CARDIOVASCULAR RADIOLOGY

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CARDIOVASCULAR RADIOLOGY

CARDIAC MR:

In cardiac MR, five different views of the heart: sagittal, coronal, axial (sometimes called transverse or transaxial), long axis and shortaxis. The views are presented according to the standard radiological convention of being viewed from below rather than the anatomical convention of being viewed from above. Of these five views the sagittal, coronal and axial views are classical cross-sectional views applied to all regions of the, body while the short and long axis views are standard cardiac views.

Each image is planned from a scout view that is perpendicular to the view of interest. Thus the axial view is planned from a coronal scout, the coronal from an axial, the sagittal from a coronal, the short axis from a long, and the long axis from a short axis scout. The long axis image plane is determined by the line that runs from the apex of the heart to a midpoint at the base of the heart, often taken to be midway between the mitral valve leaflets. The short axis is perpendicular to it.


(Figure A: vertical long axis)	(Figure B: horizontal long axis)	(Figure C: short axis)

(Images taken from Lawson et al)

PENTALOGY OF CANTRELL:

=tetralogy of fallot + asd

TRILOGY OF FALLOT:

PS, RV hypertrophy, patent foramen ovale

VASCULAR RINGS:

the most common cause is double aortic arch, second is R arch with aberrant L SCA, and third is pulmonary sling

HYPOPLASIA OF THE LEFT PA:

concerning hypoplasia of the left PA, the following are true:

Expiratory film is useful to differentiate from Swyer-James

The left lung is hyperlucent

Associated with a right aortic arch

Most cases are associated with tetralogy of Fallot

CHANGE IN HEART SIZE WITH SYSTOLE AND DIASTOLE:

In a study of 324 patients, comparison was made between systole & diastole. The change in diameter, was < 0.3 cm in 52 %, 0.4-0.9cm in 41 %, and 1-1.7 CM IN 7%

CORONARY ARTERY TERRITORIES:

LCA: anterior wall and superior 2/3 of the septum

RCA: inferior wall and inferior 1/3 of the septum

CX: lateral and posterior wall

dominance refers to the artery that supplies the diaphragmatic aspect of the septum and LV and 85% of pts have R sided dominance

APPROACH TO CHD:

approach to classification of CHD (Weissleder): see the figure below:

in D-TGA:

there are 2 independant circulations, ie it is uncorrected. The following diagram from the Green Book can help determine the relative postions of the valves in TGA. NOTE: The orientation is looking down on it:

CARDIAC VALVULAR CALCIFICATIONS:

in MR you do get ca++ of the annulus fibrosis (weissleder p 134). They are degen in pts > 70. For AS, valvular Ca++ is the most common. Get them in bicuspid and rheumatic. The radiographic appearance of valve calcs of the aorta correlates with the severity of dz.

Subvalvular: 50% are AD and seen in IHSS. They can be congenital. Supravalvular: Williams and Rubella.

VALVE AREAS:

mitral: 4-6 cm2 and aortic: 2-4 cm2 are considered normal

LV ANEURYSMS:

1. congenital: rare

submitral and subaortic

2. acquired: MI, Chagas.

True (70%): come from transmural MI, L anterior is most common while anterior apical is less common. You see a focal bulge near the left heart border.Rim Ca++ are rare. There is a wide communication. They rarely rupture. Because of the large area of involvement of the LV, they are more likely to produce arrythmias and LV dysfunction then the false aneurysms

False (30%): they are a contained rupture of the LV wall which is contained by pericardium----> these patients end up with pericarditis. Can be caused by trauma or s/p MI. They are located on the posterior lateral or posterior inferior diaphragmatic wall of the LV.The diameter of the mouth is small., and they have a greater risk of rupture. Thay are also called pseudoaneurysms. They involve the myocardium

CHD INCIDENCE:

vsd> tof > pda > asd. note that asd is the most common chd in pts > 20 years old. VSD is still the most common for both infants and neonates combined

R ARCH ASSOCIATIONS:

truncus arteriosus: 35%, tof: 25%. tga: 10% and ta: 5%

NEONATAL CYANOSES:

tga>ta>truncus arteriosus and tapvr below the diaphragm

ORIGIN OF TOF:

caused by abnormality in the embryology of the conal septum

EBSTEINS:

get a huge heart (box shaped). The pathologic process is atrialization of the RV due to downward displacement of the tricuspid valve leaflets which reduces forward flow to the lungs. It is associated with maternal intake of lithium containing medications

