cardiac boards review pdf

8/13/2019 Cardiac Boards Review PDF

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Cardiac

Board-type

Case Review

All photos retain the copyrights of their original owners

2004 William Herring, MD


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Cyanotic newborn

Whats the DDX?Whats the DDX?


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Cyanosis With Decreased Vascularity

Tetralogy

Truncus-type IV

Tricuspid atresia*

Transposition*

Ebstein's

* Also appears on DDx of cyanosis with increased vascularity


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Whats the diagnosis?Whats the diagnosis?

Ebsteins Anomaly


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8 year-old cyanotic male



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Cyanosis With Increased Vascularity

Truncus types I, II, III

TAPVR

Tricuspid atresia*

Transposition* Single ventricle

* Also appears on DDx of cyanosis with decreased vascularity


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TAPVR-Supracardiac type 1


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Acyanotic newborn



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Cardiomegaly with Normal Vasculature

Viral myocarditis

Endocardial fibroelastosis Aberrant left coronary artery

Cystic medial necrosis

Diabetic mother


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Viral myocarditis


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Acyanotic newborn



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Causes of CHF In NewbornImpede Return of Flow to Left Heart

Infantile coarctation Congenital aortic stenosis

Hypoplastic left heart syndrome

Congenital mitral stenosis

Cor triatriatum

Obstruction to venous return fromlungs

TAPVR from below diaphragm


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Hypoplastic Left Heart Syndrome


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7 yo acyanotic female



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Atrial septal defectAtrial septal defect


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Another exampleAnother example


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ASD (primum) with PAHASD (primum) with PAH


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Ostium Secundum

ASD-MRIAmersham


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Discontinuity in the atrial septum with systolic signal void consistent

with L to R shunt at atrial level

Right atrium is slightly dilated; RV, LV and LA size are normal

SCMR


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Ventricular Septal DefectVentricular Septal Defect


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VSD

Another example-VSDAnother example-VSD


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Amersham

Membranous VSD-MRI


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8 mos old acyanotic female



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Patent Ductus ArteriosusPatent Ductus Arteriosus


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Jet of signal loss showing continuous flow from the aorta to the MPA

consistent with sizeable PDA; MPA is severely dilated at level of PDA

SCVMR

Patent Ductus Arteriosus-MRIPatent Ductus Arteriosus-MRI

Frank Netter, MD Novartis


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9 mos old cyanotic female

ACR



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ACR

TAPVR-supracardiac typeTAPVR-supracardiac type


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Angiographic

Appearance


TAPVR

Supracardiac Type 1


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TAPVR-cardiac type-MRI



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TAPVR-infracardiac type-MRI

Amersham



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10 yo cyanotic male



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Tetralogy of FallotTetralogy of Fallot


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Tetralogy of Fallot

Other examplesOther examples


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Tetralogy of Fallot-MRI

Overriding aorta, VSD


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12 yo cyanotic male

Radiology Resource and Review



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Truncus arteriosus-Type 1Truncus arteriosus-Type 1



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Ao

Truncus Type 1

LPA

Truncus

Ao

LV



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Single large artery (T) arising

from the heart.

Pulmonary artery (arrow)originates from the left side of

the truncus

There is a right aortic arch

AmershamTruncus Arteriosus Type 1-MRI

Elliott, L Cardiac Imaging


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Truncus Type II


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Truncus Type III


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Tricuspid atresia-MRI

ECG-gated spin-

echo transaxial

image demonstrates

a bar of muscle andfat (blue arrow)

(tricuspid atresia)

separating the right

atrium (yellowarrow) from the

hypoplastic right

ventricle (red arrow)

AmershamAmersham


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Tricuspid atresia-MRI

Enlarged right

atrium

Small right

ventricle

Wh t th di i ?Wh t th di i ?


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3 mos old cyanotic male


T iti f th G t V lT iti f th G t V l


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Transposition of the Great VesselsTransposition of the Great Vessels


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Transposition of the Great Vessels -

RVgram



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Transposition of the Great Vessels -

LVgram



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Korean JournalEbsteins Anomaly

Oblique axial spin-echo image

shows displaced attachment (thick

arrow) of the posterior leaflet (thin

arrows)



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Acyanotic adult

What s the diagnosis?What s the diagnosis?

Coarctation of the aortaCoarctation of the aorta


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Arrow points to indentation representing area of coarctation with dilated aorta (or

LSCA) above and post-stenotic dilatation below coarct


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Coarctation of the Aorta

Convexity

above aorticknob due to

dilated LSCA

or Aorta

proximal to

coarct

Ascending

Ao may be

dilated,

normal or

small

Yellow

arrows

point to

rib-notching


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Contrast enhanced MRA shows

long segment coarctation of the aorta

Amersham


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AO

BCA

Coarct

Oblique sagittal spin-echo-Coarctation of the Aorta

Amersham


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Axial spin-echo MRI-Coarctation of the Aorta

Amersham



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Acyanotic adult

What s the diagnosis?What s the diagnosis?

