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167 Cards in this Set
- Front
- Back
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What is infective endocarditis? |
An infection involving the endothelial layer of the heart |
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What layer of the heart usually gets infected with infective endocarditis? |
Endothelial layer |
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What does infective endocarditis commonly affect? What can it also affect? |
Commonly affects the valves but it can affect the lining of the heart or great vessels |
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What are the causes of infective endocarditis? |
1. Introduction of a pathogen 2. Vegetation 3. Organisms attach to the flow side of the valves |
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How is a pathogen introduced to cause infective endocarditis? |
Into the circulation viable oral cavity, upper respiratory tract, gastrointestinal tract, female reproductive tract, skin or circulatory system causing bacteremia (most common) or fungemia (less common) |
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Where do vegetations accumulate? |
Vegs are usually attracted to cardiac structures that are damaged, particularly areas that create turbulent blood flow. After attaching itself, circulating microorganisms attach to the veg and proliferate (multiply). It becomes a cyst-like structure that defends the colony from defensive cells |
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Where do the majority of organisms attach during infective endocarditis? |
Attach to the flow side of the valves. This would be the proximal chamber. For example: the atrial side of the atrioventricular valves and the ventricular side of the semilunar valves |
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Which side would vegetations attach to when attached to the atrioventricular valve? |
Atrial side |
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Which side would vegetations attach to when attached to the semilunar valve? |
Ventricular side |
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What are the different types of infective endocarditis? |
-acute infective endocarditis -subacute infective endocarditis |
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What's the differentiation between acute infective endocarditis and subacute infective endocarditis? |
Acute IE: highly virulent (powerful, dangerous) pathogens that display sudden onset and rapid destruction of cardiac tissues. It often involves the invasion of a normal valve and is typically caused by the bacteria staphylococcus aureus Subacute IE: takes as long as 8 weeks and has a subtle presentation. It often involves the invasion of an abnormal valve and is typically caused by the bacteria streptococcus viridans. Patient may complain of feeling "run-down" |
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What type of infective endocarditis involves the invasion of a normal valve and is typically caused by the bacteria staphylococcus aureus? |
Acute infective endocarditis |
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What type of infective endocarditis often involves the invasion of an abnormal valve and is typically caused by the bacteria streptococcus viridans |
Subacute infective endocarditis |
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Who's at high risk for infective endocarditis? |
Patients with prosthetic heart valves, aortic valve disease, mitral regurgitation, patent ductus arteriosus, VSD, coarctation of the aorta, Marfan Syndrome, history of IE and intravenous drug abusers |
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Who's at intermediate risk for infective endocarditis? |
Calcific aortic sclerosis, mitral valve prolapse, mitral stenosis, tricuspid valve disease, pulmonic valve disease, pressure monitoring lines in the right atrium and non-valvular cardiac implants (pacemaker) |
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Who's at low risk for infective endocarditis? |
ASD, coronary artery disease/plaque, aortitis and pacemaker |
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Who needs prophylactic (preventative) antibiotics for infective endocarditis? |
Only those at the greatest risk and should take antibiotics before dental and medical procedures Greatest risk patients include: -prosthetic heart valves -history of IE -cardiac transplant w/ a valvular problem -serious congenital anomalies (unrepaired or partially repaired cyanotic lesions, a repaired congenital defect w/ a prosthetic material/device, any repaired defect w/residual defect at site or adjacent to site |
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What are some signs and symptoms of infective endocarditis? |
-fever of unknown origins -chills -Osler's nodes (red, tender spots under the skin of the fingers) -petechiae (tiny purple or red spots on other areas of the skin) -new or changed heart murmur -positive blood cultures -night sweats -arthralgia (joint pain)/muscle pain -unexplained weight loss -anemia (decrease in RBCs) -shortness of breath -persistent cough -tachycardia |
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What are some complications of infective endocarditis? |
1. Embolization (when veg or part of veg breaks off) 2. Structural and hemodynamic changes 3. Abscess 4. Heart failure due to severe regurgitation |
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What criteria has a higher chance of a vegetation becoming embolized? |
- greater than 5mm - mobile - pedunculated (attached by a stalk) |
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What are some examples of structural and hemodynamic changes from infective endocarditis? |
-stenosis -regurgitation -flail/ruptured leaflets or chordae tendineae -aneurysm -perforation -intracardiac fistula (connection) -prosthetic valve dehiscence (bacteria eats away tissue - tears down tissue causing dehiscence) |
