Week 2 Chapter 3: Cardiac Imaging and Catheterization

*Memorize highlighted tables

*Understand a waves, v waves, whatever waves, etc

Traditional modalities of cardiac imaging: chest radiography, echocardioagraphy (echo), cardiac

catherization with angiography, and nuclear imaging.
New technoologies: computed tomography (CT) and magnetic resonance imaging (MRI)

Cardiac Radiography
Extent of penetration of x-rays thorugh the body is inversely proportional to tissue density.
i.e. Air filled tissues (lungs) absorb few x-rays and expose underlying film (appears
black)
Dense materials (bones) absorb more radiation and appear white/radiopaque.
For boundary to show between two structures, they must differ in density
Similarly dense structures (i.e. Adjacent blood and myocardium, valves, intercardiac
structures) cannot be delineated unless they are calcified.
Heart borders adajacent to lung are depicted clearly because the heart and air filled lung
have different densities.
Frontal and lateral radiographs used to assess heart and lungs
Frontal view: posterior-anterior image
x-rays are transmitted from behind; electronic sensor/film placed on chest
Positions heart close to x-ray recording film so image is minimally distorted
Lateral view: patient's left side is placed against film plate and x-rays pass through body
from right to left
Useful for assessing size of left ventricle, left atrial appendage, pulmonary artery,
aorta, and superior vena cava
Lateral view evaluates right ventricular size, posterior borders of left atrium and
ventricle, and anteror posterior diameter of thorax
Cardiac Silhouette
Alterations in chamber size are reflected by changes in cardiac silhouette
Cardiothoracic ratio (maximum width of heart divided by maximum internal diameter of
the thoracic cage) of greater than 50 % indicates enlarged heart
Sometimes, cardiac silhouette inaccurately reflects heart size
i.e. Elevated diaphragm (narrow chest anterorposterior diamter) may cause silhouette to
expand transversely so the heart looks bigger than it actually is.
Therefore, chest anterorposterior diameter should be assessed before concluding
enlarged heart.
i.e # 2: Presence of pericardial effusion around heart can also widen cardiac silhouette
b/c fluid and myocardial tissue affect x-ray penetration similarly.
Radiographs can depict dilatation of individual cardiac chambers
Concentric ventricular hypertrophy (without dilatation) may not result in radiographic
abnormalities b/c it occurs at expense of cavity's internal volume and produces little or
no change in overall cardiac size.
Major causes of chambers + great vessel dilatation include heart failure, valvular lesions,
abnormal intracardiac and extracardiac communications (shunts), and certain pulmonary
disorders.
Dilatations take time to develop
Recent lesions (i.e. Acute mitral valve insufficiency) may present without apparent
cardiac enlargement
Week 2 Chapter 3: Cardiac Imaging and Catheterization