Aortic StenosisAortic Stenosis


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Aortic StenosisAortic Stenosis


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Aortic stenosis

Prominenceof ascending

aorta from

post-stenotic

dilatation


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yp p y



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Atretic aorta

yp p y

Neufeld, HN, Circulation, 1962


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Hypoplastic Left heart SyndromeGated spin echo at base of heart shows hypoplastic aorta

(arrow) posterior and right of main pulmonary artery

RA

MPA

Ao

LA

Amersham


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Cor Triatriatum - angiography


Cor Triatriatum - angiography


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g g p y



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LA

LA

RVOT

RAAo

RV

LALA

MPA

Ao

Cor Triatriatum

Amersham


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Aortic Regurgitation

Cine MR image during diastole shows signal void

emanating from the aortic valve

LV

Ao

RA



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Acyanotic adult

Mitral Stenosis


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Mitral Stenosis

Convexity from

enlarged left

atrial appendage


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Mitral Stenosis

Convexity from

enlarged left

atrial appendage


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Upper lobevessels equal

to or larger

than size of

lower lobevessels =

Cephalization

Upper lobe

vessels equal

to or larger

than size of

lower lobevessels =

Cephalization


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Mitral Stenosis

Cine MR image in axial plane demonstrates a diastolic signal

void emanating from the mitral valve

LA

LV

RA

RV


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Left Atrial Myxoma

Contrast-enhanced CT shows large filling

defect in lumen of LA


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Left Atrial Myxoma

Cine MRI shows soft tissue mass arising from wall

of left atrium and projecting into lumen

LA

RA LVAo



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Acyanotic adult


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Mitral Regurgitation

Cine MR image in axial plane during systole depicts a

signal void emanating from the mitral valve

LALV

Difference in heart size MS and MR


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Mitral Stenosis Mitral Regurgitation



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Amersha,m

Acyanotic adult

Pulmonic stenosis


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Amersha,m

Prominent main

pulmonary

artery segment


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Pulmonic Stenosis

Normal-

sized heart

Enlargement

of leftpulmonary

artery



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Acyanotic adult

Right Arch with Aberrant Left SCARight Arch with Aberrant Left SCA


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Trachea is bowed forward by aberrant left

subclavian artery (arrow)


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Right Aortic Arch with Aberrant Left Subclavian (Arrows)

Whats the diagnosis?


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36 yo cyanotic female


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Left Aortic Arch with Aberrant R SCA

A


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C

BReview-Name the

abnormalities.Are they the good

or bad variety?

A


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Left Aortic Archwith Aberrant R SCA

Right Aortic Arch with

Aberrant Left Subclavian

C

Mirror Image

Right Aortic Arch

B



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2 month old with stridor

Double aortic arch


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Right arch is larger and higher

Left arch is smaller and lower


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Double Aortic Arch

Miller-requisites


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Double Aortic Arch-angiographic appearance

Miller-requisites


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Double Aortic Arch

Impressions on Trachea and Esophagus

Dahnert



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4 month old with stridor


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Pulmonary Sling

Dahnert

Tracheal/esophageal impressions


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Aberrant SCA Pulmonary SlingDouble Ao Arch Isolated Anomalies(Rare)

Dahnert


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If you see cases like

these, you passed


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Miller-RequisitesMiller-Requisites

Myxoma in Left Atrium


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Elliot-Cardiac ImagingElliot-Cardiac Imaging

Thrombus in left atrial appendage


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End systole

Amersham

End diastole

Dilated Cardiomyopathy

Cine MR images in the short axis plane show little change in size

between end diastole and end systole


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ECG-gated spin-echo image - enlargement

of both atria and normal size of

ventricles with thickened walls

Amersham

Restrictive cardiomyopathy


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ECG-gated spin-echo image in

coronal plane - severe symmetrical hypertrophy of LV

Hypertrophic Cardiomyopathy

Amersham

Asymmetric septal hypertrophyAsymmetric septal hypertrophy


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Amersham

Miller-RequisitesMiller-Requisites

Thickened

apex

Thickened

apex


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Marked

wall

thickening

Marked

wall

thickening

MitralRegurgitation

From SAM

MitralRegurgitation

From SAM

Elliot-Cardiac ImagingElliot-Cardiac Imaging

Almost

complete

emptying of

LV

Almost

complete

emptying of

LV


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Congenital Defect in the Pericardium


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Cardiac

Malpositions

Cardiac Malpositions

Types


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Situs solitus with dextrocardia

Situs inversus with levocardia

Situs inversus with dextrocardia

Rule of Thumb


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If aortic arch/apex of

heart are on opposite

sides from stomach

bubble, high

incidence of CHD

Asplenia

Bilateral Right-sidedness


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Male

Cyanotic

High risk of infection

Severe cardiac abnormalities

Transposition

TAPVR

Polysplenia

Bilateral left-sidedness


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Female

Abnormalities are more benign

Azygous continuation of IVC Bilateral superior vena cava

PAPVR

ASD

Asplenia/Polysplenia


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Asplenia bad boy

Polysplenia good girl


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Situs Ambiguous-polysplenia


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