Page 26 Flashcards
(192 cards)
1
Q
Four-chambered heart lies in the left hemithorax
A
Levoposition
2
Q
Orientation: Cardiac apex is normally located to the left of midline
A
Levocardia
3
Q
Cardiac apex is to the right of midline
A
Dextrocardia
4
Q
Heart is displaced to the right lying in the right hemithorax
A
Dextroposition
5
Q
Include a trilobed lung (with eparterial bronchus) in the chest and liver in abdomen
A
Right-sided organs
6
Q
Include a bilobed lung (with hyparterial bronchus) in chest and spleen in abdomen
A
Left-sided organs
7
Q
Normal cardiac positioning, morphologic RA on the right and morphologic LA on the
left
A
Situs solitus
8
Q
All major organs are reversed or mirrored from normal position, morpho RA is on the
left and morpho LA is on the right
A
Situs inversus totalis
9
Q
Assoc w/ polysplenia. Each lung contains 2 lobes and hyparterial bronchi
A
Left isomerism
10
Q
Assoc w/ asplenia. Each lung with 3 lobes.
A
Right isomerism
11
Q
RA: receives systemic venous return from
A
1) SVC - free opening
2)IVC - partially guarded by Eustachian valve
3)coronary sinus - guarded by Thebesian valve
12
Q
RA: divided into 2 portions by crista terminalis
A
1) smooth posterior wall -sinus venosus, SVC IVC in continuity 2) trabeculated anterior wall -from embryonic RA
13
Q
RA: triangular or pyramid shape with broadbase containing pectinate muscles
A
RA appendage
14
Q
RA: medial or posterior wall
A
Interatrial septum - fossa ovalis is located
15
Q
Most anterior cardiac chamber
A
RV
16
Q
RV: divided into 2 portions by crista supraventricularis
A
1)posterior/inferior portion(heavily trabeculated) -inflow/sinus portion; 2)less trabeculated anterior/superior portion - outflow tract or pulmonary conus
17
Q
RV: muscular band carrying part of RBB conduction system (consistent feature)
A
Moderator band (septomarginal band)
18
Q
RV: smooth cephalic portion
A
Infundibulum (conus arteriosus)
19
Q
How to distinguish RV from LV?
A
By having having coarser trabeculae (particularly at apex), moderator band, apical displacement of R AV valve, lack of fibrous continuity b/w inlet and outlflow valves, and much thinner wall
20
Q
LPA location
A
extends posteriorly coursing over the top of the L main stem bronchus (L hyparterial bronchus)
21
Q
RPA location
A
extends horizontal to the right, bifurcates and exits the R hilum as truncus anterior (supplies RUL) and interlobar artery (supplies RML RLL) = L hyparterial bronchus, 2) portion of PV return to the right heart or SVC (PAPVR)
22
Q
What are the normal variance of pulmonary venous drainage?
A
1) direct drainage from the right middle lobe to LA
23
Q
PAPVR from the R lung is 2x as common as from the L. T or F?
A
TRUE
24
Q
Congenital malformation in which all 4 PV drain into systemic veins (SVC or IVC) or directly into RA
A
TAPVR
25
directly into RA
TAPVR
In TAPVR, an ASD is required for survival. T or F?
TRUE
26
Most superior and posterior cardiac chamber
LA
27
LA: borders
Nestled b/w R and L bronchi, posterior wall abuts anterior wall esophagus
28
LA: part where pulm veins enter
Posterior part
29
Mitral valve leaflets
1) anterior leaflet -near IV septum, 2)smaller posterior leaflet -posterior and to the left
30
LV: inflow portion
Posterior to anterior mitral leaflet
31
LV: outflow portion
Anterior and superior to anterior mitral leaflet
32
Interventricular septum is concave to?
Bulging into RV
33
Aortic valve: tricuspid
1) right - right coronary, 2)left - left coronary, 3)posterior -noncoronary cusp
34
Branches of aortic arch
1) right brachiocephalic, 2)L common carotid, 3)L subclavian
35
Pectinate muscles: what chamber?
LA (fewer) and RA
35
Chordae tendineae: what chamber
LV
35
Moderator band: what chamber?
RV
36
Papillary muscles: what chamber?
RV and LV
36
Trabeculae: what chamber?
RV (coarser) and LV (FINE)
36
Conduction system: recorded as P wave on ECG
SA node
36
Source of 2nd heart sound
Aortic and pulmonic valve closure
36
Remnant of ductus arteriosus
Ligamentum arteriosum
37
What is the value of oblique measurement to confirm LA enlargement?
