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Chest-Mostly-Fixed-1 Chest 1997-2008 2008 Chest L-Transposition (Recall): A. AV disconcordance, Arteriovent concordance B. AV/Arterioventricular discordance C. Atrioventricular Discordance, Ventriculoarterial Discordance L-Transposition of Great Vessels. A. Artioventricular concordance Arterioventricular concordance B. Every other possible combination L-Transposition of Great Vessels. Artioventricular concordance Arterioventricular concordance ArtioventriculardisconcordanceArterioventriculardisconcordance Every other possible combination L transposition A. Arteriorventricular concordance and Atrioventricular discordance B. And multiple variations of this 2008 Chest L-Transposition (Recall): A. AV disconcordance, Arteriovent concordance B. AV/Arterioventricular discordance C. Atrioventricular Discordance, Ventriculoarterial Discordance L-Transposition of Great Vessels. A. Artioventricular concordance Arterioventricular concordance B. Atrioventricular Discordance, Ventriculoarterial Discordance C. Every other possible combination L-Transposition of Great Vessels. Artioventricular concordance Arterioventricular concordance ArtioventriculardisconcordanceArterioventriculardisconcordance Every other possible combination L transposition A. Arteriorventricular concordance and Atrioventricular discordance B. Atrioventricular Discordance, Ventriculoarterial Discordance C. And multiple variations of this Levo-Transposition of the Great Arteries Commonly referred to as congenitally corrected transposition of the great arteries (CC-TGA) Acyanotic heart defect Aorta and PA are transposed The Aorta is anterior and to the Left of the PA The Morphological LV and RV are also transposed In segmental analysis= Atrioventricular Discordance (ventricular inversion) with ventriculoarterial discordance Blue blood is pumped from the RA into the morphological LV (which lies on the right side of the heart), then through the pulmonary artery to the lungs. The red blood then returns, via the pulmonary veins, to the LA from which it is pumped into the morphological RV, then through the aorta wikipedia statdx Dextro-Transposition of the Great arteries Also referred to as complete transposition of the great arteries Cyanotic congenital heart defect The aorta and PA are transposed In segmental analysis = Ventriculoarterial discordance with atrioventricular concordance or just ventriculoarterial discordance Blue blood from the right heart is pumped immediately through the aorta and circulated to the body and the heart itself, bypassing the lungs altogether, while the left heart pumps red blood continuously back into the lungs through the pulmonary artery. In effect, two separate “circular” (parallel) circulatory systems are created. wikipedia wikipedia RV Characteristics of a RV Infundibulum (tunnel of myocardium) separating the AV and Semilunar Valves Moderator Band Corrugated Surface of the Right Ventricular aspect of the septum L- TGA = Atrioventricular Discordance (ventricular inversion) with ventriculoarterial discordance D-TGA = Ventriculoarterial discordance with atrioventricular concordance or just ventriculoarterial discordance Chest? Calcification in the coronary artery is significant because (recall variant): It is source of emboli It is marker for stenosis There is calcification in a coronary artery on cardiac CTA. What does this imply: Implies there is a region of stenosis at the calcification The source of thromboembolic event Correlates to an area of prior plaque ulceration Coronary atherosclerotic calcification on CTA… Most likely predicts an area of stenosis Chest Answer Calcification in the coronary artery is significant because (recall variant): It is source of emboli It is marker for stenosis There is calcification in a coronary artery on cardiac CTA. What does this imply: Implies there is a region of stenosis at the calcification The source of thromboembolic event Correlates to an area of prior plaque ulceration Coronary atherosclerotic calcification on CTA… Most likely predicts an area of stenosis Coronary Calcifications Represents atherosclerotic changes in the intima and the internal elastic membrane of the coronary arteries most frequently calcified site: 1. LAD 2. left circumflex artery 3. RCA increases with age and may be part of the normal aging process Generally, in pts <60, there is a strong correlation btw calcification and severity of atherosclerosis; the association is not as strong in older pts. influenced by risk factors such as increased cholesterol and lipids, smoking, HTN, and a family history of CAD. There is a correlation btw calcification and the severity of coronary stenosis; however, some severe stenoses may not be calcified and some