non-invasive cardiac imaging

7/29/2019 Non-Invasive Cardiac Imaging

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TRANSCRIBED BY: PREGO, Jessica Grace QUAN, Nathalyn REAL, Maricar SINCO, Emma Concepcion

CARDIOVASCULAR IMAGING

Significantly enhanced the practice of cardiology over the pastfew decades.

InvasiveCoronary angiogramPulmonary angiogramAortic angiogram

Non-Invasive2D echocardiographyNuclear imagingPositron Emission TomographyCardiac Magnetic ResonanceCardiac Computed Tomography

2D ECHOCARDIOGRAPHY

Visualize the heart directly in real time using ultrasound(lower frequency sound)Instantaneous assessment of the myocardium, cardiacchambers, valves, pericardium, and great vesselsFlat image (2D) is seenCan also use the principle of Doppler

Doppler echocardiography

Velocity of moving red blood cellsAlternative to cardiac catheterization for assessment ofhemodynamics.2 methods

Transthoracic Echocardiogram (TTE)

Transesophageal Echocardiogram (TEE)

Basic Principle

Ultrasound reflection of cardiac structures to produce imagesof the heart

Doppler effectDescribes the influence of a moving object on sound wavesAn object travelling towards the listener causes sound waves tobe compressed giving a higher frequency; an object travellingaway from the listened gives a lower frequency

The higher the frequency and amplitude, the closer theobject to the observerOne can observe the blood flow towards and away fromthe heart or the hemodynamics (output, murmur,

turbulence)

Transthoracic Echocardiogram (TTE):

Performed with a handheld transducer placed directly on thechest wall

less clear due to presence of impedance from the skin,

muscle and lung parenchymaIn selected patients, a TEE may be performed, in which an

ultrasound transducer is mounted on the tip of an

endoscope placed in the esophagus and directed toward

the cardiac structures.Views the heart from the surface (sagittal view of the heart;visualizes the right ventricle, which is the most anterior part ofthe heart)

Transesophageal Echocardiogram (TEE):

An ultrasound transducer is mounted on the tip of anendoscope placed in the esophagus and directed toward thecardiac structures.

Esophagus clearer and better view; more proximal to

the heart; less impedance; high definition; better reception

and resolutionInvasive; seeing the heart from behind; posterior viewAdvisable for patients with valve problems and congenital heartdisease

Orientation

Short Axis View

Right and left ventriclesCross-section of the heart. The left ventricle is more

muscular and circular. The right ventricle is bullet-

like and more trabeculated but less muscular.

There is a decrease in the left ventricular cavity size

during systole as well as an increase in wall thickening

Parasternal/Long Axis View

Right ventricle (especially the right ventricular outflowtract), left ventricle, left atrium, aorta

Evaluate the heart by looking at the thickening of the

walls. During systole, there is normal thickening of the

myocardium and reduction in the size of the left

ventricle (LV); valve leaflets are thin and open widely

Function of the heart is measured by the ejection

fraction.

LEGENDNormal text : lecture and recordingItalics : Harrisons Principles of Internal Medicine 17

thEdition

NON-INVASIVE CARDIOVASCULAR IMAGINGRodney M. Jimenez, M.D. November 30, 2010


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EF = SV = LEDVLESV

EDV EDV

Calculate by measuring the area during diastole minus the area

during systole divided by the area during diastole

Standard orientation of the heart, the left ventricle is at theright side. It is the largest chamber.

Parasternal Long Axis View:

Used when you want to see the relationship between the leftventricle, left atrium, and aortaViews mitral and aortic valve defects. Detects flow disturbanceinvolving these valves.

Only 2 of the aortic cusps will be seen

4 Chamber ViewView when the patient is vertically oriented (heart isvertically oriented)From the apex: left and right ventricles, left and rightatrium

Sagittal section. Right ventricle is smaller5 chamber view includes the aortic lumenUsed especially when considering septal defects

Using Doppler effect: if color goes from leftventricle to the right ventricle, there is VSD; if

color goes from left atrium to the right atrium,there is ASDRight to left shunting (pulmonic circulationpressure > systemic circulation pressure). Whenthere is irreversible right to left shunting, theEisenmenger phenomenon occurs.Involves pulmonary hypertension, cyanosis, etc.

