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Imaging of the Heart and Great Vessels

Imaging of the Heart and Great Vessels

Worldwide, the most frequent cause of death is heart disease. Thus, the common conditions that are evaluated in healthcare facilities are often related to the heart or the cardiovascular system: hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, atherosclerotic disease, and heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR). In radiologic terms, this region is likely the most frequently studied aspect of human anatomy in healthcare delivery settings. Multiple methods are used, including X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests, CT, MRI, echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA), nuclear imaging Nuclear Imaging Nuclear imaging is the radiologic examination using radiopharmaceuticals, which are radioactive substances taken up by specific types of cells. Nuclear medicine is more concerned with the functional and molecular aspects of the organ or pathology being investigated rather than the structure. Nuclear Imaging, and angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery. Each test has its advantages and disadvantages and is obtained on the basis of the clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor, acuity of symptoms, and risks and benefits to the patient. It is important to know the roles of imaging studies to help determine the proper treatment.

Last updated: 15 Feb, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Chest X-ray

Overview

  • Chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests: most common imaging test to evaluate the heart and great vessels; usually the initial test before using more expensive diagnostic tools:
    • Shadows that form the cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) silhouette allow for assessment of the size and shape of the heart and major vessels. 
    • Lung parenchymal findings also give information regarding pulmonary pathologies secondary to cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) abnormalities (e.g., pulmonary edema Pulmonary edema Pulmonary edema is a condition caused by excess fluid within the lung parenchyma and alveoli as a consequence of a disease process. Based on etiology, pulmonary edema is classified as cardiogenic or noncardiogenic. Patients may present with progressive dyspnea, orthopnea, cough, or respiratory failure. Pulmonary Edema). 
    • Also used in the evaluation of the mediastinum Mediastinum The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels. Mediastinum and Great Vessels: Anatomy 
  • Positioning for specific views:
    • Posteroanterior (PA):
      • Board is against the anterior chest.
      • X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests beams posterior → anterior direction through patient
    • Anteroposterior (AP):
      • Board is against the back. 
      • X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests beams anterior → posterior direction through the patient
    • Lateral (from side):
      • Patient is upright.
      • Board is against the left or right side.
    • Lateral decubitus (from side while laying down): 
      • Patient is supine.
      • Board is against the side.
      • Usually left side down on table 
  • Penetration Penetration X-rays: degree to which radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma has passed through body, resulting in darker or lighter image
    • Good penetration Penetration X-rays:
      • Ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy are only faintly visible behind the heart. 
      • Vascular markings are nonprominent but clear. 
    • Underpenetration: film appears whiter and features are less apparent.
    • Overpenetration: film appears darker and features are less apparent. 
  • Different standard projections

    Different standard projections:
    Chest X-rays can be taken from multiple directions, called “views.” Each view has benefits and drawbacks for different pathologies. The 3 common views are posteroanterior, anteroposterior, and lateral.

    Image by Lecturio.
  • Differences between expiratory and inspiratory chest x-ray

    Differences between an expiratory and an inspiratory chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests:
    Note that in the inspiratory X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests, the posterior ribs Ribs A set of twelve curved bones which connect to the vertebral column posteriorly, and terminate anteriorly as costal cartilage. Together, they form a protective cage around the internal thoracic organs. Chest Wall: Anatomy and the pulmonary parenchyma are more easily seen, while in the expiratory X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests, the parenchyma looks hazy and lacks definition.

    Image by Hetal Verma.

Anatomy

The following structures must be identified and checked for abnormalities in size or shape:

  • Pa projection of the chest identifying mediastinal structures

    Posteroanterior projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms of the chest identifying the mediastinal structures:
    PA: pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy
    SVC: superior vena cava Superior vena cava The venous trunk which returns blood from the head, neck, upper extremities and chest. Mediastinum and Great Vessels: Anatomy

    Image by Hetal Verma.
  • Lateral projection of the chest identifying the mediastinal structures

    Lateral projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms of the chest identifying the mediastinal structures

    Image by Hetal Verma.

Heart

  • On a plain chest film, heart size is quickly assessed calculating the cardiothoracic index (CI): the percentage of the chest diameter occupied by the heart. 
    • A normal CI is < 50%. 
    • However, this is reliable only on a PA projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms taken upright.
  • An enlarged heart can be due to:
    • Cardiomegaly Cardiomegaly Enlargement of the heart, usually indicated by a cardiothoracic ratio above 0. 50. Heart enlargement may involve the right, the left, or both heart ventricles or heart atria. Cardiomegaly is a nonspecific symptom seen in patients with chronic systolic heart failure (heart failure) or several forms of cardiomyopathies. Ebstein’s Anomaly
    • Pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade (water-bottle heart): pericardial effusions must be ≥ 250 mL to be detectable on a chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests.
    • Valvular disease
    • Congenital Congenital Chorioretinitis heart disease
    • Masses
Table: Artifactual causes of cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) enlargement
Cause Observation
Rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays The shadow of the heart appears bigger in the projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms because of the rotation Rotation Motion of an object in which either one or more points on a line are fixed. It is also the motion of a particle about a fixed point. X-rays of the subject to either side.
Suboptimal inspiration Inspiration Ventilation: Mechanics of Breathing The diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy moves upward and compresses the heart.
Portable supine film Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) silhouette undergoes magnification because the cassette is placed in contact with the posterior aspect of the patient and the X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests beam penetrates from the anterior aspect.
Pectus excavatum Pectus Excavatum Cardiovascular Examination The heart is compressed between the sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy and the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.
  • Pa x-ray projections of the chest showing the calculation of the cardiothoracic index
    Posteroanterior (PA) X-ray projections of the chest showing the calculation of the cardiothoracic index:

    Left: Normal index (< 50%)

    Right: Cardiac index > 50%, indicative of cardiac enlargement. Image by Hetal Verma.
  • Lateral x-ray projections showing a normal heart (left) and an enlarged heart (right)

    Lateral X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests projections showing a normal heart (left) and an enlarged heart (right):
    On the left, note how the anterior and posterior spaces of the heart are preserved, while on the right the posterior aspect of the heart is almost in contact with the thoracic spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy.

