CT cardiac anatomy M.Todorova Tokuda Hospital Sofia 1 MDCT vs US 2 Position of the heart • Position in the thoracic cavity • Cardiac apex • Cardiac base 3 Systematic approach Cardiac CT • Right atrium • Aorta • Right ventricle • Coronaries • PA • Cardiac Veins • PV • Valves • Left atrium • Pericardium • Left ventricle 4 Right atrium 5 Right atrium • RA appendage – Pectinate muscles >2mm – 20 sc.cm normal size on 4 ch.view • Crista terminalis • Sulcus terminalis • Coronary sinus • Thebesian valve • Eustachian valve • Internal septum • Fossa ovalis 6 Tricuspid valve • Tricuspid valve- separates RA from RV • Trileflet valve- anterior,posterior, septal • Structure- leflet,annulus,commi ssures 7 Right ventricle 8 RV-anatomy inflow tract 4 chamber view outflow tract 9 Volumetric parameters of RV • Normal quantitative RV Values • EF = 61+/-6 • End diastolic volume = 173+/-39 • End systolic volume = 69+/-22 • Strike volume = 104+/=21 • Mass = 35-45 10 RV-anatomic structure • Tricuspid valve • RV wall • Pulmonary valve • Intrventricular septum • Anterior longitudinal sulcus • Posterior longitudinal sulcus • Moderator band 11 • Interventricular septum – Separates ventricles – Thin wall – Convexity toward the right ventricle – Muscular ventricular septum – Membrannous ventricular septum • Anterior and posterior longitudinal sulcus – Ventricles separeted externally by grooves – Anterior longitudinal sulcus – Posterior longitudinal sulcus – Moderator band 12 Pulmonary valve • Three leaflet • Semilunar morphology 13 PA anatomy 14 Left atrium and pulmonary veins 15 • Pulmonry veins – Two inferior and two superior into either side of LA 16 LA - anatomy • LA • LA appendage – Arises from the superiorlateral aspect of the LA – Projects anteriorly over the proximal LCX artery – Pectinate muscles >1mm 17 Mitral valve • represent inflow tract of LV • bicuspid • fibrous ring mitral valve-annulus • triangular leaflets 18 Left ventricle 19 LV - anatomy • Inflow tract • Outflow tract • Chordae tendinae • Papillary muscles 20 LV wall Normal Anterior MI LV papillary muscles Ferencik et al. Am J Cardiol 2004;93:949951 diastolic systolic 21 AHA Scientific Statement Standard Myocardial Segmentation 17 segment model Cerqueira et al. Circulation 2002;105:539542 22 • Normal quantitative LV Values GLOBAL AND REGIONAL • EF = 69+/-6 LV FUNCTION • End diastolic volume = 150+/-31 • End systolic volume = 47+/-15 • Strike volume = 104+/=21 • Mass = 96-123 END DIASTOLE END SYSTOLE 23 Cury RC et al, RSNA 2006 Aortic Valve • Three semilunar leaflet • Aortic sinuses of Valsalva • Outflow tract of LV • Annulus,cusps and commissures 24 Sinus of Valsalva • Left coronarius sinus of Valsalva • Right coronarius sinus of Valsalva • Posterior sinus of Valsalva 25 CORONARY ARTERIES AHA Coronary Coronary Segments Segments Classification 1.RCA prox 2. RCA mid 3. RCA dist 4. RCA PDA 16. RCA PLV 5. LM 6. LAD prox 7. LAD mid 8. LAD dist 9. LAD D1 10. LAD D2 11. LCX prox 12. LCX OM1 13. LCX mid 14. LCX OM2 15. LCX distal 26 17. RI Coronary arteries • Normal diameter – 3-4mm • Arterial wall • Coronary arteries-dominance The CA that gives rise to the PDA and posterolateral branch is referred as the dominant artery • Aneurysm – focal abnormal dilatation of an adjacent normal CA • Ectasia – diffuse process 27 Main Left Coronary Artery • Arises from left sinus of Valsalva • Courses antrolaterally in the epicardial fat • Bi/trifurcates • Supplies the LV 28 LCA – segmental anatomy • LCA – main branch to the level of bi/trifurcation • LAD – Proximal – to the first septal branch – Middle – to the level of obtuse angle (second septal perforator) – Distal – to the apex of the heart • LCX – Proximal – to the first obtuse marginal branch 29 – Distal Left coronary artery • LAD – Courses antrolaterally in the epicardial fat of the ant. interventricular groove – Diagonal (supplies LV free wall) – Septal perforating arteries (supplies interventricular septum and the AV bundle) • CX – Courses in the left AV groove – Marginal branches – Supplies the LV free wall and 30 anterolateral papillary muscle Left coronary artery - variants • No LMCA • Unilateral origin of right and left coronary arteries • CX gives rise to posterolateral and posterior desc. Artery, suppling the diaphragmatic portion of the LV • Ramus intermedius (RI) as a division of LCA, resulting in trifurcation • Supplies the LV free wall 31 RCA – segmental anatomy • Proximal – from the ostium to the point halfway to the acute margin of the heart • Mid – the other half of the distance • Distal – courses along the posterior AV grove, from the acute angle of the heart to the origin of the PDA 32 Right coronary artery • Arises from right CS • Courses in the right AV groove toward the crux of the heart • Acute marginal branch • Sinoatrial nodal branch • Posterior descending artery • Postero-lateral branch 33 RCA - variants • Conus artery branch (directly from the Ao in 30%) • Supplies the RV outflow tract 34 CARDIAC VEINS 35 Coronary veins • Coronary sinus – Runs along the inferior aspect of the heart in the AV groove Small cardiac ve – Empties into RA • Branches Middle cardiac vein – Post. Interventricular vein LA (middle cardiac vein), courses in the posterior interventricular groove from base to apex – Posterior vein of the LV Anterior IV vein – Left marginal vein Coronary sinus – Anterior interventricular vein, courses from the base of the heart toward to the apex Great cardiac vein 36 Abbara S, Cury RC et al. AJR 2005; 185:10011006 Pericardium 37 Pericardium • Thin layer – Parietal envelops the heart and attaches to the sternum and proximal great vessels – serous layer lines both the fibrous pericardium and the outer surface of the heart • Pericardial recessess – Oblique recessus – Transverse recessus 38 Pericardium LA LV RV LV RV < 2mm = Normal pericardial thickness > 4mm = Suggests pericardial constriction > 6mm = High specificity for pericardial constriction 39 40 Thank you 41.