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Pericardial Diseases

Echocardiography is the first imaging modality of choice in patients with suspected pericardial effusion and tamponade, due to its rapid image display and portability. For patients with suspected constrictive pericarditis, either MRI or CT scanning is the imaging modality that best delineates pericardial thickness. Hemodynamic analysis of the enhancement of ventricular interaction that occurs in pericardial constriction can be assessed by Doppler echocardiography.

Calcification within heart: causes
1. Endocardial calcification:     Endomyocardial fibrosisQ
2. Myocardial calcification:       Ventricular aneurysm
                                             Calcified infarct
3. Pericardial calcification:       Chronic pericarditis (tuberculous, hemopericardium, pyogenic, viral)
                                               Uremic pericarditis
                                               Hydatid cyst
  1. Pericardial Effusion
    About 300ml of rapidly accumulating fluid can cause more symptoms than that of chronic effusion of >1000 ml.
    1. Radiographic features:
      1. Cardiomegaly (with narrow pedicle), producing classical 'flask-shaped' heart.
      2. Non-chamber specific cardiac enlargement.
      3. ‘Rounded or globular’ appearance’
      4. Very clear or distinct or sharp cardiac contour/borders.
      5. In large effusion → Obstruction of venous return to right heart causes decreased flow and pressure through lungs producing characteristic cardiomegaly with clear/oligemic rather than congested/plethoric lung fields.
      6. In later stages, after cardiac decompensation, pulmonary plethora/hyperaemia may develop.
      7. CXR Frontal and Lateral view : The heart had become rapidly enlarged in this patient suggestive of pericardial effusion. Lateral view demonstrates the pleural fluid lying posteriorly. Unenhanced CT through the level of the valve replacement demonstrates the large
  1. The epicardial fat pad sign is positive, when visualized in lateral view on anterior pericardial stripe is thicker than 2mm. This sign is diagnostic of pericardial thickening or fluid. 
  1. Valvular Heart Disease
    2D and Doppler echocardiography provide both anatomic and hemodynamic information regarding valve dis- ease, thus echocardiography is the first test of choice. MRI can also vi- sualize valve motion and determine abnormal flow velocities across valves, but there is less validation of quantitative hemodynamic mea- surements in comparison to echocardiography.
  1. Valve motion on fluoroscopy
    The aortic valve is oriented near the horizontal plane and usually overlies the spine, while the mitral valve is more vertically positioned and lies to the left of the spine. However, because the valves have a common insertion, it may be difficult to distinguish calcification of one valve from the other in the frontal view. This can be resolved with fluoroscopy in the same projection, because the motion of the aortic valve during the cardiac cycle is near to the vertica while the mitral valve moves more from side to side. Q
  2. Left Ventricular Size and Function
    2D echocardiography is the primary imaging modality obtained for assessment of LV cavity size, systolic function, and wall thickness. It is widely available, portable, and provides an instantaneous view of the heart. Echocardiography can also provide concomitant information on valve function, pulmonary artery pressures, and diastolic filling, which are valuable in the patient presenting with possible heart failure. The disadvantage is poor endocardial resolution in some patients and the lack of reproducible quantitative measurements.
    Equilibrium radionuclide angiography can provide an accurate quantitative measurement of LV function but is not widely available and cannot be used in patients with irregular rhythms. Gated SPECT can measure ejection fraction as a part of stress imaging. MRI provides the highest quality resolution of endocardial border and thus is the most accurate of all modalities.
  1. Diseases Of Aorta -
    Both CT scanning and MRI are the imaging modalities of choice for the evaluation of the stable patient with suspected aortic aneurysm or aortic dissection, although MRI is bit better than CT in general. In the acutely ill patient with sus- pected aortic dissection, either TEE or CT scanning is a reliable imaging modality.
    QMRI (most sensitive and specific investigation): 95–100 (98.3) % sensitive and 90–100 (97.8) % specific.
    If the patient is unstable, TEE can be done instead of MRI.
Extra Edge

MRI is more accurate and most comprehensive technique compared to established methods such as echocardiography, CT, or angiography. Although cost-effectiveness of MR imaging has not been established, it has emerged as the preferred technique in selected areas, including diseases of the aorta, such as aneurysm, dissection, and its precursors, intimal tears and intramural hematoma, congenital and inherited heart diseases, and, in particular, for postoperative follow-up of aortic repair and cardiac malformations.