    Image by Hetal Verma.
  • Differences between ap (left) and pa (right) x-ray projections

    Differences between anteroposterior (AP) (left) and posteroanterior (PA) (right) X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests projections:
    In the AP view, the structures that are farther away from the cassette, such as the heart, are magnified.

    Image by Hetal Verma.
  • Pa (left) and lateral (right) x-ray projections of the chest showing left ventricular enlargement

    Posteroanterior (PA) (left) and lateral (right) X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests projections of the chest showing left ventricular enlargement:
    On the PA projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms, note the enlargement of the left cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) margin (arrow). On the lateral projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms, note the posterior cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) margin occupying the posterior cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) space (arrow).

    Image by Hetal Verma.
  • Chest x-ray showing right atrial enlargement

    Chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests showing right atrial enlargement:
    Note the enlargement of the right cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) margin.

    Image by Hetal Verma.
  • Chest x-ray showing left atrial enlargement

    Chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests showing left atrial enlargement:
    Note the enlargement of the upper portion of the left cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) margin.

    Image by Hetal Verma.

Great vessels

  • In the PA and AP projections, the great vessels can be identified at either side of the mediastinal shadow. 
  • In a lateral projection Projection A defense mechanism, operating unconsciously, whereby that which is emotionally unacceptable in the self is rejected and attributed (projected) to others. Defense Mechanisms, only the shadow of the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy can be distinguished.

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Echocardiography

Overview

  • Ultrasound principles are used in echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) to produce anatomical images of the heart and great vessels. 
  • Common indications:
  • Echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) is likewise an essential tool in assessing the dynamic function of the heart in stress tests (exercise or dobutamine Dobutamine A catecholamine derivative with specificity for beta-1 adrenergic receptors. Sympathomimetic Drugs stress echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA)).

Evaluation of the heart and great vessels

  • Transthoracic echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) (TTE):
    • More common; noninvasive
    • Uses a handheld transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) positioned on the chest to scan the heart
    • Provides the clinician Clinician A physician, nurse practitioner, physician assistant, or another health professional who is directly involved in patient care and has a professional relationship with patients. Clinician–Patient Relationship with the ability to quickly assess the heart, especially in life-threatening situations
    • Allows for the rapid distinction between cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) (e.g., pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade) and extracardiac (e.g., pulmonary embolus) causes of illness
  • Transesophageal echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) (TEE):
    • Improved image quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement (especially posterior cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) structures) because of the proximity of the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy to the heart
    • Because of TEE’s invasive nature, TTE often precedes TEE.
    • Commonly used in:
      • Evaluation for a cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) source of embolus
      • Valvular assessment in cases of endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis 
      • Determination of left atrial appendage (LAA) thrombi in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation 
  • Modalities:
  • Interpretation includes:
    • Reason for the test
    • Quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement of image
    • Rate and rhythm
    • Chamber sizes
    • Hypertrophy Hypertrophy General increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia). Cellular Adaptation
    • Right ventricular function
    • Left ventricular systolic function:
      • Ejection fraction Ejection fraction Cardiac Cycle = ( stroke volume Stroke volume The amount of blood pumped out of the heart per beat, not to be confused with cardiac output (volume/time). It is calculated as the difference between the end-diastolic volume and the end-systolic volume. Cardiac Cycle [end diastolic volume – end systolic volume]/end diastolic volume) Ă— 100
      • Wall motion
    • Left ventricular diastolic function
    • Valves
    • Mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast or thrombus
    • Atrial or ventricular septal defect Ventricular Septal Defect Tetralogy of Fallot
    • Pericardium Pericardium A conical fibroserous sac surrounding the heart and the roots of the great vessels (aorta; venae cavae; pulmonary artery). Pericardium consists of two sacs: the outer fibrous pericardium and the inner serous pericardium. The latter consists of an outer parietal layer facing the fibrous pericardium, and an inner visceral layer (epicardium) resting next to the heart, and a pericardial cavity between these two layers. Heart: Anatomy
    • Other findings can include aneurysms, pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. Pleural Effusion, and incidental findings.
  • Process of obtaining transthoracic echocardiographic imaging

    Process of obtaining transthoracic echocardiographic imaging: transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) is placed on the chest to obtain views of the heart.

    Image: “Heart lpla echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) diagram” by Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. License: CC BY 2.5
  • Diagram of transesophageal echocardiogram

    Transesophageal echocardiogram Echocardiogram Transposition of the Great Vessels:
    An endoscope is used to guide the transducer Transducer A device placed on the patient’s body to visualize a target Ultrasound (Sonography) into the esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy. In most adults, the probe Probe A device placed on the patient’s body to visualize a target Ultrasound (Sonography) is advanced to the proximal esophagus Esophagus The esophagus is a muscular tube-shaped organ of around 25 centimeters in length that connects the pharynx to the stomach. The organ extends from approximately the 6th cervical vertebra to the 11th thoracic vertebra and can be divided grossly into 3 parts: the cervical part, the thoracic part, and the abdominal part. Esophagus: Anatomy or midesophagus (or a depth of 28 to 30 cm from the incisors Incisors Any of the eight frontal teeth (four maxillary and four mandibular) having a sharp incisal edge for cutting food and a single root, which occurs in man both as a deciduous and a permanent tooth. Teeth: Anatomy).

