MEN syndrome and Blue Nevi (Carney complex)

118

Where is LA myxoma usually located? appearance?

They are attached to interatrial septum.

They may be calcified.They may prolapse through the MV.
Will enhance with Gd- important discriminator against thrombus.

119

Rhabdomyoma

Most common fetal cardiac tumour. Hamartoma.
Prefer the LV. Associated with Tuberous sclerosis.,

120

Fibroma

2nd most common in paeds.
IV septum
Dark on T1 and T2
Enhance very brightly on perfusion and late Gd.

121

Fibroelastoma

Most common neoplasm to involve the valve (80% aortic or mitral).
Highly mobile on SSFP cine
Systemic emboli are common- especially on the left side.

122

Most common fetal cardiac tumour?

Rhabdomyoma.

123

These cardiac tumours are associated with tuberous sclerosis:

Rhabdomyoma

124

Most common cardiac tumour to involve the cardiac valves?

Fibroelastoma

125

Systemic emboli are common with these tumours.

Fibroelastoma

126

Define dilated cardiomyopathy:

This is dilatation with end diastolic diameter > 55mm and reduced EF.

127

Causes of dilated cardiomyopathy: (5)

1. Idiopathic- No enhancement or linear mid myocardial enhancement.
2. Ischaemic- Sunendocardial enhancement
3. Alcohol
4. Chagas
5. Cyclosporin

128

What valvular pathology is dilated cardiomyopathy associated with?

MR

129

What is Restrictive cardiomyopathy?

What are the main 3 types?

This is anything that reduces the diastolic function.

1. Replacement by fibrosis: Endocardial fibroelastosis
2. Infiltration: Amyloidosis
3. Damage by Fe: Haemochromatosis.

130

Typical appearance of amyloidosis on heart:

causes abnormal diastolic function:
- biatrial enlargement
- concentric thickening of the LV
- Reduced systolic function of both ventricles.

131

The inversion time is very long for this condition and it will be very difficult to suppress the myocardium.

Amyloidosis.

132

In this confition, there will be bilateral ventricular thrombus:

Eosinophilic cardiomyopathy (Loeffler)
Long TI is needed.

133

Causes of constrictive pericarditis:

1. TB/Viral
2. Iatrogenic secondary to CABG
3. Radiation.

134

Signs associated with constrictive pericarditis:

1. Calcification is diagnostic esp in the AV groove.
2. Pericardium is thickened > 4mm
3. Sigmoidisation on SSFP cine images: DIASTOLIC BOUNCE- more pronounced during inspiration.

135

Re Myocarditis

Define it:
Distribution:

Inflammation of the heart. The late Gd follows a non vascular distribution preferring the lateral free wall. The pattern will be epicardial or mid wall and NOT subendicardial

136

Re Cardiac Sarcoidosis

Signal intensities.
Parts affected

Signal in both T2 and early Gd will be increased
Late Gd may be middle and epicardial in non coronary distribution.

Often involves the septum.

The RV and papillaries are rarely affected.

137

DDx for cardiac sarcoidosis:

Focal wall thickening from oedema can mimic hypertrophic cardiomyopathy

138

Takutsubo cardiomyopathy

Def

BUZZWORD

Transient akinesia of the LV apex without coronary stenosis.

Ballooning of the LV apex is a buzzword.

No delayed enhancement.

139

Classic history for Takutsubo cardiomyopathy

chest pain with ECG changes in post menopausal women after :
- break up
- winning the lottery
- some form of stress

140

What is ARVC?

- Which heart chamber affected?
- Which ventricle is normal?
- What MR sequence is useful?

It is Arrhymogenic Right Ventricular Cardiomyopathy
- It is the fibrofatty degeneration of the RV leading to arrhythmia and sudden death.

The LV is NORMAL.

FAT SAT: FAT in RV

141

What is hypertrophic cardiomyopathy?

Abnormal cardiomyopathy (from disarray of myofibrils) of the myocardium that affects diastole.

one type is the asymmetric hypertrophy of IV septum- cause of sudden death.

142

What are the imaging features of hypertrophic cardiomyopathy?

Patchy midway delayed enhancement of the hypertrophied muscle.

143

What is non compaction cardiomyopathy?

It is as a result of loosely packed myocardium affecting the LV.
The LV has a spongy appearance with increased trabeculation and deep intertrabecular recesses

144

How would you diagnose non compaction cardiomyopathy?

Ratio of non compacted end diastolic myocardium to compacted end diastolic myocardium of more than 2.3:1

145

Muscular dystrophy:

They have biventricular replacement of myocardium with connective tissue and fat (delayed Gd enhancement in the midwall). They often have dilated cardiomyopathy.

146

What are the two main types of muscular dystrophy?

Becker ( Mild)
Duchenne ( Severe)

Both are X linked.

147

BUZZWORD for Muscular dystrophy:

kid with dilated heart and midwall enhancement.

148

Causes of pericardial effusion: (3)

1. Lupus
2. Dressler's syndrome - inflam effusion post MI
3. Uraemia

149

What is the name of the sign seen on lateral CXR in pericardial effusion:

Oreo cookie sign- two lucent lines on CXR with a central opaque line (pericardial fluid)

150

What are the two signs of cardiac tamponade?

1. "short axis imaging during deep inspiration showing flattening or inversion of inter ventricular septum towards the LV, a consequence of augmented RV filling.

2. Reflux of contrast into the IVC and azygos system.

151

A cystic mass lesion seen in the right cardiophrenic sulcus, separate from the pericardium.

What is the lesion?

Pericardial cyst

152

What part of the heart is affected in congenital absence of pericardium?

Partial absence of pericardium over the left atrium and adjacent pulmonary artery.

153

What happens to the heart when there is left partial absence of pericardium?

The heart shifts to the LEFT. The heart could be contacting the left chest wall on CT/MR.

154

What patients are at increased risk of cardiac volvulus/herniation?

Patient who undergo extra pleural pneumonectomy- herniation can only occur if the lung has also been removed.

155

Which part is the most at risk to become strangulated?

The LEFT atrial appendage.

156

With regard to imaging techniques in detection of hibernating myocardium, what method has the greatest specificity?

Dobutamine stress MRI is a good method for the assessment of myocardial hibernation- using a low dose protocol, and ischaemia (high dose protocol),
MRI provides superior spatial resolution when compared with echo, and improvement in resting wall motion abnormality is considered a sign for myocardial hibernation.