CAUSES OF PULM EDEMA IN THE IMMEDIATE NEONATAL PERIOD:

cor tritriatrium, tapvr below the diapragm, hypoplastic L heart

CAUSES OF CYANOSIS WITH DECREASED VASCULARITY:

tof, ta, ps. of these, tof is the most common cause

TAPVR:

type 1 or supracardiac is 52% of total and is drainage of pulmonary veins into L BCV, R and L persistent SVC/azygous

type 2 is cardiac which is 30% of total. drainage is into the coronary sinus or RA

the hemodynamics is a funtional L to R shunt. An ASD is required to restore oxygenated blood to the left side. there is cyanosis due to mixing of systemic and pulmonary venous blood in the RA

type 3 is the subdiaphragmatic drainage type (12%) which is a functional R to L shunt. drainage is into the portal vein, IVC, ductus venosus, L gastric vein with constriction of the descending pulmonary vein by the diaphragm on route through the esop hiatus leading to pulmonary venous hypertension and RV pressure overload. death in a few days. it is associated with asplenia (80%) and polysplenia

VARIANT ANATOMY OF THE CORONARY ARTERIES:

A TV star sued his cardiac surgeon because, in a by-pass operation, he negligently removed the healthy coronary artery leaving the defective one behind. The surgeon was an experienced cardiac surgeon. The attorney for the surgeon argued in court that the mix-up was a natural result of "abnormalities in the patient's heart". The lawyers put the patient's arteries on trial. Their defense was that the patient had "freakish anatomy". The case was settled out of court in favor of the patient. Information source: People (Weekly). 612/00. Variations of the coronary arteries are numerous, well known and are easily accessed.

NORMAL RELATIONSHIPS OF THE HEART VALVES:

One more thing they might ask: pulmonary valve in relation to the aortic valve is anterior, inferior and left. Almost anything can possible be asked in terms of what is anterior or posterior to what so check this out:

Key: AC = anterior cusp, RC = right cusp, LC = left cusp, NC = non coronary cusp, PL = posterior leaflet, AL = anterior leaflet, SL = septal leaflet

ABERRANT VS ANOMALOUS CORONARY ARTERY:

The aberrant coronary artery originates from the right cusp and usually presents in young adults during athletic activity. The anomalous coronary artery originates form the pulmonary artery and presents in infancy. In the case of an anomalous right coronary trunk, there are usually no dire consequences. In the case of an anomalous left coronary trunk, the patients usually die of myocardial ischemia at 13 months or longer (see below)

MORE ON ANOMALOUS CORONARY ARTERIES:

The right coronary artery occasionally arises from the pulmonary trunk, usually without adverse consequences. Cases have also been reported of the left coronary arising from the pulmonary trunk, but this is usually associated with myocardial ischemia, with patients dying at 13 months or younger. In one case, however, a female patient survived 60 years; in another case, a male survived 34 years (cause of death unrelated to heart disease). In 14,000 consecutive autopsies, this condition was found three times. When both coronary arteries arise from the pulmonary trunk, death occurs shortly after birth.

EVEN MORE ON ABERRANT VS ANOMALOUS CORONARY ARTERIES:

Aberrant origin of either the right or left coronary artery occurs from the opposite sinus of Valsalva. The aberrant artery travels between the aorta and right ventricular outflow tract (RVOT) and may be hypoplastic and /or kinked. It may be mechanically compressed by the great vessels particularly during exercise or with hypertension.

Anomalous origin of the left coronary artery (LCA) from the pulmonary artery.

This occurs in 1/300,000 births. The ectopic LCA has a variable number of intercoronary collaterals which connect to the otherwise normal RCA. There may be segmental left ventricular dysfunction and papillary muscle dysfunction with associated mitral regurgitation. As mentioned above, the condition is fatal in infancy if it involves the left coronary artery, but is not fatal if it involves the right ventricle

Pulmonary hypertension with an intracardiac shunt may mask the presence of the ectopic LCA which then presents as mitral regurgitation.

The above figure 1 caption should say "aberrant origin of left main coronary....."

The second diagram shows an unusual left coronary artery, with origin from right aortic sinus, and course between the bases of aorta and pulmonary artery. No circumflex branch.