    Image: “Transesophageal echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA) diagram” by Patrick J. Lynch, medical illustrator; C. Carl Jaffe, MD, cardiologist. License: CC BY 2.5
  • Echocardiogram apical 4 chamber view of the heart

    Echocardiogram Echocardiogram Transposition of the Great Vessels:
    Apical 4-chamber view of the heart

    Image: “Apical 4 chamber view” by Patrick J. Lynch and C. Carl Jaffe. License: CC BY 2.5
  • Echocardiogram apical 2 chamber view of the heart

    Echocardiogram Echocardiogram Transposition of the Great Vessels:
    Apical 2-chamber view of the heart

    Image: “Apical2Chamber” by Patrick J. Lynch and C. Carl Jaffe. License: CC BY 2.5
  • Echocardiogram showing a left atrial myxoma

    Echocardiogram Echocardiogram Transposition of the Great Vessels showing a left atrial myxoma Myxoma A benign neoplasm derived from connective tissue, consisting chiefly of polyhedral and stellate cells that are loosely embedded in a soft mucoid matrix, thereby resembling primitive mesenchymal tissue. It occurs frequently intramuscularly where it may be mistaken for a sarcoma. It appears also in the jaws and the skin. Cardiac Myxoma

    Image: “ Echocardiogram Echocardiogram Transposition of the Great Vessels showing left atrial myxoma Myxoma A benign neoplasm derived from connective tissue, consisting chiefly of polyhedral and stellate cells that are loosely embedded in a soft mucoid matrix, thereby resembling primitive mesenchymal tissue. It occurs frequently intramuscularly where it may be mistaken for a sarcoma. It appears also in the jaws and the skin. Cardiac Myxoma (arrow)” by Al AL Amyloidosis-Said Y, Al AL Amyloidosis-Rached H, Baeesa S, Kurdi K, Zabani I, Hassan A. License: CC BY 3.0

Cardiac Scan

Overview

  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) scan: 
    • Also called heart scan or myocardial perfusion imaging Myocardial perfusion imaging The creation and display of functional images showing where the blood is flowing into the myocardium by following over time the distribution of tracers injected into the bloodstream. Nuclear Imaging
    • Detects variation in blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure and myocardial extraction of radiotracers 
    • Materials: 
      • Isotopes: technetium-99m, thallium-201 
      • Radiopharmaceutical (radioisotope + organic molecule): sestamibi, teboroxime
  • Procedure:
    • In normal coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology, significant arterial dilatation is seen in response to exercise/stress.
    • Stenotic areas do not show dilatation; thus, ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage and ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) changes occur. 
    • In this test, stress is either:
      • Exercise-induced by running on a treadmill
      • Pharmacologically induced by injecting adenosine Adenosine A nucleoside that is composed of adenine and d-ribose. Adenosine or adenosine derivatives play many important biological roles in addition to being components of DNA and RNA. Adenosine itself is a neurotransmitter. Class 5 Antiarrhythmic Drugs or dobutamine Dobutamine A catecholamine derivative with specificity for beta-1 adrenergic receptors. Sympathomimetic Drugs for those who cannot run 
  • Imaging is obtained both during stress and at rest.
  • Radiopharmaceuticals Radiopharmaceuticals Compounds that are used in medicine as sources of radiation for radiotherapy and for diagnostic purposes. They have numerous uses in research and industry. Nuclear Imaging are injected when 85% of the maximum predicted heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology (MPHR) is reached.
  • Indications:
    • Myocardial ischemia Myocardial ischemia A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries (coronary artery disease), to obstruction by a thrombus (coronary thrombosis), or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Coronary Heart Disease or MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction evaluation
    • Wall-motion abnormalities: done by ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG)-gated SPECT SPECT An imaging technique using a device which combines tomography, emission-computed, single-photon and tomography, x-ray computed in the same session. Nuclear Imaging scan
    • Calculate left ventricular ejection Ventricular ejection Cardiac Cycle fraction
  • Normal cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) scan obtained in 3 different planes:
    • The top row of each set is performed under cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) stress
    • Bottom row of each set is performed at rest
    • Normal flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure to all aspects of the heart both at rest and during stress
Normal myocardial perfusion scan with thallium-201

Normal myocardial perfusion scan with thallium-201 for the rest images (bottom rows) and technetium-sestamibi for the stress images (top rows)

Image: “Nl mpi2” by Myohan. License: CC BY 3.0

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CT

Overview

  • Thoracic CT is very useful for studying the anatomy of the heart Anatomy of the heart The heart is a 4-chambered muscular pump made primarily of cardiac muscle tissue. The heart is divided into 4 chambers: 2 upper chambers for receiving blood from the great vessels, known as the right and left atria, and 2 stronger lower chambers, known as the right and left ventricles, which pump blood throughout the body. Heart: Anatomy, great vessels, and mediastinum Mediastinum The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels. Mediastinum and Great Vessels: Anatomy. 
  • The use of IV contrast allows for adequate visualization of the heart chambers and the venous and arterial anatomy. 
  • Even though a CT scan is usually displayed as slices, the image data can be manipulated to obtain a 3-dimensional reconstruction of the anatomy.
  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) CT, though, is associated with high dose of ionizing radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma, and use of contrast material carries a risk for renal failure Renal failure Conditions in which the kidneys perform below the normal level in the ability to remove wastes, concentrate urine, and maintain electrolyte balance; blood pressure; and calcium metabolism. Renal insufficiency can be classified by the degree of kidney damage (as measured by the level of proteinuria) and reduction in glomerular filtration rate. Crush Syndrome.

Heart

  • Coronary CTA CTA A non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases. Pulmonary Function Tests (CCTA):
    • For evaluation of the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology in cases of indeterminate stress tests
    • Characterizes coronary or cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) anomalies, including location and patency of bypass grafts
    • Triple rule-out in emergency situations of atypical chest pain Atypical chest pain Vasospastic Angina:
      • Atherosclerotic disease
      • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism
      • Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection
  • Coronary artery Coronary Artery Truncus Arteriosus calcium Calcium A basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes. Electrolytes (CAC) scoring:
    • Noninvasive test that detects and quantifies CAC.
    • Generally recommended in asymptomatic adults ≥ 40 years of age with intermediate atherosclerotic cardiovascular disease risk
    • Requires a relatively low radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma dose (comparable to that for a screening Screening Preoperative Care mammography Mammography Radiographic examination of the breast. Breast Cancer Screening)
    • The amount of calcified plaque Plaque Primary Skin Lesions present in the epicardial coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology, reported as the total calcium Calcium A basic element found in nearly all tissues. It is a member of the alkaline earth family of metals with the atomic symbol ca, atomic number 20, and atomic weight 40. Calcium is the most abundant mineral in the body and combines with phosphorus to form calcium phosphate in the bones and teeth. It is essential for the normal functioning of nerves and muscles and plays a role in blood coagulation (as factor IV) and in many enzymatic processes. Electrolytes score (Agatston score):
      • No identifiable disease: 0 Agatston units
      • Mild disease: 1–99 Agatston units
      • Moderate disease: 100–399 Agatston units
      • Severe disease: ≥ 400 Agatston units 
    • Scoring provides guidance on further management (e.g., recommending aspirin Aspirin The prototypical analgesic used in the treatment of mild to moderate pain. It has anti-inflammatory and antipyretic properties and acts as an inhibitor of cyclooxygenase which results in the inhibition of the biosynthesis of prostaglandins. Aspirin also inhibits platelet aggregation and is used in the prevention of arterial and venous thrombosis. Nonsteroidal Antiinflammatory Drugs (NSAIDs) and lipid-lowering agents).
  • Anatomy of the heart on chest ct axial view