When there is a sandy effect, it indicates stasis of the blood;blood flow is slowAlso guided by ECG to note when the heart is in diastole

Diastole is atrial contractionDuring diastole, the ECG tracing will be after the T wave

(The start of the hearts relaxation in the ECG is at the Rwave. QRS complex is the start of systole but the heartbegins to relax at the R wave)

Clinical Applications

Two-Dimensional Echocardiography

Cardiac chambersChamber sizeLeft ventricular hypertrophy 2D Echo is the gold standardRegional wall motion abnormalitiesValveMorphology and motionPericardiumEffusion

TamponadeMassesGreat vessels

Stress Echocardiography

Stress test is done by having the patient go on a bike ortreadmill thus simulating the hearts conditions at stress levels

The stress test is mainly used to diagnose ischemia, assessfunctional capacity, and BP control.The hearts most important function is to pump blood and

distribute oxygen during stress. Stress testing assesses ifthe heart is normal or functional during stress.ECG is used to check for presence/absence of ischemia.ECG and stress testing only have sensitivity and specificity

of 60-70%. Large chance for false positive or falsenegative.Can only be used for patients with intermediate to highprobability for ischemic heart disease but not for low riskor super high risk.

Normal Stress Echocardiogram should show myocardialthickening and decrease of the diameterduring contraction


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During ischemia, there will be hypokinesia. Some parts of themyocardium will not thicken because of weakened contractility.

Ischemia is an imbalance between the oxygen supply andoxygen demand.Chest pain is a delayed response to ischemia

Two-dimensionalMyocardial ischemiaViable myocardium

Doppler

Valve disease

Doppler Echocardiography

Valve stenosisGradientValve areaValve regurgitationSemiquantitationIntracardiac pressuresVolumetric flowDiastolic fillingIntracardiac shunts

Transesophageal Echocardiography

Inadequate transthoracic imagesAortic diseaseInfective endocarditisSource of embolismValve prosthesisIntraoperative

Advantages

Portable (hand-held) and can be wheeleddirectly to thepatient's bedsideAbility to obtain instantaneous images of the cardiac structuresfor immediate interpretation.Handheld echocardiographic units weighing 6 lb (


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severity of the stenosis can be ascertained from a directplanimeter measurement of the mitral valve orifice

Assessed with color. With disease, there is turbulenceor jets of color will be seen

presence and the etiology of stenosis of the semilunar valvescan be made by 2D echocardiography

but evaluation of the severity of the stenosis requiresDoppler echocardiography.

by assessing velocity. If there is stenosis, there isimpedance/stenosis and flow is compromised

diagnosis of valvular regurgitation must be made by Dopplerechocardiography, 2D echocardiography is valuable for determining the etiology of

the regurgitationas well as its effects on ventricular dimensions, shape, and

function.

Pericardial Disease

2DEmodality of choice for the detection of pericardial

effusion

In myocardial-pericardial effusion, fluid or lucencyseen in between the myocardiumIf with thickening, calcification is seen outside of the

myocardiumblack echolucentovoid structure surrounding the heart.pericardial tamponade can also be seen

dilated inferior vena cava, right atrialcollapse, andthen right ventricularcollapse, usually at the base ofthe ventricle.oRA and RV have thin muscles

During diastole, RV will need to relax to collect the venousreturn. But during tamponade, the RV is pushed by the effusionduring relaxation. There is decrease in venous return resultingin decreased output.

There is a need to perform pericardiocentesis to take outthe fluid

Echocardiographically guided pericardiocentesis is the

standard of care.Especially with large pericardial effusion

2DE can directly visualize the location of the pericardial fluid toguide the entry point of the needle.If there is effusion, the heart is pushed by the fluid resulting indecrease size. (the pericardium is of limited size) There isresulting problem in contraction and relaxation of themyocardium.

DOPPLER ECHOCARDIOGRAPHY

Basic Principles

Doppler echocardiographyuses ultrasound reflecting offmoving red blood cells tomeasure the velocity of blood flowacross valves, within

cardiac chambers, and through the great vessels.

Color-flow Dopplerimagingdisplays the blood velocities in real time superimposedupon a 2D echocardiographic image.colors indicate the direction of blood flow (colorassignments)

red toward the transducerblue away from the transducergreen superimposed when there is turbulent flow.

Tip! BARTBlue Away, Red TowardsPulsed-wave Doppler

measures the blood flow velocity in a specific location onthe 2D echocardiographic image.

