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Cardiac Imaging
Rotations in Radiology
Published and Forthcoming Books in the Rotations in Radiology Series

Pediatric Radiology
Janet Reid, Edward Lee, Angelisa Paladin, Caroline Carrico, and William Davros

Cardiac Imaging
Charles White, Linda B. Haramati, Joseph J.S. Chen, and Jeffrey M. Levsky

Chest Imaging
Melissa Rosado de Christensen, Sanjeev Bhalla, Gerald Abbott, and Santiago Martinez-Jiminez

Gastrointestinal Imaging
Angela Levy, Koenraad Mortele, and Benjamin Yeh
Rotations in Radiology

Cardiac
Imaging Edited by

Charles S. White
Professor of Radiology and Medicine
Chief of Thoracic Radiology
Department of Diagnostic Radiology
University of Maryland School of Medicine
Baltimore, Maryland

Linda B. Haramati
Professor of Clinical Radiology and Medicine
Division Head, Cardiothoracic Imaging
Department of Radiology
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, New York

Joseph Jen-Sho Chen

Clinical Assistant Professor of Radiology
Department of Diagnostic Radiology
University of Maryland School of Medicine
Baltimore, Maryland

Jeffrey M. Levsky
Research Assistant Professor of Radiology
Associate Director of Research
Department of Radiology
Albert Einstein College of Medicine
Montefiore Medical Center
Bronx, New York

1
3
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It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide.

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All rights reserved. No part of this publication may be reproduced, stored in a
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and you must impose this same condition on any acquirer.

Library of Congress Cataloging-in-Publication Data

Cardiac imaging / edited by Charles S. White, Linda B. Haramati, Joseph Jen-Sho Chen,
Jeffrey M. Levsky.
p. ; cm.—(Rotations in radiology)
Includes bibliographical references and index.
ISBN 978–0–19–982947–7 (alk. paper)
I. White, Charles S., editor of compilation. II. Haramati, Linda B., editor of
compilation. III. Chen, Joseph Jen-Sho, editor of compilation. IV. Levsky, Jeffrey M.,
editor of compilation. V. Series: Rotations in radiology.
[DNLM: 1. Heart Diseases—diagnosis. 2. Cardiac Imaging Techniques—methods.
WG 141]
RC683.5.E5
616.1′20754—dc23
2013007376

This material is not intended to be, and should not be considered, a substitute for medical or
other professional advice. Treatment for the conditions described in this material is highly
dependent on the individual circumstances. And, while this material is designed to offer
accurate information with respect to the subject matter covered and to be current as of the
time it was written, research and knowledge about medical and health issues is constantly
evolving and dose schedules for medications are being revised continually, with new side
effects recognized and accounted for regularly. Readers must therefore always check the
product information and clinical procedures with the most up-to-date published product
information and data sheets provided by the manufacturers and the most recent codes of
conduct and safety regulation. The publisher and the authors make no representations or
warranties to readers, express or implied, as to the accuracy or completeness of this material.
Without limiting the foregoing, the publisher and the authors make no representations or
warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The
authors and the publisher do not accept, and expressly disclaim, any responsibility for any
liability, loss or risk that may be claimed or incurred as a consequence of the use and/or
application of any of the contents of this material.

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
Dedication

To my wife, Eunju, and my daughter, Claire—you make my life fun!

—Joseph Jen-Sho Chen

For my eishes chayil, Dena—batach bah leiv ba’lah.

—Jeffrey Levsky

To my parents Suse and Barret Broyde who raised me in a home dedicated to the love of learning.
—Linda Broyde Haramati
Contents

Preface xi D. Pulmonary Arterial Disease 87

Contributors xiii
17. Pulmonary Hypertension 89
18. Pulmonary Artery Aneurysm and
Section 1: Techniques 1
Pseudoaneurysm 95
1. Cardiovascular Computed 19. Pulmonary Artery Stenosis 98
Tomography 3
2. Cardiovascular Magnetic Resonance 8
E. Pulmonary Venous Disease 103

Section 2: Normal Anatomy 15 20. Pulmonary Vein Stenosis 105

21. Partial Anomalous Pulmonary Venous
3. Normal Cardiac Anatomy 17 Return 109
4. Normal Coronary Arterial and Venous 22. Scimitar Syndrome 113
Anatomy 22 23. Total Anomalous Pulmonary Venous
5. Normal Great Vessel Anatomy 27 Return 117
24. Cor Triatriatum 120

Section 3: Great Vessel Abnormalities 33

Section 4: Congenital Heart Disease 123
A. Aorta—Anomalies 33
25. Introduction to Congenital Heart Disease
6. Aberrant Right Subclavian Artery 35
Imaging 125
7. Double Aortic Arch 38
8. Right Aortic Arch 42
9. Coarctation of the Aorta 47 A. Left to Right Shunts 135

26. Ostium Secundum Atrial Septal Defect 137

B. Pulmonary Artery—Anomalies 51 27. Sinus Venosus Atrial Septal Defect 141
28. Ventricular Septal Defect 145
10. Anomalous Origin of the Left Pulmonary
Artery: The Pulmonary Sling 53 29. Patent Ductus Arteriosus 149

11. Absent Pulmonary Artery 56 30. Eisenmenger Syndrome 154

C. Aorta—Acquired Disease 61 B. Complex Congenital Heart Disease 159

12. Aortic Dissection 63 31. Tetralogy of Fallot 161

13. Aortic Intramural Hematoma 67 32. D-Transposition of the Great Arteries 166
14. Penetrating Atherosclerotic Ulcer 72 33. L-Transposition of the Great Arteries 170
15. Thoracic Aortic Aneurysm 76 34. Ebstein Anomaly 174
16. Aortic Vasculitis 81 35. Tricuspid Atresia 179
viii C o n te n t s

36. Truncus Arteriosus Communis 183 60. Dilated Cardiomyopathy 295

37. Double-Outlet Right Ventricle 187 61. Hypertrophic Cardiomyopathy 299
38. Heterotaxy Syndrome 192 62. Cardiac Amyloidosis 304
39. Hypoplastic Left Heart Syndrome 197 63. Cardiac Sarcoidosis 308
64. Arrhythmogenic Right Ventricular
Dysplasia 311
Section 5: Coronary Artery Variants
and Anomalies 203 65. Myocarditis 314
66. Noncompaction Cardiomyopathy 317
40. Myocardial Bridging 205
67. Takotsubo Cardiomyopathy 320
41. Benign Anomalous Coronary Artery 208
68. Cardiac Herniation 323
42. Malignant Anomalous Coronary Artery 213

Section 9: Myocardial Disease—Masses 325

Section 6: Coronary Artery Disease 219
A. Tumor-like Conditions 325
43. Coronary Artery Calcium Score 221
44. Coronary Artery Atherosclerosis 226 69. Left Atrial Thrombus 327
45. Left Main Coronary Artery Stenosis 231 70. Left Ventricular Thrombus 330
46. Other Coronary Artery Stenosis 235 71. Lipomatous Hypertrophy of the Interatrial
47. Coronary Artery Aneurysm 240 Septum 334

48. Kawasaki Disease 244

B. Tumor—Benign 337

Section 7: Myocardial Disease—Ischemia 72. Cardiac Myxoma 339

and Infarction 249
73. Cardiac Rhabdomyoma 343
49. Stunned or Hibernating Myocardium 251
C. Tumor—Malignant 347

A. Infarction 255 74. Cardiac Angiosarcoma 349

75. Pulmonary Artery Sarcoma 352
50. Acute Myocardial Infarction 257
76. Cardiac Lymphoma 355
51. Chronic Myocardial Infarction 260
77. Cardiac Metastases 358
52. Microvascular Obstruction 263
53. Transmural Myocardial Infarction 266
54. Nontransmural Myocardial Infarction 269 Section 10: Cardiac Valvular Disease 363

A. Aortic 363
B. Complications 273
78. Aortic Valve Stenosis 365
55. Ventricular Septal Rupture 275 79. Aortic Regurgitation 370
56. Left Ventricular Aneurysm 278 80. Bicuspid Aortic Valve 375
57. Left Ventricular Pseudoaneurysm 281
B. Mitral 379
Section 8: Myocardial Disease—
Cardiomyopathy 285 81. Mitral Stenosis 381
82. Mitral Valve Prolapse 385
58. Left Heart Failure 287 83. Mitral Annular Calcification 389
59. Ischemic Cardiomyopathy 291 84. Mitral Valve Prosthesis 392
 C o n te n t s ix

C. Right-Sided 397 100. In-Stent Restenosis 461

101. Thoracic Endovascular Aortic Repair 464
85. Pulmonary Stenosis 399
86. Pulmonary Regurgitation 402
87. Tricuspid Regurgitation 405 B. Systemic Pulmonary Anastomotic
Surgeries 467

D. Masses 409 102. Blalock-Taussig Shunt 469

103. Glenn and Fontan Procedures 473
88. Papillary Fibroelastoma 411 104. Rastelli Procedure 478
89. Infective Endocarditis 414

C. Chambers 483
Section 11: Pericardial Disease 419
105. Left Ventricular Apical Aortic Conduit 485
90. Pericardial Calcification 421 106. Atrial Septal Defect Closure Device 488
91. Constrictive Pericarditis 426
92. Pericardial Effusion 430
D. Support Devices 491
93. Infectious Pericarditis 435
94. Cardiac Tamponade 439 107. Pulmonary Artery Catheter 493
95. Pneumopericardium 442 108. Pacemakers and Other Cardiovascular
96. Congenital Absence of the Implantable Electrical Devices 497
Pericardium 445 109. Intra-aortic Balloon Pump 502
97. Pericardial Cyst 448 110. Left Ventricular Assist Devices 506

Index 511
Section 12: Postintervention/Postoperative 451

A. Stents and Grafts 451

98. Patent Coronary Artery Bypass

Grafts 453
99. Post-CABG Thrombosis 458
Preface

Cardiac imaging has made great strides in the last 15 years. have a strong emphasis on technical details and research
While this is true for nearly all imaging techniques, it is applications. Nearly all of the available texts either are quite
particularly apropos to cardiovascular computed tomog- voluminous and comprehensive or, conversely, use a case
raphy (CT) and magnetic resonance imaging (MRI). presentation approach without attention to details.
Multidetector cardiac CT has evolved from a new tech- In contrast to existing publications, our book is
nique to a mature and widely disseminated modality. directed to the middle ground. Our goal is to provide a
Moreover, substantial progress has been made in address- review of nearly all of the major cardiac conditions in a for-
ing challenges related to radiation dose. Cardiac MR mat that is highly accessible to the reader. Thus, the text
imaging has also seen considerable progress. Steady-state is organized so that each chapter covers a specific entity.
free precession bright-blood sequences have enabled a In addition to a summary of the condition, each chapter
much better assessment of cardiac anatomy and func- reviews its imaging appearance, particularly with reference
tion. Viability sequences have become a critical part of the to CT and MRI, a differential diagnosis, the clinical context
examination, allowing precise delineation of the myocar- and treatment approaches to the condition. Although the
dium in a variety of ischemic and nonischemic conditions. imaging focal point is cardiac CT and MRI, other relevant
The consequence of this rapid progress is that CT and MRI imaging techniques, such as radiography, echocardiogra-
can provide substantially better evaluation of many car- phy, coronary angiography and nuclear cardiology are dis-
diac conditions than in previous decades. In fact, MRI has cussed and presented within this context.
become the reference standard for quantitating ventricular It is our expectation that this book will provide a quick,
volume and function. thorough, and highly readable reference for practitioners
As these techniques have evolved, a series of books and trainees who are interested in cardiac disease and who
highlighting their utility have been published. Most of wish to learn more about the imaging appearances of a
the books focus on either CT or MRI, but not both, and spectrum of cardiac diseases on CT and MRI.
Contributors

Olaguoke Akinwande, MD Netanel S. Berko, MD

Resident Resident
Department of Diagnostic Radiology Montefiore Medical Center
University of Louisville Hospital Albert Einstein College of Medicine
Louisville, Kentucky New York, New York

Christopher Aquino, MD, MS Netta M. Blitman, MD

Resident Associate Professor of Clinical Radiology
Department of Diagnostic Radiology and Nuclear Jacobi Medical Center
Medicine Albert Einstein College of Medicine
University of Maryland Medical Center New York, New York
Baltimore, Maryland
Steven L. Blumer, MD
William F. Auffermann, MD, PhD Division of Pediatric Radiology
Assistant Professor of Radiology and Imaging Sciences Dupont Hospital for Children
Division of Cardiothoracic Imaging Department of Medical Imaging
Emory University School of Medicine Wilmington, Delaware
Atlanta, Georgia
Einat Blumfield, MD
Leon Bacchus, MD Associate Director of Pediatric Radiology
Cardiothoracic Radiology Fellow Jacobi Medical Center
Montefiore Medical Center Assistant Professor of Radiology
Albert Einstein College of Medicine Albert Einstein College of Medicine
New York, New York New York, New York

Anna S. Bader, MD Stephanie K. Burns, MD

Resident Cardiothoracic Radiology Fellow
Montefiore Medical Center Montefiore Medical Center
Albert Einstein College of Medicine Albert Einstein College of Medicine
New York, New York New York, New York