    Anatomy of the heart Anatomy of the heart The heart is a 4-chambered muscular pump made primarily of cardiac muscle tissue. The heart is divided into 4 chambers: 2 upper chambers for receiving blood from the great vessels, known as the right and left atria, and 2 stronger lower chambers, known as the right and left ventricles, which pump blood throughout the body. Heart: Anatomy on chest CT axial Axial Computed Tomography (CT) view:
    A 4-chamber view of the heart can be obtained with chest CT. The left atrium (LA) can be recognized with 2 pulmonary veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: Histology returning blood to it. The left ventricle (LV), with its thicker walls, is seen in continuity with the left atrium. The right atrium (RA) and right ventricle (RV) are more difficult to see in this image. The ascending and descending aorta Descending aorta Mediastinum and Great Vessels: Anatomy (A) are also visible.

    Image by Hetal Verma.
  • Axial chest ct visualizing the heart chambers

    An axial Axial Computed Tomography (CT) cut of a chest CT scan visualizing the heart chambers:
    Note the thickness of the left ventricular wall. Also, notice the descending aorta Descending aorta Mediastinum and Great Vessels: Anatomy behind the left atrium (LA).
    LV: left ventricle
    RA: right atrium

    Image by Hetal Verma.
  • Anatomy of the heart on chest ct on coronal view

    Anatomy of the heart Anatomy of the heart The heart is a 4-chambered muscular pump made primarily of cardiac muscle tissue. The heart is divided into 4 chambers: 2 upper chambers for receiving blood from the great vessels, known as the right and left atria, and 2 stronger lower chambers, known as the right and left ventricles, which pump blood throughout the body. Heart: Anatomy on chest CT on coronal Coronal Computed Tomography (CT) view:
    Coronal Coronal Computed Tomography (CT) view of the heart on chest CT provides more readily recognizable anatomic landmarks, with the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy (A) arising from the left ventricle (LV) and the superior vena cava Superior vena cava The venous trunk which returns blood from the head, neck, upper extremities and chest. Mediastinum and Great Vessels: Anatomy (SVC) feeding into the right atrium (RA). The left pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy (PA) can be seen head on, but its source (the right ventricle) is hidden in this image.

    Image by Hetal Verma.

Aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy

Aortic CTA CTA A non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases. Pulmonary Function Tests:

  • Contrast-enhanced CT can provide information on the thickness and composition of the vessel wall. 
  • Most common initial imaging for aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection evaluation
  • Allows for:
    • Documentation Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature. It often involves authenticating or validating information. Advance Directives of size and shape of aneurysms
    • Visualization of the true and false lumen False lumen Aortic Dissection in aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection
    • Characterization of calcification and stenoses 
    • Visualization of the anatomy of congenital Congenital Chorioretinitis anomalies
    • Evaluation of vasculitis Vasculitis Inflammation of any one of the blood vessels, including the arteries; veins; and rest of the vasculature system in the body. Systemic Lupus Erythematosus
  • Also useful to detect postoperative complications Postoperative Complications Pathologic processes that affect patients after a surgical procedure. They may or may not be related to the disease for which the surgery was done, and they may or may not be direct results of the surgery. Postoperative Care: 
    • Restenosis
    • Thrombosis Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus
    • Endoleak after aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms repair

Pulmonary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology

CT pulmonary angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery ( CTPA CTPA Pulmonary Function Tests):

  • Also called chest CT angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery with contrast
  • Most frequently used imaging to evaluate the pulmonary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
  • High sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques and specificity Specificity Specificity is the probability of correctly determining the absence of a condition. Immunoassays for pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism
An axial cut of a chest ct scan visualizing the great vessels

An axial Axial Computed Tomography (CT) cut of a chest CT scan visualizing the great vessels
A: aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy
PA: pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy

Image by Hetal Verma.

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Coronary Circulation – Heart (Cor)

Chest MRI

Overview

  • A thoracic MRI is for studying the heart and great vessels; it has greater definition of anatomy than CT. 
  • The function of MRI is based on the utilization of magnetic fields and radiofrequencies to generate 3-dimensional, high- fidelity Fidelity Conflict of Interest images. 
  • Use is restricted to large medical centers because of its great cost and required operational expertise. 
  • MRI is often reserved for evaluation of complex thoracic pathology initially assessed with more accessible imaging methods (e.g., CT).
  • Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation: patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with metallic or electrical implants, devices, or foreign bodies that are not MRI-compatible. 

