10 THE NORMAL HEART: ANATOMY ANDTECHNIQUES OF EXAMINATION

CARDIOVASCULAR SYSTEMDAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

• Fig. 10.1 Normal gated spin-echo MRI series-transverse plane slices from superior to inferior; (A) The brachiocephalic arteries lie to the left of the trachea (T). (B) The transverse aortic arch (Ao) lies to the left of the trachea (T); the oesophagus lies posterior to the trachea (arrowed).

• Fig. 10.1 Normal gated spin-echo MRI series-transverse plane slices from superior to inferior; (C) The tracheal bifurcation (large arrow) lies posterior to the ascending aorta (AA) and the superior vena cava (small arrows) is to the right of the ascending aorta. (D) The left pulmonary artery (L) lies more superiorly than the right and is seen on the uppermost pulmonary artery slice.

• Fig. 10.1 Normal gated spin-echo MRI series-transverse plane slices from superior to inferior; (E) The right pulmonary artery (R) is seen lower than the left as it passes posterior to the ascending aorta and the superior vena cava. (F) The left atrium (LA) lies anterior to the descending aorta (D) and oesophagus (arrowed); pulmonary veins enter the left atrium.

• Fig. 10.1 Normal gated spin-echo MRI series-transverse plane slices from superior to inferior; (G) The left atrium, left ventricle (LV) and left ventricular outflow tract are seen; the right atrial appendage is at this level (arrowed). (H) The lowest part of the left atrium (arrowed) is level with the main right atrial chamber (RA).

• Fig. 10.1 Normal gated spin-echo MRI series-transverse plane slices from superior to inferior; (I) The tricuspid valve (T) is seen; the right ventricular free wall is thin in comparison to the left; the coronary sinus enters the right atrium (arrowed). (I) The inferior vena cava is seen at the level of the diaphragmatic domes(arrowed)

• Fig. 10.2 Normal gated spin-echo MRI series-coronal plane slices from anterior to posterior. (A) The most anterior coronal section shows the ascending aorta (A) curving to the right of the main pulmonary trunk (P); the brachiocephalic venous confluence lies to the right of the first brachiocephalic branch (arrowed). (B) The next slice shows how the superior vena cava (S) and the right atrium (RA) form the right heart border; the aortic knuckle, the pulmonary trunk, the left atrial appendage and the left ventricle form the left heart border (arrowed).

• Fig. 10.2 Normal gated spin-echo MRI series-coronal plane slices from anterior to posterior. (C) Pulmonary veins (arrowed) are seen entering the left atrium in the plane of the tracheal bifurcation; the most posterior part of the aortic root is just visible in the slice (A). (D) The left atrium (LA) lies below the tracheal bifurcation and the right pulmonary artery; the interatrial septum lies obliquely above the right atrium (RA); the IVC is to the right of the descending aorta

• Fig. 10.3 Normal gated spin-echo MRI series-sagittal plane slices from right to left. (A) The inferior vena cava (I) enters the right atrium (RA) near the Eustachian valve; the left atrium lies above and posterior to the right atrium and below the right pulmonary artery (R). (B) The ascending aorta (A) lies anterior to the left atrium (L) and right pulmonary artery (R).

• Fig. 10.3 Normal gated spin-echo MRI series-sagittal plane slices from right to left. (C) The transverse and posterior aortic arch lie at the same level as the main pulmonary artery (M). (D) The relationship between the right and left ventricles is clearly seen; the pulmonary valve lies above the right ventricular outflow tract (arrowed).

• Fig. 10.4 The posterior aspect of the pericardial space. The transverse sinus lies between the aorta/pulmonary artery and the great veins. The oblique sinus lies between the pulmonary venous confluence. Ao = aorta; PA = pulmonary artery; PV = pulmonary vein; SVC = superior vena cava; IVC = inferior vena cava.