Pattern of chamber enlargement may suggest specific diseases

dilatation of left atrium + right ventricle + signs of pulmonary hypertension -->
mitral stenosis
Dilatation of pulmonary artery and right heart chambers but without enlargement of
left sided heart dimensions --> patients with pulmonary vascular obstruction,
increased pulmonary artery blood flow (due to atrial septal defect) or pulmonary
hypertension of diverse causes
Chest x-rays can detect dilatation of aorta
Aortic enlargement causes include aneurysm, dissection, and aortic valve disease.
Normal agining and artheroscleoriss may also cause aorta to become dilated and
tortuous
Figure 3-2: Posteroanterior chest radiograph of patient with severe mitral senosis and
secondary pulmonary vascular congestion
Prominent left atrial appendage with straigtening of left heart border and double density
right cardiac border produced by enlarged left atrium --> suggests low cardiac output
Pulmonary vascular congestion radiograph signs include increased caliber of upper-zone
pulmonary vessel markings and decreased caliber of lower-zone vessels.
Pulmonary Manifestations of Heart Disease
Appearance of pulmonary vasculature reflects abnormalities of pulmonary arterial and
venous pressures and blood flow.
Increased pulmonary venous pressure (i.e. Left heart failure) causes
Increased vascular markings, redistribution of blood flow from bases to apices of
lungs (aka cephalization of vessels), interstitial edema, and alveolar edema.
Cephalization marked by increase in number or width of vascular markings at apex.
Interstial edema occurs as pulmonary congestion progresses, and connective tissue
spaces become thickened with fluid.
Kerley B lines (short horizontal parallel lines at periphery of lungs adjacent to
pleura, most often as lung bases) depict fluid in interlobular spaces that results
from inerstitial edema
When fluid accumulates in air spaces, alveolar forms of pulmonary edema
produce opacity radiating from the hilar region bilaterally ("butterfly"
pattern) and air bronchograms may be seen
Abnormal pulmonary blood flow may alter apperance of pulmonary blood vessels
Focal oligemia (reduction in size of blood vessels due to decreased blood flow) is
occasionally observed distal to pulmonary embolism (Westermark sign).
Enlarged central pulmonary arteries + small peripheral vessels (peripheral pruning)
suggests pulmonary hypertension.
Table 3-1: Chest Radiography of Common Cardiac Disorders
Congestive Heart failure
Pulmonic valve stenosis
Aortic valve stenosis
Aortic reguritation
Mitral stenosis
Mitral regurgitation
Echocardiography
Safe, noninvasive, and inexpensive
High frequency (ultrasonic) waves by piezoelectric element travel though body and
reflect at interfaces where there are differences in acoustic impedance of adjacent
Week 2 Chapter 3: Cardiac Imaging and Catheterization

tissues. Reflected waves return to transducer and are recorded. Machine measures time
elapsed between initiation and reception, allowing it to calculate for distance.
3 types of imaging are used
M-mode, two-dimensional (2D) and Doppler.
Each type can be performed from various body locations
Most commonly, transthoracic studies are performed (transducer is placed on surface of
chest). When greater detail is required, transducer is transesophogeal.
M-mode echocardiography
Oldest form of cardiac ultrasonography
Provides data from only one ultrasonic beam
Now, rarely used by itself
Supplements other modalities to provide accurate measurements of wall thickness
and timing of valve movements.
2D echocardiography
Multiple ultrasonic beams transmitted through wide arc
Returning signals integrated into 2D image of heart on video monitor
Depicts anatomic relationships, defines movement of cardiac structures relative to one
another. Wall and valve motion abnormalities, and many types of intracardiac masses
(e.g. Vegetations, thrombi, tumors) can be depicted.
Each 2D plane delineates one part of cardiac structure.
Optimal evaluation of entire heart is achived using combinations of views
TTA (transthoracic echocardiography) transducer placed on parasternal long axis,
parasternal short axis, apical views, and subcostal views
Apical TTE
Doppler Imaging
Depicts blood flow direction and velocity and identifies regions of vascular turbulence.
It also permits estimation of pressure gradients within heart and great vessels.
Color flow mapping converts doppler signals to scale of colors that represent direction,
velocity, and turbulence of blood flow
Transesophageal echocardiography
Uses miniaturized transducer mounted at end of modified endoscope to transmit and
receive ultrasound waves from within esophagus, thus producing very clear images
Modern probes permit multiplanar imaging and doppler interrogation.
Helpful in the assessment of aortic and atrial abnormalities, conditions that are less well
visualized by conventional transthoracic echo imaging
i.e. TEE is more sensitive than TTE for detection of thrombus within left atrial
appendage
Proximity of esophagus to the heart makes TEE advantageous in patients with
unsatisfactory TTE results (those with COPD).
TEE is also advantageous for patients withi prosthetic heart alves
Because in transthoracic echocardiography, prosthetic heart reflects lots of ultrasonic
waves, leading to distorted results, but TEE is the most sensitive noninvasive
technique for evaluating perivalvular leaks, endocarditis (vegetations and myocardial
absesses)
TEE is commonly used to evaluate patients with cerebral ischemic events (strokes) of
unexplained etiology b/c it can identify cardioavscaular sources of embolism with high
sensitivity. Etiologies include 9intracaardiac thrombi or tumors, artherosclerotic debris
within aorta, and valvular vegetations. TEE is also highly sensitive and specific for the
Week 2 Chapter 3: Cardiac Imaging and Catheterization

detection of aortic dissection.