SUPPLY OF THE SA AND AV NODES:

It has been reported that in 50% of hearts, the sinoatrial and atrioventricular nodes were supplied by the right coronary, and in 7% of hearts, these nodes were supplied by the left coronary. In the remainder (43%), one artery supplied one node and the other artery supplied the other, in either combination. Spalteholz, however, reported the sinoatrial node to be supplied in 68% of cases by the right coronary, in about 32% by the left coronary, and very rarely by an extracardiac artery.

THE LCX:

The left coronary circumflex branch may be larger and longer than usual, giving off the posterior interventricular artery before anastomosing with a smaller right coronary artery on the posterior surface of the heart.

SEPTAL BRANCH OF THE R CORONARY ARTERY:

An infrequent branch of the right coronary is a septal branch that supplies the middle part of the septum and both limbs of the conduction system.

OTHER ORIGINS OF THE CORONARY ARTERIES:

Occasionally, a coronary artery arises from the common carotid, later giving rise to right and left branches. "Large and direct" anastomoses between the right and left coronary arteries have been reported in 9% of individuals. Smaller anastomoses between the two vessels occur in most hearts. The absence of right/left coronary anastomoses was said to occur in 3% of hearts.

THE INTERVENTRICULAR OR DESCENDING CORONARY ARTERY:

The anterior interventricular (descending) coronary artery and vein have been reported to arise from the left internal thoracic (mammary) artery and vein (Robicsek, et al.).

BENIGN CORONARY ANOMALIES:

a) Separate origin of left anterior descending artery and left circumflex from the left sinus Valsalva (513 cases, 0.41% incidence, 30.4% of all anomalies).

b) Absent left circumflex (with maximally dominant right coronary artery) (4 cases, 0.003% incidence, 0.24% of all anomalies).

c) Origin of left circumflex from right coronary or right sinus of Valsalva (467 cases, 0.37% incidence, 27.7% of all anomalies).

d) Ectopic origin of right coronary artery or left main trunk from posterior sinus of Valsalva (Left main trunk; 16 cases, 0.0008% incidence, 0.95% of all anomalies. Right coronary; 4 cases, 0.003%, 0.24% of all anomalies).

e) Ectopic coronary origin from the ascending aorta (Left main trunk; 16 cases, 0.013% incidence, 0.95% of all anomalies. Right coronary; 188 cases, 0.15% incidence, 11.2% of all anomalies).

f) Intercoronary communication (3 cases, 0.002% incidence, 0.18% of all anomalies).

g) Small coronary artery fistulae (163 cases, 0.12% incidence, 9.7% of all anomalies). Total No. Anomalies...1359, Incidence...1.07%, Of all anomalies...80.6%.

POTENTIALLY MORE SERIOUS ANOMALIES:

a) Ectopic coronary origin from the pulmonary artery (Bland-White-Garland syndrome) (Left main trunk from pulmonary; 10 cases, 0.008 % incidence, 0.59% of all anomalies).
Left anterior descending; 1 case, 0.0008% incidence, 0.06% of all anomalies.

Right coronary artery from pulmonary artery; 2 cases, 0.002% incidence, 0.12% of all anomalies).

b) Ectopic origin of the left coronary artery from the right sinus of Valsalva Left main trunk from right sinus of Valsalva; 22 cases, 0.017 % incidence, 1.3% of all anomalies.

Left anterior descending from right sinus of Valsalva; 38 cases, 0.03% incidence, 2.3% of all anomalies.

Right coronary artery from left sinus of Valsalva; 136 cases, 0.107% incidence, 8.1% of all anomalies.

VARIATIONS IN CORONARY OSTEA:

MORE VARIATIONS IN THE OSTEA (upper left; The typical pattern of ostia and vessels. 1,2,3, pulmonary semilunar valve; 4,5,6, aortic semilunar valve; 7,8,9, tricuspid valve; 10,11, mitral valve; 4, origin of left coronary artery; 5, origin of right coroner artery):

