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150 Cards in this Set

  • Front
  • Back
In Cardiac MRI, which plane is best for left ventricular volume?
• A. Sagittal
• B. Coronal
• C. Short axis
• D. Horizontal long axis
• E. Vertical long axis
• Answer: C short axis
On gadolinium-enhanced MR angiography, focal signal dropout in vessels can be caused by all of the following except:
• A. Part of artery outside field of view
• B. Slow flow in vessel
• C. Metallic clips adjacent to artery
• D. Occlusion
• E. Stenosis
Answer: B slow flow (false)

• “Metallic implants such as clips and sternal wires may also cause image artifacts.”
• “The use of contrast allows for signal intensity to become largely flow independent, which is critically important for the depiction of slow flowing blood and reliable detection of vascular disease.” Source: Cardiovascular Magnetic Resonance. 2003 1st Ed. Martin Dunitz.
• “Distal to a total occlusion, vessels with no collateral flow have decreased or background (fat suppressed) signal intensity.” “Discrete coronary lesions, both total and subtotal occlusions, may appear as either areas of signal void, decreased flow signal, or vessel wall irregularity.”
• Source: Imaging of coronary artery disease-MR. Journal of Thoracic Imaging 2001; 16:25-34.
• Therefore by process of elimination, slow flow in a vessel will be seen in contrast enhanced MR angiogram.
MR findings of valvular disease:
• A. Systolic jet with aortic stenosis
• B. Diastolic jet with mitral insufficiency
• C. Diastolic jet with pulmonic stenosis
• D. Systolic jet with tricuspid stenosis
ANSWER: SYSTOLIC JET With AS
In Cardiac MRI, 20-minute delayed post-gadolinium images are acquired to:
• A. Predict functional recovery after infarct
• B. Predict functional recovery after therapy
• C. Evaluate mitral valve after mitral valvuloplasty
• D. Predict future MI
• E. Predict future ischemia
• F. Assess normal regional function after revascularization
Answer: A. Looking for viable myocardium post infarct.
Viable myocardium may recover function if the cause of the dysfunction is corrected; non-viable myocardium will not. Armed with this information, physicians would be able to identify those patients with coronary artery disease and left ventricular dysfunction that could benefit from more aggressive revascularization strategies.
Myocardial viability imaging with MRI is performed after I.V. administration of gadolinium contrast (0.2 mmol/kg) injected over 20 seconds; imaging begins after 10-15 minutes). Nonviable (infarcted) myocardium enhances on delayed contrast images. Stunned or hibernating myocardium is viable and will not enhance, but will have abnormal contractility. Stunned myocardium is viable tissue that demonstrates abnormal function after an ischemic event and the abnormal function is reversible once reperfusion ensues. Hibernating myocardium is viable tissue that is in an altered hypo metabolic state due to chronic ischemia. It will demonstrate abnormal function, however, once adequate perfusion ensues normal function will return.
“On contrast enhanced cardiac MR the amount of transmural enhancement predicts the degree of functional recovery after an acute MI.”
Rest and stress imaging predicts functional recovery after therapy.
• Concerning cardiac surgery, which of the following are true:
a. mitral annuloplasty reverses the effects of calcific mitral stenosis.
b. Coronary ostial markers are not necessary when the coronary ostia are occluded
c. In repairing VSD’s, the patches are on the low pressure RV side
d. The Jantene or switch procedure for transposition involves switching of the venous inflow to the atria
Which is false:
• Mitral annuloplasty fixes mitral stenosis
Treatment of Mitral Stenosis
 Intervention should only be performed when the patient develops moderate to severe symptoms, or if there is asymptomatic pulmonary hypertension.
 TEE is used to determine valve score. Valves are graded on leaflet mobility, calcification, leaflet thickness, and disease of the subvalvular apparatus. Each category is given a score of 0-4, where 0 is normal and 4 is severely diseased. The minimum score is usually 4 (1 point for each category).
 Balloon valvotomy is effective therapy for scores of 8 or less. TEE must first be performed to also assess for possible LA thrombus, which if present is treated with a 3-month trial of Coumadin.
 Commissurotomy if valves pliable, calcium absent, and mitral valve regurgitation absent.
 Valve replacement for symptomatic patients with severely stenotic valves.
 (Danhert pp 636-637; Imaging in Cardiovascular Disease pp 581-584)
Atrial myxoma
• Gives CXR like mitral stenosis
• Arises from mitral valve
• Gives aortic valve symptoms
A is true. Creighton web site
1. Chronic edema
Mitral Stenosis - #1, look for Lt atrial enlargment
Left Atrial Myxoma - #1 primary tumor of the heart
originates from septa near fossa ovalis, 10% calc
also includes L atrial enlargement as w stenosis
• Left Atrial Myxoma (75-80%)
– Obstruction of mitral valve
– Pulmonary venous congestion
– Enlargment of LA
– No enlargment of atrial appendage
– Ossific lung nodules
• Right Atrial Myxoma (10-20%)
– Obstruction of tricuspid valve
– Tumor calcification
– Enlargment of RA
– Prominent SVC, IVC, azygos vein
– Decreased pulmonary vascularity
– Occasional pleural effusion
Regarding left atrial myxoma :
a) it most commonly arises from the mitral valve
b) it has increased echogenicity on ultrasound
c) it can embolize
d) it mimics aortic stenosis
e) enlargement can mimic mitral valve pathology on CXR
Ans: E.
Which doesn’t change heart size?
• Distance
• kVp
• Breathing
• Cardiac cycle
B) KVP
 Factors which influence cardiac size and configuration include thoracic cage abnormalities, obesity and ventilation.
 Patients with emphysema usually have a small cardiac silhouette due to their overinflated lungs; apparently normal cardiac size in these patients is often abnormal.
 In obese patients there may be significant magnification on both the PA and lateral views causing apparent cardiomegaly.
 Suboptimal inspiration elevates the cardiac apex and enlarges the cardiothoracic ratio.
 The clavicular heads should be midline in position, because slight degrees of rotation will substantially affect the cardiac contour and size.
 Distance between object and image also affect magnification.
(Imaging in Cardiovascular Disease, pp323-339)
Best plane to evaluate mitral and tricuspid valves
• Sagittal
• Coronal
• Horizontal long axis
• Vertical long axis
• Short axis
• Answer C. Horizontal long axis

• Evaluation of the atrioventricular (AV) valves requires modification of the imaging plane. Breath-hold cine sections are prescribed along a doubly oblique plane that is parallel to a line connecting the cardiac apex and middle of the mitral valve and perpendicular to the septum (see image 1). The result is a standard 4-chamber view (see image 2). Cine GE imaging in this plane enables dynamic assessment of the tricuspid and mitral valves. Parasagittal images parallel to the AV junction can be used to measure the valve orifice area. Images obtained in a plane perpendicular to the long axis of the 4-chamber view are true short-axis views.


Cardiac planes of MR
Short axis ~ coronal plane view R & L ventricles, it is perpendicular to vertical & horizontal long axis views.
Vertical long axis: atrium & ventricle.
Horizontal long axis is the 4 chamber view

 Image 1: Coronal single-shot fast spin-echo image obtained off the sagittal plane: To localize the atrioventricular valve level, an imaging plane is prescribed along a line connecting the cardiac apex and the level of the middle of the atrioventricular valve, as shown.
 Image 2: Four-chamber gradient-echo image (flip angle, 15°) obtained off the coronal localizer provides a cross-sectional depiction of the atrioventricular valves. On the image, the right ventricle is anterior, and the left atrium and ventricle are posterior; the mitral valve is visible in an axial plane.
 The sagittal series is used to configure a breath-hold coronal SS-FSE acquisition through the heart and great vessels.
 Ventricular analysis requires a true short-axis plane.
 The coronal series depicts both the cardiac apex and proximal ascending aorta.
What condition most commonly causes restrictive cardiomyopathy?
• Amyloid
• Sarcoid
• IHSS
• Subaortic hypertrophic stenosis.
• Ans: A. Amyloid
• The most common causes of restrictive cardiomyopathy are amyloidosis and idiopathic myocardial fibrosis (a scarring of the heart of unknown cause). It frequently occurs after a heart transplant.
Other causes of restrictive cardiomyopathy include sarcoidosis, hemochromatosis, radiation fibrosis, and various tumor infiltrations of the heart. More rarely, restrictive cardiomyopathy is caused by diseases of the endocardium (the lining of the heart) such as endomyocardial fibrosis and Loeffler's syndrome.
In a 40-year-old with new diagnosis of aortic stenosis, what is the most common cause?
• Bicuspid valve
• Atherosclerotic disease
• age related AS
• IHSS
• rupture of chordae tendinae
Ans A. Bicuspid valve
Causes of aortic stenosis
What is the left side of the snowman’s head in TAPVR?
• Vertical vein
• Duplicated SVC
• SVC
• Vein of Galen
• AVM
• Answer: Vertical Vein, Repeat from prior years
• Supracardiac Type—Type I
Most common (52%)
Pulmonary veins drain into vertical vein (behind left pulmonary artery) to left brachiocephalic vein to SVC
DDx: VSD with large thymus
Which is a branch of the left circumflex artery?
• Acute marginal
• Diagonal
• Obtuse marginal
• Septal branches
C. OBTUSE MARGINAL
• Acute marginal – RCA
• Diagonal – LAD
• Obtuse marginal – LCX
• Septal branches – LAD
C. OBTUSE MARGINAL

SUMMARY: CORONARY ANATOMY
RCA:
- SANA
- AVNA
- ACUTE MARGINALS
- PDA (in 85%)

LCA:
- LAD:
- DIAGONAL BRANCHES
- SEPTAL BRANCHES
- LCX:
- OBTUSE MARGINALS
- LACX
Septal infarct in heart involves what vessel?
• LAD
• RCA
• Diagonal
• LCX
A. LAD
Coronary Artery Supply
- LAD: Septum and Anterior wall
- LCX: Lateral wall
- RCA: Posterior and Inferior (diaphragm) wall
- Watershed: Apex and Inferolateral wall
Carotid evaluation with parvus-tardus waveform
• Aortic insufficiency
• Aortic stenosis
• Cerebral edema
• Aortic balloon pump
B. AORTIC STENOSIS
Pulsus parvus et tardus (or parvus-tardus) waveform is seen on carotid evaluation in aortic stenosis. This is an arterial waveform characterized by a slowed systolic upstroke and a delayed time to peak systole with a rounded systolic peak.
Parvus-tardus waveforms are strongly suggestive of more proximal arterial disease. This term is used most often in post-stenotic renal artery waveforms (usually in renal transplants) but also characterizes carotid artery evaluation of aortic stenosis.
Which plane is best to measure LV function quantitatively on MR?
• a) coronal
• b) sagittal
• c) vertical long axis
• d) horizontal long axis
• e) short axis
Ans: E. short axis.
True about endothelium:
– proliferation of muscular cells by heparan sulfate.
– Vasa vasorum in outer portion…
– Multiple layers of endothelial cells
– Histiocytes in the adventitia producing prostaglandins?
True about endothelium:
– proliferation of muscular cells by heparan sulfate.
– Vasa vasorum in outer portion…
– Multiple layers of endothelial cells
– Histiocytes in the adventitia producing prostaglandins?


Ans: B.
• A short-axis gated MR image of the heart was shown (appeared similar to a shoulder). Isointense structure near posterolateral wall indicated. The most likely diagnosis is:
a. Clot
b. Left atrial myxoma
c. Papillary muscle
d. lipoma
e. valve
• C. Papillary muscle.The fish-mouthed appearance of the mitral valve characterizes the short-axis view of the base of the heart. In this view, the papillary muscle level, the ventricular myocardium can be divided into segments for the purpose of describing regional function. In the parasternal short-axis view at the papillary muscle level you can see both the anterolateral and posteromedial papillary muscles. [fairly confident this is what was shown—review Card. Req. p. 119 Fig. 3-21. http://www.madisonradiologists.com/SvcCardiacMRI.htm]Myxoma – the most common primary benign cardiac tumor, most arise in the atria (75-80% LA, 10-20% RA, 5% ventricle). May be pedunculated and protrude through the valve into the ventricle. Iso- / hypointense on T1WI relative to myocardium, marked hyperintensity on T2WI (Dähnert 5th p. 639); Isointense to myocardium on both T1WI and T2WI (Requisites p. 281-282).Clot – heterogenous appearance on T1WI and T2WI** From 2001 – the 2003 image was almost identical to that shown at left **
• On a cardiac MRI, an area of the left ventricular wall shows hypointensity on T1 with delayed contrast enhancement. This is most consistent with
a. arrhythmogenic dysplasia
b. aneurysm
c. ischemia
d. hibernating myocardium
• C. (probably)consistent with the description in this ‘Net Reference.new
• A 40 yo female is scheduled for tricuspid and pulmonic valve replacement. What is the most likely diagnosis?
a. Bronchial carcinoid
b. Gastrointestinal carcinoid with liver metastasis
c. Rheumatic heart disease
• B. Gastrointestinal carcinoid with liver metastases

