Imaging of the Heart and Great Vessels

Chest X-ray

Overview

• 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: 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 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 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. 

Anatomy

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

• PA projection:
  • Structures:
    • Trachea Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea: Anatomy: should be on the midline
    • 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)
    • Ascending and descending aorta Descending aorta Mediastinum and Great Vessels: Anatomy ( aortic arch Aortic arch Mediastinum and Great Vessels: Anatomy)
    • Pulmonary hilum Hilum Lungs: Anatomy (right and 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
    • Right atrium (right heart border)
    • Left ventricle (left heart border)
  • To easily identify the structures on the left border in a cephalocaudal order, remember:
    • 1st bump: aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy
    • 2nd bump: 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
    • 3rd (the largest) bump: left ventricle
• Lateral projection:
  • Retrosternal space
  • Right ventricle
  • Right hemidiaphragm
  • Aortic arch Aortic arch Mediastinum and Great Vessels: Anatomy
  • Pulmonary hilum Hilum Lungs: Anatomy
  • Left ventricle
  • Left hemidiaphragm
  • Posterior cardiac space

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 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 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.
  • Valvular disease
  • Congenital Congenital Chorioretinitis heart disease
  • Masses

Great vessels

• In the PA and AP projections, the great vessels can be identified at either side of the mediastinal shadow.
  • Right mediastinal margin (cephalocaudal):
    • SVC
    • Right 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 coinciding with the right pulmonary hilum Hilum Lungs: Anatomy
  • Left mediastinal margin (cephalocaudal):
    • Aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy
    • 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 coinciding with the left pulmonary hilum Hilum Lungs: Anatomy
• In a lateral projection, only the shadow of the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy can be distinguished.

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:
  • Evaluation of ventricular function
  • 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
  • Congenital Congenital Chorioretinitis heart disease
  • Valvular heart disease
  • 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
  • Cardiac masses
  • Proximal aortic disease
• 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 (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 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 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:
  • 2-Dimensional: by undergoing complex processes (e.g., filtering, signal amplification), the signal received forms a cardiac image displayed on the monitor. 
  • M-mode:
    • M = motion
    • Movement of the structures is graphically imaged over time by directing a linear beam of ultrasound at a single structure. 
  • Doppler Doppler Ultrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow. Ultrasound (Sonography):
    • Provides information regarding blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure ( hemodynamics Hemodynamics The movement and the forces involved in the movement of the blood through the cardiovascular system. Vascular Resistance, Flow, and Mean Arterial Pressure)
    • Especially helpful in valvular and cardiac function assessment, as well as in evaluating intracardiac Intracardiac Total Anomalous Pulmonary Venous Return (TAPVR) shunts
• 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) × 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.

Cardiac Scan

Overview

• Cardiac scan Cardiac Scan 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:
  • 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 Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). 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-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 fraction Ejection fraction Cardiac Cycle
• Normal cardiac scan Cardiac Scan 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 obtained in 3 different planes:
  • The top row of each set is performed under cardiac 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

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 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 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).

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 and specificity Sensitivity and Specificity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Specificity is the probability of correctly determining the absence of a condition. Epidemiological Values of Diagnostic Tests 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

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 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 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 cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle 
  • 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 Constrictive pericarditis Inflammation of the pericardium that is characterized by the fibrous scarring and adhesion of both serous layers, the visceral pericardium and the parietal pericardium leading to the loss of pericardial cavity. The thickened pericardium severely restricts cardiac filling. Clinical signs include fatigue, muscle wasting, and weight loss. 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 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:
  • Performed under fluoroscopic guidance
  • Contrast material is injected to confirm the location of the catheter and to highlight the cardiac structures for diagnostic evaluation ( angiography Angiography Radiography of blood vessels after injection of a contrast medium. Cardiac Surgery).
• 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:
  • Diagnostic:
    • Defines the cardiac and coronary artery Coronary Artery Truncus Arteriosus anatomy, cardiac function, and pulmonary arterial hemodynamics Hemodynamics The movement and the forces involved in the movement of the blood through the cardiovascular system. Vascular Resistance, Flow, and Mean Arterial Pressure
    • Also used for endomyocardial biopsy Endomyocardial biopsy Myocarditis and intravascular ultrasonography
  • Therapeutic:
    • For coronary artery Coronary Artery Truncus Arteriosus disease therapy ( percutaneous coronary intervention Percutaneous coronary intervention A family of percutaneous techniques that are used to manage coronary occlusion, including standard balloon angioplasty (percutaneous transluminal coronary angioplasty), the placement of intracoronary stents, and atheroablative technologies (e.g., atherectomy; endarterectomy; thrombectomy; percutaneous transluminal laser angioplasty). Ptca was the dominant form of pci, before the widespread use of stenting. Cardiac Surgery (PCI))
    • For valvuloplasty and valve replacement
• 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).

Clinical Correlation

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)

• 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) refers to the inability of the heart to supply the body with normal cardiac output Cardiac output The volume of blood passing through the heart per unit of time. It is usually expressed as liters (volume) per minute so as not to be confused with stroke volume (volume per beat). Cardiac Mechanics 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 HF (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). 

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):
  • 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): 1 of the initial tests for suspected 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, giving information on cardiac structure and function
  • Cardiac MRI provides assessment of:
    • Ventricular volumes and systolic function ( ejection fraction Ejection fraction Cardiac Cycle)
    • Myocardial mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast and wall thickness
    • Wall motion (in cine sequences)

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.

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 condition in which the inner coat ( tunica intima Tunica intima The innermost layer of an artery or vein, made up of one layer of endothelial cells and supported by an internal elastic lamina. Arteries: Histology) of the aortic wall develops a fissure Fissure A crack or split that extends into the dermis Generalized and Localized Rashes allowing blood to enter the media layer to form a secondary lumen.
• 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:
  • Most common initial test
  • Findings include:
    • Intimal flap with a false lumen False lumen Aortic Dissection (which is often larger than the true lumen True lumen Aortic Dissection)
    • Possible thrombus
    • Enlarged aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy 
  • An alternative is MRA.
• TEE:
  • For those with suspected ascending aortic involvement or for hemodynamically unstable patients Hemodynamically Unstable Patients Blunt Chest Trauma
  • Requires skilled operators and patient sedation
• Aortography: when initial tests are inconclusive.

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 scan Cardiac Scan 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 (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:
    • CAC scoring: screening Screening Preoperative Care for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with moderate or intermediate risk
    • 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: screening Screening Preoperative Care for those with indeterminate stress tests and/or ECGs
  • 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

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

• Inflammatory disease of the interior cardiac lining that can be due to either infectious or noninfectious causes; primarily and most notably affects the valves
• 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):
  • All patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with suspected infective endocarditis Infective endocarditis Infective endocarditis (IE) is caused by infection or inflammation of the inner lining of the heart (endocardium), most commonly affecting the heart valves. Endocarditis should undergo 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).
  • Findings can include:
    • Vegetation
    • Abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
    • New dehiscence of a prosthetic valve Prosthetic Valve Soft Tissue Abscess
  • TTE:
    • 1st diagnostic test
    • If images are inadequate, or complications are suspected ( abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease, valvular abnormality needing cardiac surgery Cardiac surgery Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Cardiac Surgery), TEE is performed.

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 filling becomes restricted → cardiac 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 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: 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 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