DEBAKEY CLASSIFICATION OF AORTIC DISSECTION:

type 1: 29-34% is ascending aorta and portion distal to arch

type 2: 12 - 21% is ascending aorta only

type 3: 50% is descending aorta only

stanford A: 70%ascending aorta plus or minus arch in 4 cm (affects ascending aorta and arch)

stanford B: 20-30% affects descending aorta only

surgical procedures for cardiac:

ap window: side to side between ascending aorta and left pa for tof

blalock taussig: end to side sca to pa for tof/ta/pulmonic stenosis

pott: descending ao to l pa for tof

waterson cooley: ascending ao to r pa for tof

blalock hanlon: surgical asd for tga

mustard: septostomy and atrial baffle for tga

rashkind: septostomy for tga

rastelli: conduit rv to pa for tga

jetene: arterial switch for tga

fontan: conduit ra to pa for ta

glenn: svc r pa for ta

norwood: pa and descending ao conduit, followed by pa banding for palliation prior to heart transplant for hypoplastic l heart sydrome

senning: this is the same as the mustard except it uses synthetic material

pulmonary artery banding: multiple small VSDs and pulmonic stenosis

ross: autologous transfer of pulm vein to aortic postition for aortic stenosis

TRUNCUS ARTERIOSIS:

One great artery arising from the heart giving rise to coronary, pulmonary, systemic arteries. It straddles a large vsd. It represents 2% of all CHD. (by comparison TGA is 10%). There are 4 types: see figure. Type 1 (50%) main PA and aorta arising from common trunk. Type 2 is 25%; both PA's come from the back of the trunk. Type 3 (10%) both PA's come from the side of the trunk. Type 4 pseudotruncus or absent PA's. Pulmonary supply comes from collaterals arising from the descending aorta

COR TRITRIATRIUM:

quick note on cortriatriatum since i keep on forgetting what this is:

very rare, incomplete incorporation of PV into the LA causing obstruction to pulmonary venous return. It mimics congen mitral stenosis but has a normal LA size. It is associated with a parachute MV, mitral web and CHF

AORTIC STENOSIS-ANGIODYSPLASIA ASSOCIATION:

aortic stenosis is associated with angiodysplasia in 20% of cases, and usually present as R colon GI bleed

MOST COMMON CHD CAUSING CENTRAL CYANOSIS SHORTLY AFTER BIRTH (GRAINGER AND ALLISON):

uncorrected tga or d-tga is most common shortly after birth even though Fallot is more frequent than tga overall sue to its peak presentation at 2-6 y of age. d tga usually have a normal heart size at birth. dtga usually needs an additional anomaly for the circulations to mix. This is usually a vsd. d tga is only associated with R sided arch in 5%. d-tga has an egg on its side configuration. Corrected tga is only 15% of tga

SOME INPORTANT CAUSES OF A RIGHT SIDED ARCH (GRAINGER AND ALLISON):

truncus arteriosus, tof, tricuspid atresia. All these are cyanotic

MOST COMMON CAUSE OF A VASULAR RING:

this is right arch with aberrant L subclavian artery; however, this does not usually require surgery. The most common cause of a tight ring that requires surgery is type 1 double aortic arch

there are 3 types of rings:

#1: DAA

#2: R arch with aberrant L SCA and ductus arising from PA to descending aorta

#3: R arch with mirror image branching and a ductus to the descending aorta

sling L PA arisin from R PA

BICUSPID AORTIC VALVE:

this is the most common cause of congenital valvular stenosis. Most cases of bicuspid aortic valve do not cause problems until until the valve thickens and calcifies in early adulthood. Supravalvular aortic stenosis is associated with peripheral pulm artery stenosis (Williams syndrome)

WILLIAMS SYNDROME:

hypercalcemia, elfin facies, mental retardation, dwarfism, supravalvular aortic stenosis, and peripheral pulmonary artery stenosis

WHERE IS THE NARROWING IN TOF?

before the valve ie rvot

EISENMENGERS:

in rare cases of VSD, can get reversal of flow through a vsd called eisenmengers syndrome. Other causes are asd and pda in addition to vsd. It is usually caused by long standing shunts

OTHER CAUSES OF RIB NOTCHING:

takayasu, tof, vena cava obstuction

VERTICAL VEIN IN SUPRACARDIAC AND SUPRADIAPHRAGMATIC TAPVR:

it is on the L and behind the LA and ascends vertically in front of the L hilum to drain into the L BCV. PAPVR may also be associated with the vertical density on the L. This is scimitar sydrome: R>L

INFRACARDIAC DRAINAGE OF TAPVR:

it is usually obstructed. There is pulm venous congestion, and edema. The heart size is not enlarged as there is RV pressure overload and not volume overload