heavy calcifications may not denote stenotic arteries Chest? CT coronary angio shows RCA lesion. What to do (new)? CABG Invasive angio Medical management Stent Coronary CTA shows severe/hi grade stenosis of the RCA…what to do next? A) Invasive coronary angiogram B) Bypass C) Medical mangagment D) Angioplasty and stenting Coronary CTA shows severe/hi grade stenosis of the RCA…what to do next? Invasive coronary angiogram Bypass Medical mangagment Angioplasty and stenting Chest? CT coronary angio shows RCA lesion. What to do (new)? CABG- not indicated Invasive angio Medical management Stent (? It’s possible) Coronary CTA shows severe/hi grade stenosis of the RCA…what to do next? A) Invasive coronary angiogram B) Bypass- not indicated C) Medical mangagment D) Angioplasty and stenting (? Its possible) Coronary CTA shows severe/hi grade stenosis of the RCA…what to do next? Invasive coronary angiogram Bypass- not indicated Medical mangagment Angioplasty and stenting (? Its possible) High grade stenosis of the right coronary artery on CTA. What is the next step? Diagnostic coronary angiogram Angioplasty and stent CABG Do nothing Medical management INDICATIONS/CONTRAINDICATIONS: INDICATIONS FOR CORONARY BYPASS SURGERY ANATOMY Left main coronary artery disease Triple-vessel disease involving the proximal left anterior descending coronary artery with normal or diminished ejection fraction Double-vessel disease involving the proximal left anterior descending coronary artery with normal or diminished ejection fraction SYMPTOMS Unstable (crescendo) angina Postmyocardial infarction Angina Acute coronary occlusion after percutaneoustransluminal coronary angioplasty Symptoms unsuccessfully controlled with medical therapy Controlled symptoms, but with unacceptable lifestyle Chest Answer Any pt with severe CAD should be referred to a cardiologist for angiography and possible interventional therapy or surgery Severe CAD by CCTA is soft or hard plaque with vessel narrowing (stenosis ) of 70% or greater 50% of left main coronary artery is considered severe CAD those with stenosis >70% underwent catheterization and pts with intermediate lesions or uninterpretable sccans underwent nuclear stress testing. http://www.proscan.com/_filelib/FileCabinet/CCTA/CCTA_Physician_Guide.p df?FileName=CCTA_Physician_Guide.pdf http://www.emcreg.org/pdf/monographs/cta.pdf Chest? Lateral wall ischemia seen which vessel… A)LAD B) Circumflex C)RCA Lateral wall ischemia seen which vessel… LAD Circumflex RCA Chest? Lateral wall ischemia seen which vessel… A)LAD B) Circumflex C)RCA Lateral wall ischemia seen which vessel… LAD Circumflex RCA Coronary Artery Territory Septum = LAD Anterior wall = LAD Lateral Wall = LCX Posterior Wall = RCA Inferior/ Diaphragmatic wall = RCA Apex + Inferolateral wall = watershed areas Coronary Artery Dominance Determined by the origin of the posterior descending artery (PD), which supplies the inferior portion of LV - from RCA in 85% From LCX in 10% RCA + LCA = codominance/balanced supply (5%) Chest? On cardiac MRI a patient presents with left lateral wall akinesis with signal abnormality. Which coronary lesion is affected? Left circumflex artery Right coronary artery Left coronary artery LAD Chest? On cardiac MRI a patient presents with left lateral wall akinesis with signal abnormality. Which coronary lesion is affected? Left circumflex artery Right coronary artery Left coronary artery LAD Chest? On cardiac MRI there is abnormal signal on T1 in the lateral wall of the left ventricle without delayed enhancement. What is the most likely etiology: Myocardial ischemia Myocardial infarction Myocarditis Amyloidosis Chest? On cardiac MRI there is abnormal signal on T1 in the lateral wall of the left ventricle without delayed enhancement. What is the most likely etiology: Myocardial ischemia Myocardial infarction Myocarditis Amyloidosis Chest? On cardiac MRI there is abnormal signal on T1 in the lateral wall of the left ventricle without delayed enhancement. What is the most likely etiology: Myocardial ischemia- Myocardial infarction- infarcted tissue would demonstrate delayed enhancement Myocarditis Amyloidosis MRI- Ischemic Heart Disease rest Cine An essential feature of normal myocardium includes the preservation of normal contractile fx Viable myocardium may apear dysfunctional as a result of either acute reversible ischemic insults (myocardial stunning) or a chronic, gradual decrease in blood supply (hibernating myocardium) Thinning of the myocardial wall at rest is a reliable feature of scarred tissue resulting from extensive myocardial injury and remodeling Systolic wall thickening at rest or during dobutamine stress of greater than 2mm as determined by
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