In operating room, TEE permits immediate evaluation of surigcal repair of cardiac
lesions. Imaging of ventricular wall motion can identify periods of myocardial ischemia
during surgery.
3D echocardiography and intracardiac echocardiography.
3d echo are of benefit in assessment of valvular defects, intracarfdiac masses, and
congential malformations.Uses transducer mounted on catheter to provide imaging
during interventional procedures in the cardiac catherization laboratory.
Contrast Echocardiography
Sometimes used to supplement standard imaging for abnormal intracardiac shunts
"Bubble study", uses contrast agent (i.e. Agitated saline) rapidly injected into
peripheral vein. Contrast is visualized
Normally, contrast does not reach left-sided chambers due to rapid opacification
of right-sided chambers an dfiltered out harmlessly in the lungs
In the presence of abnormal shunt, bubbles of contrast appear in left-sided
chambers as well.
Typical evolatuion: cardiac chamber sizes, wall thickness, wall motion, valvular
function, blood flow, and intracardiac hemodynamics
Ventricular Assessment
Echocardiography allows measurement of ventricular wall thickness and mass and
calculation of the ejection fraction (measure of contractile function), depicts ventricular wall
motion abnormalities (sign of CAD) and displays right ventricular function qualitatively.
Diastolic dysfunction (caused by ischemic disease, ventricular hypertrophy or restrictive
cardiomyopathy) ca ben evlatued by doppler techniques.
i.e. Doppler tissue imaging: readily record maximum velocity of mitral annular
movement in early diastole (indicator of the left ventricle's ability to relax nromally).
Doppler measurement of flow velocity across the mitral valve in early, compared with
late, diastole also provides information about diastolic function.
Valvular lesions
Echocardiography can determine underlying causes of valvular abnormaltiies and doppler
imaging quantitates degree of valvular stenosis and regurgitation.
Pressure gradient = 4 * v^2
Continuity equation: A1V1=A2V2
Cross sectional area = pi (d/2)^2
Aortic valve area = AAV = ALVOT * VLVOT/ VAV
Coronary Artery Disease
Stress echocardiography aids in diagnosis of coronary artery disease
Visualizes left ventricular regional wall motion abnormalties that are induced by
exercise, or the infusion of specific pharmcologic agents (dobutamine) as a sign of
myocardial ischemia
since transthoracic echocardiography isn't sensitive enough to image coronary
arteries.
Cardiomyopathy
Heart muscle disorders that include dilated, hypertrophic, and restrictive forms
Echocardiography can distinguish these and permits assessment of hte severity of systolic
and diastolic dysfunction
Pericardial Disease
Two dimensional echocardiography can identify abnormalities in the pericardial cavity
Week 2 Chapter 3: Cardiac Imaging and Catheterization

(excessive pericardial fluid and tumor)