Heart

  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) MRI (CMR): 
    • Single-plane 2-dimensional (2D) or multiple-plane 2D or 3-dimensional (3D) images can be obtained.
    • Can provide images of the heart going through a cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) cycle Cycle The type of signal that ends the inspiratory phase delivered by the ventilator Invasive Mechanical Ventilation 
    • Usual indications:
      • Congenital Congenital Chorioretinitis heart disease
      • Valvular dysfunction
      • Suspected intracardiac Intracardiac Total Anomalous Pulmonary Venous Return (TAPVR) masses
      • Myocardial disease, including cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types, ischemic heart disease Ischemic heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease, myocarditis Myocarditis Myocarditis is an inflammatory disease of the myocardium, which may occur alone or in association with a systemic process. There are numerous etiologies of myocarditis, but all lead to inflammation and myocyte injury, most often leading to signs and symptoms of heart failure. Myocarditis
      • Pericardial disease (e.g., noncalcified constrictive pericarditis Pericarditis Pericarditis is an inflammation of the pericardium, often with fluid accumulation. It can be caused by infection (often viral), myocardial infarction, drugs, malignancies, metabolic disorders, autoimmune disorders, or trauma. Acute, subacute, and chronic forms exist. Pericarditis, pericardial tumor Tumor Inflammation invasion)
      • Aortic abnormality (e.g., aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms, aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection)
  • MRA:
    • Contrast-enhanced angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery
    • Can be used to identify anomalous coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology as well as other blood vessels ( aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy) and to monitor coronary artery Coronary Artery Truncus Arteriosus aneurysms
Cardiac mri images

Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) MRI images:
A: Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) MRI gradient echo Gradient Echo Imaging of the Head and Brain sequence of the normal dimensions and function of the left ventricle
B: T2-weighted short Ď„ inversion recovery sequence
C: Late gadolinium Gadolinium An element of the rare earth family of metals. It has the atomic symbol gd, atomic number 64, and atomic weight 157. 25. Its oxide is used in the control rods of some nuclear reactors. Magnetic Resonance Imaging (MRI) hyperenhancement sequence

Image: “ Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR)-MRI images” by Renilla González, A., et al AL Amyloidosis. License: CC BY 2.0

Cardiac Catheterization and Angiography

Overview

  • Among the most commonly performed cardiovascular imaging tests
  • A catheter is introduced into a peripheral vessel such as the femoral or axillary vein Axillary Vein The venous trunk of the upper limb; a continuation of the basilar and brachial veins running from the lower border of the teres major muscle to the outer border of the first rib where it becomes the subclavian vein. Axilla and Brachial Plexus: Anatomy or artery (catheterization) and is positioned in the region of interest:
  • Images are digitally recorded and stored and can be videotaped.
  • While complications are rare, the following can occur:
    • Bleeding/ hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
    • Infection
    • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
    • Stroke
    • Arrhythmia
    • Allergic reaction (to contrast agent)
    • Renal failure Renal failure Conditions in which the kidneys perform below the normal level in the ability to remove wastes, concentrate urine, and maintain electrolyte balance; blood pressure; and calcium metabolism. Renal insufficiency can be classified by the degree of kidney damage (as measured by the level of proteinuria) and reduction in glomerular filtration rate. Crush Syndrome (due to contrast agent)

Evaluation of the heart and great vessels

  • Cardiac catheterization Cardiac Catheterization Procedures in which placement of cardiac catheters is performed for therapeutic or diagnostic procedures. Cardiac Surgery:
  • Left heart catheterization: 
    • Coronary angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery to assess coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology (gold standard)
    • Assessment includes the ventricular outflow tracts, left ventricular motion, ejection fraction Ejection fraction Cardiac Cycle, mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy, and aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy function. 
    • Aortic angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery evaluates the aortic structure and function (e.g., aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection).
  • Right heart catheterization:
    • Checks right atrial and ventricular pressure
    • Assesses pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy pressure and pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy occlusion pressure
    • Pulmonary angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery can evaluate for pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism (though this has been largely replaced by CTPA CTPA Pulmonary Function Tests).
  • Main coronary arteries labeled

    Main coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology:
    The left main coronary artery Coronary Artery Truncus Arteriosus provides blood supply to the left side of the heart. The two branches are the left anterior descending artery and circumflex artery. The right coronary artery Right coronary artery Heart: Anatomy supplies the right side of the heart.

    Image: “Blausen 0256 CoronaryArteries 02” by BruceBlaus. License: CC BY 3.0
  • Normal coronary angiogram

    Normal coronary angiogram:
    a: Normal left main coronary artery Coronary Artery Truncus Arteriosus (LM), left anterior descending artery (LAD), circumflex artery (Cx)
    b: Normal right main coronary artery Coronary Artery Truncus Arteriosus (RCA)

    Image: “Coronary angiogram” by Cardiology Research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest. License: CC BY 2.0, cropped by Lecturio.

Clinical Correlation

Congestive heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR)

  • Congestive heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR) ( CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure) refers to the inability of the heart to supply the body with normal cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) output to meet metabolic needs.
  • Multiple causes, including ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage/ coronary artery Coronary Artery Truncus Arteriosus disease, hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, valvular heart disease, and cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types.
  • Types:
    • Heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR) with reduced ejection fraction Ejection fraction Cardiac Cycle (HFrEF) or systolic failure: left ventricle unable to contract normally
    • Heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR) with preserved ejection fraction Ejection fraction Cardiac Cycle (HFpEF) or diastolic failure (or diastolic dysfunction Diastolic dysfunction Restrictive Cardiomyopathy): left ventricle unable to normally relax to fill the ventricle with blood
  • Tests:
    • X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays:
      • Initial test used in evaluating patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with symptoms of CHF CHF Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure (e.g., shortness of breath Shortness of breath Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, orthopnea Orthopnea Pulmonary Edema)
      • Gives information regarding any chamber enlargement or associated pulmonary congestion
    • Echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA):
      • Can confirm the diagnosis
      • Results include EF EF Cardiac Cycle, associated structural and hemodynamic abnormalities which depend on the type and etiology of the heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR) (HF). 
  • Chest x-ray showing prominent cardiomegaly and bibasilar interstitial markings

    Chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests showing prominent cardiomegaly Cardiomegaly Enlargement of the heart, usually indicated by a cardiothoracic ratio above 0. 50. Heart enlargement may involve the right, the left, or both heart ventricles or heart atria. Cardiomegaly is a nonspecific symptom seen in patients with chronic systolic heart failure (heart failure) or several forms of cardiomyopathies. Ebstein’s Anomaly and bibasilar interstitial markings in a patient with cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types