Lindsay S. Baron, MD Lyndsey Burton, MD

Resident Fellow
Montefiore Medical Center Department of Diagnostic Radiology and Nuclear
Albert Einstein College of Medicine Medicine
New York, New York University of Maryland Medical Center
Baltimore, Maryland
Shahine Baghai, MD
Resident Victoria Chernyak, MD
Department of Diagnostic Radiology and Nuclear Associate Professor of Clinical Radiology
Medicine Montefiore Medical Center
University of Maryland Medical Center Albert Einstein College of Medicine
Baltimore, Maryland New York, New York

Piyush Banker, MD, MHS Munish Chitkara, MD

Resident Resident
Montefiore Medical Center Montefiore Medical Center
Albert Einstein College of Medicine Albert Einstein College of Medicine
New York, New York New York, New York
xiv C o n t r i b u to r s

Irina Decter, MD Caryn Gamss, MD

Resident Radiology Resident PGY 5
Montefiore Medical Center Montefiore Medical Center
Albert Einstein College of Medicine Albert Einstein College of Medicine
New York, New York Bronx, New York

R. Joshua Dym, MD Rebecca Gamss, MD

Assistant Professor Resident
Department of Radiology Montefiore Medical Center
Montefiore Medical Center Albert Einstein College of Medicine
Albert Einstein College of Medicine New York, New York
New York, New York
Subha Ghosh, MD
James E. East, PhD Assistant Professor
Fellow Cardiothoracic Radiology
Department of Microbiology and Immunology Wexner Medical Center at the Ohio State University
University of Maryland Medical Center Columbus, Ohio
Baltimore, Maryland
Marc Gibber, MD
David Baruch Erlichman, MD Cardiothoracic Fellow
Resident Division of Cardiac Surgery
Montefiore Medical Center University of Maryland Medical Center
Albert Einstein College of Medicine Baltimore, Maryland
New York, New York
Alla Godelman, MD
Assistant Professor of Radiology
Charles F. Evans, MD
Montefiore Medical Center
Resident in Cardiac Surgery
Albert Einstein College of Medicine
University of Maryland Medical Center
New York, New York
Baltimore, Maryland
Arash Gohari, MD
John P. Fanatuzzi, MD Resident
Resident Montefiore Medical Center
Montefiore Medical Center Albert Einstein College of Medicine
Albert Einstein College of Medicine New York, New York
New York, New York
Menachem Gold, MD
Reza Fardanesh, MD Attending Neuroradiologist
Fellow Lincoln Medical and Mental Health Center
Department of Diagnostic Radiology and Nuclear Assistant Professor of Clinical Radiology
Medicine Weill Cornell Medical College
University of Maryland Medical Center New York, New York
Baltimore, Maryland
Judah Goldschmiedt, MD
Jessica S. Fisher, MD Resident
Resident Montefiore Medical Center
Montefiore Medical Center Albert Einstein College of Medicine
Albert Einstein College of Medicine New York, New York
New York, New York
Felix M. Gonzalez, MD
Erin FitzGerald, MD Resident
Resident Department of Diagnostic Radiology and Nuclear
Montefiore Medical Center Medicine
Albert Einstein College of Medicine University of Maryland Medical Center
New York, New York Baltimore, Maryland
 C o n t r i b u to r s xv

Jay N. Gross, MD Daniel A. Krieger, MD

Director, Pacemaker Center Resident
Professor of Clinical Medicine (Cardiology) Montefiore Medical Center
Montefiore Medical Center Albert Einstein College of Medicine
Albert Einstein College of Medicine New York, New York
New York, New York
Sampson K. Kyere, MD, PhD
Adina Haramati, BA Resident
Medical Student Department of Diagnostic Radiology and Nuclear
Albert Einstein College of Medicine Medicine
New York, New York University of Maryland Medical Center
Baltimore, Maryland
Travis S. Henry, MD
Assistant Professor of Radiology Kian Lahiji, MD
Cardiothoracic Division Fellow
Emory University School of Medicine Department of Diagnostic Radiology and Nuclear
Atlanta, Georgia Medicine
University of Maryland Medical Center
David A. Hirschl, MD Baltimore, Maryland
Radiology Resident and Interventional Radiology Fellow
Montefiore Medical Center Larry A. Latson Jr, MD, MS
Albert Einstein College of Medicine Cardiothoracic Radiology Fellow
New York, New York Montefiore Medical Center
Albert Einstein College of Medicine
Andrew Hutchens, MD New York, New York
Resident
Department of Diagnostic Radiology and Nuclear Jenna Le, MD
Medicine Resident
University of Maryland Medical Center Montefiore Medical Center
Baltimore, Maryland Albert Einstein College of Medicine
New York, New York
Adam Jacobi, MD
Assistant Professor of Radiology Jay S. Leb, MD
Mount Sinai School of Medicine Resident
New York, New York Jacobi Medical Center
Albert Einstein College of Medicine
Vineet R. Jain, MD New York, New York
Associate Professor of Radiology
Montefiore Medical Center Terry L. Levin, MD
Albert Einstein College of Medicine Professor of Clinical Radiology
New York, New York Children’s Hospital at Montefiore Medical Center
New York, New York
Matthew R. Kinzie, MD
Assistant Professor Michael L. Lipton, MD, PhD
Department of Radiology Associate Professor
The Ohio State University Medical Center Associate Director
Columbus, Ohio Gruss Magnetic Resonance Research Center
Department of Radiology
Mariya Kobi, MD Montefiore Medical Center
Fellow in Abdominal Imaging Albert Einstein College of Medicine
Montefiore Medical Center New York, New York
Albert Einstein College of Medicine
New York, New York
xvi C o n t r i b u to r s

Brent P. Little, MD Cesar E. Orellana, MD

Assistant Professor Resident
Division of Cardiothoracic Imaging Department of Medicine
Department of Radiology and Imaging Sciences State University of New York Upstate Medical University
Emory University Baltimore, Maryland
Atlanta, Georgia
Viktoriya Paroder, MD, PhD
Alexander H. MacArthur, MD Fellow in Body CT/MR
Resident Albert Einstein College of Medicine
Department of Diagnostic Radiology and Nuclear Montefiore Medical Center
Medicine New York, New York
University of Maryland Medical Center
Baltimore, Maryland P. Gabriel Peterson, MD
Diagnostic Radiologist, Walter Reed National Military
Eric D. McLoney, MD Medical Center
Department of Radiology Assistant Professor of Radiology and Radiological
The Ohio State University Medical Center Sciences
Columbus, Ohio Uniformed Services University of the Health Sciences
Bethesda, Maryland
Monika Misra, MD
Fellow in Body CT/MR Andrew J. Plodkowski, MD
Montefiore Medical Center Cardiothoracic Radiology Fellow
Albert Einstein College of Medicine Montefiore Medical Center
New York, New York Albert Einstein College of Medicine
New York, New York
Tara A. Morgan, MD
Resident Jessica K. Rosenblum, MD
Department of Diagnostic Radiology and Nuclear Resident
Medicine Montefiore Medical Center
University of Maryland Medical Center Albert Einstein College of Medicine
Baltimore, Maryland New York, New York

Tzvi Neuman, DO Alla M. Rozenblit, MD

Department of Medicine Professor of Clinical Radiology
Division of Critical Care Medicine Director of Abdominal Imaging
Montefiore Medical Center Department of Radiology
Albert Einstein College of Medicine Albert Einstein College of Medicine
Bronx, New York Montefiore Medical Center
Bronx, New York
Cuong Nguyen, MD
Resident Meir H. Scheinfeld, MD, PhD
Department of Diagnostic Radiology and Nuclear Assistant Professor of Radiology
Medicine Director of Emergency Radiology
University of Maryland Medical Center Montefiore Medical Center
Baltimore, Maryland Albert Einstein College of Medicine
New York, New York
Seong Cheol Oh, MD
Resident Rajesh U. Shenoy, MD, FAAP, FACC
Montefiore Medical Center Assistant Professor of Pediatrics
Albert Einstein College of Medicine Director of Pediatric Cardiology
New York, New York The Children’s Hospital at Montefiore
New York, New York
Anna Orellana, MD
Resident
Department of Radiology
State University of New York Upstate Medical University
Baltimore, Maryland
 C o n t r i b u to r s xvii

Narendra Shet, MD Amanda Weiss, MD

Resident Resident
Department of Diagnostic Radiology and Nuclear North Shore-LIJ Health System
Medicine Hofstra North Shore-LIJ School of Medicine
University of Maryland Medical Center Long Island, New York
Baltimore, Maryland
Brody Wehman, MD
Daniel Sova, BS Resident
Medical Student Division of Cardiac Surgery
Albert Einstein College of Medicine University of Maryland Medical Center
New York, New York Baltimore, Maryland

Hugo Spindola-Franco, MD, FACR, FACC Kathleen B. Wooten, MD, MHA

Professor of Clinical Radiology Resident
Montefiore Medical Center Department of Diagnostic Radiology and Nuclear
Albert Einstein College of Medicine Medicine
New York, New York University of Maryland Medical Center
Baltimore, Maryland
Ari J. Spiro, MD
Resident Rebecca E. Wright, MD
Montefiore Medical Center Resident
Albert Einstein College of Medicine Department of Diagnostic Radiology and Nuclear
New York, New York Medicine
University of Maryland Medical Center
Nathaniel C. Swinburne, MD Baltimore, Maryland
Resident
Department of Radiology Cody M. Young, DO
Mount Sinai School of Medicine Pediatric Radiologist, Department of Radiology
New York, New York Nationwide Children’s Hospital
Clinical Assistant Professor of Radiology
Benjamin H. Taragin, MD Ohio State University School of Medicine and
Associate Professor of Radiology and Pediatrics Public Health
Albert Einstein College of Medicine Adjunct Assistant Professor-Radiology
Director, Pediatric Radiology School of Medicine, University of Toledo Medical College
Children’s Hospital at Montefiore Columbus, Ohio
New York, New York
Benjamin Zalta, MD
Jonathan Trambert, MD Assistant Professor of Radiology
Associate Professor of Clinical Radiology Montefiore Medical Center
Clinical Director of Interventional Radiology, Albert Einstein College of Medicine
Weiler Division New York, New York
Montefiore Medical Center
Albert Einstein College of Medicine Auzhand Zonozy, MD
New York, New York Resident
Department of Diagnostic Radiology and Nuclear
William R. Walter, MD Medicine
Resident University of Maryland Medical Center
Montefiore Medical Center Baltimore, Maryland
Albert Einstein College of Medicine
New York, New York
Section One sdglsdf;gl;fg

Techniques
CHAPTER 1

Cardiovascular Computed Tomography

Jeffrey M. Levsky

Definition instructions is of paramount importance. In some cases, an

Computed tomography (CT) technology has progressed inhale-exhale-inhale-and-hold sequence or use of supple-
rapidly over the past four decades, making it the noninva- mental oxygen by nasal cannula can permit a longer breath
sive modality of choice for evaluation of the aorta, pulmo- hold. A high number of scanner detector rows and the
nary arteries and veins, coronary arteries, central systemic capability for high-pitch scanning can shorten acquisitions
veins, and the pericardium. CT also plays an important and decrease the need for sedation. The presence of child
role in the evaluation of cardiac masses, postsurgical states, life specialists and the use of welcoming scanner room
vascular shunts, and indwelling devices. The use of electro- décor can work wonders for pediatric protocols.
cardiographic (ECG) gating and modern scanner technol- ECG gating is used to compensate for cardiac motion.
ogy has improved the temporal resolution of CT to permit It is imperative that the ECG tracing be checked to ensure
motion-free visualization of small moving structures such that signal is adequate, the noise level is low, that each
as the epicardial coronary arteries, as well as assessment R-wave is marked by the monitor and that spurious beats
of wall motion, valvular function, and myocardial perfu- are not marked. It is more difficult or even impossible to
sion. CT entails the risk of ionizing radiation, although obtain adequate images of small, moving structures such
technological improvements have lowered the dose of as the coronary arteries in patients with tachycardia or dys-
cardiovascular exams dramatically. CT is more rapid and rhythmia (most commonly atrial fibrillation or frequent
less operator dependent than alternative modalities. It also ectopy). The use of retrospective scanning protocols or
provides simultaneous evaluation of the cardiovascular sys- postscan ECG editing can improve image quality.
tem, lungs, bronchi, pleura, mediastinum, and bony thorax. Heart rate–controlling premedication is used to reduce
cardiac motion. Metoprolol tartrate, the most common
agent, can be used orally (at least 1 hour before the scan) or
Clinical Features intravenously (IV) (nearly immediate onset). Metoprolol is
Cardiovascular CT is performed most often for symptoms contraindicated in active asthma, hypotension, heart block,
of chest pain and dyspnea to evaluate for pulmonary embo- and suspected cocaine use. Nitroglycerine is commonly
lism, acute aortic syndromes, and cardiac disease. Clinical given to dilate the coronary arteries as a sublingual tablet
tools like the Wells’ score for pulmonary embolism help or spray. It is contraindicated in recent use of a phospho-
select appropriate (at least moderate risk) patients for CT. diesterase 5 inhibitor erectile dysfunction medication, sig-
Coronary CT is best employed in low- to intermediate-risk nificant aortic stenosis, and hypotension.
patients, which can be assessed with Diamond-Forrester Cardiovascular CT depends on rapid administration
chest pain criteria or Thrombolysis in Myocardial Infarction of IV contrast followed by scanning at optimal opacifica-
(TIMI) score. Cardiovascular CT is often performed when tion. This requires a power injector (even at slower flow
other noninvasive tests (e.g., serum cardiac biomarkers rates for patients with small IV catheters). Contrast tim-
or D-dimer, plain radiographs, ECG, echocardiography, ing can be performed empirically (e.g., a 30-second delay
radionuclide myocardial perfusion imaging) are equivocal for aortic phase), by a trigger (scanning is commenced
or abnormal. when a threshold of enhancement is reached), or by a for-
mal prescan timing run (small bolus of contrast followed
by repeated, timed images of the central vessels). The tim-
Anatomy and Physiology ing run may be most reliable, but it comes at the cost of a
Accurate depiction of anatomy requires meticulous con- minor increase in contrast load and radiation. Contrast is
trol of physiology. The prime enemy of high-quality often immediately followed by a saline injection in order
images is motion artifact, which may be due to patient to flush very bright contrast out of the central veins and
movement (voluntary or not), respiration (Fig. 1.1a– reduce the volume of contrast necessary. Some protocols
b), or cardiac motion (Fig. 1.2a–b). Careful instruc- use a triphasic injection consisting of contrast, followed
tion and patient rehearsal of standardized breathing by a contrast-saline mix, followed by saline.