• Fig. 10.6 (A) Gated spin-echo MR] short-axis section of the left and right ventricles. The papillary muscles are clearly seen in the left ventricle comparative TOE image (B) showing a short-axis section of both ventricles-the gastric position of the transducer is at the bottom of the image.

• Fig. 10.7 Transthoracic echocardiogram showing a long-axis view of the left ventricle (A) with a corresponding M-mode trace. (B) The anterior leaflet of the mitral valve arises from the posterior aortic annulus (arrowed).

• Fig. 10.8 Transoesophageal long-axis view from the transgastric window showing the chordae running from the papillary muscles to the mitral valve (M). LA = left atrium; LV = left ventricle.

• Fig. 10.9 M-mode sweep from mitral to aortic valve. The anterior leaflet of the mitral valve (arrowed) is in continuity with the posterior wall of the aortic root. The anterior wall of the aorta is in continuity with the interventricular septum.

• Fig. 10.10 The anterior view of the septal surface of the right ventricle. The basal, middle, apical, tonal and high anterior portions of the septum are marked. The Eustachian valve (e) lies between the opening of the inferior vena cava and the tricuspid valve annulus (t). The limbus of the fossa ovalis is arrowed. The membranous septum (ms) lies on the upper aspect of the tricuspid valve annulus and forms part of the ventriculoatrial septum (v). The transected moderator band of the right ventricle (m) lies in the mid septum. The parietal band of muscle (P) forms the tonal or outflow septum. The right (r) and non-coronary (n) aortic sinuses are marked.

• Fig. 10.11 Four-chamber transoesophageal echocardiogram showing the mobile sinuous appearance of a Chiari malformation in the right atrium. RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.

Fig. 10.12 Longitudinal transoesophageal echocardiogram showing the left atrial appendage (arrowed). LA = left atrium; LV = left ventricle.

• Fig. 10.13 Gadolinium contrast MRI angiography in the coronal plane showing the four pulmonary veins entering the left atrium.

• Fig. 10.14 Short-axis transoesophageal echocardiogram of the aortic valve in systole (A) and diastole (B). The right (R), left (L) and noncoronary (N) sinuses are shown. The lower part of the images lie anteriorly.

• Fig. 10.15 Anomalous right subclavian artery. (A) Barium study showing the oblique posterior esophageal indentation. (B) Coronal MRI showing diverticulum of origin of anomalous vessel (arrow). (C) Coronal MRI showing obliquely running anomalous vessel (arrow)

Fig. 10.15 Anomalous right subclavian artery. (A) Barium study showing the oblique posterior esophageal indentation. (B) Coronal MRI showing diverticulum of origin of anomalous vessel (arrow). (C) Coronal MRI showing obliquely running anomalous vessel (arrow). (D) Sagittal MRI showing diverticulum of origin of anomalous vessel (arrow). (E) Sagittal MRI showing anomalous vessel posterior to oesophagus (arrow)

• Fig. 10.16 Main pulmonary artery bifurcation. (A) Contrast-enhanced CT. (B) Gated spin-echo MRI. (C) Transthoracic echocardiogram.

• Fig. 10.17 (A) The transverse plane showing the orientation of the three aortic sinuses and the origins of the coronary arteries. Angiographic projections are annotated. (B) The levels of the three aortic valve sinuses from two different projections. RAO = right anterior oblique; LAO = left anterior oblique; LAT = lateral; L = left sinus; R = right sinus; N = non-coronary sinus.

• Fig. 10.18 Series of normal coronary artery angiograms. LMS = left main stem; LAD = left anterior descending artery; D = diagonal branch; S = septal branch; I = intermediate branch; Cx = circumflex artery; OM = obtuse marginal branch; PDA = posterior descending artery; RV = right ventricular branch; LV = inferior left ventricular branch. (A) Right anterior oblique view of the left coronary artery. (B) Cranially angulated view of the left coronary artery.