• The cardiac lesions due to gastrointestinal carcinoids are almost exclusively in the right side of the heart and occur only when there are hepatic metastasis, suggesting that the substance responsible for the cardiac lesions is inactivated by passage through the liver and the lungs. The clinical syndrome is that of tricuspid regurgiation and pulmonary stenosis and the treatment of some severely symptomatic patients is valve replacement.Rhuematic heart disease typically affects the left side of the heart. When it effects the right side of the heart, it usually affects the tricuspid valve. Very rarely does rheumatic heart disease effect the pulmonary valve. HARRISON’S PAGE 1344* repeat from 2000 *
• A left-sided SVC typically empties where?
a. right atrium
b. left atrium
c. coronary sinus
d. left atrial appendage
• C. coronary sinus.
• can rarely empty into LA. see Dähnert 5th p. 586.
• Which of the following does Ebstein’s anomaly involve?
a. tricuspid valve
b. pulmonic valve
c. mitral valve
d. aortic valve
• A. tricuspid valve
• Which of the following etiologies is the most common cause of cardiomegaly in a newborn?
a. ASD
b. VSD
c. Tetralogy of Fallot
d. Ebstein’s anomaly
• B. Probably—VSD causes cardiomegally, and is the most common congenital heart disease (25-30%). see Dähnert 5th p. 655.
• Which native structure is preserved during an orthotopic heart transplant?
a. Pulmonic valve
b. Posterior wall of left atrium
c. Right atrial appendage
d. Coronary sinus
e. Non coronary sinus of Valsalva
• B. Left atrial wall
• Most heart transplant surgeries are done with a method called "orthotopic." Your heart is removed but the back half of both upper chambers (atriums) are left in place. The front half of the donor heart's atrium is sewed to the back half of yours, which was left in place. Then the donor heart's right atrium is sewed to the still-in-place back half of your original atrium. Once the heart is in place, the donor's main arteries - the aorta and pulmonary arteries - are sewn to yours. http://www.chfpatients.com/tx/txsurgery.htm
• A 28-year-old female has an episode of syncope. Her brother died of cardiac arrest. A cardiac MRI demonstrates an area of high signal in the right ventricular wall. What is the most likely etiology?
a. Right ventricular arrhythmogenic dysplasia
b. IHSS
c. Dilated Cariomyopathy
• A. Right ventricular arrhythmogenic dysplasia
• Also called arrhythomogenic right ventricular dysplasia which is a rare cardiomyopathy associated with arrhythmias and sudden death in young individuals and is similar to Uhl anomaly (a congential defect of the right ventricular myocardium from birth causing right heart failure). In right ventricular dysplasia, the right ventricular anterior wall is replaced by fatty fibrous tissue. MRI is performed with a surface coil to maximize the resolution of the anterior heart. The free wall fo the right ventricle has no visible myocardium in systole or diastole and has mainly fat on a fibrous thin wall between the cavity and the pericardium. Fat-supressed images may helping resolving the residual wall, which is about a pixel wide. Cardiac Requisities 288Echocardiography, which has been most commonly used for the diagnosis of ARVD, usually only demonstrates right ventricular enlargement with associated hypokinesia and with normal left ventricular chamber size. The disease is familial in about 30% of cases with an autosomal dominant inheritance.(note: in previous years this question was reversed  In a patient with an arrhythmogenic RV, what is the most common MRI finding? Answer: fat focus in RV)
• Which of the following is the most common benign primary cardiac tumor?
a. rhabdomyoma
b. myxoma
c. Lipoma
d. papillary fibroclastoma
e. teratoma
• B. Myxoma
• see Card. Req. p. 280.
• A patient has evidence of constrictive pericarditis on physical exam. What other disease process might closely mimic this?
a. restrictive cardiomyopathy
b. dilated cardiomyopathy
c. IHSS
• A. restrictive cardiomyopathy
• Card. Req. p. 274: “…constrictive pericarditis may be impossible to distinguish from restrictive cardiomyopathy based on hemodynamic tracings alone…”
• In a patient with an ASD, which of the following is most likely to be enlarged?
a. Pulmonary artery
b. Left ventricle
c. Ascending aorta
d. Left atrium
e. IVC
• A. Pulmonary Artery
• After birth, increase in LA pressure creates a L-to-R shunt (3-4 times volume of systemic flow) with volume overload of the right side of the heart, particularly the RV leading to RV dilatation. Source: Dähnert 5th ed. p.614-615“The classic chest film features of an ASD are enlargement of the right atrium, the right ventricle, and all segments of the pulmonary arteries (shunt vascularity)… the large size of the main pulmonary artery is usually striking when compared with the normal size of the aortic arch.” Card. Req. p. 343.ASD is the most common congenital cardiac anomaly with the ostium secundum (60%), ostium primum (35%) and sinus venosus defect (5%). Blood flow from LA to RA (Primer 112).
• A 45-year-old man presents to the ED with atypical CP and undergoes a calcium scoring CT that shows no calcification. What is the likelihood that he has significant coronary stenosis?
a. <15%
b. 40%
c. 65%
d. 90%
• A. < 15% The absence of calcification implies the absence of angiographically significant coronary vessel narrowing Source: Dähnert 5th p. 584 Electron-beam CT is 85% sensitive (= TP / TP + FN). Therefore, ~15% will be missed. Card. Req. p. 23.In one trial, a 0 calcium score had a 100% predictive value in the exclusion of angiographic evidence of obstructive epicardial coronary lesions. The higher the calcium score, the more likely the presence of angiographic obstructive disease. http://www.emedicine.com/radio/topic865.htm
• Which of the following structures is not formed by (or is not part of) the endocardial cushion?
a. Mitral valve
b. Infundibular septum
c. Tricuspid valve
d. Atrial septum
e. Ventricular septum
• B. Infundibular septum
• Endocardial cushion tissue (aka atrioventricular septal defect) contributes to the formation of the ventricular septum, the lower atrial septum, and the septal leaflets of the mitral valve and tricuspid valve.
• Infundibular septum (infundibulum = conus arteriosus) – the anterosuperior portion of the RV which joins the pulmonary trunk forming the RV outflow tract Source: Primer 2nd ed. p.114
• Which of the following is most commonly associated with left atrial dilatation?
a. Left atrial myxoma
b. Mitral regurgitation
c. Mitral stenosis
d. Atrial fibrillation
• B. Mitral regurgitation
• This is a classic cause of LAE due to backward flow of blood from the LV to the LA during systole with increased volume of blood under increased pressure causing the dilatation. Having said that….all the others can cause LAE as well. Dähnert 5nd ed. p.635; Card. Req. p. 10.ACR chest learning file Case #LB100 also gives mitral valve regurgitation as a common cause; similarly, myxoma is listed as a “rare” cause. No discussion of Atrial fibrillation; but note that left atrial enlargement causes atrial fibrillation, not the reverse.
• Left atrial enlargement is caused by which of the following (2001 repeat)
• Atrial fibrillation
• Right atrial myxoma
• Pulmonary artery hypertension
• Aortic regurgitation
• Pulmonary artery stenosis
• Answer: A. Atrial fibrillation results in poor atrial contraction, with enlarged atria over time. Rheumatic mitral valve disease was the most common cause of LA enlargement prior to antibiotics. Now myocardiopathies are more common. Other causes include VSD, PDA and LV failure. Most cardiac atrial myxomas are left sided 75%-80%. Answers B, C, and D would all cause the downstream LA to see less pressure and volume, so should not cause LA enlargement. (Paul and Juhl p. 1203 and Brant and Helms p. 565)
• Which of the following is most closely associated with left atrial enlargement?
• a. Atrial fibrillation
• b. Right atrial myxoma
• c. Tricuspid stenosis
• d. Pulmonary veno-occlusive disease
• Answer: A. Atrial fibrillation results in poor atrial contraction, with enlarged atria over time. Rheumatic mitral valve disease was the most common cause of LA enlargement prior to antibiotics. Now myocardiopathies are more common. Other causes include VSD, PDA and LV failure. Most cardiac atrial myxomas are left sided 75%-80%. Answers B, C, and D would all cause the downstream LA to see less pressure and volume, so should not cause LA enlargement. (Paul and Juhl p. 1203 and Brant and Helms p. 565)
• Most common cardiac abnormality seen on fetal ultrasound in the four chamber view.
a. double outlet right ventricle
b. coarctation
c. high membranous VSD
d. truncus arteriosus
e. endocardial cushion defect (aka AV canal defect)
• E. endocardial cushion defect (av canal defect)
• Using only the four-chambered view, the overall detection rate for significant cardiac anomalies approaches 70%. However, the rate reported by some observers has been less, as low as 50%. Therefore, although the four-chamber view is valuable, it has limitations. It is only able to detect certain anomalies, and typically only the larger ones. These are listed by frequency (likelihood) of detection – hypoplastic right or left ventricle, single ventricle, ATRIOVENTRICULAR (ENDOCARDIAL CUSHION) DEFECT, large ventricular septal defect, double-outlet right ventricle….coarctation. Ultrasound: the Requisites (pg 240).
• Where is the moderator band located at?
• Left atrium
• Left ventricle
• Right atrium
• Right ventricle
RV
• Which is true of coronary artery bypass?
a. ostial markers are not needed if the native vessels are completely occluded.
b. in repairing VSD's, the patches are on the low pressure RV side.
c. The Jantene or switch procedure involves switching the venous inflow to the atria.
• B. in repairing VSD’s, the patches are on the low pressure RV side
• 40% of VSD require surgery for repair. They can be repaired using suture or placement of a patch. Either way, the RV is the one opened. Ventricular Septal Defect: Effects, Assessment & Treatment on askjeeves.com.; Dähnert 5th p. 656. Jantene procedure is a repair for D-TGA. In it the ascending aorta and pulmonary arteries are divided above the sinus of Vasalva and the coronary arteries excised from the aorta. The coronary arteries are replanted in the new aortic root, which is connected to the left ventricle. The pulmonary artery bifurcation is brought anterior and anastomosed to the right ventricular sinuses. Cardiac Requisites, 324
• What is a Blalock-Taussig shunt?
• a. Anastomosis of subclavian artery to the ipsilateral pulmonary artery
• B. SVC to ipsilateral pulmonary artery connection
• C. right atrium to pulmonary artery
• D. ascending aorta to the pulmonary artery
Answer A. subclavian to ipsi pa
• An easy way to remember the surgical connections for congenital heart disease:
• Name of procedure: What connects to the Pulmonary artery (follow blood flow from SVC to descending aorta):
• G (Glenn shunt) SVC (i.e.-SVC->Pulmonary artery connection)
• F (Fontan) RA to pulm art
• R (Rastelli) RV to pulm art
• W (Waterston) Ascending Aorta
• B (Blalock-Taussig) Subclavian artery
• P (Pott shunt) Descending Aorta
• What is the 2nd most common vascular ring (after double aortic arch)?
• Right aortic arch with aberrant left subclavian artery
• Right aortic arch with mirror image branching
• Left aortic arch with aberrant right subclavian artery
• Pulmonary sling
• Answer: A. True vascular rings cause concomitant posterior esophageal and anterior tracheal impressions. The most common entity is a double aortic arch. The second most common vascular ring is a right aortic arch with an aberrant left subclavian artery. The ring is completed by the ductus remnant. Left arch with aberrant right subclavian artery is the most common arch anomaly, being found in 1% of individuals.
• Bulge of the aortic valve cusps is seen in?
• Subvalvular aortic stenosis
• Supravalvular aortic stenosis
• Pseudocoartatoin of aorta
Maybe subvalvular stenosis per Dr Awan. Can get a jet that might make cusps buldge.

• Supravalvular findings:
• dilatation and tortuosity of coronary arteries (may undergo early atherosclerotic degeneration secondary to high pressure)
• narrowing of the supravalvular area (normal root diameter: 20-37mm)
• normal movement of cusps

• Subvalvular findings:
• asymmetrically thicker ventricular septum than free wall of the left ventricle (95%)
• normal/small left + right ventricular cavities (95%)
• systolic anterior motion of the mitral valve
• lucent subaortic filling defect in systole
• coarse systolic flutter of valve cusps
• may see mitral regurgitation (secondary to abnormal position of anterolateral pappilary muscle)


• The tissue at the base of the aorta can be affected by various conditions such as: Marfan's syndrome, ankylosing spondylitis, rheumatoid arthritis, Reiter's syndrome, relapsing polychondritis, syphilis.
• Rarer conditions that cause aortic valve regurgitation include a disorder of the body's connective tissues (Marfan's syndrome), a type of arthritis (ankylosing spondylitis), some autoimmune diseases, and syphilis.
• . What is the normal relationship of the pulmonary to aortic valve? (2001 repeat)
• Anterior, superior and to the left
• Anterior superior and to the right
• Posterior inferior and to the right
• Posterior inferior and to the left
• Anterior and superior
• Anterior, superior and to the left
• Left atrial enlargement is caused by which of the following (2001 repeat*
• Atrial fibrillation
• Right atrial myxoma
• Pulmonary artery hypertension
• Aortic regurgitation
• Pulmonary artery stenosis
• Atrial fibrillation
• Regarding pulmonary angiography which of the following will result in the worst adverse effect. (similar to 2001)

