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Well, let's go ahead and get started. So I'll be

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showing a host of cardiovascular cases predominantly

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involving the thorax

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exclusively thorax.

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And what I'll do is at the

0:17

outside discuss some cardiac Anatomy.

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And and then go into cases and

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I'll ask that you take a look at the cases and

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see if you can identify abnormalities and then

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we'll review the abnormalities and and

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you can see if you can come to a diagnosis or

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a differential diagnosis. That would be appropriate for

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the empty findings and clinical scenarios. I'm presenting

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so we'll start off with these six. Transaxle

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CT images from a gated

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CT study of the chest with contrast.

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And I have provided a host of

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arrows and what I'm asking you

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to do is to see if you can Define what these

1:01

arrows are pointing to and I'll go through

1:04

them with you from top left to bottom,

1:07

right.

1:08

So we'll start with the arrow on the

1:11

topmost image. It's closest to the top.

1:14

What is the structure?

1:16

that this arrow is pointing to

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on a gated study. It looks a little different than it

1:24

does on non-gated study and you can see there's a lot of trepeculation in

1:27

this chamber and this is the right atrial appendage.

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The next structure on the same image that the arrow is pointed

1:34

to is a vascular structure rising from

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the aortic root. And it looks like

1:40

it's pinched. That's not that's just a an effective

1:43

the slice selection,

1:46

but that's the left main coronary artery.

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In this case. It appears to try for Kate into the

1:53

LED.

1:55

The ramus intermedius which is an occasional normal variant

1:58

and the certain Flex which we can barely see there.

2:01

on the next

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top right image where we see arrows. There's an

2:07

arrow that's pointing to a very thin.

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structure

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it seems to be contiguous.

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With another Fuller structure

2:17

just anterior to the right ventricle. And

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I think most of you will recognize that as the

2:23

pericardium and the reason that I'm highlighting it here is that this is

2:26

normal thickness pericardium. Those are two layers visceral and

2:29

parietal pericardium and together. They really

2:32

are a paper thin membrane. Now,

2:36

obviously the pericardium does have a normal amount

2:39

of fluid which is about 10 to 50 CC's. We

2:42

see a little bit of fluid on this slice anteriorly.

2:46

but for the most part

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the the fluid is small and

2:52

barely detectable

2:54

the second arrow on this image

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Is pointing to a structure that seems to be in continuity

3:01

with both the left ventricle?

3:04

And the ascending aorta is that we see a little

3:07

bit higher the level of the aortic balance and this is called the

3:10

left ventricular outflow tract.

3:14

Just posterior to that in this image is the

3:17

anterior leaflet of the mitral valve.

3:20

I will point out that the mitral valve

3:23

is in fibrous continuity with the aortic valve.

3:26

There is no muscle separating them

3:29

and that's in contradistinction to what's

3:32

happening in the right ventricle where there is muscle called

3:35

infundibulum that separates the tricuspid valve

3:38

from the monic valve.

3:40

Moving to the bottom left image. We have two arrows

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the first one. Let me actually Define these the

3:46

first one is pointing to

3:49

kind of a band of tissue

3:52

arising from the interventricular septum going

3:55

towards the right ventricle and in the cavity

3:58

right ventricle.

4:00

and that's referred to as the moderator band and it's important because both

4:03

gives rise to

4:07

Portions of papillary muscle but it also carries

4:10

conductive tissue.

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It's prominent in this case and I'll also

4:16

point out that the RV itself is a little bit thicker than we normally see

4:19

it.

4:20

And we'll get to that a little bit later.

4:24

The second arrow in the bottom left image points to

4:27

the interatrial septum and specifically to

4:30

the really thin portion of that interatrial septum

4:33

known as the moderator band. I'm sorry,

4:36

the Fosso valis tripped myself

4:39

there. The fossil valis is where the septum premium

4:42

and septum segundum come together

4:45

and in 75% of

4:48

the population they fuse

4:50

in 25% of the population or so, they

4:53

don't fuse and we have a scenario that's referred

4:56

to as a patent foramenovo Valley. So that's almost

4:59

what we would consider a normal variant because

5:02

a quarter of the population has it

5:06

now a PFO if present is

5:10

this distinct and different from an atrial

5:13

septal defect which is actually the

5:16

absence of tissue. So if there was

5:19

a hole right here, we would refer to

5:22

it as an Asian secundum atrial septal

5:25

defect.

5:26

Moving on to the bottom row middle image

5:29

the arrow is pointing to looks like

5:32

a muscular structure rising from the left

5:35

ventricular free wall within the

5:38

LV cavity.

5:40

That's a papillary muscle more specifically.

5:43

It's the anterior capillary muscle.

5:46

There are two papillary muscles in the left ventricle.

5:49

Anterior and posterior and the posterior

5:52

papillary muscle is more inferior and

5:55

generally smaller. We can see here on

5:58

this gated study a very

6:01

thin communication with the mitral valve

6:04

and this is the chordae 10 today.

6:08

One final image on the bottom right has an arrow

6:11

pointing to a tubular

6:14

low density structure that is in

6:17

continuity with the right atrium.

6:20

and that is

6:22

the

6:24

coronary sinus which is the major draining vein

6:27

of the left ventricle.

6:29

So blood from the coronary sinus.

6:32

Will pass into the right atrium and cross over

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a tiny valvular structure here that's called the thebesian valve

6:38

and that the little member

6:41

in a structure is in continuity itself with the

6:44

eustachian valve which separates the

6:47

IVC from the right atrium

6:50

both of these little membranous or

6:53

valve either structures.

6:56

Move blood flow in embryologic setting

7:00

to cross the patent

7:03

frame and O Valley as blood

7:06

is directed away from rape principal and

7:09

towards the left atrium.

7:12

Now one thing that I haven't pointed out here is the pathology

7:15

on these images and

7:18

it's only found on one image invite you to take a

7:21

look and see if you can identify.

7:23

The pathology it's in the top right image and

7:26

you may recognize it. If I direct

7:29

you now to the LDL flow tract and

7:32

see that there's a communication. This is a ventricular

7:35

septal defect. It's a communication between

7:38

the LV outflow tract and the right ventricle

7:41

in this case. It's passing through muscle. So we

7:44

call it a muscular vsd as opposed to

7:47

one slightly higher up at the membranous portion of

7:50

the interventricular septum, which would be a membranous vsd.

7:54

And it's because of this vsd that

7:57

we're seeing signs of RV thickening.

8:00

associated with pulmonary hypertension

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Okay, so that's our first review of anatomy. Now,

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let's look at some cases.