• Fig. 10.18 Series of normal coronary artery angiograms. LMS = left main stem; LAD = left anterior descending artery; D = diagonal branch; S = septal branch; I = intermediate branch; Cx = circumflex artery; OM = obtuse marginal branch; PDA = posterior descending artery; RV = right ventricular branch; LV = inferior left ventricular branch. (C) Right anterior oblique view of the right coronary artery. (D) Left anterior oblique view of the right coronary artery. The posterior descending artery is foreshortened. (E) Cranially angulated left anterior oblique view of the right coronary artery. The posterior descending artery is now well profiled.

• Fig. 10.19 Normal chest X-ray. (A) PA view annotated to show measurements for cardiothoracic ratio. (B) Lateral view.

• Fig. 10.20 Pulsed-Doppler study showing normal mitral inflow. The left panel shows an apical image with the sample volume (S) placed in the mitral orifice between left atrium (LA) and left ventricle (LV). The right panel shows the normal inflow pattern with an initial large passive flow (E) followed by a later smaller active flow (A) produced by atrial systole.

• Fig. 10.21 Transoesophageal echocardiogram showing color flow through a normal mitral valve. There is aliasing (yellow and red) in the central part of the flow where the velocity is highest.

• Fig. 10.22 Transoesophageal echocardiogram showing agitated saline contrast in the right atrium (RA). There is no evidence of bubble contrast in the left atrium (LA), indicating an intact atrial septum. LV = left ventricle.

Fig. 10.23 Transthoracic apical four-chamber view showing a bolus of transpulmonary contrast agent entering the left ventricle through the mitral valve after peripheral intravenous injection. LV = left ventricle; RV = right ventricle; LA = left atrium.

• Fig. 10.24 Technetium SPECT study showing a normal series of short-axis slices along the left ventricle after exercise stress (top) and at rest (bottom).

• Fig. 10.25 Technetium SPECT study showing a normal series of vertical long axis slices of the left ventricle after exercise stress (top) and at rest (bottom).

• Fig. 10.26 Technetium SPECT study showing a normal series of horizontal long-axis slices of the left ventricle after exercise stress (top) and at rest (bottom).

• Fig. 10.27 Technetium SPECT study showing a normal 'bull's eye view' display (A). The apex of the left ventricle is represented at the centre of the image and the regions around the ventricle are annotated. (B) Quantitation of the same display showing only minor variation in counts across the left ventricular myocardium. ?????????????

• Fig. 10.28 Technetium SPECT study showing surface-rendered images of a normally contracting left ventricle. The systolic contour is represented within the diastolic contour short-axis view (A) and vertical (top) and horizontal (bottom) long-axis views (B).

• Fig. 10.29 High-resolution multislice contrast CT demonstrating the left coronary artery with a stenosis (S) in the mid left anterior descending branch. Ao = aorta; MPA = main pulmonary artery; LMS = left mainstem; LAD = left anterior descending artery; GCV = great cardiac vein. (Courtesy of Dr A. Baumbach and Dr S. Schroeder.)

Fig. 10.30 Double oblique MRI gradient-echotime sequence of the left ventricular short axis in diastole (A) and systole (B).

• Fig. 10.31 Coronal MRI gradient-echotime sequence of the left ventricular outflow tract and aortic valve in diastole (A) and systole (B).

• Fig. 10.32 Left ventricular angiogram in the right anterior oblique projection using a pigtail catheter. (A) Plain frame. (B) Diastolic frame. (C) Systolic frame. The papillary muscles are arrowed.

• Fig. 10.33 Cut film pulmonary angiogram series. (A) Early arterial phase. (B) Late arterial phase. (C) Capillary phase. (D) Pulmonary venous phase. (E) Laevophase.

• Fig. 10.33 Cut film pulmonary angiogram series. (A) Early arterial phase. (B) Late arterial phase. (C) Capillary phase. (D) Pulmonary venous phase. (E) Laevophase.

• Fig. 10.33 Cut film pulmonary angiogram series. (A) Early arterial phase. (B) Late arterial phase. (C) Capillary phase. (D) Pulmonary venous phase. (E) Laevophase.