  1. Origin of Congenital heart diseases
  • More common anomalies of cardiac development
Embryological precursor Abnormality
Sinus venosus and tributaries
Interartrial septum and atria
a. Anomalous systemic venous drainage                         
b. Persistent foramen oval
c. Ostium secundum defect                                             
d. Sinus venous defect
e. Ostium primum defect
Endocardial cushions a. Ostium primum defect                 
b. Endocardial atrioventricular defect
c. Tricuspid atresia/stenosis            
d. Ebstein's anomaly
e. Cor triatrium
Interventricular septum and ventricles a. Ventricular septal defect (membranous, muscular)
b. Common ventricle
c. Hypoplastic left ventricle
d. Uhl's dysplastic right ventricle
Bulbus cordis and ventricular outflow a. Pulmonary stenosis (valve/infundibular
b. Aortic stenosis (valve/subaortic)
c. Tetralogy of Fallot
d. Ventriculo-arterial discordance (uncorrected and corrected transposition)
Truncus arteriosus a. Common arterial trunk, persistent truncus ateriosus
b. Aortopulmonary window
c. Uncorrected transposition (discordance ventricles and great arteries)
d. Congenitally corrected transposition of great arteries
e. Pulmonary arterial trunk atresia
Branchial (aortic) arches a. Double aortic arch: aortic rings
b. Right aortic arch either isolated or with congenital heart disease
c. Aberrant right subclavian artery
d. Interruption or absence of right or left pulmonary artery
e. Patent arterial duct (ductus arteriosus)
f. Supravalvular aortic stenosis
g. Coarctation of the aorta
Quick Specifics : Cardiovascular System
Snowman’s sign
Figure of 8 sign
Cottage loaf sign
TAPVC – Supracardiac variety
Stag antler / Hands up sign CCF
Double aortic knuckle sign Aortic dissection
Double density sign
Bedford sign
LA enlargement
Schimitar sign / Turkish sword appearance Congenital venolobar syndrome
Sitting duck heart Persistant trunkus arteriosus
Egg on side appearance
Egg on a string sign
Square root sign
Egg in cup sign
Constrictive pericarditis
Boot shaped heart
Tetralogy of Fallot
Moneybag heart
Waterbottle heart
Flask shaped heart
Epicardial fat pad sign
Pericardial effusion
Great box shaped heart Tricuspid atresia
Great hilar dance ASD
Maladie de roger defect Small VSD
Jug handle appearance Primary pulmonary hypertension
Dock’s sign
E – sign
Reverse figure of 3 sign
Coarctation of aorta
Yin yang sign Pseudo aneurysms
Small heart sign Tension pneumopericardium
High attenuating crescent sign Impending rupture of abdominal aortic aneurysm
Draped aorta sign Contained rupture of abdominal aortic aneurysm

Extra edge:
  1. Torus aorticus the anterosuperior part of septal wall of the right atrium bulges to a variable degree into the atrial cavity as torus aorticus.It is caused by the proximity of right posterior aortic sinus and cusp.
  2. Torus auditory The posteroinferior wall of external meatus occasionally presents a smooth to roughened longitudinal elevation, known as auditory torus.
  3. Torus mandibularis above mylohyoid line, the bone medial to roots of molar teeth is sometimes developed into a rounded ridge called torus mandibularis.
  4. Torus palatine Intermaxillary suture are sometimes raised forming a longitudinal midline ridge called torus palatine.
  5. Torus maxillaris It is occasionally present on the alveolar process spanning the palatal aspect of subcervical roots of upper molar teeth.

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