Tamponade and constrictive pericarditis (the main complications of pericardial disease) are
associated with particular echocardiographic abnormalities.
Tamponade, increased intrapericardial pressure compresses cardiac chambers and results
in diastolic "collapse" of the right atrium and righ ventricle.
Constrictive percarditis is associated with icnreased thickness of that pericardial echo,
abnormal patterns of diastolic left ventricular wall motion, alterations in pulmonary and
hepatic venous flow patterns, and exaggerate dchange sin mitral and tricuspid valve in
flow velocities during respiration.
Table 3-2: Echocardiography in common Cardiac Disorders
Cardiac catherization
Measure pressures in heart chambers to determine cardiac output and vascular resistances
and to inject radiopaque material to examine heart structures and blood flow
Measurement of Pressure
Catheter is inserted into femoral, brachial, or jugular vein of sedated patient. Pressure in
the aorta and ventricle are measured via catheteres inserted into a radial, brachial or
femoral artery. Once inside, catheter is guided by fluoroscopy (continuous x-ray images)
to the area of study where pressure measurements are made
Measurement of right heart pressures is performed with Swan-Ganz catheter
(specialized balloon tipped catheter that is advanced through the right side of hte
heart with the aid of normal bloo flow and into the pulmonary artery. As it travels,
pressure measurements are recorded.
Right Atrial Pressure
Equal to the central venous pressure (esimated by the jugular venous pressure on
physical examination) b/c no obstructing valves impede blood return from the central
veins into the right atrium.
Right atrial pressure equals right ventricular pressure during diastole b/c the right heart
functiosn as a common chamber when the tricuspid valve is open
Mean right atrial pressure is reduced when intravascular volume is depleted.
Elevated in right ventircular fialure, right-sided valvular disease, adn cardiac
tamponade (in which cardiac chambers are surrounded by high pressure pericardial
fluid)
Certain abnormalities cause characteristic change sin individual components of right
atrial (therefore jugular venous) pressure
i.e. Prominent a wave is seen in tricuspid stenosis and right ventircular
hypertrophy. In these conditions, right atrium contracts vigorously against
obstructing tricuspid vale or stiffened right ventricle respectively, generating a
rpominent pressure wave.
Similarly, amplified "cannon" a waves may be produced by conditions of
atrioventricular dissociation when right atrium contracts against a closed
tricuspid valve.
Prominent v wave is observed in tricuspid regurgitation brecause normal
right atrial filling is augmented by the regurigtated blood in systole.
Right ventricular pressure
Increased by pulmonic valve stenosis or pulmonary hypertension
Right ventricular diastolic pressure increases when the right ventricle is subjected to
pressure or volume overload and may be a sign of right heart failure.
Table 3-3: Causes of increased intracardiac pressures
Week 2 Chapter 3: Cardiac Imaging and Catheterization

Pulmonary Artery Pressure

Elevation of systolic and diastolic pulmonary artery pressure occurs in three conditions
Left sided heart failure
Parenchymal lung disease (e.g., chronic bronchits or end-stage emphysema)
Pulmonary vascular disease (pulmonary embolism, primary pulmonary hypertension,
or acute respiratory distress syndrome).
Normally, pulmonary artery diastolic pressure is equivalent to left atrial pressure b/c of
low resistance of the pulmonary vasculature that separates them. If the left atrial pressure
rises because of left-sided heart failure, both systolic and diastolic pulmonary artery
pressure increase in an obligatory manner to maintain forward flow throught the lungs.
This leads to "passive" pulmonary hypertension.
In certain conditions, pulmonary vascular resistance becomes abnormally high, causing
pulmonary artery diastolic pressure to be elevated compared with left atrial pressure.
i.e. Pulmonary vascular obstructive disease may develop as a complication of a
chornic left to right cardiac shunt (such as an atrial or ventricular septal defect).
Pulmonary Artery Wedge Pressure
IF catheter is advanced into right or left pulmonary artery, tip will reach one of small
pulmonary artery branches and temporarily occlude forward blood flow beyond it.
During this time, column of stagnant blood stands between tip and portions of
pulmonary capillary and pulmonary venous sgements distal to it
This column of blood acts as extension of catheter and the pressure recocrded
through catheter reflects that of the downstream chamber, namely, the left atrium.
Such a measreuement is termed the pulonary artery wedge pressure or pulmonary
capillary wedge pressure (PCW) and closely matches the LEFT ATRIAL
PRESSURE in most individuals.
While the mitral valve is open during diastole, pulmonary venous bed, left atrium, and
left ventricle share the same pressures.
Thus, the PCW can be used to estimate the left ventricular diastolic pressure, a
measurement of ventricular preload. As a result, measurement of PCW may be useful in
managing certain critically ill patients int he ICU.
Elevation of PCW seen in left-sided heart failure and in mitral stenosis or regurgitation.
Individual components of PCW tracing can also become abnormally high
A wave may be increased in conditions of decreased left ventricular compliance (left
ventricular hypertrophy or acute myocardial ischemia and in mitral stenosis).
V wave is greater than normal when there is left atrial filling during venticular
contraction, as in mitral regurgitation.
Measurement of blood flow
Cardiac output measured by either thermodilution methord of the FICK techniques
termodilution method (saline of known tempreature) is injected rapidly through catheter
side port into right side of heart at a specific distance from distal tip of catheter.
Catheter tip contains thermistor that registers change in temperature induced by
injected saline
Cardiac output is proportional to the rate of temperature change and is automatically
calculated by equipment.
Fick method
Relies on quantitity of oxygen consumed by tissues is related to amount of O2
content removed from blood as it flows through tissue capillary bed
O2 consumption = O2 content removed * flow
Week 2 Chapter 3: Cardiac Imaging and Catheterization