>7cm (measured from inferior midpoint L main bronchus to the R border of LA)
37
Conduction system in the IV septum: first to activate
Anterior or septal RV
37
What are the indirect signs of LA enlargement?
1) splaying of carina (tracheal bifurcation >90degrees), 2)posterior displacement of of L mainstem bronchus (lat view), 3) superior displacement of L mainstem bronchus (frontal view)
38
Conduction system in the IV septum: last to activate
Posterior or basal LV
38
Source of 1st heart sound
AV valve closure
38
This standard view in oarasternal window is useful to evaluate size and contractility of ventricles and assess morphology and function of mitral and aortic valves
Long axis view
38
Cardiac enlargement: increase convexity along right heart border
RA enlargement
38
Type of echocardiography: probe is passed into patient's esophagus
TEE transesophageal echocardiography
38
Cardiac enlargement: rounding of L heart border and apex pointing downward
LV enlargement
38
Type of echocardiogram: probe is placed on the chest or abdomen
TTE transthoracic echocardiography
39
Main TTE windows
Physical location of transducer - suprasternal, parasternal, apical, and subcostal (subxiphoid)
39
Cardiac enlargement: uplifting of apex
RV enlargement
39
This standard view in apical window is usefule for visualization of all 4 chambers
including apex, ejection fraction assessment (Simpson method), and mitral flow assessment
Four-chamber view
39
This standard view in apical window including aortic valve is useful for aortic stenosis
Five-chamber view
39
TEE advantage
Useful in imaging LA and LAnappendage when thrombus or clot is suspected
39
TEE disadvantage
More invasive and requires sedation
40
What is the largest coronary artery yet variable in length?
L main coronary artery
41
What are the 2 branches of LMCA?
1) LAD - course anteriorly 2)LCx -course posteriorly
42
Trifurcation of LMCA will produce what branch?
Ramus intermedius (20-30%) -course anterolaterally similar to diagonal br or posteriorly similar to OM br
43
Coronary artery that runs along anterior surface of LV
LAD
43
What are the portions of LAD?
1) proximal -origin to 1st branch (septal/diagonal); 2)mid-LAD -end of proximal LAD to 1/2 distance to LV apex; 3) distal LAD -end of midLAD to termination
43
Coronary artery that course anteriorly in the R AV groove
RCA
43
What are the branches of RCA?
1) conus branch 2) acute marginal br - anterior surface RV, 3) PDA -course posterior interventricular sulcus, 4)PLV post left ventricular- along posterior AV groove b/w inferior aspect of LA and LV, 5)small septal branches 6) sinoatrial nodal branch 7)atrioventricular nodal branch
44
What are the branches of LAD?
1) diagonal (2-4) branches- anterolateral LV; 2) septal (numerous but small) branches - anteroseptal LV
44
Coronary artery that courses posterolaterally b/w LV and LA
LCx
44
RCA branch: first br and supply RVOT or conus
Conus branch - may also arise from right coronary sinus (origin of RCA)
45
What are tha branches of LCx?
1) obtuse marginal (OM) -inferolateral LV (at least 2- smaller first, larger second); 2) distal Lcx
45
Co-dominance?
(20%) 2 PDA arising from RCA and from Lcx (LCx is also larger)
45
RCA branch: referred to as the arterial circle of Vieussens
Conus branch acting as a collateral pathway for blood flow to the LAD
45
What are the 3 territories of RCA?
1) proximal -origin to 1/2 distance toacute margin of heart, 2)mid-RCA -end of proximal RCA to acute margin of heart, 3) distal RCA -end of mid-RCA to origin of PDA
45
Right dominance vs Left dominance
Right dominance (majority 70%)- distal RCA divides into PDA and PLV, diminutive distal LCx. Left dominance (10%) - distal LCx will be larger in size and give rise to PDA
46
RCA branch: to supply inferior wall of LV
PDA
46
RCA branch: course superiorly toward the posterior annulus of mitral valve
Atrioventricular nodal branch
46
RCA branch: to supply imferior and inferolateral LV base
PLV
46
RCA branch: arising from PDA to supply inferolateral aspect of LV septum
Small septal branches
46
Small vessel which may be supplied by both RCA (course posterior) and LCx (course medial) and terminates along posterior aspect of SVC/RA
Sinoatrial nodal branch
47
Imaging method to best visualize anomalous coronary anatomy
ECG-gated CT angiography
47
Coronary anomalies are divided based on?