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What is the most serious complication of infective endocarditis? |
An abscess |
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What are some treatments for infective endocarditis? |
1. Antibiotics after positive blood tests 2. High doses of IV antibiotics 3. Antibiotics continue after hospital 4. Antibiotics may be required for up to 6 weeks |
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What are some echo signs for infective endocarditis? |
1. Infected area and/or veg may appear thickened, shaggy, swinging or pedunculated 2. Vegs vary in size (TTE > 2-3 mm; TEE > 1mm) 3. Structural and hemodynamic changes: stenosis, regurgitation, flail /ruptured leaflets or chordae tendineae, aneurysm, perforation, intracardiac fistula, abscess, prosthetic valve dehiscence 4. Hyperdynamic or normal LV 5. Pericardial effusion 6. Severe, acute regurgitation can cause heart failure |
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What happens when acute infective endocarditis causes severe acute regurgitation? |
It creates a sudden left ventricular volume overload pattern resulting in dilatation and a hyperdynamic state Frank-Starling: the more blood that enters the ventricle during diastole, the greater the quantity of blood pumped during systole |
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What size vegetation can a TTE detect? |
Veg > 2-3 mm |
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What size vegetation can a TEE detect? |
Veg > 1mm |
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If a sonographer doesn't see a vegetation by echo, can that rule out infective endocarditis? |
No! |
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What can M-Mode detect with a patient with infective endocarditis? |
1. Oscillations (flapping veg) 2. Aortic insufficiency due to an AoV veg may cause flutter of the AMVL 3. Acute IE causes severe, acute regurgitation, which creates a sudden LV volume overload pattern (LV enlargement w/ hyperkinesis) 4. MV closes prematurely due to increased LVEDP that exceeds LAP 5. AoV opens early |
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What can color flow determine in infective endocarditis? |
- secondary stenosis through the infected valve - secondary regurgitation through the infected valve -if abscess is present, examine the flow through and around the abscess |
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What can Doppler determine with infective endocarditis? |
-veg may create an obstruction that mimics stenosis -regurgitation is probable |
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Name some diseases of the aorta |
-aortic dissection -sinus of Valsalva aneurysm -Marfan syndrome -aortic aneurysm -coarctation of the aorta |
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What is an aortic dissection? |
Involves a tear in the intimal (inner) lining of the aorta. The tear creates a false lumen or intimal flap. Blood enters the false lumen, destroys the media and strips the intima from the adventitia (the outer layer of the aorta) possibly causing the tear to extend further |
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What can cause an aortic dissection? |
-hypertension (stress on lining of the aorta, resulting in degeneration and necrosis in areas of previous medial abnormalities -atherosclerotic related conditions that cause damage to the intima -hereditary (Marfan syndrome or Ehlers-Danlos) -chromosomal aberrations (abnormality) such as Turner syndrome -Pregnancy which causes increased blood volume and hypertension (3rd trimester - greatest risk) -coarctation of the aorta creates an area of weakness making it prone to dissection -strenuous physical exertion -trauma (deceleration injuries - car accident - tear at isthmus) -African American men over 40 @ greatest risk |
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What is the most common factor that predisposes aortic dissection? |
Hypertension |
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What trimester of pregnancy is at the greatest risk for aortic dissection? |
Third trimester |
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Where is the aortic isthmus? |
Aortic arch joins the thoracic aorta |
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Where do 65% of dissections originate? |
Within ascending aorta |
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Where do 20% of dissections occur? |
Descending aorta |
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Where do 10% of dissections occur? |
Within the aortic arch |
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What are the two classification systems for an aortic dissection? What's the differentiation between the two? |
1. Stanford system is based on the site of the intimal tear 2. The DeBakey system is based on the dissection's anatomic location |
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What are the two types of aortic dissection based on the Stanford system? What does each type involve? |
Type A (proximal): tear in the ascending aorta; requires surgical treatment Type B (distal): tear in the descending aorta; requires medical management |
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What are the three types of aortic dissection based on the DeBakey system? What does each type involve? |
Type 1: involves the ascending aorta, aortic arch and descending aorta Type 2: involves the ascending aorta Type 3: involves the descending aorta |
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What are the signs and symptoms of aortic dissection? |
1. Described as a ripping, tearing, or sharp pain in the abdomen, chest and/or through the back. The pain tends to move if the dissection gets worse 2. The point of pain often serves to locate the tear 3. Generally hypertensive (>200 mmHg systolic blood pressure) |
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What are some complications of aortic dissection? |