aka O2 consumption = AVO2 difference * Cardiac output

AVO2 = difference in oxygen content between arterial and venous
compartments
O2 consumption determiend by expired air from lungs and arterial and
venous O2 content is measured in blood samples
Cardiac output = O2 consumption/AVO2 difference
Arterial blood in normal adult contains 190 mL of O2/liter and venous blood contains
150 mL of O2;liter. AV difference is 40 mL of O2/liter. If patient has O2 consumption of
200 mL/min, cardiac output is 5 L/min.
Many forms of heart disease, cardiac output is lower than normal
Total body oxygen consumption does not change significanlty, but a greater percentage
of O2 is extracted per volume of circulating blood by metabolizing tissues.
Results is lower-than-normal venous O2 content and therefore an increased AVO2
difference.
Since AVO2 increases, cardiac output decreases since CO = O2 consumption (stays
same)/ AVO2 difference (increases)
Cardiac index, equal to the cardiac output diveded by patient's body surface area
normal range: 2.6-4.2 L/min/m^2
Calculation of Vascular Resistance
After pressures and cardiac output have been determined, pulmonary and systemic vascular
resistances can be calculated
Based on princples that pressure difference across a vascular bed is proprotional to the
product of flow and resistances
PVR = MPAP LAP/CO * 80
pulmonary vascular resistancesMean pulmonary arter pressure
Left atrial pressure
Cardiac output
normal PVR: 20 to 130 dynes-sec-cm
SVR = MAP RAP/CO * 80
Systemic vascular resistance
Mean arterial pressure
Mean right atrial pressure
Cardiac output
Normal SVR is 700 to 1600 dynes-sec-cm
Contrast Angiography
Uses radiopaque contrast to visualize regions of cardiovascular system
Catheter is introduced into appropriate vessel and guided under fluorscopy to site of
injection
X-rays are transmitted through area of interest
Continuous series of x-ray exposures is recorded to produce motion picture
cineangiogram (cine or angiogram)
Selective injection of contrast into specific chambers used to identify valvular insufficiency,
intracardiac shunts, thrombi within heart, congential malformations, and to measure
ventricular contractile function.
Noninvasive techniques have largely supplanted the need for invasive contrast
angiography for these purposes.
Coronary artery angiography is important application of contrast angiography (examine
location and severity of coronary artherscloerotic lesions
Week 2 Chapter 3: Cardiac Imaging and Catheterization

To maximize test's sensitivity and reproducibility, each patient is imaged in several

standard views.
When necessary, angioplasty and stent placement can be performed.
Small risk associated with catherterization and contrast angiography
myoarcadial perforation by catheter, precipitation of arrhythmias, and conduction
blocks, damage to vessel walls, hemorrhage, dislodgement of artheroscleoritic
plauqes, pericardial tamponade, and infection.
Contrast meidum itself can cause anaphylaxis and renal toxicity.
Table 3-4: Cardiac Catheterization and Angiography in Cardiac Disorders
Nuclear Imaging
Heart function can be evaluated using injected, radioactively labeled tracers and gamma-
camera detectors
Resulting images reflect distribution of tracers within cardiovascular system
Nuclera techniques used to assess myocardial perfusion, image blood passing through
heart and great vessels, localize/quanitfy myocardial ischemia and infarction, and assess
myocardial metabolism.
Assessment of Myocardial Perfusion
Ischemia and infarction from coronary artery disease can be detected by myocardial
perfusion imaging
uses various radioisotopes, (compounds labeled with thallium-201) adn technetium-
99m.
Techtenium (Tc)...Tc-sestamibi and Tc-tetrosofmis are used.
Both are sensitive for detection of ischemic or scarred myocardium, but each
has distinct advantages.
Tc agents provide better image quality and superior for detailed single photo
emission computed tomography (SPECT)
Myocardial cellular viability is possible with 201 Ti (thallium) imaging
TI imaging...radioisotopic is injected intravenously while patient exercises on
treadmill or stationary bicycle.
B/c thallium is potassium analogue, it enters normal myocytes, a process
thought to be partially governed by sodium-potassium ATPase.
Intracellular concentration of thallium (estimated by density of image)
depends on vascular supply (perfusion) and membrane function (tissue
viability).
In normal heart, radionuclide shows homogenous distribution of thallium
in the myocardial tissue.
Myocardial regions that are scarred (by previous infarction) or have
reduced perfusion during exercise (transient myocardial ischemia) do not
accumulate as much thallium as normal heart muscle. These areas will
appear on thallium scan as light or "cold" spots
When evaluating for myocardial ischemia, initial set of images taken right
after exercise and TI injection.
Well perfused myocardium will take up more tracer than ischemic or
infarcted myocardium at this time.
Delayed images acquired several hours later b/c TI accumulation does not
remain fixed in myocytes. Continuous redistribution of isotope occurs
across cell membrane. After 3 to 4 hours of redistribution, all viable
myocytes will have qual concentrations of TI 20.
Week 2 Chapter 3: Cardiac Imaging and Catheterization