Continuous-wave Dopplermeasure high velocities of blood flow directed along theline of the Doppler beam, such as occur in the presence ofvalve stenosis, valve regurgitation, or intracardiac shunts.

These high velocities can be used to determineintracardiac pressure gradients by a modified Bernoulliequation:

Pressure change = 4 x (velocity)2

If there is no problem with the valve, the velocity of blood

flow should be equal from one heart chamber to the next.derived pressure gradient can be used to determine

intracardiac pressures and stenosis severity.

Tissue Doppler echocardiographymeasures the velocity of myocardial motion.velocity of myocardium is several magnitudes lower thanthe velocity of moving red blood cells.can be used to determine myocardial strain rate

a quantitative measure of regional myocardialcontraction and relaxation

Valve Gradient

Valvular stenosisincrease in the velocity of blood flow across the stenoticvalve.continuous-wave Doppler beam is used to determine an

instantaneous gradient across the valve.

Mitral Stenosis

most common cause in the Philippines is rheumatic heart

disease

hockey-stick

there is a doming effect during diastole

Valvular Regurgitation

diagnosed by Doppler echocardiographythere is abnormal retrograde flow across the valve.Color-flow imaging is the Doppler method used most

frequently

visualization of a high-velocity turbulent jet in the chamber

proximal to the regurgitant valvesize and extent of the color-flow jet into the receiving

cardiac chamber provide a semiquantitative estimate of

the severity of regurgitation

Mitral Regurgitation

Insufficient mitral valve (overly compliant)

There is backflow of blood from LV to LA

Occurs during systole

High-pitched systolic murmur appreciated

Aortic Regurgitation

There is backflow of blood from the aorta to LV during diastole

Occurs during diastole

Other Uses of Echocardiography

detection of congenital stenotic or regurgitant valvelike in VSD, color flow abnormality will be seen across theseptum

detection of intracardiac shunts and determination of patencyof surgical shunts and conduits

can measure the pressure in the pulmonary artery and thepressure across the aortic valve

measurement of cardiac output

Volume flow rates (or stroke volume and cardiac output) is

calculated as the product of the cross-sectional area of the

vessel or chamber through which blood moves and the

velocity of blood flow (time-velocity integral) as assessed

by continuous-wave Doppler determination multiplied by

the heart rate

indicators of myocardial ischemianew regional wall motion abnormalitiesa decline in ejection fractionan increase in end-systolic volume with stress


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determine LV size and function, right ventricular size andfunction, and the presence of acute valvular regurgitation andpericardial tamponadenoninvasive evaluation of ventricular diastolic filling and

dectection of diastolic dysfunction

transmitral velocity curves reflect the relative pressure

gradients between the left atrium and ventricle throughout

diastole which are influenced by the rate of ventricular

relaxation, the driving force across the valve, and the

compliance of the ventricle

progression of diastolic dysfunction can be assessed byDoppler flow velocity curves

Early phase of diastolic dysfunction

impairment of LV relaxation, with reduced early

transmitral flow and a compensatory increase in flow

during atrial contraction

Pseudonormalization

As disease progresses, and ventricular compliance

declines, left atrial pressure rises, resulting in a higher

early transmitral velocity and shortening of the

deceleration of flow in early diastole so that the filling

pattern becomes normal

Restrictive filling pattern

seen in patients with the most severe diastolic

dysfunction; there is further elevation of left atrialpressure and early diastolic flow velocity

detection of acute mechanical complications (e.g., papillarymuscle rupture, ventricular septal defect, myocardialperforation with tamponade, and right ventricular infarction)

NUCLEAR CARDIOLOGY

injection into the patient of an isotope that emits photons(energy)

generally gamma rays generated during radioactive decaywhen the nucleus of an isotope changes from one energylevel to a lower one.

uses a special camera that images these photonsexpressed by using x-rays with colors. Isotopes are used as

a dye.