• Right bundle branch block
• Left bundle branch block
• Pulmonary artery pressure 25mmHg/15mmHg
• INR of 8.0
• IVC filter
LBBB
• Other major risk factors in pulmonary angiography include the presence of a left bundle branch block, a history of ventricular irritability, or a recent myocardial infarction. In the presence of a left bundle branch block, the transient right bundle branch block that may occur when the catheter is passed through the right heart may result in complete heart block. The electrical system on the right side of the heart is often irritated during catheter and guidewire manipulation, especially in the right ventricle. Another important risk factor is a severely elevated pulmonary arterial pressure. Therefore, a temporary pacemaker should be in place before the procedure is performed
• Which of the following is associated with anterior motion of the anterior leaflet of the mitral valve?
a. Mitral valve prolapse
b. Papillary muscle dysfunction
c. Hypertrophic cardiomyopathy
d. mitral valve stenosis
• C. Hypertrophic cardiomyopathy
• Hypertrophic cardiomyopathy often leads to Systolic Anterior Motion (SAM) of the anterior leaflet of the mitral valve. This is movement of the anterior leaflet of the mitral valve into the outflow region in systole, causing an increasing stenosis. This abnormal motion of the mitral valve increases throughout systole and frequently causes the valve to touch the ventricular septum, creating an occlusion of the outflow from the left ventricle. SAM is variable. Cardiac Imaging Requisites, pg 291; Dähnert 5th p. 622.
• Which of the following requires a PDA for life?
a. D-transposition of the great vessels
b. Hypoplastic left ventricle
c. AP window
d. Tetralogy of Fallot
e. Truncus, Type II
• B. Hypoplastic left ventricle
• Hypoplastic left heart is a spectrum of cardiac anomalies characterized by underdevelopment of the LA, LV, MV, aortic valve, and aorta. Survival requires a large ASD and PDA with R-L and L-R shunting.
• Complete Transposition of the Great Arteries (D-TGA) is when there are two independent circulations, from body to body via the RV and from lung to Lung via the LV. It is incompatible with life unless there are associated anomalies that permit mixing of the two circulations (eg, ASD, VSD, PDA).
• Aorticopulmonary window have plain film findings identical to PDA; PDA associated 10-15%.
• Tetralogy of Falot and Truncus have a VSD.
• Primer of Diagnostic Imaging, 3rd
• Alcoholic cardiomyopathy is associated with which of the following?
a. left ventricle diastolic dysfunction
b. left ventricle systolic dysfunction
c. right ventricle diastolic dysfunction
d. decreased right atrial filling
• B. left ventricle systolic dysfunction
• Alcohol is one of many causes of dilated cardiomyopathy. In this, systolic function is depressed but diastolic function is nearly normal. Typically the left ventricle is enlarged with global hypokinesis whereas the right ventricle is less dilated and has a less severe contraction abnormality. Mild mitral and tricuspid regurgitation are common. Decreased EF with reduced stroke volume results from this and may have reduced cardiac output.
Cardiac Requisites pg 288; Dähnert
• Which of the following is false regarding cardiac transplants?
a. rejection rate is the same for orthotopic and heterotopic transplants
b. angina is uncommon
c. the heart rate after transplant is slower than the native heart rate
• C. the heart rate after transplant is slower than the native heart rateWhen the heart is removed from the body, the nervous system is disconnected and cannot be re-attached. The heart continues to beat adequately, but without an external nervous supply. The denervated heart beats faster at rest, but its rate does not rise as quickly with exercise. In addition, patients usually do not experience angina.. Orthotopic heart transplant: This is the procedure of choice for most patients, with the donor heart replacing the recipient's, and taking the correct position in the thorax. It is the most reliable and effective type of cardiac transplant, and accounts for almost 99% of such procedures. Heterotopic heart transplant: This procedure is also known as "piggy-back" heart transplantaion, as it leaves the recipient's heart intact to work in series with the donor heart. Rare--accounts for only 1% of procedures. Originally it was used when there was a moderately elevated pulmonary vascular resistance, and also in urgent cases when the donor heart is under-sized.
Askjeeves.com and Heart1.com, multiple articles
• Which is true regarding left atrial myxomas?
a. Most commonly arises from mitral valve
b. Mimics ASD
c. Mimics mitral stenosis
d. Mimics aortic stenosis
• C. mimics mitral stenosis
• Primary tumors of the heart are rare, but the most common is the myxoma (25% of heart tumors), typically arising in the left atrium from the interatrial septum. 75% occur in the left atrium, remainder in the RA, very few occur in the ventricles. They occur more commonly in women. Interference with function by the tumor mimics symptoms and signs of valvular dysfunction due to rheumatic disease. Thus, left atrial myxomas may cause pulmonary congestion and signs of mitral stenosis (eg, the typical murmur, an opening snap, an accentuated first heart sound). Murmurs of mitral insufficiency may also result from chronic damage to the valve leaflets or to the tumor's interference with proper closure.
Cardiac Requisites 280, Merck Manual, Benign Cardiac Tumors (via askjeeves.com)
• Which MRI sequence best evaluates blood flow when imaging the heart?
a. gradient echo
b. spin echo
c. Phase contrast
• A. Gradient echo
• Flow-related enhancement occurs in both spin-echo and gradient reversal sequences; however, it is more prominent on gradient-reversal sequences.Cardiac Requisites 103
• Which of the following best demonstrates blood flow hemodynamics on MR?
• single shot fast spin echo
• HASTE
• 3D time of flight gradient echo
• phase contrast
• 2D time of flight gradient echo
• Phase contrast
• What causes the interventricular septum to rotate clockwise on the MRI transverse view?
a. aortic stenosis
b. pulmonary arterial hypertension
• B. pulmonary arterial hypertension
• Increase in right ventricular afterload (caused by pulmonary arterial htn) results in hypertrophic myocardium which results in right ventricular htn. The normal convexity of the interventricular septum towards the right ventricular cavity is straightened or even reversed so that the septum bows toward the LV cavity.
Cardiac Requisites, pg 112 (picture on 117, image 3-15).
• Which of the following is true regarding calcification of the mitral annulus?
a. more common in men
b. associated with aortic stenosis
• B. associated with aortic stenosis
• Mitral annulus calcifications are more common in the elderly and in women. It usually has little clinical significance although in extreme cases can cause mitral regurg and stenosis or grow posteriorly into the ventricular wall causing heart block. Aortic stenosis and htn have a higher incidence of mitral annulus calcification. Mitral annular calcification differs from mitral valve calcification, which is often caused by rheumatic valvular dz.
Cardiac Requisites, 17
• Ischemia associated with anomalous origin of left coronary artery is associated with which of the following?
a. decreased oxygen content from an anomalous vessel
b. steal
c. spasm / intermittent flow
d. small caliber of the vessel
e. abnormal distribution of the LCA
• B. Steal
• Bland-White-Garland syndrome: anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA) is a rare but serious congenital anomaly. Initially, myocardial ischemia is transient, occurring during periods of increased myocardial demands, such as when the infant is feeding and crying. Further increases in myocardial oxygen consumption lead to infarction of the anterolateral left ventricular free wall and/or papillary muscle dysfunction (terminating in CHF).Mechanism: with postnatal fall in pulmonary arterial pressure, perfusion of LCA drops (ischemic left coronary bed) as flow is preferentially directed towards the lower-resistance pulmonary vascular bed (steal); there may be collateral flow from RCA with flow reversal in LCA:
- adequate collateral circulation = lifesaving
- inadequate collateral circulation = myocardial infarction
- large collateral circulation = L-to-R shunt with volume overload of
heart. Dähnert 5th p. 603; Emedicine.com; Card. Req. p. 225.* This makes sense from a physiology standpoint, as the mean pressure in the aorta is 70-90 mm Hg, but that in the PA is 15-20 mm Hg—a huge difference in perfusion pressure.[Update—7/01/03: Primer 3rd p. 145 lists “venous blood” as the mechanism. This is incorrect, as the pressure differential will allow little (if any) venous blood to enter the coronary circulation.].
• A fetal ultrasound shows parallel cardiac outflow tracts. Most likely diagnosis?
a. truncus arteriosus
b. Tetralogy of Fallot
c. Transposition of great vessels
d. total anomalous pulmonary venous return
e. normal
• C. Transposition of great vessels
• Transposition of the great vessels can only be detected by seeing parallel cardiac outflow tracts.
• Truncus arteriosus dx is made with echo by demonstrating a large, single great vessel which overrides a large VSD.
• Tetralogy of Fallot shows a VSD beneath a large overriding aortic root, right ventricular hypertrophy, and often underdeveloped pulmonary artery (due to stenosis). Total anomalous pulmonary venous return has variable findings.
Cardiac Requisites 87-91 Primer 130-132
• A false cardiac aneurysm (i.e., pseudoaneurysm) is lacking which of the following layers?
a. myocardium and endocardium
b. epicardium
c. endocardium
d. myocardium, epicardium and endocardium
e. myocardium
• A. myocardium and endocardium.
• When the pericardium rather than myocardium composes the wall of the aneurysm, it is a false aneurysm or pseudoaneurysm. The usual cause is a rupture of the left ventricle into the pericardial space after myocardial infarction. Because of adhesions from previous pericarditis, the pericardium locally attaches to the epicardium which restrains the ventricular blood from extending into the remaining pericardial space and causing tamponade. Cardiac Requisites, 238 Ed. Note: Epicardium = visceral pericardium. Some references suggest endocardium is initially lost after an MI, then myocardial (muscle) thinning ( true aneurysm). When the myocardial wall further ruptures completely, but is contained by fused visceral/parietal pericardium, a pseudoaneurysm is formed. In any case, all references seem clear that the wall of a false aneurysm is pericardium (= no endocardium or myocardium).
• A patient has big atria, enlarged hepatic veins and IVC. Anterior pericardial calcifications are seen on CT. Most likely diagnosis:
a. restrictive cardiomyopathy
b. constrictive pericarditis
c. Asbestoses
d. Uremia
• B. constrictive pericarditis
• The pericardium calcifies in 50% of cases of constrictive pericarditis. The pericardium does not calcify in restrictive cardiomyopathy. Constrictive pericarditis is a thickening of the pericardium that restricts diastolic filling of the heart. It can occur after any pericarditis but is frequently ascribed to viral or TB pericarditis, uremia with pericardial effusion, or cardiac surgery. Because of the restriction to right ventricular filling the right atrium, VC, and hepatic veins are dilated. Hemodynamically, restrictive cardiomyopathy and constrictive pericarditis can appear similar. Asbestosis is lung parenchymal fibrosis with likely calcified pleural plaques. Cardiac Requisites 271-276, 288-290
• What artery supplies the A-V node?
a. branch of the proximal RCA
b. branch of the distal RCA
c. conus branch of the RCA
d. branch on the LCA
e. brach of the left circumflex
• B. branch of the distal RCA
• Arterioventricular nodal artery supplied by a distal branch from the RCA 90% of the time. The Conus artery is the first branch of the RCA. The SA node is supplied by a proximal RCA branch 40-55% of the time. Primer, 111
• Which of the following is most commonly associated with aortic stenosis?
a. Angina
b. Aortic nipple
c. Enlarged left ventricle
d. Dilatation of aorta
• C. Enlarged left ventricle
• LVH is commonly associated with aortic stenosis. Poststenotic dilatation of the aorta is only present in valvular AS. Aortic valve calcification occurs in all types of AS after age 40 if severe. Types of AS: Subvalvular, Valvular (most common, bicuspid aortic valve most common congenital anomaly causing), Supravalvular.
Cardiac Requisites, 149-162 Primer 123
• Which of the following most commonly metastasizes to the heart?
a. Melanoma
b. Breast
c. Lymphoma
d. Bronchogenic CA
e. colon
• D. Bronchogenic CA
• Metastatic tumors to the heart and pericardium are 20 to 40 times more frequent than primary heart tumors. Melanoma, leukemia, and malignant lymphoma are the tumors that more frequently metastasize to the heart. Because of their adjacent location, lung and breast tumors frequently go to the pericardium during the terminal stage of the dz. In order of decreasing frequency: lung, breast, melanoma, lymphoma/leukemia.
Cardiac Requisites, pg 278-279 and Metastatic Tumor of the Heart, from www.rbrs.com
• D-transposition of the great vessels is associated with--
a. AV concordance
b. AV discordance
c. LV connects to aorta
d. RV connects to PA
• A. AV concordance
• In D-TGA the atria and ventricles are in normal position—AV concordance. In L-TGA there is inversion of the ventricles—AV discordance. Primer, 128
• D- transposition – AV concordance, ventriculoarterial discordance (RA  RV  aorta; LA  LV  PA); closed loop, requires shunt for viability [VSD in 50%]
• L- transposition – AV discordance, ventriculoarterial discordance
(RA  LV  PA, LA  RV  aorta); “corrected” transposition, but 40% 1-yr survival (other defects); high incidence of dextrocardia Req 60-61; Dähnert 5th p. 652
• Which of the following increases the ejection fraction?
a. aortic insufficiency
b. idiopathic hypertropic cardiomyopathy
• B. idiopathic hypertropic cardiomyopathy
• Hypertrophic cardiomyopathy tends to be associated with a hyperdynamic heart with ejection fractions above 60-65%. Ejection fraction is often not reduced in aortic insufficiency, but is not elevated.
Headdocs.com, Hypertrophic Cardiomyopathy
• In a patient with an ASD, which of the following is most likely to be enlarged?
a. Pulmonary artery
b. Left ventricle
c. Ascending aorta
d. Left atrium
e. IVC
• A. Pulmonary Artery After birth, increase in LA pressure creates a L-to-R shunt (3-4 times volume of systemic flow) with volume overload of the right side of the heart, particularly the RV leading to RV dilatation. Source: Dähnert 5th ed. p.614-615“The classic chest film features of an ASD are enlargement of the right atrium, the right ventricle, and all segments of the pulmonary arteries (shunt vascularity)… the large size of the main pulmonary artery is usually striking when compared with the normal size of the aortic arch.” Card. Req. p. 343.ASD is the most common congenital cardiac anomaly with the ostium secundum (60%), ostium primum (35%) and sinus venosus defect (5%). Blood flow from LA to RA (Primer 112).
• A short-axis gated MR image of the heart was shown (appeared similar to a shoulder). Isointense structure near posterolateral wall indicated. The most likely diagnosis is:
a. Clot
b. Left atrial myxoma
c. Papillary muscle
d. lipoma
• C. Papillary muscle.
• The fish-mouthed appearance of the mitral valve characterizes the short-axis view of the base of the heart. In this view, the papillary muscle level, the ventricular myocardium can be divided into segments for the purpose of describing regional function. In the parasternal short-axis view at the papillary muscle level you can see both the anterolateral and posteromedial papillary muscles. [fairly confident this is what was shown—review Card. Req. p. 119 Fig. 3-21. http://www.madisonradiologists.com/SvcCardiacMRI.htm]Myxoma – the most common primary benign cardiac tumor, most arise in the atria (75-80% LA, 10-20% RA, 5% ventricle). May be pedunculated and protrude through the valve into the ventricle. Iso- / hypointense on T1WI relative to myocardium, marked hyperintensity on T2WI (Dähnert 5th p. 639); Isointense to myocardium on both T1WI and T2WI (Requisites p. 281-282).Clot – heterogenous appearance on T1WI and T2WI
• What are the best findings on chest x-ray for situs inversus?
a. right stomach bubble and right cardiac apex (dextrocardia)
b. right stomach bubble and right aortic knob
c. right stomach bubble and left cardiac apex
d. stomach on the right side and aortic knob on the left
e. stomach on the left side and cardiac apex on the right side
• A. Right stomach bubble and right cardiac apex (dextrocardia)
• Key concept—the most general application of the term “situs” is visceroatrial situs [assumed here]. Other uses may refer to the position of the ventricles, great vessels, or abdominal viscera.
- position of the atria is almost always concordant with the viscera
- discordance (e.g., right stomach bubble, left cardiac apex)  high risk of CHD
• Situs inversus (totalis) indicates mirror image development of both the visceral and cardiac anatomy; incidence 0.01%. (Caffey 829); “left atrium and stomach on right and dextrocardia (cardiac apex on right)”—AFIP syllabus ’02-’03 p. 976.
- “…the position of the aortic arch (left or right) is NOT a good indicator of situs” AFIP syllabus ’02-’03 p. 977 (bottom).Situs solitus (totalis) - normal; Heterotaxy – ambiguous. Dähnert 5th p. 582.
• A patient has a brachial pressure of 180/40. Which of the following is the most likely cause?
a. Coarctation of the aorta
b. Pseudo-coarctation
c. Aortic Stenosis
d. PDA
• D. PDA
• Coarctation of the aorta – differential BP in arms and legs (however, may have widened pulse pressure)
• Pseudo-coarctation – Variant of coarctation associated with HTN, without pressure gradient
• Aortic Stenosis – Narrowed pulse pressure
• PDA – Wide pulse pressure Source: Dähnert 5th ed. p. 640,644; Primer 2nd ed. p.117
• Regarding calcium scoring CT, which of the following is true?
a. CT is more sensitive than thallium in the detection of significant CAD
b. Amount of calcification is directly proportional to degree of stenosis
c. Left circumflex calcifies more commonly than LAD
d. Calcification most commonly occurs in the proximal 2 cm of the LAD
• D. Calcification most commonly occurs in the proximal 2 cm of the LAD