Any uptake abnormalities on the initial eercise scan that were caused
by myocardial ischemia will have resolved (filled in) on delayed scan
(are are therefore termed reversible defects)
Those representing infarcted or scarred myocardium will persist as
cold spots ("fixed" defects).
Some myocardial segments demonstrate persistent TI defects on both
stress and redistribution imaging are falsely characterized as nonviable,
scarred tissue.
Sometimes, these areas represente ischemic, noncontractile, but
metabotically, active areas aka HIBERNATING MYOCARDIUM
(segments that demonstrate diminished contractile function owing to
chronic reduction of coronary blood blow).
This viable state (in which affected cells can be predicted to
regain function following coronary revascularization) can often be
differentiated from irreversibly scarred myocardium by repeat
imaging at rest after the injection of additional TI to enhance
uptake by viable cells.
Tc-sestmibi (MIBI)
Large lipophillic molecule that is taken up in myocardium in proportion to
blood flow
Uptake differs from thalladium
compound crosses myocyte membrane passively, dirven by negative
membrane potential.
Once inside, further accumulates in mitochondria (which has even more
negative membrane potential)
Myocardial distribution of MIBI reflect perfusion at moment of injection,
remains fixed intracellulary (redistributes minimally over time).
Thus, MIBI imaging is more flexible since images can be obtained 4 to 6
hour after injection and repeated as necessary.
MIBI study is usually performed as 1 -day protocol in which intital
injection of a small tracer dose and imaging are performed at rest. Later, a
larger tracer dose is given after exercise and imaging is repeated.
Stress nuclear imaging studies with either TI or Tc have greater sensitivyt and
specificity than standard exercise electrocardiography for detection of ischemia, but
ar emore expensive and should be ordered judiciously.
Nuclear imaging is particularly approrpirate for patients with certain baseline
electrocardiogram (ECG) abnormalities of the ST segment that preclude accurate
interpretation of a standard exercise test.
i.e. Patients with electronic pacemaker rhythms, those with left bundle branch
block, those with ST abnormalities due to left venticular hypertrophy, and those
who take certain medications that alter the ST segment (i.e. Digoxin).
Nuclear scans also provide more accurate anatomic loclaization of ischemic
segments(s) and quantification of the extent of ischemia compared with standard
exercise testing.
Electronic synchronizing (gating) of nuclear images to the ECG cycle permits
wall motion analysis.
Patients with orthopedic or neurologic conditions (as well as those with severe
physical deconditioning or chronic lung disease) may be unable to perform as
adequate exercise test on treadmill or bicycle
Week 2 Chapter 3: Cardiac Imaging and Catheterization