1) origin, 2)course, 3) termination
48
BENIGN anomalous origin: LAD and LCx have independent origins from left sinus of Valsalva
Absence of L main coronary artery
49
Valsalva Absence of L main coronary artery BENIGN anomalous origin: commonly affecting RCA where it originates from ascending aorta (>1cm above sinotubular jxn)
High origin of RCA
50
BENIGN anomalous origin: commonly affecting LCA or LCx arising from right sinus of Valsalva (either from aorta or proximal RCA) and course posteriorly b/w aortic root and LA
Retroaortic course
50
BENIGN anomalous origin: LAD or LCx arises from right sinus Valsalva and course anteriorly around RVOT
Prepulmonic or precardiac course
51
BENIGN anomalous origin: LAD arising from right coronary sinus coursing
inferomedially before diving into IV septum
Septal (intramuocardial) course
51
Possibly ALIGNANT anomalous origin: LCA arises from pulmonary artery
ALCAPA or Bland-Garland-White syndrome
51
BENIGN anomalous origin: RCA or LMCA arising from noncoronary sinus
Noncoronary sinus
51
Possibly MALIGNANT anomalous origin: coronary artery arises from opposite sinus and course medially b/w aorta and pulmonary artery
Interarterial course - can lead to myocardial ischemia, infarction, sudden cardiac death
52
Possibly MALIGNANT anomalous origin: all coronary artery branches arise from a single vessel
Single coronary artery
52
T or F. A single RCA is more common than a left.
TRUE
52
Possibly MALIGNANT anomalous origin: osteum of RCA or LCAdoes not develop
Ostial atresia - commonly affects LCA
52
draining to pulmonary artery Coronary artery fistula Coronary artery plaques (fibroatheroma) classification
1) calcified, 2) noncalcified, 3)mixed
53
Anomalous course: involves mid-LAD where a band of myocardial tissue extends around the vessel
Intramyocardial course or MYOCARDIAL BRIDGING
53
Anomalous course: RCA course within RA
Intracavitary course
53
T or F. Low attenuation plaque w/ a larger lipid-rich necrotic core has higher propensity to ruptue.
TRUE
53
Anomalous course: one coronary artery arising from sinus of Valsalva, which then divides in its proximal portion into 2nparallel arteries that mirror their courses
Split or double coronary artery
53
High attenuation plaquecorresponds to larger and thick fibrous cap has smaller
likelihood of rupture.
TRUE
54
Anomalous termination: dilated and tortuous affected coronary artery with a portion draining to pulmonary artery
Coronary artery fistula
54
T or F. Positive remodelling and negative remodelling occur together
TRUE
54
Coronary CTA finding of "napkin-ring sign"
Indicative of a thin-cap atheromatous vulnerable plaque (rim of high attenuation surrounding an area of low attenuation) representing inflamed fibrous cap surrounding necrotic lipid core
54
What is "negative remodelling"?
Inward growth of plaque causing stenosis
55
Coronary CTA finding of "in-stent" restenosis
Area of hypoattenuation within the stent
55
What is "positive remodelling"?
Outward growth or expansion of both coronary and associated plaque
55
Coronary stent diameter that is more likely to be evaluable
3mm or more
55
Degrees of coronary stenosis by CTA
Minimal (1-24% narrowing), Mild (25-49% narrowing), moderate (50-69% narrowing), Severe (70-99% narrowing), Occlusion (100%)
55
Excellent tool for assessing the patency of CABG
ECG-gated CTA of the thorax
56
Coronary artery aneurysm diameter
1.5x the adjacent normal coronary artery
56
What are complications of CABG?
SVG aneurysm -not uncommon, thrombosis, pseudoaneurysms -uncommon usually at the anastomotic site
56
What are the grafts used in CABG?
