NON-INVASIVE CARDIOVASCULAR IMAGING

Rodney M. Jimenez, M.D. November 30, 2010

LEGEND Normal text : lecture and recording th Italics : Harrisons Principles of Internal Medicine 17 Edition CARDIOVASCULAR IMAGING Significantly enhanced the practice of cardiology over the past few decades. Invasive Coronary angiogram Pulmonary angiogram Aortic angiogram Non-Invasive 2D echocardiography Nuclear imaging Positron Emission Tomography Cardiac Magnetic Resonance Cardiac Computed Tomography 2D ECHOCARDIOGRAPHY Visualize the heart directly in real time using ultrasound (lower frequency sound) Instantaneous assessment of the myocardium, cardiac chambers, valves, pericardium, and great vessels Flat image (2D) is seen Can also use the principle of Doppler Doppler echocardiography Velocity of moving red blood cells Alternative to cardiac catheterization for assessment of hemodynamics. 2 methods Transthoracic Echocardiogram (TTE) Transesophageal Echocardiogram (TEE) Basic Principle Ultrasound reflection of cardiac structures to produce images of the heart Doppler effect Describes the influence of a moving object on sound waves An object travelling towards the listener causes sound waves to be compressed giving a higher frequency; an object travelling away from the listened gives a lower frequency The higher the frequency and amplitude, the closer the object to the observer One can observe the blood flow towards and away from the heart or the hemodynamics (output, murmur, turbulence) Transthoracic Echocardiogram (TTE): Performed with a handheld transducer placed directly on the chest wall less clear due to presence of impedance from the skin, muscle and lung parenchyma In selected patients, a TEE may be performed, in which an ultrasound transducer is mounted on the tip of an endoscope placed in the esophagus and directed toward the cardiac structures. Views the heart from the surface (sagittal view of the heart; visualizes the right ventricle, which is the most anterior part of the heart) Orientation

Transesophageal Echocardiogram (TEE): An ultrasound transducer is mounted on the tip of an endoscope placed in the esophagus and directed toward the cardiac structures. Esophagus clearer and better view; more proximal to the heart; less impedance; high definition; better reception and resolution Invasive; seeing the heart from behind; posterior view Advisable for patients with valve problems and congenital heart disease

Short Axis View Right and left ventricles Cross-section of the heart. The left ventricle is more muscular and circular. The right ventricle is bulletlike and more trabeculated but less muscular. There is a decrease in the left ventricular cavity size during systole as well as an increase in wall thickening Parasternal/Long Axis View Right ventricle (especially the right ventricular outflow tract), left ventricle, left atrium, aorta Evaluate the heart by looking at the thickening of the walls. During systole, there is normal thickening of the myocardium and reduction in the size of the left ventricle (LV); valve leaflets are thin and open widely Function of the heart is measured by the ejection fraction.

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EF = SV = LEDV LESV EDV EDV Calculate by measuring the area during diastole minus the area during systole divided by the area during diastole

4 Chamber View View when the patient is vertically oriented (heart is vertically oriented) From the apex: left and right ventricles, left and right atrium Sagittal section. Right ventricle is smaller 5 chamber view includes the aortic lumen Used especially when considering septal defects Using Doppler effect: if color goes from left ventricle to the right ventricle, there is VSD; if color goes from left atrium to the right atrium, there is ASD Right to left shunting (pulmonic circulation pressure > systemic circulation pressure). When there is irreversible right to left shunting, the Eisenmenger phenomenon occurs. Involves pulmonary hypertension, cyanosis, etc.

Standard orientation of the heart, the left ventricle is at the right side. It is the largest chamber. Parasternal Long Axis View:

When there is a sandy effect, it indicates stasis of the blood; blood flow is slow Also guided by ECG to note when the heart is in diastole Diastole is atrial contraction During diastole, the ECG tracing will be after the T wave (The start of the hearts relaxation in the ECG is at the R wave. QRS complex is the start of systole but the heart begins to relax at the R wave) Used when you want to see the relationship between the left ventricle, left atrium, and aorta Views mitral and aortic valve defects. Detects flow disturbance involving these valves. Clinical Applications Two-Dimensional Echocardiography Cardiac chambers Chamber size Left ventricular hypertrophy 2D Echo is the gold standard Regional wall motion abnormalities Valve Morphology and motion Pericardium Effusion Tamponade Masses Great vessels Stress Echocardiography Stress test is done by having the patient go on a bike or treadmill thus simulating the hearts conditions at stress levels The stress test is mainly used to diagnose ischemia, assess functional capacity, and BP control. The hearts most important function is to pump blood and distribute oxygen during stress. Stress testing assesses if the heart is normal or functional during stress. ECG is used to check for presence/absence of ischemia. ECG and stress testing only have sensitivity and specificity of 60-70%. Large chance for false positive or false negative. Can only be used for patients with intermediate to high probability for ischemic heart disease but not for low risk or super high risk. Normal Stress Echocardiogram should show myocardial thickening and decrease of the diameter during contraction

Only 2 of the aortic cusps will be seen

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During ischemia, there will be hypokinesia. Some parts of the myocardium will not thicken because of weakened contractility. Ischemia is an imbalance between the oxygen supply and oxygen demand. Chest pain is a delayed response to ischemia Two-dimensional Myocardial ischemia Viable myocardium Doppler Valve disease Doppler Echocardiography Valve stenosis Gradient Valve area Valve regurgitation Semiquantitation Intracardiac pressures Volumetric flow Diastolic filling Intracardiac shunts Transesophageal Echocardiography Inadequate transthoracic images Aortic disease Infective endocarditis Source of embolism Valve prosthesis Intraoperative Advantages Portable (hand-held) and can be wheeled directly to the patient's bedside Ability to obtain instantaneous images of the cardiac structures for immediate interpretation. Handheld echocardiographic units weighing 6 lb (<2.7 kg) enhancing the ease and portability of echocardiography Essential initial diagnostic modality for the critically ill patient in the emergency room and critical care setting Limitations Inability to obtain high-quality images in all patients with: Thick chest wall Example: obese patients Severe lung disease Ultrasound waves are poorly transmitted through lung parenchyma because of the presence of air ex. COPD Harmonic imaging and IV contrast agents (which traverse the pulmonary circulation) can now be used to enhance endocardial borders in patients with poor acoustic windows Chamber Size and Function qualitative assessment of the cavity sizes of the ventricles and systolic function ideal imaging modality for assessing left ventricular (LV) size and function diagnosis of LV hypertrophy the imaging modality of choice for the diagnosis of hypertrophic cardiomyopathy Other chamber sizes are assessed by visual analysis, including the left atrium and right-sided chambers

Short axis view: best view to see if the myocardium is contracting well

Valve Abnormalities "gold standard" for imaging valve morphology and motion Leaflet thickness and mobility, valve calcification, and the appearance of subvalvular and supravalvular structures can be assessed. Valve stenosis is reliably diagnosed by the thickening and decreased mobility of the valve. also the gold standard for the diagnosis of mitral stenosis which produces typical tethering and diastolic doming Presence of calcifications fuses the commisures. When the commisures are fused, the valve does not open well causing stenosis. Normally, valves should open as widely as possible, almost touching the muscles of the heart during opening to equalize the pressure in the LA and LV. When there is disturbance in the flow, the chamber enlarges to accommodate blood. when the valve doesnt open well, it will cause a doming or hockey-stick effect most common cause of mitral stenosis in the Philippines is rheumatic heart disease caused by post-Streptococcal infection Ag-Ab sticks to the valve causing inflammation and calcification radiologic stasis pooling of blood within the chambers

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severity of the stenosis can be ascertained from a direct planimeter measurement of the mitral valve orifice Assessed with color. With disease, there is turbulence or jets of color will be seen presence and the etiology of stenosis of the semilunar valves can be made by 2D echocardiography but evaluation of the severity of the stenosis requires Doppler echocardiography. by assessing velocity. If there is stenosis, there is impedance/stenosis and flow is compromised diagnosis of valvular regurgitation must be made by Doppler echocardiography, 2D echocardiography is valuable for determining the etiology of the regurgitation as well as its effects on ventricular dimensions, shape, and function.