In such patients, stress images can be obtained instead by administering

pharcologic agents such as adenosine or dipyradamole.
These agents induce diffuse coronary vasodilation, augmenting blood flow to
myocardium perfused by healthy cornary arteries. Since ischemic regions are
already maximally dilated (b/c of local metabolite accumulation), the drug-
induced vasodilation causes a "steal" pheonomenon, reducing isotope uptake
in regions distal to significant cononary stenoses.
Dobutamine can be infused intravenously to increase myocardial oxygen dmeand
as a means to assess for ischemia.
Radionuclide Ventriculography (RVG aka blood pool imaging)
Occasionally used to analyze right and left ventricular function.
Radioisotope (usually 99Tc) bound to red blood cells or to human serum albumin and
then injected as a bolus
Nuclear images obtained at fixed time intervals as labeled material passes through the
heart and great vessels.
Multiple images displayed sequentially to produce a dynamic picture of blood flow
Calculations such as determination of ejection fraction are based on difference between
radioactive counts present in the ventricle at the end of diastole adn at the end of systole.
Measurements largely independent of any assumptions of ventricular geometry and
are highly reproducible.
Studies suggest RVG and echocardiography provide similar left ventricular ejection
fraction values.
RVG used historically to assess baseline cardiac function in patients scheduled to
undergo potentially cardiotoxic chemotherapy (e.g., doxorubicin) and to follow cardiac
function over time in such patients
Echocardiography provide usually easier to perform, does not epxose patient to ionizing
radiation, adn now commonly serves this role.
Assessment of Myocardial Metabolism
PET (positron emission tomography) is a specialized nucler aimaging technique
Assesses myocardial perfusion and viability
PET imaging employs positron emitting isotopes (rubidium-82, nitrogen-13, and
fluorine-18) attached to metabolic or flow tracers
Sensitive detectors measure positron emission from the tracer molecules.
Myocardial perfusion commonly assessed using nitrogen -13-labeled ammonia or
rubidium 82
Both taken up by myocytes in proportion to blood flow
Myocardial viability can be determined by PET by studying glucose utilization in
myocardial tissue.
In normal myocardium under fasting conditions, glucose is used for
approximately 20% of energy production, with free fatty acids providing the
remaining 80%.
In ischemic conditions, metabolism shifts toward glucose use, and the more
ischemic the myocardial tissue, the stronger the reliance on glucose.
Fluoro-18 deoxygluocse (FDG18) created by substituting fluorine-18 for
hydrogen in 2-deoxyglucose, used to study glucose uptake
This substance competes with glucose both for transport with myocytes and
for subsequent phosphorylation
Unlike gluocse, FDG is not metabolized and becomes trapped within
Week 2 Chapter 3: Cardiac Imaging and Catheterization

myocyte
Combined evaluation of FDG metabolism allows assessment of both regional blood
flow andn glucose uptake
PET scanning helps determine areas of ventricular contractile dysfunction with
decreased flow represent irreversibly damaged scar tissue or wheter the region is still
viable (hibernating myocardium)
In scar tissue, both blood flow to affected area and FDG uptake are decreased.
B/c myocytes in this region are permanently damaged, such tissue is not likely to
benefit from revascularization.
Hibernating myocardium in contrast, shows decreased blood flow but normal or
elevated FDG uptake. Such tissue may benefit from revasculzation procedures.
Table 3-5: Nuclear imaging in cardiac disorders
Computed Tomography (CT scan)
CT uses thin x-ray beams to obtain large series of axial plane images
X-ray tube programmed to rotate around body
Generated beams partially abosrbed by body
Remaining beams emerge and captured by electronic detectors, relays information to a
computer for image composition
requires adminsitration of intravenous contrast agent to distinguish intravascular
contents (i.e. Blood) from neighboring soft tissue structures (e.g., myocardium)
Application of CT include assessment of great vessels, pericardium, myocardium, and
coronary arteries.
Used to diagnose aortic dissections and aneurysms.
Can identify abnormal pericardial fluid, thickening, and calcification
Myocardial abnormalities (regional hypertrophy or ventricular aneurysms, and
itnracardiac thrombus formation can be distinctly visualized by CT
Limitation of CT is artifiact generated by patient motion (i.e. Breathing) during image
acquisition
Modern spiral CT (helical CT) allows more rapid image acquisition, often dring single
breath-hold at relatively lower radiation doses than conventional CT.
Spiral CT is important in diagnosis of pulmonary embolism.
When intravenous iodine-based contrast agent is administrered, emboli create
apperance of "filling defects" in otherwise contrast-enhanced pulmonary vessels.
Electron beam computed tomography (EBCT) uses direct electron beam to acquire images
in a matter of milliseconds
Rapid succession fo images depicts cardiac structres at multipel times during single
cardiac cycle
Displaying images in a cine format can provide estimates of left ventircular volumes and
ejection fraction
Capable of detecting coronary artery calcification, EBCT used primarly to screen for
CAD
b/c calcified coronary artery plaques ahve radiodesnity similar to bone, they appear
attentuated (white) on CT.
The Agatston score, a measure of total coronary calcium, correlates well with
artehroscleoritc plaque burden adn predicts risk fo coronary events,
independently of other cardiac risk factors.
Newer CT technolocy can characterize artherosclerotic stenoses in great detail.
Current multiedetector row CT scanners acquire as many as 320 anatomic sections
Week 2 Chapter 3: Cardiac Imaging and Catheterization