    Image: “ Chest x-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests showing moderate cardiomegaly Cardiomegaly Enlargement of the heart, usually indicated by a cardiothoracic ratio above 0. 50. Heart enlargement may involve the right, the left, or both heart ventricles or heart atria. Cardiomegaly is a nonspecific symptom seen in patients with chronic systolic heart failure (heart failure) or several forms of cardiomyopathies. Ebstein’s Anomaly and prominent bibasilar interstitial markings” by Ibebuogu UN, Thornton JW, Reed GL. License: CC BY 2.0
  • Echocardiogram showing left ventricular dilatation during acute heart failure

    Echocardiogram Echocardiogram Transposition of the Great Vessels showing left ventricular dilatation during acute heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR)

    Image: “Echocardiograph showing dilatation of the left ventricle in the acute phase Acute phase Short Bowel Syndrome” by Gangadhar TC, Von der Lohe E, Sawada SG, Helft PR. License: CC BY 2.0

Cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types (CM)

  • Disorder in which the heart muscle is structurally and functionally impaired and is not due to coronary artery Coronary Artery Truncus Arteriosus, valvular, or congenital Congenital Chorioretinitis heart disease or hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension.
  • Types:
    • Dilated CM: dilated ventricle(s) associated with impaired contraction
    • Hypertrophic CM: hypertrophy Hypertrophy General increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia). Cellular Adaptation of the left (and, occasionally, the right) ventricle (seen as increased wall thickness)
    • Restrictive CM: ventricles not dilated or hypertrophied but have impaired ventricular filling Ventricular filling Cardiac Cycle
    • Arrhythmogenic right ventricular CM: 
      • Genetic heart muscle disease 
      • Ventricular arrhythmias with fibrofatty tissue in the myocardium Myocardium The muscle tissue of the heart. It is composed of striated, involuntary muscle cells connected to form the contractile pump to generate blood flow. Heart: Anatomy of the right ventricle
    • Unclassified
  • Tests (findings depend on the CM type):
  • Transthoracic echocardiogram

    Transthoracic echocardiogram Transthoracic echocardiogram Endocarditis:
    A: Parasternal long- axis Axis The second cervical vertebra. Vertebral Column: Anatomy view showing asymmetric septal hypertrophic cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types in end diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle
    B: 4-chamber view showing a combination of basal and midventricular hypertrophic cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types and an apical aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Thoracic Aortic Aneurysms (*)
    Ao: aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy


    LA = left atrium


    LV: left ventricle

    RA = right atrium


    RV = right ventricle

    Image: “ Transthoracic echocardiogram Transthoracic echocardiogram Endocarditis” by Cianciulli TF, Saccheri MC, Konopka IV, Serans DF, Acunzo RS, Escudero AM, Masoli OH, Prezioso HA HA Hemolytic anemia (HA) is the term given to a large group of anemias that are caused by the premature destruction/hemolysis of circulating red blood cells (RBCs). Hemolysis can occur within (intravascular hemolysis) or outside the blood vessels (extravascular hemolysis). Hemolytic Anemia. License: CC BY 2.0
  • Cardiac mri showing a marked hypertrophic cardiomyopathy

    Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) MRI showing a marked hypertrophic cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types:
    Balanced fast-field echocardiogram Echocardiogram Transposition of the Great Vessels (bFFE) cine sequence, short- axis Axis The second cervical vertebra. Vertebral Column: Anatomy view (A); 4-chamber view (B); a left ventricular hypertrophy Hypertrophy General increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia). Cellular Adaptation with normal contractility was recognized.
    T1-weighted black blood turbo spin echo sequence, short- axis Axis The second cervical vertebra. Vertebral Column: Anatomy view (C); left ventricular hypertrophy Hypertrophy General increase in bulk of a part or organ due to cell enlargement and accumulation of fluids and secretions, not due to tumor formation, nor to an increase in the number of cells (hyperplasia). Cellular Adaptation is evident, specifically in the septal region. Corresponding view with transmural late gadolinium Gadolinium An element of the rare earth family of metals. It has the atomic symbol gd, atomic number 64, and atomic weight 157. 25. Its oxide is used in the control rods of some nuclear reactors. Magnetic Resonance Imaging (MRI) enhancement (arrow) in the lateral wall using a T1-weighted inversion recovery 3D fast gradient echo Gradient Echo Imaging of the Head and Brain sequence (D).

    Image: “ Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) MRI showing a marked hypertrophic cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types” by Tanislav C, Feustel A, Franzen W, Wüsten O, Schneider C, Reichenberger F, Rolfs A, Sieweke N. License: CC BY 2.0

Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism

  • A potentially fatal condition resulting from the mechanical obstruction Mechanical Obstruction Any impairment, arrest, or reversal of the normal flow of intestinal contents toward the anal canal. Imaging of the Intestines of the pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy or its branches
  • Can be due to any material (such as thrombus, air, or fat) from anywhere in the body. 
  • CTPA CTPA Pulmonary Function Tests:
    • 1st-choice diagnostic imaging method, especially in emergent settings
    • Highly sensitive in detecting pulmonary emboli (seen as filling defects Filling Defects Imaging of the Intestines)
    • Alternative diagnoses can be ruled out.
Pulmonary embolism

Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism:
Chest CT showing multiple filling defects Filling Defects Imaging of the Intestines of the principal branches (arrows) due to pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism

Image: “Chest Spiral Spiral Computed tomography where there is continuous x-ray exposure to the patient while being transported in a spiral or helical pattern through the beam of irradiation. This provides improved three-dimensional contrast and spatial resolution compared to conventional computed tomography, where data is obtained and computed from individual sequential exposures. Computed Tomography (CT) TC” by Serra W, De Iaco G, Reverberi C, Gherli T. License: CC BY 2.0

Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection

  • Ct scan of aortic dissection

    CT scan of aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection:
    a: Plain axial Axial Computed Tomography (CT) slices demonstrating a hyperintense Hyperintense Magnetic Resonance Imaging (MRI) crescent Crescent Rapidly Progressive Glomerulonephritis on the right margin of the aortic lumen indicating intramural hematoma Intramural hematoma Dissection of the Carotid and Vertebral Arteries (arrow)
    b: Contrast-enhanced axial Axial Computed Tomography (CT) slices demonstrating the intimal flap (arrow) that underlies the pathognomonic double-lumen sign Double-Lumen Sign Imaging of the Lungs and Pleura
    c: Volume-rendered reconstructed image showing the margins of the Stanford type A aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection (arrow)
    The right coronary artery Right coronary artery Heart: Anatomy and the major thoracic and cervical arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology are not involved.