Left internal mammary (LIMA) graft and saphenous vein graft (SVG)
57
Type of aortic dissection involving ascending aorta which may extend into aortic root
Type A
58
3 catastrophic mechanical complications of MI
1)LV free wall rupture (LV pseudoaneurysm), 2)ventricular septal rupture (VSR), 3)papillary muscle rupture (within first week)
59
LV true aneurysm vs psuedoaneurysm
Pseudoaneurysm -inferior and inferolateral walls, narrow neck (<50% of max diameter of distal outpouching), contained by surrounding pericardium or scarring; True aneurysm - anterior walls, broad neck, surrounded by thin myocardium
60
Classification of cardiac tumors
1) primary (benign vs malignant) 2)secondary (mets)
60
Findings of asymmetric edema most notably in the RUL, echo shows flair posterior
leaflet with severe mitral regugitation in px with worsening dyspnea
LV posteromedial papillary muscle rupture
60
Classification of cardiac masses
1) tumors , 2)tumor-like lesions
60
DDx: tumor-like lesions
Thrombus, vegetation, lipomatous hypertrophy, caseous necrosis of mitral valve, pericardial cyst, fat necrosis
61
DDx: Myocardial perfusion defect
Fatty metaplasia or calcification of myocardium, LV aneurysm, and thrombus
61
MALIGNANT features
Large (>5cm), multiple, RIGHTsided, irregular ill-defined borders with direct invasion thru tissue planes, (+)hemorrhagic pericardial effusion, pericardial invasion or multiple nodular masses, heterogeneous (dt hemorrhage and necrosis), prominent early enhancement and variable delayed enhancement
61
BENIGN features
Small (>5cm), single, LEFTsided, smooth well-defined borders w/ no extension thru tissue planes, pericardium not involved, homogenous w/ absent to minimal early enhancement and variable delayed enhancement
61
DDX: Benign cardiac tumors
Myxoma, lipoma, fibroelastoma, rhabdomyoma, fibroma, hemangioma, teratoma
62
Cardiac tumor associated with Carney complex
Myxoma
62
DDx : Malignant cardiac tumors
Angiosarcoma, rhabdomyosarcoma, fibrosarcoma, lymphoma, melanoma
62
Ddx: INTRAMURAL (benign) cardiac masses
Fibroma, rhabdomyoma, lipoma, paraganglioma, lipomatous hypertrophy (interatrial septum)
62
Cardiac tumor demonstrating chemical shift/india ink artifact
Lipoma
62
First imaging technique used to evaluate cardiac masses
Transthoracic echocardiography
62
Current modality of choice in evaluating cardiac masses
Cardiac MRI
62
Ddx: INTRAMURAL (malignant) cardiac masses
Metastasis, sarcoma, lymphoma
63
Ddx: INTRACAVITARY (benign) cardiac masses
Thrombus, myxoma, lipoma, rhabdomyoma
63
Ddx: INTRACAVITARY (malignant) cardiac masses
Metastasis, sarcoma
63
Cardiac tumor with increased risk for embolization
Villous or papillary myxoma
63
Lipomatous hypertrophy of interatrial septum vs true lipoma
Both have identical signal characteristics; lipomatous hypertrophy - sparing of fossa ovalis
64
Cardiac mass that is small and highly mobile with propensity to attach to the valve
leaflets
Valvular papillary fibroelastoma
64
Valvular fibroelastoma vs vegetation
Vegetation -mild or absent delayed enhancement within vegetation, valvular or perivalvulae regurgitation, subpoeural cavity nodules in lung; Fibroelastoma - with delayed Gd enhancement, no valvular destruction
64
Best modality to detect and evaluate papillary fibroelastoma
Echocardiography
64
Cardiac tumor associated with tuberous sclerosis
Rhabdomyom
64
Ddx for cardiac mass in neonate or infant
Rhabdomyoma, fibroma, teratoma, and rhabdomyosarcoma
64
What is Gorlin syndrome?
AD syndrome of basal cell ca, odontogenic keratocyst and other neoplasm
64
These are hamartomas of enlarged cardiac myocytes located within ventricular myocardium or intracavitary and attached to myocardium
Rhabdomyom
64
Cardiac tumor associated with Gorlin syndrome (Basal cell nevus syndrome
Cardiac finroma
65
Heterogeneous mass, predom hyperintense on both T1 and T2, with intense enhancement
Cardiac hemangioma
66
MC location of cardiac hemangioma
Intramural (any part of heart). Can also be intracavitary
67
MC location paraaganglioma
LA wall (roof or posterior wall)
67
MC route of metastatic spread to the heart
Direct invasion or lymphatic extension to pericardium and epicardium
67
What is Kasabach-Merritt syndrome?
Multiple hamangiomas causing recurrent thrombocytopenia and consumptive coagulopathy
67
Cardiac tumor associated with Kasabach-Merritt syndrome
Cardiac hemangioma
68
Cardiac tumor producing catecholamines causing hypertension. Extremely hypeintense on T2 with intense enahncement.
Paraganglioma
68
Cardiac tumor associated with Carney triad
Paraganglioma
68
What comprises carney triad?