with each rotation, providing excellent spatial resolution.

Administration of intravenous contrast and computer reformatting allows
visualization of the arterial lumena nd regions of coronary narrowings.
B/c image acquisition is timed with cardiac cycle, a relatively low heart rate is
desirable, such tha ta B-blocker is often adminsitrered prior to scanning.
CT is not as sensitive as conventional angiography for detection of coronary lesions
Cannot adquealtey evaluate stenosis within coronary artery stents
Results in siginficant radiation exposure
However, CT is rapid, relatively inexpensive, and significantly less invasive than
convetional angiography.
Its role in assessing patients with symptoms suggestive of CAD and for following
the progression of known coronary disease is under active evaluation.
Magnetic Resonance Imaging (MRI)
Uses powerful mangietc field to obtain detailed images of internal structures
Based on magnetic poliarty of hydrogen nuclei, which align themselves with an applie
dmagnetic field.
Radio frequency excitation causes nuclei to move out of alignment momentarily
As they return to their resting states, the nuclei emit absorbed energy into signals that are
translated into cmoputer generated images.
Therefore, unlike CT imaging, MRI requires no ionized radiation.
Among all imaging modalities, MRI is best at differnating tissue contrasts (blood, fluid,
fat, and myocardiu) and can often do so even without the use of contrast agents.
Addition of gadolinium-based contrast allows further characterization of cardiac
structures and tissues.
Detail of soft tissue structures is often demonstrated in MRI.
CMR has established role in evaluating congential anomalies, such as shutns and
diseases of the aorta, including aneurysm and dissection.
Also used to assess left and right ventircular mass adn volume, intravascular
thrombus, cardiomyopathies, and neoplastic disease.
ECG-gated adn cine MRI techniques capture images at discrete times int eh cardiac
cycle, allowing for evaluation fo valvular and ventricular function.
Two application of CMR
Coronary magnetic resonance angiography (coronary MRA) is non-invasive,
contrast-free angiographic imaging modality.
Laminar blood flow appears as bright signal intensity, whereas turbulent blood
flow at the site of stenosis result sin less bright or absent signal intesnity.
Has shown high sensitivity and accuracy for detection of important CAD in the
left main coronary artery and in the proximal and midportions of the three major
coronary vessels.
Coronary MRA is also useful in delineating coronary artery congential
anomalies.
Contrast-enhanced MRI
Gadolinium-based agent is adminsitered intravenously to identify infarcted
(irreversibly damaged) myocardium and to differentiate it from impaired (but
viable) muscle segments
based on fact that gadolinium is excluded from viable cells with intact cell
membranes but can permeate and concentrate in infarcted zones, producing
"hyperenhancement" on image
Week 2 Chapter 3: Cardiac Imaging and Catheterization

Owing to high spatial resolution of htis technique, the transmural extent of

myocardial scan can be depicted, adn the pattern of infarcting tissue can be
differentiated from that of acute myocarditis, a condition that my present with
similar clinical features.
Use of late-enhancing gadolinium imaging also allows for identification of
poorly contractile hibernating myocardium tissue that is chronically ischemic,
but would be expected to recover function if adequate blood perfusion is
restored.