1. Aortic insufficiency 2. Pericardial effusion/tamponade 3. Fatal hemorrhage 4. Occlusion of the major systemic arteries 5. If there is an occlusion of a coronary artery(s) it may lead to a myocardial infarct |
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What views do you use to check for aortic dissection? |
All of views involving the aorta - aortic valve (AOV) - aortic root (AO root) - ascending aorta (AAO) - aortic arch (AO arch) - descending aorta (DAO) |
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Which type(s) of aortic dissection presents with a dilated AO root and AAO with severe, acute aortic insufficiency (AI)? |
Type 1 or 2 |
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Which type(s) of dissection presents with a dilated DAO? |
Type 1 or 3 |
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Presence of a(n) ________ that appears as a thin, linear structure. The ________ runs between the true and false lumen and it can be difficult to differentiate between the two lumens. |
Intimal flap (both answers) |
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What can indicate a rupture of an aortic dissection into the pericardium? |
Pericardial effusion/tamponade |
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Which parts of the aorta can you see in the LAX? |
AoV, AO root, AAO (ascending aorta), DAO (descending aorta in short axis) |
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Which view can you see the AoV, AO root, ascending aorta (with angulation)? |
SAX |
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Which view can you see the AoV, AO root, and ascending aorta? |
5C |
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Which view can you see the descending aorta? |
2C |
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Which view can you see the AoV, AO root, and ascending aorta? |
3C |
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Which parts of the aorta can you see in the SAX? |
AoV, AO root, AAO (ascending aorta - may be visible with angulation) |
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Which parts of the aorta can you see in the 5C? |
AoV, AO root, AAO (ascending aorta) |
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Which parts of the aorta can you see in the 2C? |
DAO (long axis) |
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Which parts of the aorta can you see in the 3C? |
AoV, AO root, AAO |
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Which parts of the aorta can you see in the Subcostal? |
AoV, AO root, DAO (long axis) |
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Which parts of the aorta can you see in the Suprasternal? |
AAO, AO arch, branches of the AO arch (innominate artery, left carotid and left subclavian artery), DAO (thoracic) |
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What is this an example of? |
An intimal tear that creates a false lumen (shaded area) originating in the ascending aorta, continuing through the arch, and down into the descending aorta |
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What are some diseases of the aorta? |
-aortic dissection -sinus of Valsalva aneurysm -Marfan syndrome -aortic aneurysm -coarctation of the aorta |
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How many sinuses of Valsalva are there and where are they located? |
-Three sinuses of Valsalva -located proximal to the aortic valve cusps |
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What is a sinus of Valsalva aneurysm? |
A saccular type of dilatation that typically only affects one of the three sinuses of Valsalva |
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Which sinus of Valsalva is most commonly affected by a sinus of Valsalva aneurysm? |
Right coronary sinus |
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What can cause a sinus of Valsalva aneurysm? |
-Congenital -acquired |
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What are some associated findings with sinus of Valsalva aneurysm? |
-bicuspid aortic valve -ventricular septal defect -coarctation of the aorta |
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If there is a sinus of Valsalva aneurysm, what is the patient in risk of if ruptures or abscesses? |
Leads into endocarditis |
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What can happen if the right coronary sinus develops an aneurysm? |
If the aneurysm protrudes into the RVOT, it can create subvalvular pulmonic stenosis |
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What is a fenestration? |
Creation of a new opening |
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What is Marfan Syndrome? |
Heritable condition of the connective tissue (skeleton, eyes, nervous system, skin, lungs, heart and blood vessels) |
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What part of the heart can Marfan Syndrome effect? |
The aorta Marfan syndrome causes increased elasticity of the aortic wall because of the deficiency of connective tissue and an ineffective cross-linking of collagen |
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What are some potential echo findings of Marfan Syndrome? |
-dilatation of sinuses of Valsalva -dilatation of the proximal aorta, ascending aorta and possible dissection -holosystolic mitral valve prolapse -MR, TR, AI -tricuspid valve prolapse |
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What are other heart related issues of Marfan Syndrome if there is pericardial effusion? |
Tamponade and early death |
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What are some physical characteristics of a patient with Marfan syndrome? |
Slender, tall habitus, pectus excavatum (sunken in chest), long, flexible extremities |
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What is an aortic aneurysm? |
An abnormal dilatation that may occur anywhere along the length of the aorta |
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Where is the most common location of an aortic aneurysm? |
Along the abdominal aorta |
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What are the different types of aortic aneurysms? |