3
4 C a rd i a c I m a g i n g

(a) (b)

Figure 1.1. (a) Oblique coronal CT image degraded by respiratory motion causes an apparent filling defect in a left lower lobe
pulmonary arterial branch mimicking pulmonary embolism. An axial image at the same level on lung windows (b) shows extensive
respiratory motion artifact. The artery with the spurious filling defect is marked (arrow).

How to Approach the Image images look poorly aligned along the Z axis (also
Image data sets should always be inspected in more than known as “stair-step”) (Fig. 1.3a–b).
one plane in search of artifacts that may limit the study’s ■ Beam hardening—spurious low attenuation streaks
sensitivity or may cause spurious findings. Familiarity are due to a highly attenuating object, such as dense
with common artifacts is of vital importance for accurate contrast in the superior vena cava (SVC), surgical
interpretations: clips (Fig. 1.4), or devices.
■ Partial volume averaging—voxels of data represent an
■ Motion—structures are blurred, streaked, or doubled, average attenuation value such that highly attenuat-
rendering vessel lumina impossible to evaluate (Figs. ing materials like calcium and stents cause apparent
1.1a–b, 1.2a–b); respiration may cause gaps in or luminal narrowing (Fig. 1.5a–b).
overlaps of data.
■ Misalignment—a subset of motion artifact is often There are multiple methods for reconstruction of cardio-
due to variable heart rate or dysrhythmia that makes vascular CT (see Table 1.1).

(a) (b)

Figure 1.2. (a) CT image of the right atrioventricular groove degraded by cardiac motion causes “doubling” of the right coronary
artery. (b) Image of the same location at a cardiac phase without motion artifact shows the vessel clearly.
 C a rd i ova s c u l a r C o m p u te d To m o g ra p hy 5

(a) (b)

Figure 1.3. (a) CT image showing misalignment due to heart rate variability mimicking a stenosis of the distal left anterior
descending coronary artery. (b) An oblique sagittal reconstruction shows the misalignment of scan “slabs” oriented along the Z axis.

What Not to Miss CT imaging and will be missed if attention is not directed
Cardiovascular CT studies image the entire surrounding to them.
anatomy. How to deal with this “unintended” data is the
subject of controversy. Some practices routinely recon-
struct extra wide field-of-view images in order to detect Differential Diagnosis
noncardiac findings that may explain the patient’s symp- Clinically useful cardiovascular CT requires appropriate
toms or may be incidental. Other practices use algorithms selection of patients and knowledge of the capabilities of
designed to remove as much of the surrounding anatomy as alternative modalities. In general, asymptomatic and very
possible. A third option is to interpret the anatomy depicted low-risk patients should not undergo imaging. High-risk
on the standard field-of-view only. Regardless of the option patients may benefit from cardiac catheterization as a first
selected, noncardiac findings are present on cardiovascular diagnostic modality instead of coronary CT. The use of IV
contrast for CT can discourage or delay an appropriate
conventional angiogram. Echocardiography and magnetic
resonance, instead of CT, are the primary modalities for
assessment of ventricular and valvular structure and func-
tion. Radionuclide scintigraphy, stress echocardiography,
and positron emission tomography are the primary modal-
ities for detection of ischemia.

Common Variants
■ Arterial phase (for systemic or pulmonary arterial CT

angiography)
■ Venous phase (often with a 90-second delay; for

central venous obstruction, cavopulmonary shunt/

Fontan patients, cardiac masses or masses involving
the heart, detection of endoleaks)
■ Pre- and postcontrast (for aortic CT angiography and

some postoperative patients to help identify intra-

mural hematoma, postsurgical hematoma, and dense
surgical materials)
■ Noncontrast coronary calcium score (for cardiovas-

Figure 1.4. CT image showing surgical clips associated with a

cular risk assessment)
left internal mammary artery coronary artery bypass graft (white ■ Retrospective gating (coronary/cardiac CT through-
arrow) that cause beam hardening. The bypass graft and target out the cardiac cycle such that images can be recon-
vessel (left anterior descending coronary artery, black arrow)
cannot be evaluated at the level of the clips.
structed of any cardiac phase; for anatomic imaging of
6 C a rd i a c I m a g i n g

(a) (b)

Figure 1.5. (a) CT image showing dense mid-left anterior descending coronary arterial calcification that causes partial volume
averaging, exaggerating the degree of luminal stenosis. (b) Multiplanar reconstruction with a wide display window reduces the effect
and shows a patent lumen at the level of calcification.

patients with higher heart rates and for evaluation of ■ Late delay (at least 10 minutes post IV contrast injec-
ventricular or valvular function) tion; for detection of delayed hyperenhancement due
■ Prospective gating (cardiovascular CT triggered to to myocardial infarction or fibrosis)
image at a specific point in the cardiac cycle, often
mid-diastole; for anatomic imaging without function)
■ “Triple rule-out” (single-phase study designed to Clinical Issues
assess the pulmonary arteries, aorta, and coronary Imaging utilization is an issue at large in modern medicine.
arteries when the suspected cause of chest pain can- Cardiovascular imaging in particular has been the subject
not be differentiated) of focus of governmental bodies, payors, and the public.
■ Endovascular intervention planning (study of the The basic premise of any imaging exam must be that its
desired site of intervention, such as an aortic aneu- results are needed to make the best clinical decisions for
rysm or a stenotic aortic valve, which is extended to the patient. This is predicated on an appropriate level of
cover the path of vascular access for intervention, pretest risk and the diagnostic performance characteris-
such as the iliofemoral runoff vessels) tics of the modality. No examination is perfect; therefore,
■ Rest/stress imaging (to detect ischemia/abnormal patients with the highest and lowest pretest probability of
myocardial perfusion by scanning before and after disease are least likely to benefit from diagnostic imaging.
pharmacologic stress such as by adenosine) Intersociety consensus guidelines describing appropriate

Table 1.1 - Methods for Reconstruction of Cardiovascular CT

RECONSTRUCTION EXPLANATION USE PROS CONS

Multiplanar Arbitrary plane, Evaluation of Nonmanipulated data, Time consuming, not
reconstruction (MPR) interactive structures beyond easier recognition of automated
standard planes artifacts
3D volume rendering 2D image of 3D data General overview, dem- Referrers love it, gestalt Little diagnostic infor-
(VR) constructed from a onstrating structures understanding of dis- mation for specific
particular viewpoint in situ ease process lesions
Curved planar recon- “Straightens” the image Assessment of long, Measurements along a Curve definition is
struction (CPR) along a non-linear curved structures such vessel’s length in cross difficult in presence of
plane of reconstruction as blood vessels section artifacts
Maximum intensity Uses the highest value Overview of particular Fast assessment of May mask filling
projection (MIP) along a projection in area of anatomy or small, curved and defects and stenoses
the data slab pathology branching structures
 C a rd i ova s c u l a r C o m p u te d To m o g ra p hy 7

use criteria have been published. The tendency of imaging Suggested Reading
to drive intervention should be recognized before a study Halliburton SS, Abbara S, Chen MY, Gentry R, Mahesh M,
is performed. Finally, the efficacy of all potential cardiovas- Raff GL, Shaw LJ, Hausleiter J; Society of Cardiovascular
cular interventions (pharmacological, minimally invasive, Computed Tomography. SCCT guidelines on radiation dose
and surgical) must be kept in mind before imaging. and dose-optimization strategies in cardiovascular CT. J
Cardiovasc Comput Tomogr. 2011;5(4):198–224.
Radiation concerns from cardiac imaging abound.
Halliburton S, Arbab-Zadeh A, Dey D, Einstein AJ, Gentry R,
Proper patient selection must be used to avoid unwarranted George RT, Gerber T, Mahesh M, Weigold WG. State-of-
imaging. When a scan is indicated it should be done with the-art in CT hardware and scan modes for cardiovascular CT.
as low a dose as reasonably achievable. Numerous radiation J Cardiovasc Comput Tomogr. 2012;6(3):154–163.
reduction techniques have been introduced: Hurlock GS, Higashino H, Mochizuki T. History of cardiac com-
puted tomography: single to 320-detector row multislice com-
■ Number of phases (omitting one or more of precon- puted tomography. Int J Cardiovasc Imaging. 2009;25(Suppl 1):
trast, postcontrast, or delay) 31–42.
■ Scan area (limiting coronary CT from 1 cm below the Johnson PT, Pannu HK, Fishman EK. IV contrast infusion
carina to the base of the heart) for coronary artery CT angiography: literature review
■ Cardiac phase (prospective gating to target and results of a nationwide survey. AJR Am J Roentgenol.
2009;192(5):W214–W221.
mid-diastole instead of retrospective acquisition of
Khan M, Cummings KW, Gutierrez FR, Bhalla S, Woodard PK,
the entire cardiac cycle) Saeed IM. Contraindications and side effects of commonly
■ Voltage (100 kVp for normal weight, especially male used medications in coronary CT angiography. Int J Cardiovasc
patients for cardiac CT; 80 kVp for thin and pediatric Imaging. 2011;27(3):441–449.
patients) Nakanishi T, Kayashima Y, Inoue R, Sumii K, Gomyo Y. Pitfalls
■ Current (ECG-controlled tube current modulation or in 16-detector row CT of the coronary arteries. Radiographics.
a lower overall mA setting) 2005;25(2):425–38.
■ Scanned field of view (reduction to 30 cm instead of Taylor CM, Blum A, Abbara S. Patient preparation and scanning
50 cm for cardiac studies) techniques. Radiol Clin North Am. 2010;48(4):675–686.
■ Pitch (increasing pitch on a dual-source scanner) Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J,
■ Shielding (lead abdominal shielding in pregnancy) O’Gara P, Rubin GD; American College of Cardiology
Foundation Appropriate Use Criteria Task Force; Society of
Cardiovascular Computed Tomography; American College of
Radiology; American Heart Association; American Society of
Key Points Echocardiography; American Society of Nuclear Cardiology;
■ Performance of cardiovascular CT depends on proper North American Society for Cardiovascular Imaging; Society
patient selection and preparation, meticulous imag- for Cardiovascular Angiography and Interventions; Society
ing technique, and skilled interpretation. for Cardiovascular Magnetic Resonance. ACCF/SCCT/ACR/
■ Knowledge of CT artifacts is crucial in making accu- AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate
rate diagnoses. Use Criteria for Cardiac Computed Tomography. Circulation.
■ Cardiovascular CT can be performed with relatively 2010;122(21):e525–e555.
low dose by employing radiation-sparing strategies.
 CHAPTER 2