• The LAD artery is the most frequently calcified site. Card. Req. p. 21.Stenosis occurs primarily in the proximal portions of the major arteries; LAD > RCA > LCx. Coronary calcification is not found in the absence of atherosclerosis. It is uncommon to find significant stenosis of the coronary arteries in the absence of calcification but it may still occur in 8-9%. ( www.screeningctisus.com/cases/coronary.html )“Sub-second CT is sensitive for the detection of early CAD, and extent of plaque burden. But it is not helpful in defining the location or severity of coronary artery stenosis. The most powerful imaging tool for defining clinical prognosis in patients with coronary artery disease is nuclear stress testing, and therefore patients with significant coronary calcium deposition should be preferentially considered for an exercise or pharmacologic nuclear stress test for further evaluation.”
• A 45-year-old man presents to the ED with atypical CP and undergoes a calcium scoring CT that shows no calcification. What is the likelihood that he has significant coronary stenosis?
a. <15%
b. 40%
c. 65%
d. 90%
• A. < 15% The absence of calcification implies the absence of angiographically significant coronary vessel narrowing Source: Dähnert 5th p. 584 Electron-beam CT is 85% sensitive (= TP / TP + FN). Therefore, ~15% will be missed. Card. Req. p. 23.In one trial, a 0 calcium score had a 100% predictive value in the exclusion of angiographic evidence of obstructive epicardial coronary lesions. The higher the calcium score, the more likely the presence of angiographic obstructive disease. http://www.emedicine.com/radio/topic865.htm
• A 28-year-old female has an episode of syncope. Her brother died of cardiac arrest. A cardiac MRI demonstrates an area of high signal in the right ventricular wall. What is the most likely etiology?
a. Right ventricular arrhythmogenic dysplasia
b. IHSS
c. Dilated Cariomyopathy
• A. Right ventricular arrhythmogenic dysplasia
• Also called arrhythomogenic right ventricular dysplasia which is a rare cardiomyopathy associated with arrhythmias and sudden death in young individuals and is similar to Uhl anomaly (a congential defect of the right ventricular myocardium from birth causing right heart failure). In right ventricular dysplasia, the right ventricular anterior wall is replaced by fatty fibrous tissue. MRI is performed with a surface coil to maximize the resolution of the anterior heart.
• Which of the following structures is not formed by (or is not part of) the endocardial cushion?
a. Mitral valve
b. Infundibular septum
c. Tricuspid valve
d. Atrial septum
e. Ventricular septum
• B. Infundibular septum
• The location of the pulmonary valve relative to the aortic valve is:
a. Left, superior, anterior
b. Left, superior, posterior
c. Left, inferior, anterior
d. Right, superior, anterior
• A. Left, superior, anterior
• Which of the following result in increased ejection fraction?
a. IHSS
b. Cardiomyopathy
c. Mitral regurgitation
d. Aortic stenosis
• C. Mitral regurgitation Backward flow of blood from LV into LA during systole, with marked increase in LV diastolic volume but little increase in LV diastolic pressure (= increase in preload without increase in afterload = elevated ejection fraction). Source: Dähnert 5th ed. p. 635Ed. Note: As a point of clarification, idiopathic hypertrophic subaortic stenosis (IHSS) has been used in the past as a synonym for hypertrophic cardiomyopathy, which may or may not cause increased ejection fraction. (see Card Req. p. 290, 296). Even so, Mitral regurgitation (choice C) remains clearly the best answer.
• Regarding Idiopathic Hypertrophic Subaortic Stenosis (IHSS), which of the following is true?
a. Decreased compliance
b. anterior motion of mitral valve
• B. anterior motion of mitral valve.
• IHSS is a dynamic form of subaortic stenosis. The obstruction occurs in systole with the abnormal anterior systolic motion of the anterior leaflet of the mitral valve. During diastole, the stenosis disappears as the mitral leaflet resumes its normal position. Card. Req. p. 159.
• Which of the following does not form part of the cardiac border on the frontal chest radiograph?
a. RV outflow tract
b. L atrial appendage
c. LV outflow tract
d. Right atrium
e. Main pulmonary artery
I think RV outflow
• C. LV outflow tract
• The right cardiac border is formed by the RA, with the SVC entering superiorly and the IVC inferiorly. The left cardiac border is created primarily by the LV and LA appendage. The pulmonary artery (RV outflow tract), aortopulmonary window, and aortic knob extend superiorly.
Source: Brant 2nd ed. p.525; Primer 2nd ed. p.100-101.
• Constrictive pericarditis is most characterized by
a. Pericardial calcifications
b. Diminished end-diastolic volume
c. Pericardial thickness of 8 mm on CT
• C. Pericardial thickness of 8 mm on CT.
• On the chest radiograph, the pericardium is calcified in about 50% of patients with constrictive pericarditis; CT is the best imaging procedure to use when searching for calcified pericardium.
- 90% of patients with constrictive pericarditis have calcified pericardium on CT.Diminished end-diastolic volume: present in constricitive pericarditis, however, present in many other disorders (e.g., restrictive cardiomyopathy) as well. Table 8-1 in the Cardiac Requisites makes this very clear.Thickening: 8 mm would be a very high (but specific) cutoff for restrictive pericarditis—Dähnert says 2 mm, Card. Req. says 5 mm. Dähnert 5th p. 624; Card. Req. p. 274. Primer p. 142.Ed. Note: Answer changed based on a different interpretation of the question, e.g.,
- “Which of the following, if seen, would provide the strongest evidence that constrictive pericarditis is present?” Undoubtedly, an 8 mm thick pericardium would be restrictive.
- On the other hand, “…a calcified pericardium does not necessarily imply that constriction exists.” Card. Req. p. 274.
• In what plane is the short axis view obtained?
a. Parallel to the sagittal plane
b. Oblique coronal
c. Oblique transverse
d. Perpendicular to long axis
e. Perpendicular to the four chamber view
• D. Perpendicular to the long axis
• Source: Primer 3rd p. 114.
• Which of the following is most likely to occur with acute occlusion of the left anterior descending artery?
a. Rupture of the ventricular septum
b. Papillary muscle rupture
c. False aneurysm formation
• A. Rupture of the ventricular septum
• Complications of acute MI (LAD, 40%; right, 27%):
- Papillary muscle rupture, 1% (* usually posteromedial)
- Interventricular septum rupture, 0.5-2%
- Left ventricular failure, 60-70%
• Given that the LAD supplies the anterolateral papillary muscle, which uncommonly ruptures, interventricular septum rupture is probably the best choice
• .False aneurysm of the ventricle is a rupture contained by fused layers of visceral and parietal pericardium / extracardiac tissue. It can occur with trauma or myocardial infarction. Important to detect because they tend to rupture. Dähnert 5th p. 638, 655.
What is not a likely sequelae of acute LAD occlusion?
• Septal perforation
• CHF
• Papillary muscle rupture
• False aneurysm in posteroinf wall
• ANS : D:
• Patients are more likely to have inferior wall myocardial infarctions due to the occlusion of the posterior descending artery (PDA) branch of the right coronary artery (RCA) supplying the posterior wall papillary muscle. The anterolateral papillary muscle has a dual blood supply from the left anterior descending (LAD) and left circumflex (LCX) coronary arteries
• Which of the following is most commonly associated with left atrial dilatation?
a. Left atrial myxoma
b. Mitral regurgitation
c. Mitral stenosis
d. Atrial fibrillation
I think Afib is more common overall
• B. Mitral regurgitation This is a classic cause of LAE due to backward flow of blood from the LV to the LA during systole with increased volume of blood under increased pressure causing the dilatation. Having said that….all the others can cause LAE as well. Dähnert 5nd ed. p.635; Card. Req. p. 10.ACR chest learning file Case #LB100 also gives mitral valve regurgitation as a common cause; similarly, myxoma is listed as a “rare” cause. No discussion of Atrial fibrillation; but note that left atrial enlargement causes atrial fibrillation, not the reverse.
• Which of the following is most closely associated with left atrial enlargement?
• Atrial fibrillation
• Right atrial myxoma
• Tricuspid stenosis
• Pulmonary veno-occlusive disease
• Answer A. Atrial fibrillation results in poor atrial contraction, with enlarged atria over time. Rheumatic mitral valve disease was the most common cause of LA enlargement prior to antibiotics. Now myocardiopathies are more common. Other causes include VSD, PDA and LV failure. Most cardiac atrial myxomas are left sided 75%-80%. Answers B, C, and D would all cause the downstream LA to see less pressure and volume, so should not cause LA enlargement. (Paul and Juhl p. 1203 and Brant and Helms p. 565)
Regarding Eisenmenger physiology, which of the following is false?
• When due to an ASD it is more common in a child than in an adult
• More commonly caused by VSD than ASD
• Demonstrates a normal pulmonary capillary wedge tracing
• Following complete correction of a tetrology of Fallot, elevated pulmonary pressures persist
I think the ASD statement is false
• When due to ASD
• (False)Tetralogy of Fallot involves (among other things) obstruction of the right ventricular outflow tract.
- Palliative procedures (Blalock-Taussig, Waterston-Cooley) bypass the obstruction and send high-pressure left-sided blood through the lungs, with associated consequences (see below)
- 10% of BT shunts, 30% of WC procedures develop Eisenmenger’s physiology
- however, open Tet. Repair involves VSD closure and reconstruction of the right ventricular outflow tract—not associated with Eisenmenger’s physiology.Eisenmenger’s physiology (also syndrome or reaction) can be summarized as follows:
- Shunt lesion (ASD, VSD, PDA) initially allows abnormal L  R flow (because of higher left-sided pressures)
- shunting leads to increased pulmonary blood flow
- over time (depending on the size of the shunt), pulmonary microscopic vessels undergo reactive muscular hypertrophy, endothelial thickening, etc.
- PA pressure subsequently increases, such that ultimately the shunt reverses: becomes R  L (cyanotic) Dähnert 5th p. 627.
• Since an ASD has a much smaller pressure differential (~6 mm Hg) than an equivalent VSD, the magnitude of the shunt is much smaller, and it takes longer (e.g., into adulthood) for the Eisenmenger physiology to appear. http://www.emedicine.com/med/topic642.htm
- 10% of cases progress to pulmonary hypertension, typically in the 3rd decade.Once Eisenmenger’s develops, there is marked pulmonary arterial hypertension, but no longer increased flow—the pulmonary venous (and therefore left atrial) pressure becomes normal.

• Patients with ASD usually asymptomatic until 2nd or 3rd decade. Eisenmenger’s not a common complication s/p tet repair per GB. VSD more common than ASD. (Radiology of Congenital Heart Disease, Amplatz and Moller).
• Hepatic metastasis of the carcinoids involves replacement of
a. aortic and mitral valve
b. Tricuspid and pulmonic valve
• B. Tricuspid and pulmonic valve.
• Which is false regarding a bicuspid aortic valve?
a. Coronary arteries are most commonly normal
b. Density of calcifications is greater than aortic stenosis with a tricuspid valve
c. Association with mitral valve stenosis is as common as with rheumatic fever
d. Associated with pseudocoarctation
e. increased incidence of endocarditis
• C. Association with mitral valve stenosis is as common as with rheumatic fever.
• C. False. Somewhat convoluted wording; the bottom line appears to be “high association with Rheumatic fever, low association with mitral stenosis”
- Bicuspid aortic valve responsible for 50% of aortic valvular bacterial endocarditis (Dähnert CD ROM)
- In most cases of bicuspid aortic stenosis, the mitral valve is normal…” Card Req 16
• A. True. Bicuspid aortic valve is very common (1%), abnormal coronary origins are uncommon. Ed. Note: A previous question argued the coronary arteries were abnormal because of “20-50% LCA dominance” with bicuspid aortic valve. Per Moore’s anatomy, 50% of normals are RCA dominant, 20% LCA dominant, and 30% balanced. It certainly appears, then, that bicuspid valves are within the realm of normal.
• B. True: Stenotic congenital bicuspid valve = calcium first detected at an average age of 28 years; Degenerative aortic stenosis of tricuspid leaflets = calcium first detected at an average age of 54 years.
• D. True: pseudocoarctation = aortic kinking = coarctation w/o pressure gradient
- Associated with bicuspid aortic valve, PDA, VSD, etc. Dähnert CD ROM
• E. True. (see above).
• Cardiac abnormality best seen on fetal ultrasound in the four chamber view.
a. double outlet right ventricle
b. coarctation
c. high membranous VSD
d. truncus arteriosus
e. endocardial cushion defect (aka AV canal defect)
• E. endocardial cushion defect (av canal defect)
• Using only the four-chambered view, the overall detection rate for significant cardiac anomalies approaches 70%. However, the rate reported by some observers has been less, as low as 50%. Therefore, although the four-chamber view is valuable, it has limitations. It is only able to detect certain anomalies, and typically only the larger ones. These are listed by frequency (likelihood) of detection – hypoplastic right or left ventricle, single ventricle, ATRIOVENTRICULAR (ENDOCARDIAL CUSHION) DEFECT, large ventricular septal defect, double-outlet right ventricle….coarctation. Ultrasound: the Requisites (pg 240).
• Which of the following tumors are most likely associated with valvular heart disease:
a. melanoma
b. carcinoid
c. colon carcinoma
d. breast Ca
• B. Carcinoid
• Carcinoid syndrome (in 7% of SB carcinoids; rare in bronchial carcinoid):
- right-sided endocardial fibroelastosis (35%) resulting in tricuspid regurgitation + pulmonary valve stenosis + right heart failure
- recurrent diarrhea (70%), asthmatic wheezing from bronchospasm (15%), multiple telangiectasias (25%) Dähnert 5th p. 801.
• A 40 yo female is scheduled for tricuspid and pulmonic valve replacement. What is the most likely diagnosis?
a. Pulmonary carcinoid
b. Gastrointestinal carcinoid with liver metastasis
c. Rheumatic heart disease
• B. Gastrointestinal carcinoid with liver metastases
• The cardiac lesions due to gastrointestinal carcinoids are almost exclusively in the right side of the heart and occur only when there are hepatic metastasis, suggesting that the substance responsible for the cardiac lesions is inactivated by passage through the liver and the lungs. The clinical syndrome is that of tricuspid regurgiation and pulmonary stenosis and the treatment of some severely symptomatic patients is valve replacement.Rhuematic heart disease typically affects the left side of the heart. When it effects the right side of the heart, it usually affects the tricuspid valve. Very rarely does rheumatic heart disease effect the pulmonary valve. HARRISON’S PAGE 1344
• A 60 yo man is 4 yrs s/p RCA CABG (non-dominant RCA). His immediate post-op studies showed normal wall motion without infarct or ischemia. He now presents with a reversible posterior wall defect of thallium imaging. Most likely diagnosis:
a. Graft occlusion
b. New LAD ischemia
c. Infarct
d. Perioperative infarct
e. Ischemia in RCA distal to graft
• . In a non-dominant RCA situation, the posterior wall would be supplied by the left circulation and would give a reversible defect in the setting of ischemia. (D502, 917).
• Which statement is true regarding coronary artery calcifications:
a. Calcium scoring is more sensitive for atherosclerotic disease than Tl-201 stress or EKG testing
b. Found in high grade stenosis
c. Is in equal frequencies in all coronary arteries
d. Is a contraindication for angioplasty
• A. Calcium scoring Is moré sensitive for atherosclerotic disease than Tl-201 stress or EKG testing
• (a) Coronary artery calcifications are more sensitive for atherosclerostic disease than T1-201 stress or EKG testing.
Ed. Note: compare with the year 2001 question (pg. 7), which said “more sensitive for significant atherosclerotic disease…” [which was false].(b) Coronary artery calcification ---this is correlation between calcification and the severity of coronary stenosis; however, some severe stenosis may not be calcified and some heavy calcifications may not denote stenotic arteries.
Ed. Note: probably an incomplete recall, because if this is false, it seems to contradict choice A.(c) The location of calcification in the coronary arteries is not equal for each artery. The LAD (left anterior decending ) 93%, LCX (left circumflex) 77%, left main CA 70% , right coronary artery 69%(d) Calcifications are not a contraindication for angioplasty Pg 585 Dähnert 5th ed Pg 21 Cardiac Requisites
• Most common finding in aortic stenosis:
a. prominent aortic knob
b. LVH
c. angina
d. cerebral emboli
• B. Left Ventricular Hypertrophy
• Patients with Aortic stenosis will nearly uniformly have LVH from increased end-systolic pressures.There is post-stenotic dilation of the ascending arotic arch in aortic stenosis:
- 90% of acquired, 70% of congenital AS Dähnert p. 612.Echo shows increased left ventricular wall thickness in arotic stenosisAngina, syncope and CHF are clinical manifestation of aortic stenosis Card. Req. p. 155.
• Endocardial cushion defect (ECD) is associated with all the following cardiac abnormalities except:
a. cleft mitral valve
b. gooseneck deformity
c. high VSD
d. osteum secundum ASD
e. notched MV
f. Down’s syndrome
• D. osteum secundum ASD
• Atrioventricular septal defects (AVSDS) are a complex group of cardiac anomalies that share a deficiency or absence of the AV septum, resulting in an interatrial communication (ostium primum ASD) above the AV valves, a deficiency in the inlet portion of the ventricular septum immediately beneath the AV valves that results in a common AV orifice. Synonymous terms for the condition include AV canal defect, AV defects, AV communis, ostium primum defect, and endocardial cushion defect. Almost always, an interatrial communication exists through the so-called ostium primum defect, which results from the deficiency of the AV septum. In the complete form of AVSD, a moderate to large interventricular communication is present, because the bridging leaflets are floating free, which creates a connection between the ventricles. The communication is also larger in this variety because of the greater deficiency of the septum, when compared with that found with the partial form. The septal defect usually includes the adjacent membranous septum as well as the muscular portion of the inlet septum. (The membranous septum is the high portion of the ventricular septum.)25% of patients with Down’s syndrome have ECD. Dähnert 5th p. 568. Taveras and Ferrucci Vol 2 CH 80, Acyanotic Congenital cardiac malformations. Taveras & Ferrucci, CD-2000, Atrial Septal Defect—Echocardiography, Vol 2, Chap 84
• Which of the following are true regarding PDA?
a. calcification of the ductus indicates pulmonary artery hypertension
b. indomethacin can be used to keep a PDA open
c. the right recurrent laryngeal nerve loops around the ductus
d. a widened pulse pressure can be seen with a PDA
• D. a widened pulse pressure can be seen with a PDA
• Patent ductus arteriosus:
- incidence-10%; more common in girls and premature infants
- Left to right shunt leading to enlarged LA, LV, and aorta with increase in pulmonary vascularity (hard to differentiate PDA and VSD by CXR)
- Can have continuous murmur at left sternal border, full peripheral pulses, widened pulse pressure, and ECG reflection of LV volume overload. Dähnert 5th p. 641.Ductus stays open for chemical, not pressure reasons. Low O2 tension in arterial blood flow and high prostaglandin levels inhibit closure; PGE1 is potent vasodilator of duct, indomethacin inhibits PGE (closes PDA) – successful therapy in 60% (b is false)Closure begins at the pulmonic end and the ligamentum calcifies in some children indicating closure (no assoc. with pulm htn, A is false)Usually asymptomatic, but if large get CHF from LV failurethe left recurrent Laryngeal nerve loops around the ductus (c is false) Merck manual 2056; Peds requisites 59
• Which of the following is the most common cause of a vascular ring?
a. aberrant left pulmonary artery
b. right aortic arch with aberrant left subclavian a.
c. left aortic arch with aberrant right subclavian artery
d. right aortic arch with mirror image branching
• B. right aortic arch with aberrant left subclavian
• Swischuck “the term vascular rings is, at times, loosely used to include all anomalies of the aortic arch and great vessels, but strictly speaking it should be restricted to those entities in which actual encirclement of the trachea and esophagus occurs” . The most common type of right aortic arch has an aberrant retroesophageal left subclavian artery. If a left ductus connects this left subclavian artery to the left pulmonary artery, a vascular ring is formed. 5% have symptoms (airway or esophageal compression)
• .A double aortic arch is both the most common and most symptomatic of all vascular rings.
- Right arch with mirror image branching: the ductus arteriosus goes from the left subclavian artery to the left pulmonary artery in front of the trachea and does not cause a vascular ring (usually asymptomatic).
- Left aortic arch / aberrant right subclavian: most common congenital arch anomaly (1% of persons). Usually asymptomatic because no ring is formed (it’s a sling). Sources: Card. Req. p. 419-421; Primer 3rd. p. 134; Dähnert 5th p. 580.A. also known as the pulmonary sling, has the Lt PA arising from the Rt PA and it passes between the trachea and esophagus compressing both.D. Right AA with mirror branch imaging does not have vascular ring symptoms. It is associated with cyanotic heart disease in 98% of cases (TOF and TA)Peds req 15-16, Primer 3rd ed 133-136; Swischuck-imaging of newborn, infant, and young child 309-318
• Concerning cardiac surgery, which of the following are true:
a. mitral annuloplasty reverses the effects of calcific mitral stenosis.
b. Coronary ostial markers are not necessary when the coronary ostia are occluded
c. In repairing VSD’s, the patches are on the low pressure RV side
d. The Jantene or switch procedure for transposition involves switching of the venous inflow to the atria
• C. In repairing VSD’s, the patches are on the low pressure RV side
• A: False: used for M. Regurgitation.
• D: False: Mustard and Senning are the atrial switch operations while Jantene is arterial switch operation.
• Concerning Left Atrial myxomas, which of the following are true?
a. can mimic AV disease
b. when it arises from the septum it is usually not mobile
c. usually arises from the atrial wall
d. has decreased echogenecity on ultrasound
• A. can mimic AV valve disease.
• Atrial myxoma may protrude into the ventricle causing partial obstruction of the atrioventricular (AV) valve: Dähnert 5th p. 639.
- Left atrial myxoma (75-80%)  obstruction of mitral valve (= left AV valve)
- Right atrial myxoma (10-20%)  obstruction of tricuspid valve (= right AV valve)
• Attaches to the interatrial septum most commonly via a stalk (75%). Is hyperechoic, althought might contain hemorrhage. Card. Req. p. 280.
• A defect in the conal septa is associated with which of the following?
a. ASD
b. Tetralogy of Falot
c. Ebstein's anomaly
d. Truncus arteriosus
e. Tricuspid atresia
• B. Tetralogy of Falot
• TOF is associated with a high VSD
Type I VSD supracristal/high = conal septum [Ped Req p. 57, 64]“…Van Praagh and associates in 1970 proposed that this condition [TOF] is actually a “monology” with hypoplasia of the crista supraventricularis (distal conal septum) accunting for the infundibular pulmonary stenosis and the subjacent ventricular septal defect.” Card. Req. p. 366; see also http://www.tefvater.org/heart/vsd/ventricular.html; http://cats.med.uvm.edu/cats_teachingmod/pathology/path302/cv/cvel/cvwaters.htm