1. Saccular aneurysm 2. Fusiform aneurysm |
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Describe the differences between a saccular aneurysm and an fusiform aneurysm |
Saccular aneurysm = A "pouch" in a weakened area Fusiform aneurysm = a uniform dilatation of the entire circumference of the aorta |
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What can cause an aortic aneurysm? |
-smoking -atherosclerosis -trauma -systemic hypertension -Marfan syndrome -infection -mitotic (cell division) by microorganisms -syphilitic aortitis |
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What is the most significant contributors to aortic aneurysms? |
Smoking |
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Is 2D echo a valuable tool to rule out or evaluate an aortic aneurysm? |
Yes because we can visualize the entire aorta (or most of it) from a combination of windows |
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What is a coarctation of the aorta? |
A narrowing of the aorta |
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Which part of the aorta will you commonly find a coarctation of the aorta? |
Typically in the area of the aortic isthmus (preductal, juxtaductal or postductal) |
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What is myocarditis? |
Involves an inflammatory response of the Myocardium that may be diffuse or local. |
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How must you diagnose the type of myocarditis? |
Diagnosis depends on endomyocardial biopsy |
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What can cause myocarditis? |
-infectious agent (virus, bacteria, parasite or fungus -radiation -toxic physical agents/chemicals/medications -drugs (cocaine) -systemic diseases, such as Lupus, other connective tissue diseases or vasculitis |
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What is the most common cause of myocarditis? Which strain? |
Most common cause is viral and Coxsackievirus B is the most common culprit |
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What are the two ways the myocardium becomes damaged or inflamed? |
1. Invasion of the Myocardium that produces a myocardial toxin, causing the myocardium to become inflamed 2. Autoimmune response caused myocardial damage. The T-lymphocytes have been traced as the primary cause of the cell-mediated toxic response that leads to myocardial damage |
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What are some signs and symptoms of myocarditis? |
-fever, body aches, sore throat, other symptoms associated with viral infection -malaise (feel sick) -Fatigue -chest pain -Dysrhythmia -SOB with exertion -fluid retention -asymptomatic -can be accompanied by pericarditis |
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What are some treatments of myocarditis? |
-management depends on cause -if viral, corticosteroids or other medications can be prescribed to suppress immune system -anti-arrhythmics, diuretics, Digoxin (helps heart beat stronger with normal rhythm) -intra-aortic balloon pump (IABP) -left ventricular assist device (LVAD) -heart transplant |
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What are some echo and M-Mode characteristics of myocarditis? |
-dilated or hyoertrophied ventricles -ventricular dysfunction -regional wall motion abnormalities |
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What can using Doppler and color flow find in myocarditis? |
-used to evaluate valvular disease states (can cause regurg due to a dilated ventricle) -evaluate diastolic function |
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What is pericarditis? |
An inflammatory or infectious process of the parietal and visceral layers of the pericardium |
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What is the most common cause of pericarditis? |
Idiopathic (unknown) but most likely viral |
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Is Pericarditis isolated or in combination with another process? Is it local or general? Is it acute or chronic? |
Can be any/all of these |
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What is the etiology of pericarditis? |
1. Acute injury occurs 2. Fibrin, white blood cells and endothelial cells are released and cover the parietal and visceral layers of the pericardium 3. Friction between the layers causes irritation and inflammation |
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What are the different types of pericarditis? |
Acute and chronic |
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Describe acute pericarditis |
-acute onset occurs w/in 2 weeks -lasts up to 6 weeks -dryness causing painful friction rub -can cause pericardial effusion -fluid clear, straw or amber color -pericardial effusion ( >100 ml) -normal serous fluid ( 10 - 30 ml ) -heart not able to compensate for accumulating effusion |
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How can acute pericarditis cause a pericardial effusion? Does the effusion cause more pain? |
The heart is not able to compensate with acute pericarditis therefore it causes an obstruction of the venous system and lymphatic drainage. This causes fibrin material and serous fluid to accumulate in the pericardial sac which leads to effusion. This effusion will reduce the dry rubbing and eliminate some pain |
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True or false Chronic pericarditis restricts the hearts ability to compensate and produces a small, rapid accumulating effusion |
False, chronic pericarditis develops slowly and has a large effusion but since it develops slowly, the heart is able to compensate |
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What is chronic pericarditis? |
-chronic onset follows acute pericarditis -chronic pericarditis can last up to 6 months |
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What are some complications of pericarditis? |
1. Pericardial effusion 2. Tamponade 3. Constrictive pericarditis |
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What are the characteristics of constrictive pericarditis? |