Cardiovascular Magnetic Resonance

Jeffrey M. Levsky and Michael L. Lipton

Definition all patients and is challenging for both the clinicians per-
Cardiovascular magnetic resonance (MR) technology has forming the examination and the patients. Technologists
progressed rapidly over the past three decades. Current MR require special training to ensure patient safety. Access to
spatial resolution approaches that of CT, and temporal res- the MR scanner suite must be controlled; unsafe equip-
olution approaches that of echocardiography and catheter ment and patients with unsafe implants must be identified
angiography. MR is the noninvasive modality of choice for and excluded from MR imaging to prevent serious injury.
quantification of ventricular volume and function, myocar- Implanted pacemakers or defibrillators, some cerebral
dial tissue characterization, and blood flow measurement. aneurysm clips, cochlear implants, and neurostimulators
MR is a primary choice for noninvasive angiography as it are examples of important contraindications to MR scan-
does not employ ionizing radiation; in many cases, diag- ning. Careful patient positioning, placement of MR coils,
nostic MR angiography (MRA) is accomplished without and use of monitoring equipment are essential to prevent
contrast media. MR plays a role in the workup of valvu- burns. Proper positioning, such as placing the structure
lar disease, cardiac masses, disorders of the pericardium, of interest as close as possible to scanner isocenter, is also
and myocardial ischemia. MR images may be acquired in important for optimal image quality.
any plane; however, accurate quantification of flow and MR studies entail long examination times, during
assessment of abnormalities that perturb flow must be per- which claustrophobic patients may be unable to remain
formed using imaging planes carefully chosen during the within the close confines of the scanner. Cardiac MR scans
scan. Physician monitoring is usually necessary for com- typically require the patient to repeatedly hold his or her
plex cases. MR is more difficult for patients to tolerate and breath for up to 30 seconds, which is challenging for many
less available than other noninvasive modalities. MR lacks patients. As a result of these constraints, sedation and gen-
known long-term biological side effects, making it ideal for eral anesthesia are often employed, especially in children.
younger patients and when repeated imaging is expected. Obese patients may not be able to undergo MR, more com-
monly due to body shape than weight. Finally, physiologi-
cal monitoring and emergency access to the patient during
Clinical Features an MR scan is limited, which may make imaging inadvis-
Cardiovascular MR is performed most often to assess the able for the severely ill.
aorta and its branches and to evaluate for structural heart Cardiac gating is required for cine acquisitions and
disease. Patients with suspected acute aortic syndromes may to prevent image degradation by motion artifacts. A reli-
undergo emergent MR, especially when iodinated contrast able electrocardiographic (ECG) signal is essential for
agents are contraindicated. Most cardiac MR cases are per- accurate gating. Several factors may cause poor ECG
formed as a problem-solving tool when echocardiography or signal, including inadequate lead contact, which can be
electrophysiological testing suggests an underlying disease. improved by shaving the patient or using conductive gel;
Common indications include workup of life-threatening end-inspiratory breath hold, which may degrade the ECG
dysrhythmias, determination of myocardial viability prior as compared to free breathing; and radiofrequency inter-
to revascularization, defining the etiology of impaired ven- ference during some pulse sequences. Higher field strength
tricular function, and evaluation of congenital heart disease (e.g., 3 Tesla) also impairs detection of the ECG signal.
in both children and adults. MR is used to assess areas that Vector cardiographic gating (VCG) and the use of fiber
are relatively inaccessible to echocardiography, such as the optic cables to transmit the signal can improve reliability
right ventricle, central blood vessels, and surgical shunts. of the monitor tracing. Scanner operators must examine
the tracing to ensure that the R-waves are correctly recog-
nized and marked by the scanner. If ECG or VCG moni-
Anatomy and Physiology toring fails, the peripheral pulse waveform, available on
MR accurately depicts many aspects of cardiovascular most current scanners, may be used as a last resort to gate
anatomy and physiology. However, MR is not suitable for the cardiac cycle.

8
 C a rd i ova s c u l a r M a g n e t i c R e s o n a n c e 9

(a) (b)

Figure 2.1. (a) Horizontal long-axis systolic steady-state free procession (SSFP) image from a healthy volunteer demonstrates focal
low signal in the left atrium (arrow) due to turbulent inflow (“a jet”) at the orifice of the left inferior pulmonary vein. (b) Left ventricular
outflow tract view systolic SSFP image in the same individual demonstrating a large jet in the ascending aorta (arrow).

Signal from flowing blood is routinely either How to Approach the Image
enhanced or suppressed to produce “bright blood” or Cardiovascular images should be acquired in more than
“dark blood” images, respectively. Turbulent flow causes one plane so that signal artifacts can be identified and
localized signal attenuation due to dephasing, which may clearly distinguished from pathology. Artifacts are pres-
be detectable as a low signal intensity “jet” on bright ent on nearly all scans, even when correctly prescribed.
blood images. Jets can reflect partial obstruction of flow Common, important artifacts include the following:
or may indicate valve dysfunction. Jets are often detect-
able only in specific imaging planes. Imaging in a nonop- ■ Magnetic susceptibility—Even small amounts of
timal plane can lead to a false-negative assessment. Jets weakly ferromagnetic materials and some nonferro-
may also be observed in normal patients, as in normal magnetic materials, which nonetheless cause distur-
pulmonary venous return into the left atrium (Fig. 2.1a) bances in the local magnetic field, may produce areas
or in the ascending aorta due to brisk left ventricular of signal void and/or geometric distortion. Stents and
outflow (Fig. 2.1b). Turbulence-related signal loss can endovascular embolization coils, although they may
also give the erroneous impression of vascular occlu- be MRI safe, are common culprits (Fig. 2.4a–b).
sion or intravascular or intracavitary filling-defects on ■ Motion—patient movement and respiratory motion
bright blood images. On dark blood images, incomplete lead to gross misplacement of signal or blurring of
suppression of flow-related signal may result in spuri- interfaces.
ous intravascular signal that might be misinterpreted as ■ Pulsation—a form of motion artifact caused by pul-
thrombus (Fig. 2.2a–b) or mass. satile movement of the heart and blood vessels which
One of the primary advantages of MR is quantifica- causes “ghosting” or spurious duplication of the sig-
tion of direction and velocity of blood flow. In cardio- nal from the pulsing structure along the phase encod-
vascular applications this is accomplished with velocity ing direction. Exchanging the frequency and phase
specific phase contrast sequences, wherein the opera- encoding directions can make this artifact obvious in
tor defines the velocity range of interest using a velocity cases of uncertainty.
encoding factor (VENC). The VENC should be chosen on ■ Parallel imaging—these approaches may produce
the basis of highest anticipated flow velocity. In the pres- misplaced signal in the center of the image when
ence of flow that exceeds the VENC, aliasing may result in the field of view does not encompass the entire
incorrect determination of both flow direction and veloc- cross section of the patient’s body. The artifact is
ity. When measuring flow downstream of a vascular or mitigated by increasing the field of view, lowering
valvular stenosis, flow velocity may reach 500 cm/s. Phase the acceleration factor, or abandoning acceleration
images should be visually inspected for aliasing while the altogether.
patient is still in the scanner so that flow quantification
sequences can be repeated with a higher VENC, if needed Multiple pulse-sequences are routinely used for cardiovas-
(Fig. 2.3a–c). cular MR acquisitions (see Table 2.1).
10 C a rd i a c I m a g i n g

(a) (b)

Figure 2.2. (a) Axial T1-weighted dark blood image demonstrates a well-demarcated filling defect in the right pulmonary artery
(arrow). The failure of blood signal nulling is secondary to slow flow due to the patient’s long-standing right-sided pulmonary venous
obstruction. (b) Axial post-contrast, fat-suppressed T1-weighted gradient echo image in the same patient demonstrates contrast
enhancement within the entire lumen, confirming patency.

(a) (b)

(c) ml/s

250

200

150

100

50

0 50 100 150 200 250 300 350 400 450 500 550 600 650
time (ms)

Figure 2.3. Magnitude (a) and velocity (b) images from an axial phase contrast acquisition performed with a very low velocity–
encoding factor in a healthy volunteer demonstrate two appearances of aliasing. Crescentic, low signal intensity (black on white) is
present in the ascending aorta (black arrow), and central high signal intensity (white on black) is present in the descending aorta
(white arrow). (c) Plot of flow velocity throughout the cardiac cycle reflects erroneous quantification during cardiac phases with the
highest velocity, where aliasing occurs (arrow).
 C a rd i ova s c u l a r M a g n e t i c R e s o n a n c e 11

(a) (b)

Figure 2.4. (a) Axial post-contrast, fat-suppressed T1-weighted gradient echo image demonstrates a large region of signal void due
to magnetic susceptibility artifact. (b) Anteroposterior plain radiograph shows multiple embolization coils, the cause of the artifact.
Note that the approximate level of the MR image (indicated by a horizontal line) is inferior to the coils. This shows the large distance
across which magnetic susceptibility effects may be significant.

What Not to Miss often acquired to include the pulmonary arteries, sys-
Although MR volume measurements are quantitative and temic arteries, and veins. Albumin binding contrast
more reproducible than those from echocardiography, can be used to allow longer imaging time.
there is still potential for error, particularly in measure- ■ MR of cardiac structure and function—components
ment of the irregular-shaped, trabeculated right ventricle. include localizing sequences, vertical long-axis/
Measurement of the cavity area may be problematic on the LA-LV two chamber cine, short-axis cine stack, hori-
basal slices due to difficulty in determination of the tricus- zontal long-axis/four chamber cine slice or stack, and
pid valve plane. Quantitative flow measurements can be optional dark blood stack.
complicated by failure to image the vessel in cross section, ■ Myocardial perfusion—during rest and/or stress.
nonlaminar flow, movement of the structure of interest, and Adenosine or regadenoson can be used for coronary
field inhomogeneity. In general, multiple distinct methods vasodilation to elicit ischemia.
of measurement should be used to verify results. However, ■ Myocardial viability—delayed enhancement imaging
when multiple measurements, each subject to error, are to detect scar from myocardial infarction or myocar-
summed in order to infer a measurement that cannot be dial fibrosis. A pattern of enhancement that does not
made directly, reliability may be compromised. follow a coronary artery territory suggests nonisch-
emic cardiomyopathy or myocarditis.
■ Assessment of congenital malformations—dedi-
Differential Diagnosis cated cine sequences (e.g., right ventricular outflow
Optimal use of cardiovascular MR requires appropriate selec- tract and aortic valve views); MRA is used to assess
tion of patients and knowledge of the abilities and drawbacks central vessels and shunts that may not be visual-
of both MR and alternative modalities. Patients with signifi- ized on echocardiography. Branch pulmonary artery
cant claustrophobia, dysrhythmia, or tachypnea, for example, flow is compared to determine the distribution to
are not good candidates for MR. MR has the distinct advan- each lung.
tage of avoiding ionizing radiation. However, in some pediat-
ric cases, such as clarification of vascular anatomy, CT may be
performed with a relatively low radiation dose and without Clinical Issues
sedation. MRA is advantageous in patients with extensive The high expense of purchasing, maintaining, and mon-
arterial calcification, which limits the accuracy of CT. Only itoring the use of specialized MR equipment translates
few specialized centers have sufficient expertise in stress car- into a relatively costly exam that is available in fewer
diac MR to make it a first line modality for ischemia detection. clinical settings. Because many institutions have only
one MR scanner, emergency access may be limited.
The lengthy imaging times needed for complex cardio-
Common Variants vascular studies may also adversely impact limited MR
■ MRA—contrast injection timed using real-time imag- resource availability. Several methods can be used to
ing monitoring or a timing bolus; multiple phases are decrease scan times:
12 C a rd i a c I m a g i n g

Table 2.1 - Common Pulse Sequences Used for Cardiovascular MR Acquisitions

SEQUENCE EXPLANATION USE PROS CONS

Bright blood/ Single shot; signal Primary sequence for Rapid acquisition of Susceptibility, flow,
steady-state free related to T2:T1 ratio static and cine images very high signal from and acceleration
procession (SSFP) flowing blood artifacts
Dark blood T1, T2, or proton den- Motion-free anatomic Best anatomic detail for Long imaging time and
sity weighted; blood imaging; T2W for cardiac chamber and breath holds needed for
signal is suppressed edema detection large vessel walls high resolution
Flow quantitation Stationary blood Quantitative veloc- Can determine regurgi- Aliasing occurs if
(phase contrast) nulled; specific flow ity and volume tant fraction, pressure VENC is low; must
velocities highlighted measurements gradients image vessel in cross
section
Contrast-enhanced 3D T1W high resolu- Pulmonary/systemic High resolution of vessel Long breath holds; con-
angiography tion during first-pass arteries, veins, shunts lumina; dataset used for trast injection timing
post-IV gadolinium reconstructions can be difficult
(Gd)
Perfusion (dynamic Several, very rapid Rest or stress myocardial Identification of hiber- Usually limited to 4
contrast enhancement) T1W slices during first perfusion nating myocardium, slices; resting only
pass of IV Gd ischemia perfusion is often
unhelpful
Viability (delayed T1W 10–20 min. after Detection of Planning of revascular- Nulling can be chal-
enhancement) IV Gd; normal myo- post-infarction scar or ization; patterns may lenging; long imaging
cardium is nulled fibrosis suggest disease etiology times
Tissue (myocardial) Repeating lines of Regional ven- Detailed view of Low resolution and sig-
tagging nulled signal followed tricular function, myocardial motion nal to noise ratio, may
through the cardiac cardiomyopathy and functional require post processing
cycle characterization
Real-time Extremely rapid Planning image planes, Pre-planning shortens Gives qualitative
imaging without respiratory variation exams, applied without information rather
cardiac or respiratory of wall motion (e.g., breath holding and than quantitative
gating tamponade) when gating fails volume data

■ Tailored examinations (shorter protocols designed Use of low-dose Gd might be considered to limit exposure.
to answer one specific question rather than a Resulting images, however, may be of low quality.
comprehensive exam)
■ Acceleration algorithms (especially with dedicated
cardiac coils to acquire multiple slices per breath hold) Key Points
■ Omission of high-resolution anatomic sequences ■ MR is the gold standard for certain cardiovascular