• The conal septum helps divide the proximal aorta from the pulmonary artery and contributes to the membranous IV septum. The truncal and conal septa fuse to form a 180o spiral and together definitively form the aorta and the pulmonary artery.
• absent conal septum is not uncommon(7%) in Tet of F and constitutes an important variation in its anatomy that can be identified preoperatively at angiography for optimal surgical management
• A parallel configuration of the aorta and pulmonary artery is seen with which congenital anomaly?
a. Truncus
b. Tetralogy of Fallot
c. TAPVR
d. Transposition of the great vessels
• D. Transposition of the great vessels
• In TGV, the aorta arises from the right ventricle and the PA arises from left ventricle, in a parallel fashion. [Dähnert p.652]Transposition of the great vessels can only be detected by seeing parallel cardiac outflow tracts. Truncus arteriosus dx is made with echo by demonstrating a large, single great vessel which overrides a large VSD. Tetralogy of Fallot shows a VSD beneath a large overriding aortic root, right ventricular hypertrophy, and often underdeveloped pulmonary artery (due to stenosis). Total anomalous pulmonary venous return has variable findings.
Cardiac Requisites 87-91 Primer 130-132
• Multiple T/F: IHSS is associated with which of the following?
1. Anterior motion of the anterior mitral valve leaflet in systole
2. Familial inheritance pattern
3. Coronary artery dilatation
4. Increased left ventricular compliance
• 1. True. Left ventricular hypertrophy (AKA asymmetric septal hypertrophy) leads to subaortic stenosis,abnormal diastolic dysfunction and ischemia. Venturi effect – rapid blood flow through narrow outflow tract causes the anterior leaflet of mitral valve to displace anteriorly toward septum during systole
• 2. True Autosomal dominant inheritance
• 3. False. Coronary arteries are not enlarged; cardiac muscle hypertrophy leads to myocardial ischemia.
• 4. False. Hypertrophy leads to decreased left ventricular compliance and abnormal diastolic function (in this sense, just like hypertensive hypertrophy). Dähnert p.621
• The findings of chest trauma with sternal contusion and a new holosystolic murmur in a 30 year-old MVA patient likely represent which abnormality?
a. Aortic laceration/rupture
b. Interventricular septal rupture
c. Ruptured aortic cusps
d. Papillary muscle rupture
• B. Interventricular septal rupture.
• Incidence of selected cardiac injuries with blunt trauma:
Cardiac Rupture: 66%
Contusion: 25.5%
IV septum: 6.1%
Papillary muscle: 0.24%
Valve laceration: 0.24%
see Demetriades et al., J. Trauma 1998 Sep. 45(3):534-9.
http://www.medslides.com/member/Cardiology/Traumatic_Heart_Disease/19The above information is consistent with other references:
“The clinical problem is to distinguish this catastrophe [papillary muscle rupture] from rupture of the interventricular septum… clinically, both conditions present with a sudden deterioration in hemodynamic status and the development of a new pansystolic murmur…” Card. Req. p. 73, 178.
“Damage to the valve leaflets and damage to the chordae tendineae are not common and usually occur simultaneously… Harris. p. 496.Aortic injury is probably more common, however, only 10-15% of these will survivie to reach the hospital. This group survives because the laceration has tamponaded off.
• Best MR sequence to evaluate flow in a vessel:
– T2
– GRE
– T1
– Phase contrast
• THE ANSWER IS D PHASE CONTRAST MR ANGIOGRAPHY—
• Phase contrast MR angiography measures the phase shift of blood. In addition, phase-contrast MR angiography can determine the blood velocity by measuring blood proton phase shifts over time. The basic modality consist of a gradient echo acquisition that uses a velocity encoding bipolar gradient system. There is a net zero shift of stationary tissue over time; however, blood will acquire a phase shift that is proportional to its velocity. By changing the magnitude and timing of the application of the gradient system, these bipolar gradients can be calibrated to set a range of velocity measurements. The range of velocity is referred to as the velocity –encoding value. Adjusting this value for the vascular system being imaged allows a more accurate quantitative analysis of flow velocity. Because phase contrast MR angiography are not ECG gated, they have the disadvantage of being degraded easily by respiration and cardiac motion.
• T1 and T2 images alone cannot evaluate flow in vessels. GRE sequences a single section is evaluated at multiple phases of the cardiac cycle. The individual images are viewed together in a cine loop which gives a graphic depiction of the beating heart. This modality is used to assess systolic wall thickness; volumetric data about stoke volume, ejection fraction, or shunt fraction.
• A male patient has a known anomalous left coronary artery arising from the pulmonary artery. What is the most likely cause of his angina?
a. Deoxygenated blood
b. Small left coronary artery
c. Abnormal distribution of the coronary artery
d. Intermittent perfusion of the myocardium
e. Steal with reversed direction of flow in the coronary artery
• E. Steal with reversed direction of flow in the coronary artery
• Bland-White-Garland syndrome: anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA) is a rare but serious congenital anomaly. Initially, myocardial ischemia is transient, occurring during periods of increased myocardial demands, such as when the infant is feeding and crying. Further increases in myocardial oxygen consumption lead to infarction of the anterolateral left ventricular free wall and/or papillary muscle dysfunction (terminating in CHF).Mechanism: with postnatal fall in pulmonary arterial pressure, perfusion of LCA drops (ischemic left coronary bed) as flow is preferentially directed towards the lower-resistance pulmonary vascular bed (steal); there may be collateral flow from RCA with flow reversal in LCA:
- adequate collateral circulation = lifesaving
- inadequate collateral circulation = myocardial infarction
- large collateral circulation = L-to-R shunt with volume overload of
heart. Dähnert 5th p. 603; Emedicine.com; Card. Req. p. 225.* This makes sense from a physiology standpoint, as the mean pressure in the aorta is 70-90 mm Hg, but that in the PA is 15-20 mm Hg—a huge difference in perfusion pressure.
• A 65 year-old male is two years status post single-vessel CABG. Pre operative catheterization at that time revealed a non right dominant system with severe RCA disease. He now presents with chest pain and EKG changes consistent with posterior wall reversible defect. What is the most likely etiology?
a. Graft occlusion
b. Native RCA occlusion proximal to the graft
c. Native RCA occlusion distal to the graft
d. New left coronary disease/LAD ischemia
e. Circumflex ischemia
• E. Circumflex ischemia
• Pure posterior wall infarcts are extremely rare. They are usually posteroinferior or posterolateral. In this patient whom we know has a small RCA (because of a non right dominant system) the presenting chest pain with posterior wall reversible defect is likely more posterolateral in distribution. This therefore likely represents new left circumflex disease.Coronary artery distributions:
LCx – posterolateral
RCA – posteroinferiorseptal
LAD – anterior
PDA – inferiorapicalEd. Note: Nearly identical question (also from 2000) on pg. 13; this is probably a variant of the same question. Regardless of which answer choices are correct, the key is that it’s ischemia (not occlusion), and it’s in an artery supplying the posterior wall.
• Which portends the worst prognosis in a middle-aged male patient three days status post MI?
a. Bibasilar atelectasis
b. Persistent pulmonary edema
c. Bilateral pleural effusions
d. Cardiomegaly
e. Vascular redistribution/Cephalization
f. Rapidly enlarging left atrium
g. Pneumothorax
e. Rapidly enlarging azygous
• F. Rapidly enlarging left atrium
• Factors that put patients at high mortality risk following MI include at least one of the following:
CHF and low cardiac output, recurrent chest pain, arrhythmias (particularly recurrent or sustained VT or VF), ruptured papillary muscle or interventricular septum, and/or inducible ischemia and extensive CAD.
• A rapidly enlarging left atrium is indicative of papillary muscle rupture. This occurs approximately 2-7 days post MI with a holosystolic murmur of mitral regurgitation and CHF. It occurs in 1% of MI patients. If untreated, mortality in the first 24 hours is 50%, with only a 6% survival rate for two months. While persistent pulmonary edema is also an indicator of a bad prognosis, patients with complicated CHF and pulmonary edema are better off. In patients with a pulmonary arterial wedge pressure > 25mm Hg, there is a 15-20% in-hospital mortality rate. [Hurst’s The Heart, p. 1391, 1399, 1401]
• Which of the following is indicative of situs inversus?
• Right arch, left cardiac apex
• Right arch, stomach on left
• Right cardiac apex, stomach on left
• Left cardiac apex, stomach on right
• Right arch, stomach on right
. Right arch, stomach on the right
• Situs inversus means that the patient’s entire anatomic arrangement is reversed in a right-to-left direction as a mirror image. The heart apex is on the right, the stomach is on the right. Brandt and Helms, Fundamentals of Diagnostic Radiology, 2nd ed, p. 537.
• Which of the following is responsible for an increased EF
• Aortic insufficiency
• Atrial fibrillation
• idiopathic hypertropic cardiomyopathy
• dilated cardiomyopathy
Why not aortic insuff
• C. idiopathic hypertropic cardiomyopathy
• Hypertrophic cardiomyopathy tends to be associated with a hyperdynamic heart with ejection fractions above 60-65%. Ejection fraction is often not reduced in aortic insufficiency, but is not elevated.
• Ejection fraction = stroke volume/enddiastolic volumeIncreased EF would not occur with atrial fibrillation and cardiomyopathy, in fact will have decrease in EF with these conditions. Dahnert 1099 and Headdocs.com, Hypertrophic Cardiomyopathy
• A patient presents with tricuspid and pulmonary valve failure. Which one is most likely cause
• carcinoid with metastases to the liver
• Pulmonary carcinoid
• Rheumatic heart disease
• marfans
• A. Carcinoid with liver mets
• In patients with a carcinoid tumor that has metastasized to the liver, half have pulmonary and tricuspid valve lesions which cause endocardial thickening, leading to stenosis and regurgitation. Pellikka PA, Tajik AJ, and Khandheria BK et al: Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients. Circulation 87:1188, 1993.The carcinoid syndrome includes diarrhea, abdominal pain, skin flushes, asthma, and cardiac valvular lesions, usually of the right heart. The symptoms are secondary to serotonin and other hormonally active compounds (histamine, kinin peptides) produced by the tumor. The presence of the syndrome is a good indicator of liver metastases. Left-sided valvular heart disease may occur in association with bronchial carcinoids. Present in 5 % of pts with carcinoid tumors; Small bowel 30-60%; Lung 3-5 %; Appendix 1 %; Rectal carcinoids 0 %; In intestinal carcinoids, carcinoid syndrome is seen only in the setting of metastatic disease to the liver. Bronchial and other extraintestinal carcinoids may produce the syndrome in the absence of metastasis.Harrison’s Principles of Internal Medicine pg 1537
• The 4-chamber view of the heart is used primarily to diagnose:
• Double outlet right ventricle
• AV canal abnormalities
• B. AV canal abnormalities.Since this question appears at least 4 times, here’s an exact reproduction of the Table (US Req. pg. 240) that is the source of virtually all the answers
• :Frequently Detected (* in order of decreasing frequency)
Hypoplastic right or left ventricle
Single ventricle
Atrioventricular (endocardial cushion) defect
Large ventricular septal defect
Double-outlet right ventricle
Ebstein’s anomaly
Pulmonary atresia
Cardiac tumors
Ectopia cordis
Situs inversus
• Less Frequently Detected
Large atrial septal defect
Tetralogy of Fallot
Cardiomyopathy
Aortic stenosis (severe)
Coarctation of aorta (severe)
• The endocardial cushion includes the following EXCEPT:
• Infundibular septum
• Mitral valve
• Tricuspid valve
• Interventricular septum
• Atrial septum
• A. infundiblular septum
• septal defects (AVSDS) are a complex group of cardiac anomalies that share a deficiency or absence of the AV septum, resulting in an interatrial communication (ostium primum ASD) above the AV valves, a deficiency in the inlet portion of the ventricular septum immediately beneath the AV valves that results in a common AV orifice. Synonymous terms for the condition include AV canal defect, AV defects, AV communis, ostium primum defect, and endocardial cushion defect. Abnormalities of the AV vavle leaflets are invariably involved. The ventricular septal defect usually includes the adjacent membranous septum as well as the muscular portion of the inlet septum. The basic abnormality of the AVSD is centered around the AV septum, which separates the right atrium from the left ventricle in the hearts with concordant AV connection.The infundibular septum is the portion of the septum that separates the aortic valve and the right ventricular outlet. Above discussion from Taveras and Ferrucci CDROM.
• In echocardiography, the short-axis view is obtained
• Perpendicular to the 4-chamber view
• In an oblique coronal plane
• In an oblique transverse plane
• Perpendicular to the long axis view
• Parallel to the sagittal plane
• D. perpendicular to the long axis view
• Two dimensional cardiac ultrasound (Primer 107) : There are 4 common views:
• 1) Long axis view: Location of transducer in 3rd or 4th intercostal space so that the beam is parallel to a line from the right shoulder to the left flank. Image is oriented so that LA and LV are posterior and LA and aorta are left. See drawing on Primer.
• 2) Short axis views: The transducer is placed in the 3rd or 4th intercostal space but the beam is perpendicular to the long axis view. Scanned from cephalad to caudad --great arteries, plane of mitral valve and papillary muscles. Image is oriented so that posteromedial muscle is at 8 O'clock and anterolateral papillary muscle is at 4 O'clock.
• 3) Apical 4 chamber views: Patient is in a left lateral decubitus view with the transducer at maximum point of impulse (MPI). Image is oriented so that RV and LV are anterior and LV and LA are to the right. In apical 2 chamber views, the transducer (at the MPI) is directed in a plane parallel to the interventricular septum. LV image is anterior.
• 4) Suprasternal Notch view: transducer location is in the suprasternal notch with inferior and posterior beam angulation. Image is oriented so that ascending aorta is on the left and descending on the right.
• Which is true regarding calcification in coronary artery disease?
• Most commonly located in the proximal 2cm.
• Circumflex location is more common than LAD
• Represents an occlusion.
• Is secondary to hyperparathyroidism.
• Is located in a patent ductus arteriosum
• A. Most commonly located in proximal 2cm
• Calcification of the coronary arteries is the most reliable plain film sign of CAD (90% specificity on symptomatic patients) but calcified coronary arteries are not necessarily stenotic. Calcification in asymptomatic patients indicates > 50% stenosis with 72% sensitivity and 78% specificty. In symptomatic patients, 94% specificty for obstructive disease (>75%) of at least one of the three major vessels. Location: coronary artery calcification triangle=triangular area along mid left heart border, spine, and shoulder of LV containing left main coronary artery, proximal portions of LAD + LCX calcification at autopsy: LAD (93%), LCX(77%), left main CA(70%), RCA (69%).Ductus arteriosus: a) in adults: indicates patency of ductus with associated long standing precapillary pulmonary hypertension. b) in children: ductus likely closed--calcium deposition in ligament of Botallo.References: Primer page 139, Dahnert 5th p584
• Contraindications to cardiac bypass include:
• ASD
• VSD
• PDA
• aortic stenosis
• Left sided IVC
• E. left sided IVC
• The answer is "E". This is an old question from 1990. A left sided SVC complicates attachment of the bypass, although none of the answers are absolute contraindications. The surgeons need to be aware of a left sided SVC before operating so they can properly cannulate the heart and SVC in the bypass machine.
• Constrictive pericarditis is most characterized by..
• 8 mm thick pericardium on CT
• Decreased LVEDV
• Calcified pericardium
• Pulmonary edema
• C. Pericardial thickness of 8 mm on CT.On the chest radiograph, the pericardium is calcified in about 50% of patients with constrictive pericarditis; CT is the best imaging procedure to use when searching for calcified pericardium.
- 90% of patients with constrictive pericarditis have calcified pericardium on CT.
• Diminished end-diastolic volume: present in constricitive pericarditis, however, present in many other disorders (e.g., restrictive cardiomyopathy) as well. Table 8-1 in the Cardiac Requisites makes this very clear.
• Thickening: 8 mm would be a very high (but specific) cutoff for restrictive pericarditis—Dähnert says 2 mm, Card. Req. says 5 mm. Dähnert 5th p. 624; Card. Req. p. 274. Primer p. 142.
• Ed. Note: Answer changed based on a different interpretation of the question, e.g.,
- “Which of the following, if seen, would provide the strongest evidence that constrictive pericarditis is present?” Undoubtedly, an 8 mm thick pericardium would be restrictive.
- On the other hand, “…a calcified pericardium does not necessarily imply that constriction exists.” Card. Req. p. 274.
• The location of the pulmonary valve relative to the aortic valve is
• superior, posterior and left
• anterior, superior and left
• anterior, inferior and left
• anterior, superior and right
• B. anterior, superior, and left
• Pulmonary artery is the most superior/anterior structure in the heartDanhert p. 500 and Netter
• A 32 year old male becomes hypotensive and short of breath when he lays on his left side. What imaging should you perform.
• Echocardiography
• Carotid ultrasound
• Carotid angiography
• Coronary angiography
• A. Echocardiography
• Cardiac myxomas present in 30-60yr population and have positional symptoms because you change position and the mass will obstruct different areas depending on what chamber it’s located in. The workup includes echo which is the modality of choice. (Dahnert 531)A non-invasive study is first indicated. Cardiac tumors, such as atrial myxoma may cause syncope through outflow obstruction. Signs and symptoms tend to be highly dependent on position, intermittent, and sudden in onset. Ref: Harrison's pp. 64-68 and 1004-1005
• Which of the following is most correct regarding right ventricular dysplasia with arrhythmia?
• Lipomatous hypertrophy of the atrial septum
• Fatty infiltration of the right ventricular wall
• Ventricular dilatation
• Mitral stenosis
• B. fatty infiltration of the right ventricular wall; C is partially correct as there is associated tricuspid regurgitation and right ventricular dilatation
• Rt ventricular dysplasia is a primary disorder of the RV, with partial or total replacement of myocardium by adipose or fibrous tissue resulting in recurrent ventricular tachyarrythmias. It occurs in mean age of 30yr olds. Fatty degeneration of myocardium results in RV failure. MR shows increase in subepicardial fat, fatty replacement of the myocardium, global RV enlargement, dilation of the RVOT, regional thinning of the RV wall, outpouchings and bulges, wall motion abn, evident RV trabeculae and diastolic dysfunction. (Clinical MRI Edelman 1746)The diagnosis of arrhythmogenic right ventricular cardiomyopathy is made by identifying the fatty and fibrous tissue replacement in the myocardium of the right ventricle. This abnormal tissue can be suggested by motion abnormalities in the ventricle or made directly by tissue characterization. Right ventricular cine angiography can be used to identify akinesis in the anterior wall of the right ventricle and associated tricuspid regurgitation. The most specific method of identifying this disease is to image the replacement of normal anterior right ventricular myocardium with either fat or fibrous tissue. However, the normal right ventricle wall has a thickness of only 2 to 4 mm, which is nearly at the resolution of most noninvasive imaging techniques. Electron-beam CT provides temporal resolution superior to that of conventional CT and allows assessment of right ventricular volume and wall motion and identification of fat in the anterior wall. MRI also allows identification of the fatty anterior wall with pulse sequences that identify fatty tissue.Although there is little difficulty in evaluating abundant fat and fibrous replacement in the anterior right ventricular wall, subtle abnormalities overlapping with normal amounts of epicardial fat are common findings in patients referred to establish this diagnosis. Therefore, one should be cautious in making this diagnosis unless the fat is abundant and clearly has replaced myocardium rather than just being present on the epicardium.Conversely, arrhythmogenic right ventricular dysplasia can exist without the hallmark of fatty deposition detectable by MRI. Short TE spin-echo images can identify fatty tissue either focally or diffusely in the free wall of the right ventricle. Other imaging sequences that are useful are fat saturation for tissue characterization and gradient-echo cine for right ventricular motion abnormalities.Hamada S, Takamiya M, Ohe T, Ueda H: Arrhythmogenic right ventricular dysplasia: Evaluation with electron-beam CT. Radiology 187:723, 1993Auffermann W, Wichter T, Breithardt G et al: Arrhythmogenic right ventricular disease: MR imaging vs angiography. AJR 161:549, 1993Blake LM, Scheinman MM, Higgins CB: MR features of arrhythmogenic right ventricular dysplasia. AJR 162:809, 1994
• The most reliable indicator of the right atrium on imaging studies was:
• Smooth posterior wall.
• Tricuspid outflow valve.
• Receives the IVC.
• On the same side as the azygos vein.
• Smooth intra-atrial contour.
• C. receives the IVC
• The RA has a smooth posterior wall with attached SVC and IVC. The IVC is the most prominent feature. (Brant and Helms 525)“Of the various criteria for distinguishing between right and left atria, the most reliable are the shape of the atrial appendage and the connection to the inferior vena cava. The right atrial appendage is broad and pyramidal, while the left atrial appendage is thin with a narrow neck. The inferior vena cava almost always connects with the right atrium.” Card. Req. p. 302.
• Origin of the left coronary artery from the pulmonary artery (Bland White Garland syndrome) causes left ventricular myocardial ischemia and thinning secondary to what?
• Chronic perfusion with venous blood
• Pulsatile flow in the myocardium
• Steal syndrome from intracoronary vessels
• C. steal phenomena