Assessment ofventricular functionuses equilibrium radionuclide angiography, also known as

multiple-gated blood pool imaging

involves the imaging of99m

Tc-labeled albumin or red cells

that are uniformly distributed throughout the blood

volume

Resting images of the blood pool of isotopes within the

cardiac chambers are obtained by electrocardiographic

gating through multiple cycles

provides an accurate, reproducible method for assessment

of LV function

most commonly used when echocardiography is technically

difficult or when poor LV function requires accurate

quantitation

Assessment ofmyocardial perfusion by gated single-photonemission computed tomography (SPECT) - but too large andmore expensive.

utilized to assess ejection fraction and regional wall motion

usually performed post-stress by gating the acquisition of

SPECT myocardial perfusion images using99m

Tc- labeled

compounds

determines the endocardial borders of the LV cavity and

calculates the ejection fraction

Myocardial Perfusion

Two phasesCheck perfusion during RESTCheck perfusion during STRESS (again, to diagnoseischemia and cardiac function)

Compares the stressed image and the relaxed imageof the heart.

Scanning should involve the heart at rest and theheart at stress phases. Normal results show equalcolor distribution of both phases.What happens? If the isotope is injected during REST isotopes would go to the heart and give it color If theres no problem with the blood distributionisotopes will distribute well and give color to themyocardium making a donut-like shape.Were concerned with the left ventricle more because

it is the one pumping blood to the system. Checking is

from apical to the base.When you inject the isotopes to a problematic heart it will scan and reveal a blockage by revealingless/no color, since the isotopes stick to the blood.Treatment includes reperfusion by invasiveprocedures.The heart should accommodate a lot of blood during

STRESS. If there is problem of the blood supply as

impeded by the obstruction of the coronary arteries,

then there will be a problem in perfusion.

Abnormal perfusion during rest and stress infarct

Decrease perfusion ischemia

produce images of myocardial regional uptake proportional toregional blood flow

Circular shape of the LV at cross section is imaged as aperfect donut during rest. If there is problem with

perfusion, there will be a bite-like appearance of the

donut.

Maximal exercisemyocardial blood flow is increased up to fivefoldabove the resting conditionIn the presence of a fixed coronary stenosis, there isan inability to increase myocardial perfusion in theterritory supplied by the stenosiscreating a flow differential and inhomogeneousdistribution of the isotope.

patients who are unable to exercise:pharmacologic agents ---> to increase blood flow and

create similar in homogeneitiespreferred pharmacologic (increase blood flow to a similardegree as exercise)

adenosinedipyridamoledobutamine (does not increase myocardial blood flow tothe same extent) may be used as an alternative in patientswith bronchospastic lung disease.

First do the stress test. Then inject the isotope and place the

patient under the camera. If there are abnormalities in the

coronary arteries, then there will be stenosis (plaque). It will

then reflect as an abnormality in the image. Blood in the image

is colored yellow. Absence of blood flow in the cardiac muscle

causes the bite-like image of the ventricle. If the stress image

is almost similar to the rest image, then it is normal.


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Orientation

Abnormal Perfusion Image

Isotopes

201Tl (thallium) - first isotope used for this purpose99mTc, largely replaced 201Tl

higher photon energy

shorter half-life, permitting the injection of larger dosesresulting in scans of higher quality.Two technetium-labeled in common use:

tetrofosminsestamibi

both distributes to the myocardium in relation to blood

flow, and their uptake requires an intact cell

membrane and a viable myocardial cell

POSITRON EMISSION TOMOGRAPHY

a type of beta-decay of an unstable isotope.this unstable isotope, a proton

undergoes spontaneous decay into a neutron, a neutrino,and a (+) particle (positron).

positrons interact with electronsrelease of gamma-radiation (photons) upon collision withtissue.gamma emission detected by the gamma camera in the PETscanner.high energy of the photons results in far less scatter than withconventional nuclear cardiology techniques.

PET cameras are considerably more expensive thanconventional nuclear cardiology cameras

Rubidium-82the most commonly used positron emitter

available from a generator and does not require a nearbycyclotronpharmacologic stress with dipyridamole, adenosine, ordobutamine is preferred for PET scanning


Assess myocardial blood flow and myocardial metabolism.Myocardial metabolism of the hibernating muscle of the

heart. Hibernating to reserve energy for more stressfulevents.Muscles will regain normal strength whenreperfusion/bypass/angioplasty is done

Positron emitters or isotopes to assess myocardial blood flow:Nitrogen-13 ammoniaOxygen-15 waterRubidium-82

Positron Emitters

permit measurement of absolute regional blood flows,In contrast to the relative blood flows that is assessed with

201Tl- or 99mTc-labeled compounds.This advantage has been utilized for research purposes buthas generally not been exploited clinically.