(replace dark blood with static steady-state free pre- assessments, yet it is technically demanding for the
cession bright blood images) clinician as well as challenging for the patient.
■ Limiting cine stacks (obtain a complete short-axis ■ Knowledge of MR artifacts is crucial for accurate

stack for function and selected single slice views in diagnosis.

other planes) ■ MR acquisitions can be tailored to address specific

■ Efficient use of delay time after contrast injection clinical questions and decrease acquisition times.
(obtain additional cine images between first-pass
post-contrast imaging and delayed viability)

Gadolinium (Gd)-based contrast agents are central to Suggested Reading

perfusion, myocardial viability, and angiography applica- American College of Radiology; Society of Cardiovascular
tions. Current clinical concern regarding the role of Gd Computed Tomography; Society for Cardiovascular
in nephrogenic systemic fibrosis limits its use to patients Magnetic Resonance; American Society of Nuclear
with normal or perhaps mildly impaired renal function. Cardiology; North American Society for Cardiac Imaging;
 C a rd i ova s c u l a r M a g n e t i c R e s o n a n c e 13

Society for Cardiovascular Angiography and Interventions; Hartung MP, Grist TM, François CJ. Magnetic resonance angiog-
Society of Interventional Radiology. ACCF/ACR/SCCT/ raphy: current status and future directions. J Cardiovasc Magn
SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness cri- Reson. 2011;13:19.
teria for cardiac computed tomography and cardiac mag- Institute for Magnetic Resonance Safety Education and Research.
netic resonance imaging. A report of the American College http://www.mrisafety.com.
of Cardiology Foundation Quality Strategic Directions Lipton ML. Keeping it safe: MRI site design, operations, and sur-
Committee Appropriateness Criteria Working Group. J Am veillance at an extended university health system. J Am Coll
Coll Radiol. 2006;3(10):751–771. Radiol. 2004;1(10):749–754.
Geva T. Magnetic resonance imaging: historical perspective. J Lotz J, Meier C, Leppert A, Galanski M. Cardiovascular flow mea-
Cardiovasc Magn Reson. 2006;8(4):573–580. surement with phase-contrast MR imaging: basic facts and
Ginat DT, Fong MW, Tuttle DJ, Hobbs SK , Vyas RC . implementation. Radiographics. 2002;22(3):651–671.
Cardiac imaging: part 1, MR pulse sequences, imag- Nael K, Fenchel M, Saleh R, Finn JP. Cardiac MR imaging: new
ing planes, and basic anatomy. AJR Am J Roentgenol . advances and role of 3T. Magn Reson Imaging Clin N Am.
2011 ; 197 ( 4 ): 808–815 . 2007;15(3):291–300.
Section Two sdglsdf;gl;fg

Normal Anatomy
CHAPTER 3

Normal Cardiac Anatomy

Andrew J. Plodkowski and Jeffrey M. Levsky

Definition The right atrium consists of a smooth-walled sinus

Understanding normal cardiac anatomy and how it is tradi- venarum at the confluence of the superior and inferior vena
tionally displayed is indispensable for detection of disease. cavae and a triangular, trabeculated atrial appendage. These
Although the standard cardiac anatomy consisting of two parts are joined along a broad interface marked by a ridge
atria and two ventricles is elementary, disease states can called the crista terminalis (Fig. 3.1). The coronary sinus,
cause marked deviations in chamber morphology, orienta- draining the myocardium, empties into the right atrium.
tion, and relationships. In addition, some normal aspects of The coronary sinus ostium may be part covered by a flap
anatomy depicted with high-resolution, three-dimensional of tissue called the Thebesian valve. Another flap of tissue,
imaging techniques are unintuitive and can be mistaken called the Eustachian valve, can be seen in some cases at the
for pathology. The heart is variably and obliquely orien- orifice of the insertion of the inferior vena cava.
tated in the thorax, and its configuration changes through- The interatrial septum separates the atria and is com-
out the cardiac cycle. Rather than the standard anatomic posed of the larger septum secundum and the smaller sep-
transaxial, coronal, and sagittal imaging planes, the heart is tum primum. The septum primum is a flap covering the
depicted using planes that are parallel or perpendicular to central opening in the septum secundum called the fora-
its own long axis. In this way, imaging the heart is different men ovale. The fossa ovalis is a depression seen only on the
from imaging any other organ. right atrial side, surrounding the foramen ovale. The anat-
omy of the interatrial septum is important for understand-
ing patent foramen ovale (Fig. 3.2) and atrial septal defects.
Clinical Features The left atrium has a smooth-walled, posterior por-
Understanding normal cardiac anatomy is the basis for tion which receives the pulmonary venous return and an
understanding cardiovascular disease, the most common appendage. In contrast to the triangular right atrial append-
cause of mortality worldwide and a major cause of mor- age, the left atrial appendage is tubular and has a narrow
bidity and health care expenses. On average, one American base. There is no crista separating the left atrial appendage
dies of cardiovascular disease every 39 seconds. If all forms from the remainder of the left atrium.
of cardiovascular disease were eliminated, life expectancy The tricuspid valve separates the right atrium from the
would rise by almost 7 years. Contrast this to a rise of right ventricle. It consists of three leaflets (anterior, septal,
only 3 years in life expectancy if all forms of cancer were and posterior) and is anchored by three papillary muscles
eliminated. within the right ventricle. The mitral valve separates the left
atrium from the left ventricle. In contrast to the tricuspid
valve, the mitral valve consists of only two leaflets (anterior
Anatomy and Physiology and posterior) and is anchored into the left ventricle by two
The right atrium receives the systemic venous return and papillary muscles. The papillary muscles attach to the com-
connects via the tricuspid valve to the right ventricle, missures, or places where valve leaflets meet, via tendons
which pumps the blood to the lungs for oxygenation. The called chordae tendinae. An atrioventricular valve’s name
left atrium receives the pulmonary venous return and comes from the ventricle that supports it. Thus, the valve
connects via the mitral valve to the left ventricle, which associated with the right ventricle is named “tricuspid” and
pumps oxygenated blood to sustain life throughout the the valve with the left ventricle is named “mitral,” regardless
body. Although sidedness is implied in the standard nam- of its actual morphology.
ing of the cardiac chambers, the cardiac chambers’ relative The ventricles are morphologically different. In gen-
positions depend on embryonic heart development (situs, eral, the right ventricle is shaped like a deformed pyramid
direction of ventricular looping) as well as both congenital (molded by the surrounding thorax), while the left ventricle
and acquired diseases and deformities of the surrounding is bullet-shaped. The right ventricle is usually higher in vol-
thorax. The identity of each chamber can be determined by ume, lower in pressure, thinner walled, and has more lon-
reliable morphological features in nearly all cases. gitudinal contractions. In comparison, the high-pressure,

17
18 C a rd i a c I m a g i n g

Figure 3.1. Horizontal long-axis bright-blood MR image from a Figure 3.3. Short-axis bright-blood MR image from a healthy
healthy volunteer demonstrates the crista terminalis, a normal volunteer demonstrates the crista supraventricularis (arrow),
tissue ridge separating the right atrial appendage from the a normal muscular ridge on the right ventricular side of the
remainder of the atrium (arrow), and the “Coumadin ridge,” a anterior septum.
normal fold separating the left atrial appendage from the left
superior pulmonary vein (arrowhead).

thicker left ventricle has more circumferential contrac- The previous descriptions fail particularly when
tions. The interventricular septum separating the right pressures in the right and left heart are abnormal. More
and left ventricles consists of a thin, smaller membranous constant features defining the right ventricle are heavy,
part toward the inferior base and a larger, thicker, muscu- irregular trabeculations and the presence of a moderator
lar part. The septum typically bows into the right ventricle, band connecting the interventricular septum and the ante-
thereby primarily acting as a part of the left ventricle. rior papillary muscle. The right ventricle also has a conus
or infundibulum leading to the pulmonic valve which is
separated from the rest of the ventricle by a muscular ridge
on the anterior part of the septum called the crista supra-
ventricularis (Fig. 3.3). The left ventricle has fine, regular
trabeculations, no moderator band, and no conus leading
to the aortic valve.

How to Approach the Image

Traditional imaging planes used throughout the body are
less useful in imaging the heart because of its oblique ori-
entation within the chest. Cardiac imaging planes are ori-
ented with respect to the long axis of the heart, which is
defined as the line connecting the center of the base of the
ventricles and the apex. There are many planes that par-
allel this line and are therefore called “long-axis views.”
The most important of these are the horizontal long-axis
(or four-chamber) view and the vertical long-axis (or
two-chamber) view. In distinction, the single short-axis
plane is perpendicular to the long axis of the heart.
Figure 3.2. Near short-axis reconstruction from a cardiac CT Multiple steps must be taken to obtain these views prop-
through the interatrial septum demonstrates rightward septal erly with MR (Fig. 3.4). To accurately convey the location
bowing (arrowhead) diagnostic of an atrial septal aneurysm
with an associated interatrial communication, a patent foramen
of abnormalities, the left ventricle is subdivided into stan-
ovale (arrow). dard segments (Fig. 3.5).
 N o r m a l C a rd i a c A n a to my 19

(a) (b)

(d) (c)

(f) (e)

Figure 3.4. Planning standard cardiac short- and horizontal long-axis views on MR. (A) An axial image is used to plan (yellow line)
a two-chamber view through the left atrium, mitral valve, and left ventricle. (B) The two-chamber view is used to plan (blue line) a
near four-chamber view (D) through the inferior part of the left ventricle and left atrium. The near four-chamber view (D) and the
two-chamber view (B) are used to plan (green lines) the short-axis plane (C) parallel to the mitral annulus and perpendicular to
the anterior, inferior, septal, and lateral walls. Mid- (C) and apical (F) short-axis views are used to plan (light blue lines) the true
four-chamber view (E) through the center of the left ventricular cavity, the acute margin of right ventricle, and the left
ventricular apex.

What Not to Miss ■ “Coumadin ridge” (left atrium)—fold separating the

Several normal cardiac structures may be mistakenly diag- left atrial appendage from the left superior pulmonary
nosed as pathology: vein (Fig. 3.1)

■ Crista terminalis (right atrium)—ridge dividing Differential Diagnosis

between the smooth part of the right atrium and the There are many modalities for imaging the heart, each with
right atrial appendage (Fig. 3.1) strengths and weaknesses (see Table 3.1).
■ Chiari’s network (right atrium)—thin fibers that
attach at the Eustachian valve or Thebesian valve
near the orifices of the inferior vena cava or coronary Common Variants
sinus, respectively Several anatomic variants exist within the heart, although
■ Crista supraventricularis (right ventricle)—ridge on they are commonly considered to be abnormalities. A patent
the anterior part of the septum dividing between the foramen ovale (25% incidence) is present when the septum
conus and the rest of the ventricle (Fig. 3.3) primum and secundum fail to fuse, allowing communication
20 C a rd i a c I m a g i n g

Basal Anterior
1
al

Ba
pt

Mid Anterior

s
2 ose

al
7

An 6
r
nte

An
ter

l
8 pta

ter 12
lA

Mi ater
Apical

ola

ter id

ol
sa

d
e
Anterior

An M
os
ter
Ba

13

al
l
Apical Apical
Septal Apex
Lateral
14 17
16

Inf

l
11 tera
l
ra
Ba

ero 9
Apical

Mi epta

ero d
5 late
sa

Inf Mi
d

la
Inferior

s
l

o
Inf 3

15

fer
ero

l In

l
Mid Inferior
se

sa
10
pt

Ba
al

Basal Inferior
4

Anterior

Apex

Inferior

Figure 3.5. Division of the left ventricle into 17 American Heart Association standard segments. The ventricle is divided into thirds
from base to apex (bottom), and then radial segment names and numbers are assigned at each level (top). The one third of the
myocardium closest to the base of the heart extends from the mitral annulus to the tips of the papillary muscles at end diastole (far
left). The mid third extends through the papillary muscles (second from left) and the apical third extends from where the papillary
muscles end through most of the remaining cavity (second from right). The true apex is assigned its own segment (far right).