• Kirks, 1998, p. 575. . “…the significance of the anomaly lies not in the shunt, but in the steal of blood away from the left ventricular myocardium.” Either coronary artery may arise anomalously, but the left is much more common. Initially in the newborn period, relative pulmonary hypertension exists and blood flows readily from the pulmonary artery into the anomalous left coronary artery—supplying the myocardium. As the lungs expand and pulmonary vascular resistance decreases, antegrade flow through the anomalous coronary artery decreases as blood flow takes the path of least resistance (the pulmonary artery). The non-anomalous right coronary artery then enlarges and supplies collateral flow to the anomalous left coronary artery—creating a shunt (L to R). The collateral blood then flows through the anomalous artery however instead of supplying the myocardium, it also flows into the pulmonary arteryAberrant LCA is when origin of LCA is from pulmonary artery. Rare condition. Most patients have severe myocardial ischemia early in infancy or early childhood with a syndrome of FTT, tachypnea, wheezing, angina, and/or death. There is low perfusion pressure and low O2 content in blood perfusing the LV wall. A few may survive into adulthood and have MR, angina, CHF, and high incidence of sudden death. Also, either LAD or RCA may arise separately from the pulmonary artery. Survival depends on development of collaterals from the other coronary arteries. A “steal syndrome” may develop in which blood flows from the normal coronary system to the aberrant system or even into pulmonary artery. If myocardium is dead, therapy is occlusion of the LCA. If myocardium is viable, then CABG or reimplantation into aorta is performed. (Diagnostic and Therapeutic Cardiac Cath, Pepine, 1994, p. 247) Note that this is “aberrant LCA”. There are many variations on “anomalous” origins of all the coronary arteries.
• Normal pulmonary arterial pressures are
• 20/0
• 20/8
• 60/0
• 60/8
• B. 20/8
• Normal values: 25 mm Hg systolic and 10 mm Hg diastolic. Fundamentals of Diagnostic Radiology, 2nd Ed. Brant and Helms, 1999, p. 528.
• What is most commonly associated with left atrial dilatation?
• Left atrial myxoma
• Distal venal occlusive disease
• Atrial fibrillation
• C. Atrial fibrillation
• Atrial fibrillation is common, affecting more than one million Americans and left atrial enlargement predisposes to the development of atrial fibrillation. Cardiovascular Medicine, Willerson, ed. 1995, p.1355. Left atrial myxoma is also associated with left atrial enlargement, however it is rare. (Ibid, p.1529). Because AFIB is so much more common, it seems to be the best answer. Distal veno-occlusive seems to be a bogus answer, possibly referring to pulmonary veno-occlusive disease, which is associated with fibrous narrowing of intrapulmonary veins in the presence of a normal left heart. Dahnert 4th ed. CD version
• Which is false regarding a bicuspid aortic valve?
a. Coronary arteries are most commonly normal
b. Density of calcifications is greater than aortic stenosis with a tricuspid valve
c. Association with mitral valve stenosis is as common as with rheumatic fever
d. Associated with pseudocoarctation
e. increased incidence of endocarditis
• C. Association with mitral valve stenosis is as common as with rheumatic fever.C. False. Somewhat convoluted wording; the bottom line appears to be “high association with Rheumatic fever, low association with mitral stenosis”
- Bicuspid aortic valve responsible for 50% of aortic valvular bacterial endocarditis (Dähnert CD ROM)
- In most cases of bicuspid aortic stenosis, the mitral valve is normal…” Card Req 16A. True. Bicuspid aortic valve is very common (1%), abnormal coronary origins are uncommon. Ed. Note: A previous question argued the coronary arteries were abnormal because of “20-50% LCA dominance” with bicuspid aortic valve. Per Moore’s anatomy, 50% of normals are RCA dominant, 20% LCA dominant, and 30% balanced. It certainly appears, then, that bicuspid valves are within the realm of normal.B. True: Stenotic congenital bicuspid valve = calcium first detected at an average age of 28 years; Degenerative aortic stenosis of tricuspid leaflets = calcium first detected at an average age of 54 years.D. True: pseudocoarctation = aortic kinking = coarctation w/o pressure gradient
- Associated with bicuspid aortic valve, PDA, VSD, etc. Dähnert CD ROME. True. (see above).
• Characteristics of IHSS include all of the following except:
• familial tendancy
• decreased EDV
• mitral regurge
• increased ventricular compliance
• D. increased ventricular compliance
• Ihss, 50% of the time inherited as AD, LVH = decreased EDV and Decreased compliance, mitral regurg does occur; reference Dahnert and primerThe diagnosis of hypertrophic cardiomyopathy (idiopathic hypertrophic subaortic stenosis, IHSS) requires the presence of asymmetric septal hypertrophy, left ventricular outflow tract narrowing, and systolic anterior motion (SAM) of the mitral valve. When there is no evidence of SAM or other indicators of outflow obstruction, the condition is known as asymmetric septal hypertrophy (ASH).Etiology: autosomal dominant transmission• exertional angina + dyspnea, fatigue• syncope, arrhythmia, sudden deathPathophysiology:---LV hypertrophy leads to subaortic stenosis, abnormal diastolic function, myocardial ischemia. Left ventricular cavities are routinely small in all these patients, thus, choice (b). increased ventricular compliance is incorrect.---rapid blood flow through narrow outflow tract causes the anterior leaflet of mitral valve to displace anteriorly toward septum during systole (Venturi effect)---mitral regurgitation (from displaced MV leaflet), thus choice C is incorrect.---left atrium may be enlarged from mitral regurgitation, which occurs when SAM is present. Thus, there may be increased EF and large heart.ECHO: - IVS >14 mm thick; posterolateral wall >11 mm thick; IVS:LVPW thickness >1.3:1 - systolic anterior motion of mitral valve (SAM) causing narrowed LVOT in systole - midsystolic closure of aortic valve - increased LVOT gradient with late systolic peaking on Doppler
• Cardiac defect seen best on in utero US
• VSD
• AV canal
• Coarct
• Bicuspid aortic valve
• B. AV canal.
• Ultrasound Reqs p240 Box 11-1 has list by frequency with hypoplastic rieght or left ventricle and single ventricle being #1 and 2 followed by AV endocardial cushion defect as #3 which is the first of our choices
• Regarding the short axis view of the heart on cardiac MR, which of the following is not true?
• oblique to the transverse plane
• perpendicular to the long axis view
• perpendicular to the four chamber view
• parallel to the sagittal plane
• oblique to the coronal plane
• Regarding the short axis view of the heart on cardiac MR, which of the following is not true?
• oblique to the transverse plane
• perpendicular to the long axis view
• perpendicular to the four chamber view
• parallel to the sagittal plane
• oblique to the coronal plane
• MR feature of right ventricular arrhythmogenic dysplasia is:
• Increased T1 signal in the septum
• Increased t1 signal in the myocardium
• Blurring of the cardiac wall due to arrhythmia
• Tricuspid regurgitation
• Increased t1 signal in the myocardium
• A false cardiac aneurysm (i.e., pseudoaneurysm) is lacking which of the following layers?
a. myocardium and endocardium
b. epicardium
c. endocardium
d. myocardium, epicardium and endocardium
e. myocardium
• A. lacking myo and endocardium
• The wall of a false aneurysm consists of adherent pericardium and associated postinflammatory scar tissue, with some remnants of the epicardium.