For myocardial metabolism

fluorine-18 deoxyglucose.permits the detection and quantification of exogenousglucose utilization in areas of hypoperfused myocardium.

PET Scan is also used to survey cancer because more

metabolism shows the area of metastasis

Clinical Uses

been best studied clinical application - assessment ofmyocardial viability.

if the myocardium is still viable, you can subject the

patient to revascularization procedure to open up arteriesangioplasty or bypass surgery.

pattern of enhanced fluorodeoxyglucose uptake in regions ofdecreased perfusion

glucose/blood flow "mismatch"

even with good blood flow, if the myocardium does notmetabolize glucose, it is no longer viableeven if the heart is contracting weakly but it stillmetabolizes glucose, it is still viable (may have hibernatingmuscles)

indicates the presence of ischemic myocardium that haspreferentially shifted its metabolic substrate toward glucoserather than fatty acid or lactate.pattern identifies regions of ischemic or hibernating

myocardium that are likely to improve in function afterrevascularizationgold standard for the assessment of myocardial viability

also the most expensiveidentify ischemic or hibernating myocardium in 1020% ofregions that would be classified as fibrotic (infarcted) by201Tl- or 99mTc-labeled compounds

more advantageous than 201Tl- and 99mTc-labeledcompounds for obese patients in assessing myocardialperfusionPatient is not allowed to eat for 4 hours before the procedure to

prevent splitting of blood flow and energy/isotope between the

stomach and the heart.


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MAGNETIC RESONANCE IMAGING

Basic Principles

a technique based on the magnetic properties of hydrogennuclei.magnetic field induce nuclear spin transitions from the groundstate to excited statesas the nuclei relax and return to their ground state, they

release energy in the form of electromagnetic radiation that isdetected and processed into an imageGadolinium, a contrast medium, frequently employed toproduce magnetic resonance angiograms (MRAs).provide enhanced soft tissue contrast as well as theopportunity to obtain rapid angiographic images during the firstpass of contrast through the vascular systemstatic and cine images can be obtained using

electrocardiographic triggering

images can be used to quantify ejection fraction, end-systolic

and end-diastolic volumes, and cardiac mass with high

accuracy, reliability, and reproducibility

Normal Cardiac MRI

Cardiac MRI is challenging due to rapid physiologic motion ofthe heart and coronary arteries


defining anatomic relationships in patients with complexcongenital heart disease and cardiomyopathies

characterize cardiac masses and their relationship to normalanatomic structures definedallow characterization of the severity of valvular disease as well

as quantification of shunt volumes

examination of choice to determine whether a mediastinal orpulmonary mass has invaded the pericardium or heartcharacterizing pericardial effusions or pericardial thickening inpatients with indeterminate results on echocardiographySpecialized pulse sequences measure the velocity of blood in

each pixel of the image for accurate determination of flow

across valves and within blood vessels

standard technique for imaging the aorta and large vessels ofthe chest and abdomencoronary MRA is not yet an accurate and reliable clinicaltechniqueAssessment of ventricular function and wall motion at rest andduring infusion of inotropic agents

by injecting a bolus of gadolinium contrastrelative perfusion deficits - reflected as regions of low

signal intensity within the myocardium.for detecting subendocardial ischemia -cardiac MRI is more sensitive than SPECT imaging due to

its enhanced spatial resolution.

myocardial viabilityby imaging the heart 1020 min after gadolinium injection

Limitations

Relative contraindicationspresence of pacemakers or internal defibrillatorscerebral aneurysm clipsclaustrophobic and unable to tolerate the examinationwithin the relatively confined quarters of the magnet bore.However, open-bore magnets are now available to deal

with this problem.clinically unstable patients, since close monitoring isdifficult.

image quality in patients with significant arrhythmias is oftenlimited.

COMPUTED TOMOGRAPHIC IMAGING

Basic Principles

CT is fast, simple, noninvasive, and provides images withexcellent spatial resolution and good soft tissue contrast.conventional CT was too long to freeze cardiac motion.electron-beam CT and multislice spiral (helical) CT haveimproved temporal resolution and routine imaging of thebeating heart

It uses the principle of x-ray; better imaging of structures withcalcium (ex. bones, atheroma, calcified pericardium)


constrictive pericarditis is easily detected by CTcharacterizing pericardial thickening, cardiac masses,particularly those containing fat or calcium.