Table 3.1 - Common Modalities for Imaging the Heart

MODALITY PROS CONS APPLICATIONS

Computed Isotropic 3D, high resolution, Radiation, iodinated contrast, Cardiac structure and basic
tomography (CT) shortest scan time, includes need regular slow heart rate, function, luminal or mural
surrounding thorax, widely limited physiology, many masses, localizing thoracic
available incidental findings structures for operative
planning
Magnetic High resolution, no radiation, Long exam, less tolerated, con- Quantitative structure and
resonance (MR) most accurate measurement traindicated with metal implants, function (volumes, wall
of blood flow and chamber clinician monitoring, expensive, motion, mass, flow), myocar-
volume less widely available dial viability and fibrosis
Trans-thoracic echocar- Portable, inexpensive, no Limited by acoustic windows and Cardiac structure and func-
diography (TTE) radiation, can be used in body habitus, highly operator tion (wall motion, valves,
unstable patients, real time, dependent, limited imaging of the outflow tracts, flow), bubble
detects flow right heart study to detect shunts
Trans-esophageal High resolution, no radiation, Invasive, sedation, clinician opera- Cardiac thrombi or vegeta-
echocardiography (TEE) less acoustic window limita- tor, contraindicated in esophageal tions, atrial septum, left atrial
tions, real time, can be used in disorders, limited to structures appendage, guidance for
unstable patients near the esophagus interventions
Conventional/catheter Interventions, hemodynamic Radiation, invasive, sedation, Hemodynamics, expanding
angiography measurements, can be used in contrast, clinician operator, only applications in valvular and
unstable patients cavities are examined congenital disease
Nuclear myocardial Myocardial perfusion at Radiation, artifacts due to body Myocardial ischemia and
perfusion imaging stress and rest, well validated, habitus, limited resolution of viability, risk stratification
predicts outcomes cardiac structure and flow before intervention
 N o r m a l C a rd i a c A n a to my 21

between the atria (Fig. 3.2). The left atrium commonly has Suggested Reading
accessory appendages and diverticula (20% incidence). Atlas of Human Cardiac Anatomy: The Visible Heart Lab at the
Atrial septal aneurysms (1% incidence) are defined by a part University of Minnesota. http://www.vhlab.umn.edu/atlas/
of the septum measuring at least 15 mm in diameter deviat- index.shtml.
ing by more than 15 mm to either side (Fig. 3.2). Broderick LS, Brooks GN, Kuhlman JE. Anatomic pitfalls of the
heart and pericardium. Radiographics. 2005;25(2):441–453.
Cerqueira MD, Weissman NJ, Dilsizian V, et al.; American Heart
Association Writing Group on Myocardial Segmentation and
Clinical Issues Registration for Cardiac Imaging. Standardized myocardial
The advent of accurate cardiac imaging methods has largely segmentation and nomenclature for tomographic imaging
replaced more simple, inexpensive, and general techniques of the heart: a statement for healthcare professionals from
of diagnosis, including the physical exam. A “one-stop shop” the Cardiac Imaging Committee of the Council on Clinical
for cardiac diagnostic imaging has been sought for years; Cardiology of the American Heart Association. Circulation.
however, no single modality consistently provides a compre- 2002;105(4):539–542.
hensive evaluation. Improvements in MR technology make Ginat DT, Fong MW, Tuttle DJ, et al. Cardiac imaging: part 1, MR
it the likeliest bet to provide all anatomic and physiologi- pulse sequences, imaging planes, and basic anatomy. AJR Am J
cal information needed; however, an inclusive exam is time Roentgenol. 2011;197(4):808–815.
Lapierre C, Déry J, Guérin R, et al. Segmental approach to imaging
consuming at present. In most evaluations of cardiovascular
of congenital heart disease. Radiographics. 2010;30(2):397–411.
disease, patients receive two, three, or more modalities. This O’Brien JP, Srichai MB, Hecht EM, et al. Anatomy of the heart
exacerbates the growing problem of overuse of cardiac imag- at multidetector CT: what the radiologist needs to know.
ing, an often cited reason for escalating medical expenses. Radiographics. 2007;27(6):1569–1582.
Roger VL, Go AS, Lloyd-Jones DM, et al.; American Heart
Association Statistics Committee and Stroke Statistics
Key Points Subcommittee. Heart disease and stroke statistics—2012
■ The heart is composed of four chambers with charac- update: a report from the American Heart Association.
teristic morphologies. Standardized display of the heart Circulation. 2012;125(1):e2–e220.
uses planes parallel and perpendicular to its long axis.
■ The left ventricle is broken up into equal thirds from

base to apex and then subdivided into 17 standard-

ized segments.
■ Various cardiac structures and variants may chal-

lenge the untrained reader to mistakenly diagnose

pathology.
 CHAPTER 4

Normal Coronary Arterial

and Venous Anatomy
Daniel Sova, Hugo Spindola-Franco, and Jeffrey M. Levsky

Definition section. The segmental anatomy is presented according to

The coronary circulation supplies and drains the myocar- the Society of Cardiovascular Computed Tomography 2009
dium, accounting for about 5% of the total cardiac output. consensus statement designed for use in CT angiography.
During stress, such as exercise, cardiac oxygen demands are The left and right coronary arteries arise from the
normally met by an approximately fivefold increase in per- intracardiac portion, or root, of the aorta. The right coro-
fusion. The most common disease of the coronary arteries, nary artery (RCA) arises from the right coronary sinus (of
atherosclerosis, limits physiological coronary flow regula- Valsalva), and the left main coronary arises slightly cepha-
tion. Despite the presence of collateral vessels, a coronary lad, from the left posterior coronary sinus. Usually, no ves-
artery most often functions as the sole supply to part of the sel arises from the right posterior or non-coronary sinus
myocardium (“end artery”), and its compromise leads to (Fig. 4.1).
infarction. Coronary venous anatomy is far more variable The RCA proximally courses between the pulmonary
and less scrutinized than the arterial system. Profound artery and the right atrial appendage and then continues
understanding of normal and variant coronary anatomy is in the right atrioventricular groove. The conus artery is
necessary for accurate diagnosis, reporting of pathology, the first branch of the RCA. It runs anteriorly to encircle
and treatment planning. the right ventricular outflow tract. The second branch, the
sinoatrial node artery, runs rightward and cephalad to the
superior cavoatrial junction (Fig. 4.1). The proximal RCA
Clinical Features and mid RCA refer to the first and second halves of the
Atherosclerosis is by far the most important abnormality course of the artery to the acute margin, the point where it
of the coronary arteries, accounting for 1 in 6 deaths in the turns under the inferior surface of the heart. Branches prox-
United States. Given its enormous impact, atherosclerosis imal to the acute margin, called right ventricular marginals,
is the etiology implied by the general term coronary artery supply the right ventricular free wall. The acute marginal
disease (CAD). Other diseases of the coronaries include the branch arises at the level of the acute margin. The distal
following: RCA courses under the inferior wall of the right ventricle to
give off the posterior descending artery (PDA), which sup-
■ Spontaneous vasospasm—a cause of chest pain syn- plies the basal septum. Finally, at the point where the car-
dromes and, occasionally, myocardial infarction diac chambers meet, the RCA gives rise to the crux artery.
■ Anomalous course—some coronary artery paths pre- The crux artery yields the atrioventricular node artery and
dispose patients to dysrhythmia and sudden death supplies the inferior wall of the left ventricle via posterolat-
■ Fistula—anomalous termination in a cardiac chamber, eral left ventricular branches (PLV or PLB) (Fig. 4.2a–b).
the coronary sinus or a systemic or pulmonary vessel The left main coronary artery runs between the pul-
■ Aneurysm—the result of atherosclerosis or inflam- monary artery and the left atrial appendage. It bifurcates to
mation such as Kawasaki’s disease yield the left anterior descending (LAD) and left circumflex
■ Pseudoaneurysm—the result of prior trauma, surgery (LCX) arteries. The LAD runs in the anterior interventricu-
or percutaneous intervention lar sulcus and gives rise to septal and diagonal branches,
supplying the anteroseptum and the anterior wall, respec-
Coronary venous diseases are rare. The clinical applica- tively. The first, and usually largest, septal branch separates
tion of coronary vein mapping is in planning interventions, the proximal and mid LAD. Lesions of the proximal LAD
including cardiac resynchronization therapy. cause considerably greater myocardial compromise than
more distal lesions. The mid LAD continues until half of
the distance to the left ventricular apex. The distal LAD
Anatomy and Physiology includes the vessel course to the apex. The LCX runs in the
The most common configuration of the coronary arteries left atrioventricular groove and gives off obtuse marginal
is described first. Common variants are noted later in this (OM) branches, which supply the lateral wall. The takeoff

22
 N o r m a l C o ro n a r y A r te r i a l a n d Ve n o u s A n a to my 23

LAD courses along the surface of the interventricular sep-

tum in the anterior interventricular sulcus (Fig. 4.4).
The coronary veins consist of greater and lesser
systems which drain the external two-thirds and the
internal one-third of the ventricular myocardium, respec-
tively. The greater system includes the coronary sinus
and non-coronary sinus tributaries. The left ventricle is
predominantly drained by coronary sinus tributaries,
while the atria and right ventricle are mostly drained by
non-coronary sinus tributaries. The lesser system includes
channels and sinusoids within the myocardium. Imaging
of the coronary sinus tributaries is most important for elec-
trophysiology interventions; they are described next.
The great cardiac vein (GCV), the largest and most ana-
tomically constant of the coronary veins, drains the apex,
anterior portion of both ventricles, and the anterior septum.
It courses superiorly in the anterior interventricular sul-
cus alongside the LAD. The GCV then travels posteriorly
and inferiorly to course in the left atrioventricular groove
alongside the LCX to finally drain into the coronary sinus
Figure 4.1. Maximum intensity projection (MIP) CT image (Fig. 4.3a–b). The middle cardiac vein (inferior interventric-
of the aortic root (Ao) showing the left coronary sinus (LCS)
of Valsalva, right coronary sinus (RCS), and non-coronary
ular vein) travels in the inferior interventricular sulcus from
sinus (NCS). The right coronary artery (RCA) and its proximal the cardiac apex to the coronary sinus. It drains the inferior
branches, the conus artery (C) and the sinoatrial node artery walls of both ventricles and the inferior septum (Fig. 4.2a–b).
(SAN), are shown. The left main coronary artery (LM) and its
branches, the left anterior descending (LAD), left circumflex
Drainage of the inferior and lateral walls of the left ventricle
(LCX), and ramus intermedius (RI), are also shown. occurs directly into the coronary sinus via one or more pos-
terior left ventricular veins, which are favored for placement
of left ventricular pacing leads (Fig. 4.5). A left (obtuse)
of the first OM branch separates the proximal LCX from marginal vein usually drains a large portion of the remain-
the mid-to-distal segment (Fig. 4.3a–b). ing ventricular wall, passing over an OM branch of the LCX.
In review, the RCA and the LCX course around the tri- The lesser cardiac vein courses in the right atrioventricular
cuspid and mitral annuli, respectively, in the right and left groove alongside the RCA to drain the inferior right ven-
atrioventricular grooves, on opposite sides of the heart; the tricular wall into the coronary sinus.

(a) (b)

Figure 4.2. (a) MIP CT image of the right atrioventricular groove (“C-view”) demonstrates the right coronary artery (RCA)
branches: conus artery (C), sinoatrial node artery (SAN), right ventricular marginals (M), acute marginal (AM), posterior descending
artery (PDA), atrioventricular node artery (AVN), crux artery, and posterolateral left ventricular branch (PLV). The middle cardiac vein
(MCV) is noted. (b) MIP CT image of the inferior surface of the heart shows the distal (d) RCA and its branches. The great cardiac
vein (GCV) and MCV draining into the coronary sinus (CS) are shown.
24 C a rd i a c I m a g i n g

(a) (b)

Figure 4.3. (a) MIP CT image of the left main coronary artery (LM) circulation. The LAD, septal (S) and diagonal (D) branches are
shown. The LCX and multiple obtuse marginal branches (OM) are shown. The great cardiac vein (GCV) is noted. (b) MIP CT image
along the interventricular septum shows the length of the LAD and part of the LCX. The anterior interventricular part (arrowhead) and
the more distal part (arrow) of the GCV in the left atrioventricular groove are shown.

The coronary sinus is an approximately 3-cm tube How to Approach the Image
bounded proximally by its junction with the GCV and dis- Coronary CT arteriography is performed at peak arterial
tally by its drainage into the right atrium (Figs. 4.2b, 4.5). phase of enhancement after rapid IV contrast injection.
The proximal end of the coronary sinus is marked by its Coronary CT venography is performed by increasing the
confluence with the oblique vein of Marshall, the short arterial delay time by approximately 3 seconds. MR coro-
anatomic remnant of the left superior vena cava, and by nary angiography is usually performed without contrast
the valve of Vieussens. The distal coronary sinus is marked and most commonly involves a free-breathing whole heart
by the Thebesian valve. These landmarks are seen on the acquisition using an additional radiofrequency pulse that
minority of imaging studies. tracks the position of the diaphragm for respiratory gating.

What Not to Miss

Each modality for assessing the coronary arteries has diag-
nostic limitations. Coronary CT has decreased accuracy in
the setting of extensive calcification, limited assessment of
small or distal branches, and relatively poor visualization
of septal branches of the LAD. MR coronary angiography
is highly operator dependent, fails to provide diagnostic
images in a significant number of patients, and typically
identifies only proximal stenotic lesions. Catheter angiog-
raphy is insensitive to even extensive atherosclerotic disease
when there is positive remodeling and relative preservation
of luminal caliber, can miss aorto-ostial lesions, and is lim-
ited in diagnosis of anomalous coronary artery courses.

Differential Diagnosis
CT is the primary noninvasive modality for assessment of
coronary anatomy. MR currently has a limited role, usually
confined to location of coronary artery origins and proxi-
mal courses. Electrocardiographic, echocardiographic, and
Figure 4.4. Three-dimensional rendering of a coronary CT radionuclide stress imaging are important primary exami-
showing the RCA and LCX coursing in the right and left
atrioventricular grooves, respectively, and the LAD coursing nations for detection of ischemia caused by severe CAD;
along the interventricular septum. they can also be used to judge the physiological significance
 N o r m a l C o ro n a r y A r te r i a l a n d Ve n o u s A n a to my 25

fractional flow reserve, adjunct invasive modalities that

seek to assess the physiological significance of stenoses.