Extra-adrenal pheochromocytoma, GIST, pulmonary chondroma. Carney complex = myxoma
68
Cardiac mass MC located in the LV myocardium with similar signal caharacteristics to normal myocardium
Cardiac hamartoma
68
Location of cardiac sarcomas
Intramural and/or intracavitary
68
Tumor thrombus vs bland thrombus
Presence of heterogeneous enhancement on CT will help distinguish tumor thrombus from bland thrombus
68
Cardiac sarcoma subtype: RA
Angiosarcoma
68
Frequently involved in cardiac sarcoma metastasis
Lungs - Dyspna as MC symptom
69
Cardiac sarcoma subtype: LA
Undifferentiated sarcoma, osteosarcoma
69
Cardiac sarcoma subtype: posterior wall of LA or IVC
Leiomyosarcoma
70
Cardiac sarcoma subtype: no chamber predilection
Rhabdomyosarcoma
71
Cardiac sarcoma subtype: LA or RA
Liposarcoma
72
The only cardiac sarcoma that predominantly arises in the RA in the region of the R AV groove
Cardiac angiosarcoma
72
Cardiac sarcoma vs myxoma on LA involvement
Myxomas are not infiltrative and do not invade into pulmonary veins in contrast to sarcomas
73
MC location of primary cardiac lymphoma
RA (R atrioventricular groove) similar to angiosarcoma, (next RV, then Left chambers)
73
T or F Primary cardiac lymphomas are more common than secondary cardiac
FALSE
74
Usual type of cardiac lymphoma
Non-Hodgkin lymphoma
74
Acute vs chronic thrombus
Acute = hyperintense on T1 and T2. Chronic =hypointense on both T1 and T2. Both dark in delayed enhancement.
74
Thrombus vs tumor
Thrombus is hypodense on Ct and does not enhance.
75
Imaging of choice in distinguishing thrombus from tumor
Cardiac MRI
75
Distinguishing feature of cardiac lymphomas
Tendency to extend along pericardium encasing adjacent vascular structures. Infiltrative with homogeneous signal throughout the lesion dt absence of necrosis or hemorrhage
75
Septal thickness: normal vs lipomatous hypertrophy
Normal = less than 1cm; lipomatous = more than 2cm
75
Dumbell-shape fatty massin the interatrial septum with sparing of fossa ovalis
Lipomatous hypertrophy of interatrial septum (avid FDG uptake)
75
What are the mimickers of cardiac masses?
Lipomatous hypertrophy, moderator band, papillary muscles
76
How can we differentiate true cardiac masses?
Most cardiac masses do not deform the outer contour of the heart
76
MV apparatus: attach the papillary miscles to leaflets and prevent proplapse of
leaflets to atrium
Choedae tendineae
76
Blood supply: posteromedial papillary miscle
RCA
76
MV apparatus: aid the valves to rapidly coapt during systole to prevent regurgitant flow
Contraction of papillary muscles
76
Mitral valve apparatus
1)valve leaflets (anterior and posterior), 2)chordae tendineae, 3)papillary muscles
77
Tricuspid valve: leaflets
1) anterior 2)posterior 3)septal -attached by chordae tendineae to 3 papillary muscles (anterior, posterior, and septal)
77
Blood supply: anterolateral papillary miscle
LAD or LCx
78
Aortic valve: 3 cusps
Named accdg to sinuses of Valsalva: 1)left - LCA, 2)right - RCA, 3)posterior -noncoronary cusp
79
Facing sinuses of Valsalva
Left and right cusps abut/face the pulmonary valve, thus the term
80
Primary modality for evaluation of suspected valve disease
Echocardiography
81
Chronic degeneration of mitral valve fibrous ring seen as "O" or "C" shape dense structure
Mitral annular calcifications (MACs)
82
Quantitative gold standard for complete visualization of heart and measurement of blood flow
Cardia MRI
83
MC type of subaortic stenosis resulting in murmur
Subaortic membrane
83
Clinical gold standard for noninvasive measurement of blood flow and used to quantify severity of valvular stenosis or regurgitation
Phase-contrast MR
84
What are the 2 primary metrics in quantifying valvular regurgitation?
1)regurgitant volume -amount of blood flow backwards, 2)regurgitant fraction -Rvol divided by forward flow volume
85
MC CHD affecting 1% of adults
Bicuspid aortic valve (BAV) -2 leaflets are partially or completely fused
86
Valvular disease associated with aortic coarctation
BAV
87
Valvular disease: fish-mouth opening of valve during systole
BAV
88
MCC of acquired aortic valve disease
Degenerative calcification and chronic leaflet deterioration
89
Aortic stenosis grading (by measuring the estimates of aortic valve area AVA)
Moderate = AVA <1.5cm2; Severe = AVA <1cm2; Critical = <0.5cm2
90
Bowing of mitral leaflet 2mm or more beyond the annular plane into LA in ventricular systole
MVP -rupture or elongation of chordae tendineae
91
MC affected leaflet in MVP
middle scallop of posterior leaflet (P2 segment)
92
What are the conditions associated with MVP?
Marfan syndrome, COA, ASD (ostium secundum)