-pericardial thickening and scarring of the parietal and/or visceral pericardium -layers become dense and adhere to one another -pericardial space obliterated -diastolic filling restricted because it's non-compliant -decreased cardiac output -impedes diastolic filling -usually affects all four chambers but can be local |
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What happens if all four chambers are affected during constrictive pericarditis? |
If all 4 chambers are involved equally, the end diastolic pressures within the RA, RV, pulmonary artery, pulmonary capillary wedge and LV equalize and elevate |
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How is constrictive pericarditis treated? |
Pericardiectomy (removal of the pericardium) |
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What characteristics of constrictive pericarditis can you see during 2D echo? |
-normal LV -LA enlargement due to impaired filling -ventricular systolic function normal -flat LV inferior wall motion in diastole because the heart cannot expand properly because layers of wall adhere to one another -thickened pericardium -pericardial effusion -interatrial and interventricular septal bulge to left during inspiration (septal bounce) -dilated hepatic vein -dilated IVC -IVC doesn't collapse during inspiration (sniff test) |
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What is the best view to evaluate pericardial effusion? |
Subcostal window |
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What characteristics will you see during M-Mode for constrictive pericarditis? |
-LA enlargement -flat LV posterior wall motion in diastole (Inferolateral wall) -thickened pericardium -paradoxical septal motion -premature opening of pulmonic valve |
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Can color flow determine anything during constrictive pericarditis? |
MR and TR |
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What can Doppler show during constrictive pericarditis? |
-large "E" and small "A" with respiratory changes (opposite of restrictive cardiomyopathy) |
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What is this an example of? |
Restrictive/infiltrative CMO |
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What is this an example of? |
Constrictive pericarditis |
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What's the difference between restrictive cardiomyopathy and constrictive pericarditis? |
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What is pericardial effusion? |
Presence of an abnormal amount and/or type of fluid within the pericardial space (between the parietal and visceral layers of the pericardium |
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Is pericardial effusion caused by a local or systemic disorder? |
Can be either |
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True or false A loculated pericardial effusion is rare |
True |
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Can pericardial effusion be acute or chronic? |
Yes |
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What can cause a pericardial effusion? |
-secondary pericardial effusion due to trauma or injury -Dressler's syndrome causing acute myocardial infarction or post myocardial infarction -obstruction of fluid drainage -idiopathic -infectious (viral, bacterial, fungal, AIDs, tuberculosis -tumors (benign and malignant) -radiation -post-cardiac surgery -Aortic dissection -autoimmune or connective tissue disorders (lupus, rheumatoid arth. ) -drug induced |
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Which side of the heart typically develops pericardial effusion? |
Usually develops in the right side due to the low pressures but can develop on left side |
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What can pericardial effusion be confused with? |
Epicardial fat (fat pad) |
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Where is epicardial fat found? |
Appears on echo as a loculated anterior space between the epicardium and the myocardium |
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Which disease is a fat pad linked to? |
Coronary artery disease |
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How can you differentiate between pericardial and pleural effusion? |
Pericardial: anterior to descending aorta with no change with resp. Pleural: posterior to descending aorta, changes with respiration |
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Which type of effusion is positioned posterior to the descending aorta? |
Pleural effusion |
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Which type of effusion is positioned anterior to the descending aorta? |
Pericardial effusion |
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What are some signs and symptoms of pericardial effusion? |
Chest pain, pressure, discomfort, lightheadedness, syncope, dyspnea, palpations, cough, hoarseness, anxiety and confusion |
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What is 1? |
Pericardial effusion |
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What is 2? |
Pleural effusion |
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What is 3? |
Pericardium |
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What is 4? |
Epicardial fat |
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A long standing pericardial effusion or one associated with metastatic (cancer) disease rends to have __________. |
Fibrin strands |
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Pericardial effusions frequently originate near the __________ because it has the _________ pressure of the four chambers, therefore, the other chambers tend to squeeze the effusion to the area of the least resistance. |
Right atrium; lowest |
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What is tamponade? |
An elevation of intrapericardial pressure due to a pericardial effusion that is "crushing" the heart. Usually, the pericardial effusion accumulates rapidly Note: the rapid accumulation of fluid may just be pericardial effusion |