    Image: “Summary of thoracic computerized tomography findings” by Tatuene JK, Excoffier S, Vallee JP, Kleinschmidt A. License: CC BY 4.0
  • Axial source image of cta reveals the flap in the ascending aorta compatible with type a of stanford dissection

    Axial Axial Computed Tomography (CT) source image of CTA CTA A non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases. Pulmonary Function Tests reveals the flap in the ascending aorta Ascending aorta Mediastinum and Great Vessels: Anatomy compatible with type A Stanford dissection:
    Arrows: flap in ascending aorta Ascending aorta Mediastinum and Great Vessels: Anatomy
    Asterisks: hemopericardium.

    Image: “ Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a “false lumen.” Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection type I in a weightlifter with hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension” by Ahmadi H, Shirani S, Yazdanifard P. License: CC BY 2.0

Coronary artery Coronary Artery Truncus Arteriosus disease

  • The most common type of heart disease, occurring when the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology narrow, usually due to the buildup of plaque Plaque Primary Skin Lesions ( atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis)
  • As narrowing worsens, less blood can flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure through the arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology, resulting in ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage and cell death Cell death Injurious stimuli trigger the process of cellular adaptation, whereby cells respond to withstand the harmful changes in their environment. Overwhelmed adaptive mechanisms lead to cell injury. Mild stimuli produce reversible injury. If the stimulus is severe or persistent, injury becomes irreversible. Apoptosis is programmed cell death, a mechanism with both physiologic and pathologic effects. Cell Injury and Death → MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
  • Multiple methods used:
    • Stress echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA): can be used with exercise or pharmacologic stress test
    • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) scan (stress): 
      • Myocardial ischemia Myocardial ischemia A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries (coronary artery disease), to obstruction by a thrombus (coronary thrombosis), or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Coronary Heart Disease: areas of photopenia (i.e., decreased uptake) under stress that improves at rest
      • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction: persistent photopenia (i.e., decreased uptake) despite rest state
    • CT:
    • Cardiac catheterization Cardiac Catheterization Procedures in which placement of cardiac catheters is performed for therapeutic or diagnostic procedures. Cardiac Surgery and coronary angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery:
      • Both for diagnostic and therapeutic management of acute coronary syndrome (ST-segment elevation MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction)
      • For evaluation of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with chronic debilitating angina despite maximal medical therapy
      • When noninvasive testing suggests severe ischemic disease
  • Cardiac scan showing multiple perfusion defects

    Multiple perfusion defects with different degrees of severity.
    The upper images are stress phase and lower images are rest or delayed images. There is moderate ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage in the midanterolateral and midinferolateral walls.
    There also is severe ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage in the basal inferior wall. Mild ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage in the apex, apical septal, and basal anterolateral regions are also noted.

    Image: “Frequency and severity of myocardial perfusion abnormalities using Tc-99m MIBI SPECT SPECT An imaging technique using a device which combines tomography, emission-computed, single-photon and tomography, x-ray computed in the same session. Nuclear Imaging in cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) syndrome X” by Saghari, M. et al AL Amyloidosis. License: CC BY 2.0
  • Calcified plaques in the anterior descending artery

    Calcified plaques in the anterior descending artery, in addition to others (not shown) in the other coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
    CAC score = 285 (Agatston method), consistent with moderate coronary calcification, indicating moderate cardiovascular risk

    Image: “CAC score in a 65-year-old white male” by Priscilla Ornellas Neves, et al AL Amyloidosis. License: CC BY 4.0
  • Stenosis of the left anterior descending artery

    Coronary angiogram:


    Stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS) of the left anterior descending artery (arrow)

    Image: “Coronary angiogram with a stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS) of the LAD (arrow)” by Adeoye AM, Adekunle AN, Adebiyi AA AA Amyloidosis, Mullassari A, Vijayakumar S, Nwafor CE. License: CC BY 2.0

Endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis

Endocarditis transesophageal echocardiogram

Endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis:
A transesophageal echocardiogram Echocardiogram Transposition of the Great Vessels shows the left atrium (LA), parts of the mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy (MV), the left ventricle (LV), the ascending aorta Ascending aorta Mediastinum and Great Vessels: Anatomy (AO), and a thickened aortic cusp (arrow), the last of which is highly suggestive of endocarditis Endocarditis Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Endocarditis.

Image: “A transesophageal echocardiogram Echocardiogram Transposition of the Great Vessels” by Stöllberger C, Bastovansky A, Finsterer J. License: CC BY 2.0