• Pseudoaneruysm of ventricle = false aneurysm = left ventricular rupture contained by fused layers of visceral and parietal pericardium Dahnert 5th p655When the pericardium rather than myocardium composes the wall of the aneurysm, it is a false aneurysm or pseudoaneurysm. The usual cause is a rupture of the left ventricle into the pericardial space after myocardial infarction. Because of adhesions from previous pericarditis, the pericardium locally attaches to the epicardium which restrains the ventricular blood from extending into the remaining pericardial space and causing tamponade.
Cardiac Requisites, 238
• Which is not associated with unilateral rib notching?
• Blalock-Taussing shunt
• Peripheral AVM
• Brachial artery stenosis
• Coarctation with aberrant right subclavian artery
• Coarctation between the innominate and left carotid.
• C. brachial artery stenosis
• Collateral vessels from the aortic branches proximal to the obstruction enlarge in an attempt to provide adequate flow to the aorta distal to the coarctation. The intercostals arteries are a component of this collateral network and cause of the notching and sclerosis of the undersurface of the third through eight ribs posteriorly. Pg 19 Danhert: 5th ed
• Arterial source causes of rib notching include the aorta (coarctation, thrombus of the aorta), subclavian artery ( Blalock Taussig shunt ) and pulmonary artery (pulmonary stenosis, TOF, absent pulmonary artery). Venous sources of rib notching include an AV malformation of the chest which leads to enlargement of the intercostals veins.
• Which of the following is false regarding cardiac transplant??
a. rejection rate is the same for orthotopic and heterotopic transplants
b. angina is uncommon
c. the heart rate after transplant is slower than the native heart rate
d. dilated heart is a sign of early rejection
• C. the heart rate after transplant is slower than the native heart rate
• When the heart is removed from the body, the nervous system is disconnected and cannot be re-attached. The heart continues to beat adequately, but without an external nervous supply. The denervated heart beats faster at rest, but its rate does not rise as quickly with exercise. In addition, patients usually do not experience angina.. Orthotopic heart transplant: This is the procedure of choice for most patients, with the donor heart replacing the recipient's, and taking the correct position in the thorax. It is the most reliable and effective type of cardiac transplant, and accounts for almost 99% of such procedures. Heterotopic heart transplant: This procedure is also known as "piggy-back" heart transplantaion, as it leaves the recipient's heart intact to work in series with the donor heart. Rare--accounts for only 1% of procedures. Originally it was used when there was a moderately elevated pulmonary vascular resistance, and also in urgent cases when the donor heart is under-sized.
Askjeeves.com and Heart1.com, multiple articles
• A true vascular ring may be caused by a double aortic arch and:
• Aberrant right subclavian artery with a right aortic arch
• Aberrant left subclavian with a right aortic arch
• Left aortic arch with an aberrant right subclavian
• B. Aberrant left subclavian with a right aortic arch Right AA with Aberrant Left Subclavian Artery 2nd most common vascular ring. (Double AA is most common - 55%)Most common right arch anomaly, 35-72%Aberrant LSCA passes BEHIND esophagus as opposed to pulm sling.Associated with CHD 5-12% Tet (70%) > ASD/VSD > CoarctationMay become symptomatic in childhood due to tracheal edema from bronchitis or in adulthood due to aortic tortuosityMay also have Diverticulum of Kommerell which is remnant of Lt arch at origin of Aberrant LSCARt arch with aberrant RSCA – Not a ring. Not in the books. I don’t know if this even really exists.Lt arch with aberrant RSCA NOT a complete true ring, usually asymptomaticDahnert p483-4, MGH127
• Kid with pulmonary edema and pleural effusions could not be due to which one of the following:
• lymphangiectasia
• TAPVR III
• Wet lung
• Tetrology of Fallot
• D. Tetrology of Fallot
• Best answer—TOF normally has pulmonic stenosis. TOF can have CHF, but this is uncommon. see http://author.emedicine.com/PED/topic2539.htm Few conditions mimic the roentgenographic features of HMD. Several congenital heart lesions manifesting pronounced pulmonary venous obstruction (i .e., total anomalous pulmonary venous return type III, pulmonary vein atresia, and hypoplastic left heart syndrome) can produce enough pulmonary edema to masquerade as IRDS, but generally these are uncommon. In addition, some cases of pulmonary lymphangiectasia, transient respiratory distress of the newborn (wet lung syndrome), and neonatal sepsis or pneumonia can be radiographically confused with HMD.
• Pulmonary lymphangiectasia in the newborn is a rare, severe condition in which proliferation of the lymphatic tissue compromises pulmonary ventilation. The chest radiograph shows severe interstitial edema with reticular areas representing dilated lymphatics and Kerley B lines. This condition is often fatal early in the newborn period. The condition mimics precisely total anomalous pulmonary venous connection below the diaphragm.The relatively mild disorder of transient tachypnea of the newborn may simulate RDS clinically but resolves within a few days and is thought to be due to delayed resorption of fetal lung liquid following birth. “Wet lung" is another term applied to the pulmonary edema-like pattern of the lungs, which consists of perivascular haze,"interlobular septal edema, thickened fissures, and mild cardiomegaly”. A reticulogranular pattern is not apparent, and tachypnea and radiographic abnormalities subside within hours or a few days. In the early stages of the disorder, it is important to exclude other causes of pulmonary edema, particularly congenital heart disease. Radiology Volume 2 Chapter 123—The Premature Infant with Heart Disease
• Concerning PDA:
• 1. The left recurrent laryngeal nerve passes around it
• 2. Indomethacin is used to close it
• 3. The pulmonary artery is enlarged
• 4. Calcification of the PDA indicates pulmonary artery hypertension
• 1 = True (I think false) 2 = T 3 = T 4 = F
• Left recurrent laryngeal nerve passes around the aortic arch and ductus arteriosus
Ed. Note: It’s possible to argue that the recurrent laryngeal nerve simply passes “by” the ductus and not “around” it. However, a question at the bottom of pg. 14 refers to the ‘right recurrent laryngeal nerve’ looping around the ductus [which is false], which suggests that the ABR considers the left recurrent laryngeal nerve to do so.
• Indomethacin is used to close it—successful 60% of cases.
• Pulmonary artery is enlarged.
• PDA occasionally calcifies, with an unclear significance.Cardiac Requisites 352-356, Primer, 3rd 120 and Netter plate 169
• Matching:
• 1. aortic stenosis
• 2. Mitral stenosis
• 3. Can be seen in normal 75 y.o.
• a. Mitral annulus calcification
• b. Mitral valve calcification
• c Aortic valve calcification
• d. Myocardial calcification
• 1.= C 2= B 3=A
• Aotic valve calcifications usually indicate significant aortic stenosis; causes: congenital bicuspid valve (70-85%); atherosclerosis; rheumatic disease (rare); syphilis; ankylosing spondylitis.Mitral valve leaflet calcification is caused by rheumatic disease (“virtually always”) or mitral valve prolapse. It commonly causes mitral stenosis.Mitral annulus calcification is usually caused by physiologic degeneration in the elderly and may be associated with mitral prolapse. Complication is mitral insufficiency
• Myocardial calcification is usually caused by infarct, aneurysm, rheumatic fever or myocarditis and is usually located at apex or anterolateral wall of LV (also typical location for LV aneurysms). Ref: Dahnert, 3rd ed., p. 435-436 (Weissleder, R. Rieumont M, Wittenberg J; Primer of Diagnostic Imaging, 2nd ed, 1997, pp. 132-135) Primer, 3rd 123, 140-142 and Cardiac Requisites 15-18, 62, 168
• Pt. with “snowman” heart from TAPVR above the diaphragm. What does the left side of the snowman’s head represent?
• a. SVC
• b. Innominate vein
• c. Vertical vein
• d. Aortic arch
• e. Azygous vein
• C. Vertical vein.
• The left side of the snowman’s head in the supracardiac type of TAPVR is the vertical vein, which is a left sided SVC.Primer, 3rd, 130-132
• Which of the following does not cause unilateral rib notching?
• a. Blalock-Taussig shunt
• b. Coarctation between the right and left common carotid arteries
• c. Coarctation in right aortic arch with aberrant left subclavian
• d. Brachial artery stenosis
• e. AV Fistula in the forearm
• D. Brachial artery stenosis.
• Rib notching is the result of enlarged and tortuous intercostals arteries that serve as collateral channels. The notches are an exaggeration of the neurovascular groove in the inferior aspect of the rib. Rib notching is uncommon before 6 years of age.The intercostals arteries that serve as collateral channels originate from the descending aorta. For this reason the first and second ribs do not have notches because their intercostals arteries come from the superior intercostals artery, which originates from the subclavian artery, above the coarctated site.
• Unilateral rib notching implies the presence of an anomalous subclavian artery. Notching of the left ribs only occurs when an aberrant right subclavian artery originates below the coarctated segment. Unilateral notching of the right ribs exists when the coarctation originates between the left carotid and left subclavian arteries.Brachial artery stenosis is too lateral to in any way result in rib notching.Cardiac Requisites 426-428 and Netter plate 404
• Which of the following most likely to cause a tracheal ring?
• a. Left aortic arch with anomalous innominate artery take off
• b. Pulmonary sling
• c. Right aortic arch with aberrant left subclavian
• d. Right arch with mirror imaging
• e. double arch was not a choice
• C. right aortic arch with aberrant left subclavian
• Swischuck “the term vascular rings is, at times, loosely used to include all anomalies of the aortic arch and great vessels, but strictly speaking it should be restricted to those entities in which actual encirclement of the trachea and esophagus occurs” .
• The most common type of right aortic arch has an aberrant retroesophageal left subclavian artery. If a left ductus connects this left subclavian artery to the left pulmonary artery, a vascular ring is formed. 5% have symptoms (airway or esophageal compression).A double aortic arch is both the most common and most symptomatic of all vascular rings.
- Right arch with mirror image branching: the ductus arteriosus goes from the left subclavian artery to the left pulmonary artery in front of the trachea and does not cause a vascular ring (usually asymptomatic).
- Left aortic arch / aberrant right subclavian: most common congenital arch anomaly (1% of persons). Usually asymptomatic because no ring is formed (it’s a sling). Sources: Card. Req. p. 419-421; Primer 3rd. p. 134; Dähnert 5th p. 580.
• A. also known as the pulmonary sling, has the Lt PA arising from the Rt PA and it passes between the trachea and esophagus compressing both.D. Right AA with mirror branch imaging does not have vascular ring symptoms. It is associated with cyanotic heart disease in 98% of cases (TOF and TA)Peds req 15-16, Primer 3rd ed 133-136; Swischuck-imaging of newborn, infant, and young child 309-318
• Which is false concerning peripheral AVF?
• a. Many spontaneously close
• b. Increased pulsatility in the vein
• c. Increased velocity in the artery distal to the fistula
• d. Low resistance waveform in the artery feeding the AVF
• C. Increased velocity in the artery distal to the fistula.
• AV fistulas have decreased resistance to flow in the artery supplying it. Direct arterial inflow into the vein produces turbulent flow in the venous lumen and often produces an arterialized venous waveform. From a hemodynamics standpoint, the additional venous flow (from the fistula) might produce an increased velocity in the vein proximal to the fistula. But if anything, venous flow distal to the fistula will be slower due to congestion. Ultrasound Requisites, 479-481
• Best view on cardiac MR to evaluate LV wall thickening , volume, and function is:
• a. horizontal long axis
• b. longitudinal long axis
• c. transaxial
• d. short axis
• e. coronal
• D. short axis.
• “Left and right ventricular myocardial function may be assessed qualitatively in the axial or horizontal long axis section, but quantitative analysis of ventricular volume, myocardial mass, and systolic shortening should be performed in the cardiac short-axis section, normal to the long axis of the ventricle.” Card. Req. p. 114. Ed. Note: the best answer to this question appeared to be a quote straight from the Cardiac Requisites.
• Best technique to evaluate cardiac blood flow dynamics on MRI:
• a. 3D-TOF
• b. phase contrast w/ FISP dephasing
• c. Gradient echo
• d. Amplitude imaging
• e. Super duper RAS flash Baraga technique
• I think phase contrast is better for flow dynamics.

• Phase-velocity magnetic resonance imaging (PV-MRI) has recently been shown to be capable of noninvasively depicting flow direction and measuring flow velocity in 3 dimensions throughout the cardiac cycle.9 10 11 12 13 It has also been shown to allow for accurate site-specific quantification of flow rate.9 10 14 15 16 The present study, therefore, was designed to analyze and compare the in vivo 3-dimensional blood-flow patterns in APA and TCPC Fontan pathways by the use of PV-MRI.