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Describe the pressures, diastolic filling, and stroke volume during tamponade |
-An elevation and equalization of intrapericardial pressures -decreased diastolic filling (that worsens) -reduced stroke volume |
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What dimensions define a large pericardial effusion? |
> or = 1cm globally (around entire heart) |
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What dimensions define a small pericardial effusion? |
< 1 cm, it's often loculated and in the region of the right heart or left atrium |
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What can cause tamponade? |
-malignant disease -pericarditis -uremia (blood poisoning) -acute myocardial infarct -cardiac perforation during diagnostic testing (catheterization) -bacterial -tuberculosis -radiation -dissecting aorta -lupus -cardiomyopathy |
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What can 2D echo determine during tamponade? |
1. Size of effusion 2. Location of effusion 3. If effusion has a hemodynamic effect upon heart chambers and functions |
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What is Beck's Triad? |
Includes: -hypotension (low blood pressure) -muffled heart sounds -elevated venous pressure (distended neck veins) |
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What is pulses paradoxus? |
An exaggerated decrease in systolic BP with inspiration |
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What are the clinical characteristics of tamponade? |
-Beck's Triad -pulsus paradoxus -Pericardial friction rub -tachycardia -hepatomegaly (enlarged liver due to increased venous pressure) |
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What is hepatomegaly? |
An enlarged liver due to increased venous pressure |
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What are some complications of tamponade? |
-hypotension -shock (cardiogenic shock) -death |
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What are signs and symptoms of tamponade? |
Similar to pericarditis and pericardial effusion -dyspnea (improves if patient sits up) -Cough -dysphasia -cold extremities -peripheral cyanosis -tachycardia -hypotension -fatigue |
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How can you treat tamponade? |
1. Pericardiocentesis (pericardial tap) 2. Pericardial window 3. Pericardiectomy |
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Which treatment results in draining/tap the pericardial effusion |
Pericardiocentesis |
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Which location is normally used during pericardiocentesis? |
Subcostal |
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During a pericardiocentesis, how can you determine if you haven't punctured the ventricle and are only tapping the effusion? |
A bubble study. If the bubbles stay within the effusion, then it's safe to drain. The bubbles shouldn't enter the cardiac chambers |
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What is a pericardial window? |
Open pericardial drainage via a "window" made by the surgeon |
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What is a pericardiectomy? |
Removal of the pericardium |
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What 2D echo characteristics are found in tamponade? |
1. Size of pericardial effusion 2. Right atrial late systolic and early diastolic collapse 3. RV diastolic collapse (normally the RV is at its largest during filling) 4. Paradoxical septal motion (LV walls move parallel to one another 5. RV and LV volume change with respiration 6. Swinging heart (w/ large effusion) 7. Dilated IVC without inspiratory collapse (sniff test) because of pressure build-up |
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What is 1? |
Pericardial effusion surrounding the heart |
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What is 2? |
Right atrial late systolic and early diastolic collapse |
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What is 3? |
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What is 4? |
Paradoxical septal motion |
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What are the echo findings of the left heart during tamponade? |
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What are the echo findings on the right heart during tamponade? |
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What can M-Mode determine with tamponade? |
1. Rule out diastolic collapse of RV 2. Rule out paradoxical wall motion |
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What can you determine with Doppler with tamponade? |
1. Rule out respiratory variation of the MV and TV flow 2. Place PW at tips of MV or TV 3. Decrease the sweep speed to 25mm/sec 4. MV should decrease with inspiration and increase with expiration 6. TV should increase with inspiration and decrease with expiration |
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Describe the MV during inspiration and expiration during respiratory variation |
E and A wave decrease during inspiration E and A wave increase during expiration |
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Describe the TV during inspiration and expiration during respiratory variation |
The E and A wave increase with inspiration and decrease with expiration |
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If a patient uses intravenous drugs, what are they at risk for? Where would it develop? |
Endocarditis of the Tricuspid valve. Vegetations may form and may develop into a pulmonary emboli |
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Where does an aneurysm of the right coronary sinus protrude into? |
The RVOT |
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Where does an aneurysm of the left coronary sinus protrude into? |
LA |
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Where does an aneurysm of the non coronary sinus protrude into? |
RA |