Common Variants
■ Coronary dominance—the most consequential of

the variations that determines the supply of the basal

septum (via the PDA) and inferior wall of the left
ventricle (via PLV branches). In 80% of cases the
RCA supplies the PDA and PLVs via the crux artery
(“right dominant”) (Fig. 4.2a–b); in 10% of cases the
LCX supplies the PLV branches and the PDA while
the RCA is small and there is no crux artery (“left
dominant”) (Fig. 4.6); in 10% of cases the RCA gives
rise to the PDA but there is no crux artery and the
LCX supplies the PLV arteries (“codominant” or
“balanced”).
■ Separate origins—such as an additional origin of the

conus branch from the right coronary sinus (Fig. 4.6)

or individual LAD and LCX origins from the left
Figure 4.5. MIP CT image showing the posterior left ventricular coronary sinus (absent left main coronary artery)
vein (PLVV) draining into the coronary sinus (CS). The distal (Fig. 4.7).
RCA and its branches, including multiple posterior descending
arteries (PDA) and posterolateral left ventricular arteries (PLV) ■ Ramus intermedius—the left main coronary artery
are shown. trifurcates in a significant number of patients to yield
the LAD, LCX, and ramus intermedius (Fig. 4.1).
■ Ectopic origins—the coronary arteries may arise
of lesions seen on CT. Invasive/catheter angiography is
above or below the sinus of Valsalva or anomalously
considered the gold standard for coronary artery anatomy,
from the incorrect sinus.
pathology, and treatment planning. An increasing role is
■ Number of vessels—there may be duplication of ves-
played by intravascular ultrasound and measurement of
sels such as a dual LAD system or multiple PDAs
(Fig. 4.5). On the other hand, a single coronary artery
can supply the entire heart.

Figure 4.6. MIP CT image of a left dominant coronary artery

system showing both the proximal (p) and distal (d) portions
of the LCX and its obtuse marginal (OM), posterolateral left
ventricular (PLV), and posterior descending (PDA) branches. Figure 4.7. MIP CT image showing separate origins of the LAD
There are separate origins of the RCA and conus artery (C) from and LCX from the left coronary sinus (absent left main coronary
the right coronary sinus. artery).
26 C a rd i a c I m a g i n g

Clinical Issues Mehta LS, Raman SV, Ghosh S. Evidence for medical management
Treatment of CAD is a constantly evolving field with versus revascularization for coronary artery disease: guidance
diverse approaches and a large number of clinical trials. from cardiac magnetic resonance imaging and computed
tomography. Semin Roentgenol. 2012;47(3):220–227.
The choice of medical management, percutaneous inter-
Raff GL, Abidov A, Achenbach S, Berman DS, Boxt LM, Budoff
vention, and minimally invasive robotic, “off-pump” and
MJ, Cheng V, DeFrance T, Hellinger JC, Karlsberg RP; Society
classic open surgical bypass may be difficult and in many of Cardiovascular Computed Tomography. SCCT guidelines
scenarios is controversial. The advent of coronary CT offers for the interpretation and reporting of coronary computed
a new method for the diagnosis of CAD and raises ques- tomographic angiography. J Cardiovasc Comput Tomogr.
tions regarding optimal treatment. Previously used physi- 2009;3(2):122–136.
ological modalities do not typically identify disease when Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD,
it is not flow limiting, no matter how extensive. We do not Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton
have an adequate evidence basis to guide treatment of non- HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM,
obstructive but diffuse CAD. Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc
DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian
D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie
PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D,
Key Points
Turner MB; American Heart Association Statistics Committee
■ Intimate knowledge of anatomy and nomenclature is
and Stroke Statistics Subcommittee. Heart disease and stroke
necessary to diagnose, describe, and plan treatment of statistics—2012 update: a report from the American Heart
coronary diseases. Association. Circulation. 2012;125(1):e2–e220.
■ Anatomical variations are common in the arterial sys- Sakuma H. Coronary CT versus MR angiography: the role of MR
tem and are omnipresent in the venous system. angiography. Radiology. 2011;258(2):340–349.
■ CAD diagnosis and treatment are in active evolution. Saremi F, Muresian H, Sánchez-Quintana D. Coronary
veins: comprehensive CT-anatomic classification and
review of variants and clinical implications. Radiographics.
Suggested Reading 2012;32(1):E1–32.
Malagò R, Pezzato A, Barbiani C, Alfonsi U, Nicolì L, Caliari Spindola-Franco H, Fish BG. Radiology of the Heart: Cardiac
G, Pozzi Mucelli R. Coronary artery anatomy and variants. Imaging in Infants, Children and Adults. New York:
Pediatr Radiol. 2011;41(12):1505–1515. Springer-Verlag; 1985.
CHAPTER 5

Normal Great Vessel Anatomy

Andrew J. Plodkowski and Jeffrey M. Levsky

Definition cavae. The azygos vein delivers blood to the SVC from
Abnormalities of the great vessels were traditionally the posterior walls of the thorax and abdomen. The right
diagnosed by nonspecific symptoms and physical exam, atrium receives blood from lower body via the inferior vena
surgery, or autopsy. This changed dramatically with the cava.
introduction of invasive angiography over 80 years ago and After blood traverses the right heart it is pumped
has changed again with refinement of noninvasive CT and through the pulmonic valve, into the pulmonary arteries
MR imaging over the past few decades. CT and MR angiog- and the lungs. The pulmonic valve, which is attached to
raphy are now considered to be the examinations of choice the base of the right ventricular conus or infundibulum,
for a wide array of diseases and anomalies of the aorta and consists of three flaps of tissue, or cusps (anterior, left, and
its branches, the pulmonary arteries and veins, and the sys- right). Just above the valve there are outpouchings of the
temic veins. Diagnosis depends on a strong foundation of pulmonic root called sinuses of Valsalva corresponding to
understanding normal great vessel anatomy. Normal ana- each cusp. The pulmonary trunk above the sinuses courses
tomic relationships, as depicted by non-invasive imaging, posteriorly before bifurcating into a left and right branch.
are a key part of the road map for treatment planning, espe- The left pulmonary artery travels below the aortic arch
cially with the current explosive growth of image-guided and above the left bronchus. The right pulmonary artery
and minimally invasive procedures. courses below the right bronchus (Figs. 5.2, 5.3).
Blood returns from the lungs to the heart via the pul-
monary veins into the left atrium. There are typically four
Clinical Features pulmonary venoatrial junctions, with superior and infe-
Great vessel diseases include several common, critical rior vein ostia on each side. The superior veins drain the
pathologies, which are revealed by noninvasive imaging. anteriorly located upper lobes (including the lingula) and
Prompt diagnosis and classification of aortic dissection is the right middle lobe. The inferior veins drain the more
crucial for lifesaving surgical management as early mortal- posterior lower lobes. The central pulmonary veins are
ity rates are 1–2% per hour after the onset of symptoms. inferior to the left and right branch pulmonary arteries
CT angiography (CTA) has become the standard method (Fig. 5.4).
for diagnosing acute pulmonary embolism, which accounts After blood traverses the left heart it is pumped
for 290,000 fatalities in the United States every year. through the aortic valve to the rest of the body via the aorta
Noninvasive angiography is the primary means to detect (Fig. 5.2). The intracardiac part of the aorta that is attached
systemic venous obstruction, such as superior vena cava to the left ventricle is termed the aortic root. The first part
syndrome, as well as to determine its cause. Finally, imag- of the root is the aortic valve, which consists of three cusps
ing plays an important role in mapping the pulmonary vein (posterior, left, right) attached at the annulus. Above the
to left atrial junctions for catheter-based ablation therapy valve are sinuses of Valsalva, just like the pulmonary root.
for atrial fibrillation. The right coronary artery originates from the right sinus,
and the left main coronary artery originates from the left
sinus. The end of the aortic root is the sinotubular junc-
Anatomy and Physiology tion, where the aorta assumes a tubular shape (Fig. 5.5).
The right atrium receives blood from the upper body via the The aorta ascends above the pulmonary artery and arches
superior vena cava (SVC), which is formed by the conflu- posteriorly. The aortic arch is typically left-sided, meaning
ence of the left and right brachiocephalic veins. Each bra- that it crosses the anteroposterior level of the mainstem
chiocephalic vein forms from the union of a subclavian and bronchus on the left side. The aortic arch gives rise to three
internal jugular vein. As the SVC is typically a right-sided major branches: the brachiocephalic, left common carotid,
structure, the left brachiocephalic vein is longer, draping and left subclavian arteries. Finally, the aorta turns caudad
over the aorta. The left brachiocephalic vein also receives and descends along the posterior thorax. The descending
blood from the superior intercostal vein (Fig. 5.1) and may aorta gives rise to intercostal arteries at each level and a
serve as a connection between duplicated superior vena variable number of bronchial arteries.

27
28 C a rd i a c I m a g i n g

Figure 5.3. Multiplanar reformatted CT image of the normal

main pulmonary artery (MPA) bifurcation demonstrates that
the left pulmonary artery (LPA) is the natural continuation of
Figure 5.1. 3D rendered CT image of the superior intercostal the main trunk (black arrow), while the right pulmonary artery
vein (arrow) draping over the aorta and draining into the left (RPA) takes off at about a 90-degree angle (yellow arrow). The
brachiocephalic vein (LBV). This normal vein gives rise to the ascending aorta (Asc Ao), descending aorta (Desc Ao), and
“aortic nipple” shadow on plain radiographs and may be superior vena cava (SVC) are shown.
densely opacified by a left upper extremity contrast injection, as
demonstrated here. The superior vena cava (SVC), ascending
aorta (Asc Ao), right ventricle (RV), and left ventricle (LV)
are shown.

Figure 5.4. 3D rendered CT image from a posterior view

Figure 5.2. 3D rendered CT image of the normal relationship of demonstrating typical pulmonary vein drainage into the left
the great arteries. The aorta (Ao) twists around or crosses the atrium (LA). There are separate right superior (RSV), right inferior
main pulmonary artery (MPA) and arches cephalad over its (RIV), left superior (LSV), and left inferior vein (LIV) orifices. The
bifurcation. The left pulmonary artery (LPA) and superior vena right pulmonary artery (RPA) and left pulmonary artery (LPA) are
cava (SVC) are shown. shown. Part of the aorta was removed to expose the veins.
 N o r m a l G re a t Ve s s e l A n a to my 29

What Not to Miss

Common false-positive interpretations in great vessel
imaging include the following:

■ Aortic aneurysm—many imagers use incorrect

thresholds for dilation and aneurysm. Normal caliber
ranges, dependent on age, gender, and body size in
children, must be used.
■ Aortic dissection—aortic motion causes signal aver-
aging of the vessel with neighboring low-attenuation
structures to give the false impression of a dissection
flap. Gated acquisitions or half-segment reconstruc-
tion may alleviate this artifact.
■ Pulmonary embolism—several artifacts including
(1) respiratory and cardiac motion, (2) streak from
high-attenuation contrast in the SVC, and (3) slow flow
may result in filling defects. Careful evaluation for motion
(using lung windows) and linear artifacts may help.
■ Venous thrombosis—due to early phase of imaging
Figure 5.5. MIP CT image of the aorta (Ao). The aortic
from mixing of unopacified and opacified blood. An
root begins with the annulus (red line) just above the left appropriate venous delay (often ~90 seconds after
ventricular outflow tract (LVOT), includes the sinuses of contrast injection) will provide homogeneous vein
Valsalva (R—right and L—left are shown), and ends with the
sinotubular junction (blue line). The ascending (Asc), arch, and
opacification.
descending (Desc) segments are shown. The arch branches ■ Postoperative aortic leak—due to high attenuation sur-
are the brachiocephalic artery (BA), left common carotid gical materials or postoperative hematoma. Obtaining
artery (*), and left subclavian artery (+). The unopacified left
brachiocephalic vein (LBV), right pulmonary artery (RPA), left
pre-contrast imaging and having familiarity with nor-
pulmonary artery (LPA), left superior pulmonary vein (LSV), left mal postoperative appearances are important.
inferior pulmonary vein (LIV), and left atrium (LA) are shown. ■ Inaccurate MR flow quantification—often due to turbu-
lence that decreases the velocity-to-noise ratio or aliasing
due to faster than expected flow velocities. Flows should
How to Approach the Image
be assessed in regions with as little turbulence as possible
Assessment for acute pathology such as pulmonary
and with an appropriate velocity-encoding factor.
embolism or aortic dissection can usually be done with
standard axial images with occasional reference to sag-
ittal and coronal reconstructions. The most accurate
Differential Diagnosis
assessment of vessel caliber and wall thickness is from
There are many modalities for imaging the great vessels,
true cross-sectional views, which can be generated by
each of which has strengths and weaknesses (see Table 5.1).
post-processing 3D angiographic datasets or planned
in real time on the MR scanner. Obtaining an exact
cross-sectional plane requires two other, ideally orthog-
Common Variants
onal planes for proper alignment. Vessel measurements
The systemic veins and pulmonary arteries are without sig-
also depend on the following:
nificant normal variants; some anomalies of these vessels
are described in other sections of this book. There is varia-
■ Inclusion of the vessel wall (may be difficult on MRA
tion of the arborization of the pulmonary arteries, which
or subtraction datasets)
has importance in description of the level (lobar, segmen-
■ The phase of the cardiac cycle (arteries are larger dur-
tal, subsegmental) and location of pulmonary emboli. In
ing systole)
general, the bronchi should be used as an anatomic guide.
■ Signal averaging when non-gated acquisitions are
The pulmonary venous–left atrial junctions have com-
used
mon normal variations that are important for planning
■ Hydration or hemodynamic state
ablation procedures to treat atrial fibrillation. The exact loca-
tion of the venoatrial junction is uncertain in many cases,
At present, the most accurate method for noninvasive
as the vein assumes a flared or funnel-like shape. About
vessel wall analysis is CTA. The most accurate measure-
25% of people studied with CT venography have more than
ment of changing vessel caliber over the cardiac cycle is by
two right pulmonary venoatrial junctions; a separate right
bright-blood cine MR acquisition.
middle lobe vein insertion is the most common variant
30 C a rd i a c I m a g i n g