• C. Gradient Echo.
• Gradient echo is used to evaluate flow. Because of flow-related enhancement seen in GE and absence of factors that cause signal loss (as in spin echo), blood appears bright in gradient sequences. In addition the short TR reduces the signal due to stationary tissue and further increases contrast between moving blood and stationary tissue. Cardiac Requisites 103
• What is least associated with constrictive pericarditis?
• a. Thickened pericardium
• b. Small ventricular volumes
• c. Thickened myocardium
• d. Enlarged atrium
• e. Pericardial calcifications
• C. Thickened myocardium (False)
• C. False. No references could be found linking constrictive pericarditis with thickened myocardium. The diastolic dysfunction occurs because of thickened pericardium (see below)
• .A. True. Constrictive pericarditis is a thickening of the pericardium (2-5 mm) that restricts diastolic filling of the heart. Typically post-surgical, but may be due to infection (TB), etc
• .B. True. “Echocardiography shows thickened pericardium, abnormal septal motion, and increased left ventricular ejection fraction with small end-diastolic volume. B&H 2nd p. 567.
• D. True. “MR shows pericardial thickening (>4mm); dilatation of the RA, inferior vena cava, and hepatic veins…” B&H 2nd p. 567
• .E. True. Calcifications are common (50%), as is pleural effusion (60%), PVH (40%), elevated RV pressure which gives dilated SVC and azygous (80%). Primer, 3rd ed, 148-149 and Cardiac Requisites 271-274
• Pt. is 3 days s/p MI. The worst prognostic sign is:
• a. Pleural effusion
• b. Rapid atrial dilatation
• c. Pulmonary vascular redistribution
• d. Pulmonary edema
• e. Elevated central venous pressure
• B. Rapid atrial dilatation.
• Rapid atrial dilatation post-MI may indicate a papillary muscle rupture. Papillary muscle rupture: acute onset of CHF, usually 1-7 days after MI. Rupture of an entire papillar muscle due to MI is rapidly fatal due to massive mitral regurgitation. Rupture of one head of a papillary muscle may be tolerated long enough for diagnosis and surgical correctionThe complications of an acute MI include:
CHF – in patients who develop mild CHF with pulmonary congestions during acute MI, administration of diuretics may be sufficient therapy. Severe failure carrier a poor prognosis, and in particular, edema 3 days after an MI has a poor prognosis because it indicates a lack of cardiac reserve.Rapid atrial dilatation does not result from papillary muscle rupture (acute mitral regurgitation). This is very serious as well and will result in rapid death, second to ventricular wall rupture. Acute mitral regurgitation will demonstrate ventricular segmental wall motion abnormalities on ventriculogram. Right ventricular Infarction, Extension of Infarction, Hypertension..Ventricular septal rupture, ventricular aneurysm, cardiac rupture, DVT/PE, Pericarditis early after MI, dysrhythmias,Dressler’s Syndrome - occurs 2 weeks to 9 months after MI – pericarditis, pericardial and pleural effusion, and fever. May be immunologic in origin, occurs in <5% of MI. Cardiac Requisites 177-178, 199-210
• Matching.
• 1. Stunned myocardium
• 2. Hibernating myocardium
• 3. Scarred infarcted myocardium
• 4. Reversed distribution

• a. fixed defect and hypo/akinetic segment
• b. fixed defect and normal segment
• c. normal perfusion, normal segment
• d. normal perfusion, hypo/akinetic segment
• e. reversible perfusion , normal segment
• f. reversible perfusion, hypo/akinetic segment
• 1=D 2=F 3=A 4=C
• Stunned myocardium: refers to temporarily damaged cells around infarcted cells. Normal or somewhat decreased uptake with persistent contractile dysfunction. NM Req. Box 5-10 p. 78.
• Hibernating myocardium: Phenomenon associated with severe ischemia in which a defect is slow to reverse on T1-201 images. There may not be reversibility 3-4 hours after exercise - may need to image 24 hours after exercise or reinject T1-201 at rest. Important to recognize this phenomenon because it simulates infarction by no contracting at rest.
• Scarred infarcted myocardium: Decreased labeling at both exercise and rest
• Reversed redistribution means reduced 201Tl myocardial uptake on the rest images and the normal uptake on the post-stress images. This implies probable normal coronary perfusion.Nuclear Medicine Requisites, 2nd, 88-89
• Matching
A. VSD
B. no cardiac abnormality

• 1) Right-sided aortic arch and right-sided stomach
• 2) LAD coronary artery complete occlusion
• 1 = A and 2 = B Among the cardiosplenic syndromes, asplenia / bilateral right-sidedness and polysplenia / bilateral left-sidedness are both associated with right or left arches, VSDs (although more common in polysplenia) and both can have right-sided stomachs. (Dahnert. p. 366) It is possible to have an acute MI and have a normal heart on CXR (at least initially).Brant & Helms, p. 587
• Matching:
1. Systolic anterior motion of the mitral valve
2. Excessive posterior displacement of mitral valves during systole
3. Restricted diastolic excursion of mitral valve leaflet during diastole

• a. Mitral stenosis
• b. Mitral insufficiency
• c. IHSS
• d. MVP
• e. Atrial myxoma
• 1=C 2=D 3=A
• 1 = C. IHSS: (Echo) - Systolic anterior motion of mitral valve.
• 2 = D. MVP: Mitral valve normally closes when left ventricle contracts, as ventricular volume decreases, the valve leaflets prolapse into the left atrium.
• 3 = A. Mitral stenosis: echography shows decreased excursion of the mitral valve with a narrow mitral orifice. Brant & Helms, p. 595, 597-598 and Cecil Essentials of Medicine, 3rd edition, 54-58
• Matching:
1. Norwood
2. Pulmonary artery banding
3. Rastelli
4. Fontan
5. Blalock-Taussig

• a. Hypoplastic left heart
• b. TOF with aberrant LAD coming from the right coronary artery
• c. Multiple VSDs with CHF
• d. Tricuspid atresia
• e. TGV with large VSD and pulmonary artery stenosis
• 1=A 2=C 3=E 4=D 5=B
• Norwood: Treatment for hypoplastic left heart syndrome. Right ventricle pumps blood into proximal main PA which is connected to descending aorta. Functional single ventricle with surgically created truncus’ supplying both pulmonary and systemic circulation.
• Pulmonary artery banding: Treatment for multiple VSDs. PA banded to increase RV outflow resistance, decrease left to right shunt and decrease PA blood flow and pressure. Result: decreased CHF.
• Rastelli: Treatment for d-transposition (d-TGV) and large VSD. (d-TGV = complete transposition of great vessels, ascending aorta and coronary arteries arise from RV and PA arises from LV.) External conduit connects RV to PA so blood flows from LV to ascending aorta through VSD
• .Fontan: Treatment for tricuspid atresia, hypoplastic rt ventricle. An anastomosis or conduit placed from RA to main PA (RA becomes pumping chamber for pulm circulation.
• Blalock –Taussig Shunt is an end to end anastamosis of subclavian artery to pulmonary artery, performed ipsilateral to innominate artery/ opposite to arch. It is used for TOF and Triscuspid atresia with pulmonic stenosis.
• Amodified Blalock-Taussig shunt uses synthetic graft material such as polytetrafluoroethylene (Goretex) in an end to side anastomosis between subclavian artery and ipsilateral branch of pulmonary artery.Cardiac Requisites 373, Dahnert 4th p.491, Kirks 501
• A patient with an ASD is most likely to have an enlarged:
• LA
• LV
• Pulmonary Artery (PA)
• Aorta
• C. Pulmonary Artery (PA)
• The receiving chamber and all the chambers between it and the donating chamber enlarge. Thus, with an ASD, the only chamber listed that would enlarge is the PA. In an ASD the blood flows from LA to RA which results in the RA, RV, and PA being enlarged. The LA is unchanged in size. Primer, 3rd ed, 119
• Blood supply to the AV node is usually supplied by:
• circumflex artery
• left main coronary artery
• distal right coronary artery
• conus branch of right coronary artery
• proximal right coronary artery
• C. distal right coronary artery.
• The A-V nodal artery usually arises from the distal RCA (right coronary artery), from the “crux” of the RCA. The S-A nodal artery usually arises from the proximal RCA.Dähnert 296
• Concerning cardiac aneurysms (matching):
• Peripheral calcification
• Associated with atherosclerosis
• Amenable to surgery
• Associated with tamponade
• Posterior location near the diaphragm
» true aneurysm
» false aneurysm
» both true and false aneurysms
» neither
• 1. C. Both types of aneurysms can calcify. Calcifications in a true aneurysms (rare according to Dähnert) are typically located in the anterolateral wall or near the apex whereas those in a false aneurysm are typically located along the posterior (inferior or diaphragmatic) or posterolateral wall.
• 2. C. Both may be secondary prior MI
• 3. B. True aneurysm rarely rupture (< 4%), and are usually followed. On the other hand, a large percentage (45%) of False Aneurysms rupture, and are usually treated surgically. Card. Req. p. 238.
• 4. B. Both types of aneurysms can rupture (true aneurysms rarely or infrequently do so according to Dähnert) and lead into tamponade. It is more frequent in false aneurysms. False aneurysms can be the result of localized/contained rupture of a true aneurysms, as well as trauma, pericarditis and AMI.
• 5. C. Dähnert 654-5 Primer 144 Brant & Helms 534
• Regarding cardiac MRI (multiple true/false):
• Left atrial myxoma mimics aortic stenosis clinically
• The pericardial stripe is, in part, low signal secondary to fibrous tissue
• Fibroma is the most common benign lesion of the heart
• Angiosarcoma is the most common malignant lesion of the heart
• Lipomatous involvement of the septum is not a true tumor
• F may mimic mitral stenosis
• T
• F myxoma
• F metastatic most common, angiosarcoma, most common primary malignant tumor
• T Lipomatous hypertrophy of the atrium refers to a nonencapsulated hyperplasia of adipose tissue within the atrial septum (actually more common than atrial lipoma). Brant & Helms 545, 565
• Regarding gradient echo imaging of the heart (multiple true/false):
• Turbulent flow has decreased signal
• Flow velocity can be measured
• Flow direction can be determined
• Regarding gradient echo imaging of the heart (multiple true/false):
• Turbulent flow has decreased signal
• Flow velocity can be measured
• Flow direction can be determined


• T
• T
• T Brant & Helms 545
• The following is not part of the endocardial cushion (single best answer):
• atrial septum
• ventricular septum
• infundibulum septum
• central fibrous body
• a portion of the mitral valve
• C. infundibular septum.
• Infundibular septum (infundibulum = conus arteriosus) – the anterosuperior portion of the RV which joins the pulmonary trunk forming the RV outflow tract Endocardial cushion tissue (aka atrioventricular septal defect) contributes to the formation of the ventricular septum, the lower atrial septum, and the septal leaflets of the mitral valve and tricuspid valve.Caused by abnormal development of the primitive endocardial cushions that form the interatrial interventricular septa and AV valves. Commonly seens with trisomy 21. mitral valve may cleft. Brant & Helms 1144
- Todaro’s tendon… runs from the sinus septum to insert in the central fibrous body, the latter now formed from the fused endocardial cushions. http://circres.ahajournals.org/cgi/content/full/88/4/395The mitral valve is formed from endocardial cushions that originate both at the atrioventricular orifice and from muscular tissue of the ventricular wall. This process creates the 4 major components of the mitral valve, which are the mitral annulus, the mitral leaflets, the chordae tendineae, and the papillary muscles
• Match the surgical procedure with the anatomic hook-up:
• Glenn
• Fontan
• Blalock-Taussig
• Rastelli
• Waterston
• Potts



• A. SVC to PA
• B. RA to PA
• C. RV to PA
• D. Ascending aorta to PA
• E. Descending aorta to PA
• F. Subclavian artery to PA
• Match the surgical procedure with the anatomic hook-up:
• Glenn
• Fontan
• Blalock-Taussig
• Rastelli
• Waterston
• Potts



• A. SVC to PA
• B. RA to PA
• C. RV to PA
• D. Ascending aorta to PA
• E. Descending aorta to PA
• F. Subclavian artery to PA


• Answers:
• A. Glenn shunt: End‑to‑side shunt between distal end of RPA and SVC. Used for management of tricuspid atresia. Reserved for patients in which total correction is not possible.
• B. Fontan procedure: Two parts of the procedure: 1) External conduit from RA to PA trunk and 2)Closure of ASD: floor constructed from flap of atrial wall and roof from a piece of prosthetic material. Used in patients with tricuspid atresia.
• F. Blalock‑Taussig shunt: end‑to‑side anastomosis between SCA to PA, performed ipsilateral to innominate artery/opposite to where the arch lies. The modified Blalock‑Taussig shunt uses synthetic graft material such as Polytetrafluoroethylene or PTFE (also known as Gore-tex) for construction of the shunt, in an end‑to‑side anastomosis between SCA and ipsilateral branch of PA. Used in patients with tetralogy of Fallot or tricuspid atresia with pulmonic stenosis.
• C. Rastelli procedure: External conduit (Dacron, also known as polyester) with porcine valve connecting RV to PA trunk. Used in Transposition of the great vessels.
• D. Wasterston‑Cooley shunt: side‑to‑side anastomosis between ascending aorta and RPA. If done extrapericardially called Waterston, if done intrapericardially called Cooley. Used in tetralogy of Fallot. Not done anymore, because it is difficult to take down.
• E. Pott shunt: side‑to‑side anastomosis between descending aorta and left LPA. Used in tetralogy of Fallot. Not done anymore because it is difficult to take down. References: 1) Amplatz, Moller. Radiology of Congenital Heart Disease, 1992; 2) Kirks. Practical Pediatric Radiology 1997; Dähnert radiology review Manual 3rd edition 1996.
• The most common cause for cyanosis and increased pulmonary vascularity in a newborn:
• Transposition
• Tetralogy of Fallot
• PV atresia
• Tricuspid atresia
• TAPVR
• Ebstein's
• A. Transposition.
• Transposition of the great vessels is the most common cause of cyanosis and increased pulmonary blood flow in the newborn. It is the most common cause of cyanotic congenital heart disease with increased pulmonary blood flow. The most common overall causes of congenital heart disease with cyanosis are: Tetralogy of fallot (especially true in the child (defined as age > 1 year) and then Transposition of the great vessels. However, tetralogy of Fallot and transposition of the great vessels account for 8% and 10% of congenital heart disease respectively. Dähnert 570, 652-653
• Match:
• Plasma oncotic pressure
• Mean pulmonary arterial pressure
• Pulmonary capillary wedge pressure
• 5 mm Hg
• 10 mm Hg
• 15 mm Hg
• 20 mm Hg
• 25 mm Hg
• 30 mm Hg
Answers:
• E plasma 28mmhg
• C mean pulm art press ~12
• B. normal wedge 6-12
Marino: The ICU Book
• True/False - Regarding cardiovascular MRI
• Flow in wrong direction through valve may be seen as black flow jet
• EKG gating not necessary
• 1. True. "The blood pool has a homogeneous high-signal intensity throughout most of the cardiac cycle on cine-MR. Regurgitation through either the atrioventricular or semilunar valves is associated with a high velocity jet which causes a signal void within the otherwise high-signal-intensity chamber.“
• 2. False. "The blood pool is generally a signal void (spin echo), which provides high contrast between blood and the myocardial wall. When the evaluation of cardiac structure is desired, the ECG gated spin-echo technique, which provides static images with high signal-to-noise ratios, is used. When the primary goal is to assess cardiac contractile function, cine-MR (gradient echo) is used." Reference: Brant & Helms 545