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imaging patients with suspected arrhythmogenic rightventricular dysplasia ---> ability to detect small amounts of fatCine images can evaluate wall motion and determine ejectionfraction, end-diastolic and end-systolic volumes, and cardiacmass.

calcium is shown as white densities

Calcified Pericardium

Calcification is hypodenseMay be caused by tuberculosis

CT Angiography

accuracy similar to MRA in imaging the aorta and great vesselsthe examination of choice in the evaluation of patients with

suspected pulmonary embolus.excellent imaging modality for the diagnosis ofaortic dissectionor penetrating ulcers.

initial diagnosis as well as follow-up of patients with aorticaneurysmal disease can be done.

number 3 signcoarctation of the aortasimilar to the MRI except that CT uses x-ray

Coronary Calcification

Calcium in the coronary arteries occurs in atherosclerosis and is

absent in the normal coronary artery

CT is very sensitive for the detection of coronary artery

calcification

CA Calcium Scoringcounting the number of calcified coronary arteriesvery sensitive for the detection of coronary artery calcificationpromoted as a noninvasive modality for the screening anddiagnosis of CAD.

Detects patients with high risk for CADquantity of coronary calcification (coronary calcium score) isrelated to the severity of CAD.

Mild, moderate or severe moderate and severe indicates

more than 50% calcificationvery high sensitivity but low specificity.should not be used for the diagnosis of obstructive coronarydisease

Score = Area x Hn x-factorHn x-factor (Agatston Scoring)

Peak CT

130-199 1

200-299 2

300-399 3

>400 4

Contrast-Enhanced CT Angiography

accurate assessment of luminal narrowing in the majorbranches of the coronary arteries (high temporal and spatialresolution of multislice spiral CT)high sensitivity (>85%), and specificity (>90%) of CTA ascompared to cardiac catheterization.a very high negative predictive value of 98-99%highest accuracy - noted in the left main and theproximalportions of the left anterior descending and left circumflexarteriesfast, irregular heart rates and body motion limit the accuracy ofCTA.

"noninvasive coronary angiography" concept has generatedgreat interest in the widespread utility of CTA.major well-accepted indications for coronary CTA

evaluation of suspected coronary anomaliespatients with chest pain syndromes

intermediate pretest probability of CADunable to exerciseuninterpretable or equivocal stress test.

Limitations

dependence on ionizing radiation (in contrast to MRI)problematic in patients with renal insufficiency or contrastallergy.

radiation doses tend to increase as the spatial resolutionimproves

doses for coronary CTA exceed those delivered duringstandard diagnostic cardiac catheterization.

SELECTION OF IMAGING TESTS

LV Function and Size

2D echocardiography

primary imaging modality for assessment of LV cavity size,systolic function, and wall thicknesslow cost and portable

provides ancillary structural and hemodynamic informationMRI and CT

highest quality resolution of endocardial borderthe most accurate of all modalitiesHowever, expensive, lack portability, and do not provideconcomitant hemodynamic information asechocardiography does

Valvular Heart Disease

2D and Doppler echocardiography

the first test of choiceprovides images for valve motion

provide both anatomic and hemodynamic informationregarding valve disease

MRI

can also visualize valve motion and determine abnormalflow velocities across valves but there is less validation of quantitative

hemodynamic measurements in comparison toechocardiography.

Pericardial Disease

Echocardiography

first imaging modality of choice (suspected pericardialeffusion and tamponade)hemodynamic analysis that occurs in pericardialconstriction (Doppler echocardiography)

MRI or CT scanning

suspected constrictive pericarditisvisualizes pericardial thickening

Aortic Disease

CT scanning and MRI

provides images of the entire aorta

imaging modalities of choice for stable patients withsuspected aortic aneurysm or aortic dissection.

TEE or CT scanning

for rapid diagnosisfor the acutely ill patients with suspected aortic dissectiondefinitive diagnosis of a suspected aortic dissection usually

requires a TEE, which can rapidly provide high-resolution

images of the proximal ascending and descending thoracic

aorta

Cardiac Masses

2D TTE

first test to rule out an intracardiac massmasses >1.0 cm in diameter - well visualized


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Solid masses appear as echo-dense structures, which can

be located inside the cardiac chambers or infiltrating into

the myocardium or pericardium

TEE

smaller size may be visualized.provides high resolution images required for further

delineation of myocardial masses, especially those

non-invasive cardiac imaging

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