Pericardial conditions

  • Pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade:
    • Accumulation of fluid in the pericardial cavity Pericardial cavity Heart: Anatomy of the heart
    • Since the pericardium Pericardium A conical fibroserous sac surrounding the heart and the roots of the great vessels (aorta; venae cavae; pulmonary artery). Pericardium consists of two sacs: the outer fibrous pericardium and the inner serous pericardium. The latter consists of an outer parietal layer facing the fibrous pericardium, and an inner visceral layer (epicardium) resting next to the heart, and a pericardial cavity between these two layers. Heart: Anatomy does not expand, after enough fluid accumulates under pressure, the cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) filling becomes restricted → cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis
  • Pericarditis Pericarditis Pericarditis is an inflammation of the pericardium, often with fluid accumulation. It can be caused by infection (often viral), myocardial infarction, drugs, malignancies, metabolic disorders, autoimmune disorders, or trauma. Acute, subacute, and chronic forms exist. Pericarditis:
    • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the pericardium Pericardium A conical fibroserous sac surrounding the heart and the roots of the great vessels (aorta; venae cavae; pulmonary artery). Pericardium consists of two sacs: the outer fibrous pericardium and the inner serous pericardium. The latter consists of an outer parietal layer facing the fibrous pericardium, and an inner visceral layer (epicardium) resting next to the heart, and a pericardial cavity between these two layers. Heart: Anatomy
    • Can be idiopathic Idiopathic Dermatomyositis or caused by a variety of conditions, including infection, previous MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction, or systemic diseases
  • Tests:
    • Chest X-ray Chest X-ray X-ray visualization of the chest and organs of the thoracic cavity. It is not restricted to visualization of the lungs. Pulmonary Function Tests: initial test done showing enlargement of the heart (in effusion)
    • Echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA): 
      • Often normal in pericarditis Pericarditis Pericarditis is an inflammation of the pericardium, often with fluid accumulation. It can be caused by infection (often viral), myocardial infarction, drugs, malignancies, metabolic disorders, autoimmune disorders, or trauma. Acute, subacute, and chronic forms exist. Pericarditis
      • In pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade, pericardial fluid Pericardial fluid Watery fluid produced in the serous and visceral pericardium surrounding the surface of the heart. Heart: Anatomy is seen as an echolucent space between the epicardium Epicardium Heart: Anatomy and the pericardium Pericardium A conical fibroserous sac surrounding the heart and the roots of the great vessels (aorta; venae cavae; pulmonary artery). Pericardium consists of two sacs: the outer fibrous pericardium and the inner serous pericardium. The latter consists of an outer parietal layer facing the fibrous pericardium, and an inner visceral layer (epicardium) resting next to the heart, and a pericardial cavity between these two layers. Heart: Anatomy.
    • CMR and cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) CT: help in quantification of pericardial fluid Pericardial fluid Watery fluid produced in the serous and visceral pericardium surrounding the surface of the heart. Heart: Anatomy

References

  1. Carr, J. (2019). Calcium scoring for cardiovascular computed tomography. Radiologic Clinics of North America 57, 1–12. https://pubmed.ncbi.nlm.nih.gov/30454806/
  2. Cooper, L. (2021). Definition and classification of the cardiomyopathies. UpToDate. Retrieved July 6, 2021, from https://www.uptodate.com/contents/definition-and-classification-of-the-cardiomyopathies
  3. Fowler, G., Reynolds, T. (2020). Echocardiography. In G. C. Fowler (Ed.), Pfenninger and Fowler’s Procedures for Primary Care (pp. 497–509). Retrieved July 2, 2021, from https://www.clinicalkey.com/#!/content/3-s2.0-B9780323476331000752
  4. Fuisz, A., Pohost, G. (2021). Clinical utility of cardiovascular magnetic resonance imaging. UpToDate. Retrieved July 5, 2021, from https://www.uptodate.com/contents/clinical-utility-of-cardiovascular-magnetic-resonance-imaging
  5. Gupta, N., Matta, E. J., Oldham, S. A. (2014). Cardiothoracic imaging. Chapter 4 of Elsayes, K. M., Oldham, S. A. (Eds.), Introduction to Diagnostic Radiology. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=1562&sectionid=95876454
  6. Kramer, C., Villines, T. (2021). Coronary artery calcium scoring: Image acquisition and clinical utilization. UpToDate. Retrieved July 5, 2021, from https://www.uptodate.com/contents/coronary-artery-calcium-scoring-image-acquisition-and-clinical-utilization
  7. Kumamaru, K. K., Hoppel, B. E., Mather, R. T., Rybicki, F. J. (2010). CT angiography: current technology and clinical use. Radiologic Clinics of North America. 48, 213–vii. https://pubmed.ncbi.nlm.nih.gov/20609871/
  8. Marano, R., Liguori, C., Savino, G., Merlino, B., Natale, L., Bonomo, L. (2011). Cardiac silhouette findings and mediastinal lines and stripes. Chest. 139(5), 1186–1196. http://dx.doi.org/10.1378/chest.10-0660
  9. Mettler, F. (2019). Cardiovascular system. In Mettler, F. (Ed.), Essentials of Radiology (pp. 98–124). Retrieved from https://www.clinicalkey.com/#!/content/3-s2.0-B9780323508872000051
  10. Ravenel, J.G. (2011). Chapter 3. Imaging of the heart and great vessels. Chapter 3 of Chen, M. M., Pope, T. L., Ott, D. J. (Eds.), Basic Radiology, 2nd ed. McGraw Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=360&sectionid=39669010
  11. Renilla González, A., et al. (2011). Cardiogenic shock following administration of propofol and fentanyl in a healthy woman: a case report. Journal of Medical Case Reports 5:382. https://doi.org/10.1186/1752-1947-5-382
  12. Shea, M., Cascino, T. (2019). Cardiac catheterization. Merck Manuals. Retrieved July 5, 2021, from https://www.merckmanuals.com/professional/cardiovascular-disorders/cardiovascular-tests-and-procedures/cardiac-catheterization
  13. Siebelink, H. J., Westenberg, J. J. M., Kroft, L. J. M., de Roos, A. (2021). Cardiac anatomy and imaging techniques. In Adam, A., Dixon, A., Gillard, J., Schaefer-Prokop, C. (Eds.), Grainger & Allison’s Diagnostic Radiology. London: Churchill Livingstone, pp. 265–288. https://www.clinicalkey.com/#!/content/3-s2.0-B9780702075247000124
  14. Sundaram, B., Patel, S., Bogot, N., Kazerooni, E. A. (2009). Anatomy and terminology for the interpretation and reporting of cardiac MDCT: Part 1, structured report, coronary calcium screening, and coronary artery anatomy. American Journal of Roentgenology 192:574–583. https://doi.org/10.2214/AJR.08.1177
  15. Sundaram, B., Patel, S., Agarwal, P., Kazerooni, E. A. (2009). Anatomy and terminology for the interpretation and reporting of cardiac MDCT: Part 2, CT angiography, cardiac function assessment, and noncoronary and extracardiac findings. American Journal of Roentgenology. 192(3), 584–598. https://doi.org/10.2214/AJR.08.1178
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