Table 5.1 - Modalities for Imaging the Great Vessels

MODALITY PROS CONS APPLICATIONS

CT angiography Fastest; suitable for critically ill Radiation; iodinated Entire aorta; pulmonary embolism;
patients; best evaluation of vessel contrast; many incidental trauma; whole-body angiography
wall and surrounding structures, findings, minimal flow for vascular intervention;
true isotropic 3D data information pulmonary veins
MR angiography No radiation; non-contrast exams Not for critically ill or Aortic dissection; body angiography;
in patients with renal failure; quan- patients with claustrophobia ventriculoarterial valve function;
titative flow information or some metal implants pulmonary vein anatomy
Conventional Pressure measurements; highest Invasive; radiation; iodin- Increasing array of endovascular,
angiography resolution of small vessels; inter- ated contrast; only lumen cardiac and valvular interventions;
ventions; suitable for critically ill seen; clinician operator pulmonary hypertension
Echocardiography No radiation, TEE assessment of Poor visualization of great Ascending aortic dissection; peri-
ascending aortic dissection; por- vessels without TEE; TEE is operative guidance and assessment;
table; suitable for critically ill invasive, requires sedation aortic valve dysfunction
Ventilation— Low radiation; good in dyspnea Nuclear pharmacy Pulmonary embolism, especially in
perfusion (lacks respiratory motion artifact); availability; longer study; young or pregnant patients or those
scintigraphy large evidence base less suited to critically ill with normal chest x-rays
TEE, transesophageal echocardiography.

(Fig. 5.6). A common left pulmonary venoatrial junction arch. This variant is often referred to as a “bovine arch”
is also frequently present (~15%) (Fig. 5.7). Variations with (Fig. 5.8). In about 6% of people, there is a separate origin
more than two left pulmonary vein insertions or a single for the left vertebral artery from the aortic arch proximal
right pulmonary venous orifice are uncommon. to the left subclavian artery. In this case there are four arch
Variations of the aortic arch vessels are common. The vessels (Fig. 5.9).
most prevalent of these (~25%) is a common trunk that
gives rise to the left common carotid artery and the bra-
chiocephalic artery. Thus, only two vessels arise from the

Figure 5.6. 3D rendered CT image from a posterior view Figure 5.7. 3D rendered CT image from a posterior view
demonstrates an accessory right middle lobe pulmonary vein demonstrates a common left pulmonary vein (C) receiving
(RMV) draining directly into the left atrium (LA) in addition to the blood from the left superior (LSV) and left inferior veins (LIV) and
typical right superior (RSV), right inferior (RIV), left superior (LSV), draining into the left atrium (LA). Typical right superior (RSV)
and left inferior vein (LIV) orifices. The left pulmonary artery (LPA) and right inferior vein (RIV) connections are present. The right
is shown. The right pulmonary artery and part of the aorta were pulmonary artery (RPA) is shown. Parts of the pulmonary arteries
removed to expose the veins. and the aorta were removed to expose the veins.
 Another Random Document on
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Vive irritation d'Elisabeth après
le retour de lord de North. 326

424e Dépêche.—24 décemb.—

AU ROI. 327
Efforts pour empêcher la
guerre. 327
Nouvelles d'Allemagne et
d'Espagne. 327
Mise en arrêt de la comtesse
de Lennox. 328

425e Dépêche.—28 décemb.—

AU ROI. 329
Détails de la précédente
audience. 329
Demande d'explication. 334
A LA REINE. 335
Confidences sur les rapports
de lord de North. 335
Mémoire. Menace d'une guerre
générale. 337
Complot contre le roi. 341
AU ROI. (lettre secrète). 343
Détails sur le complot. 343

ANNÉE 1575.

426e Dépêche.—2 janvier.—

AU ROI. 343
Audience. 343
A LA REINE. 350
Demande d'une réponse pour
Elisabeth. 350

427e Dépêche.—7 janvier.—

AU ROI. 351
Maladie de l'ambassadeur. 352
Instances pour son rappel. 352
Affaires d'Irlande. 353
Nouvelles de la Rochelle. 353

428e Dépêche.—13 janvier.—

AU ROI. 354
Négociation de la paix. 354
Mort du duc de Bouillon. 354
Et du cardinal de Lorraine. 355

429e Dépêche.—19 janvier.—

AU ROI. 356
Affaires de Marie Stuart. 356
Négociation de la paix. 357
Nouvelles des Pays-Bas. 359

430e Dépêche.—24 janvier.—

AU ROI. 360
Armemens. 360
Nouvelles des Pays-Bas. 362
Saisie de lettres concernant
Marie Stuart. 362

431e Dépêche.—29 janvier.—

AU ROI. 363
Secours pour les protestans. 363
Projets sur l'Ecosse. 364
A LA REINE. 365
Instances pour une réponse. 365

432e Dépêche.—4 février.—

AU ROI. 366
Audience. 366
Avis à la reine-mère. 372

433e Dépêche.—10 février.—

AU ROI. 373
Conférence avec Leicester. 373
Nouvelles d'Ecosse. 375

434e Dépêche.—17 février.—

AU ROI. 376
Continuation des armemens. 377
A LA REINE. 378
Explications sur les rapports de
lord de North. 378

435e Dépêche.—21 février.—

AU ROI. 379
Audience. 379
Nouvelles d'Ecosse. 381
Sacre et mariage du roi. 381
A LA REINE. 382
Satisfaction d'Elisabeth. 382

436e Dépêche.—28 février.—

 AU ROI. 383
Détails de la précédente
audience. 383
A LA REINE. 387
Communication faite à
Elisabeth. 387

437e Dépêche.—7 mars.—

AU ROI. 390
Audience. 390
Communication du mariage du
roi. 390

438e Dépêche.—11 mars.—

AU ROI. 395
Mission de La Châtre. 395
Offres d'Elisabeth au roi
d'Espagne. 396
Dispositions pour Marie Stuart. 397

439e Dépêche.—14 mars.—

AU ROI. 398
Méfiances d'Elisabeth contre
La Châtre. 398
Rapprochement avec
l'Espagne. 399
Nouvelles d'Ecosse. 400

440e Dépêche.—20 mars.—

AU ROI. 400
Meilleure disposition
d'Elisabeth. 400
Affaires d'Irlande. 401

441e Dépêche.—24 mars.—

AU ROI. 403
Nouvelles d'Ecosse. 404
Recommandation pour les
réfugiés de Rouen. 405

442e Dépêche.—31 mars.—

AU ROI. 405
Arrivée de La Châtre. 405
Sa bonne réception. 406

443e Dépêche.—7 avril.—

AU ROI. 407
Négociation de La Châtre. 407
Renouvellement de la ligue. 407

444e Dépêche.—15 avril.—

AU ROI. 408
Audience. 409
Détails de la négociation de La
Châtre. 410
Armemens faits à Saint-Malo. 412

445e Dépêche.—21 avril.—

AU ROI. 413
Armemens et emprunts. 413
Nouvelles d'Ecosse. 415
Négociation des Pays-Bas. 415
446e Dépêche.—26 avril.—
AU ROI. 416
Négociation de la paix en
France. 416
Conférence avec l'agent
d'Espagne. 418

447e Dépêche.—30 avril—

AU ROI. 419
Audience. 419
Arrivée des députés de Bâle. 420
Le roi élu chevalier de la
Jarretière. 421

448e Dépêche.—6 mai.—

AU ROI. 422
Instances des députés de Bâle. 422
Nouvelles d'Ecosse. 424

449e Dépêche.—12 mai.—

AU ROI. 425
Négociation des Espagnols. 426
Danger de Marie Stuart. 427

450e Dépêche.—18 mai.—

AU ROI. 428
Sollicitations des protestans. 428
Poursuites au sujet de Marie
Stuart. 429
Nouvelles d'Ecosse. 430
451e Dépêche.—26 mai.—
AU ROI. 431
Audience. 431
Délibération du conseil. 436
A LA REINE. 437
Détails de l'audience. 437

452e Dépêche.—2 juin.—

AU ROI. 439
Affaires d'Ecosse. 440
Sollicitations pour Marie Stuart. 440
Le comte de Killdar prisonnier. 441

453e Dépêche.—7 juin.—

AU ROI. 442
Négociation de Mr de Méru. 442
Affaires d'Irlande. 443

454e Dépêche.—12 juin.—

AU ROI. 444
Audience. 445
A LA REINE. 447
Détails de l'audience. 447

455e Dépêche.—17 juin.—

AU ROI. 448
Secours envoyés aux
protestans. 448
Refroidissement entre 450
Elisabeth et le prince
 d'Orange.
Nouvelles d'Ecosse. 451

456e Dépêche.—26 juin.—

AU ROI. 451
Détails de la précédente
audience. 451

457e Dépêche.—1er juillet.—

AU ROI. 455
Convalescence du roi. 455
Bruit de la mort de Danville. 455
Départ de Mr de Méru. 456

458e Dépêche.—4 juillet.—

AU ROI. 457
Prises faites sur les Anglais par
ceux de Saint-Malo. 458
Menaces de guerre contre
Flessingue. 459
Nouvelles d'Ecosse. 459
A LA REINE. 460
Nécessité de donner
satisfaction sur les nouvelles
prises. 460

459e Dépêche.—8 juillet.—

AU ROI. 461
Conférence avec Burleigh. 461
Nouvelles d'Ecosse. 464
Révolte contre Morton. 464
460e Dépêche.—13 juillet.—
AU ROI. 465
Audience. 465
Résolution du roi à l'égard de
Fitz-Maurice. 466
Assurance d'amitié donnée par
Elisabeth et le conseil. 472
A LA REINE. 472
Proposition de reprendre la
négociationdu mariage. 472

461e Dépêche.—19 juillet.—

AU ROI. 473
Satisfaction d'Elisabeth. 473
Nouvelles de France. 475
Bonnes dispositions pour Marie
Stuart. 475

462e Dépêche.—24 juillet.—

AU ROI. 476
Demande de réparation pour
les prises de Saint-Malo. 476
Combat sur les frontières
d'Ecosse. 478
A LA REINE. 478
Séjour d'Elisabeth dans la
maison de Leicester. 478

463e Dépêche.—1er août.—

AU ROI. 480
Affaires d'Ecosse. 480
Instances des protestans. 481
A LA REINE. 483
Négociation du mariage. 483

464e Dépêche.—6 août.—

AU ROI. 484
Communication confidentielle
sur la négociation du
mariage. 484
A LA REINE. 488
Doute sur les intentions de la
reine au sujet de cette
négociation. 488

465e Dépêche.—13 août.—

AU ROI. 489
Nouveaux armemens. 489
Hollandais brûlés vifs pour
crime d'hérésie. 490
Méfiance contre les Anglais. 491

466e Dépêche.—20 août.—

AU ROI. 492
Arrivée de Castelnau. 492
Affaires de l'Irlande. 492
Armemens. 494
Mission donnée à
l'ambassadeur de se rendre
auprès de Marie Stuart et en
Ecosse. 495

467e Dépêche.—27 août.—

 AU ROI. 495
Nouvelles du prince de Condé. 496
Secours pour les protestans. 497
Incursion en Ecosse. 497
Craintes pour Marie Stuart. 497

468e Dépêche.—10 septemb.—

AU ROI. 498
Présentation de Castelnau. 498
Négociation du mariage. 499
A LA REINE. 500
Détails de l'audience. 500

469e Dépêche.—20 septemb.—

AU ROI. 501
Réponse sur le mariage. 502
Audience de congé. 503
Méfiance contre les Anglais. 504
A LA REINE. 505
Etat de la négociation du
mariage. 505

FIN DE LA TABLE DU SIXIÈME VOLUME ET DERNIER DES DÉPÊCHES DE LA

MOTHE FÉNÉLON.
*** END OF THE PROJECT GUTENBERG EBOOK CORRESPONDANCE
DIPLOMATIQUE DE BERTRAND DE SALIGNAC DE LA MOTTE
FÉNÉLON, TOME SIXIÈME ***

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