These high velocities can be used to determine intracardiac pressure gradients by a modified Bernoulli equation: Pressure change = 4 x (velocity)
2

If there is no problem with the valve, the velocity of blood flow should be equal from one heart chamber to the next. derived pressure gradient can be used to determine intracardiac pressures and stenosis severity. Tissue Doppler echocardiography measures the velocity of myocardial motion. velocity of myocardium is several magnitudes lower than the velocity of moving red blood cells. can be used to determine myocardial strain rate a quantitative measure of regional myocardial contraction and relaxation Valve Gradient Valvular stenosis increase in the velocity of blood flow across the stenotic valve. continuous-wave Doppler beam is used to determine an instantaneous gradient across the valve. Mitral Stenosis most common cause in the Philippines is rheumatic heart disease hockey-stick there is a doming effect during diastole Valvular Regurgitation diagnosed by Doppler echocardiography there is abnormal retrograde flow across the valve. Color-flow imaging is the Doppler method used most frequently visualization of a high-velocity turbulent jet in the chamber proximal to the regurgitant valve size and extent of the color-flow jet into the receiving cardiac chamber provide a semiquantitative estimate of the severity of regurgitation Mitral Regurgitation Insufficient mitral valve (overly compliant) There is backflow of blood from LV to LA Occurs during systole High-pitched systolic murmur appreciated Aortic Regurgitation There is backflow of blood from the aorta to LV during diastole Occurs during diastole Other Uses of Echocardiography detection of congenital stenotic or regurgitant valve like in VSD, color flow abnormality will be seen across the septum detection of intracardiac shunts and determination of patency of surgical shunts and conduits can measure the pressure in the pulmonary artery and the pressure across the aortic valve measurement of cardiac output Volume flow rates (or stroke volume and cardiac output) is calculated as the product of the cross-sectional area of the vessel or chamber through which blood moves and the velocity of blood flow (time-velocity integral) as assessed by continuous-wave Doppler determination multiplied by the heart rate indicators of myocardial ischemia new regional wall motion abnormalities a decline in ejection fraction an increase in end-systolic volume with stress

Pericardial Disease 2DE modality of choice for the detection of pericardial effusion In myocardial-pericardial effusion, fluid or lucency seen in between the myocardium If with thickening, calcification is seen outside of the myocardium black echolucent ovoid structure surrounding the heart. pericardial tamponade can also be seen dilated inferior vena cava, right atrial collapse, and then right ventricular collapse, usually at the base of the ventricle. o RA and RV have thin muscles During diastole, RV will need to relax to collect the venous return. But during tamponade, the RV is pushed by the effusion during relaxation. There is decrease in venous return resulting in decreased output. There is a need to perform pericardiocentesis to take out the fluid Echocardiographically guided pericardiocentesis is the standard of care. Especially with large pericardial effusion 2DE can directly visualize the location of the pericardial fluid to guide the entry point of the needle. If there is effusion, the heart is pushed by the fluid resulting in decrease size. (the pericardium is of limited size) There is resulting problem in contraction and relaxation of the myocardium. DOPPLER ECHOCARDIOGRAPHY Basic Principles Doppler echocardiography uses ultrasound reflecting off moving red blood cells to measure the velocity of blood flow across valves, within cardiac chambers, and through the great vessels. Color-flow Doppler imaging displays the blood velocities in real time superimposed upon a 2D echocardiographic image. colors indicate the direction of blood flow (color assignments) red toward the transducer blue away from the transducer green superimposed when there is turbulent flow. Tip! BART Blue Away, Red Towards Pulsed-wave Doppler measures the blood flow velocity in a specific location on the 2D echocardiographic image. Continuous-wave Doppler measure high velocities of blood flow directed along the line of the Doppler beam, such as occur in the presence of valve stenosis, valve regurgitation, or intracardiac shunts.

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determine LV size and function, right ventricular size and function, and the presence of acute valvular regurgitation and pericardial tamponade noninvasive evaluation of ventricular diastolic filling and dectection of diastolic dysfunction transmitral velocity curves reflect the relative pressure gradients between the left atrium and ventricle throughout diastole which are influenced by the rate of ventricular relaxation, the driving force across the valve, and the compliance of the ventricle progression of diastolic dysfunction can be assessed by Doppler flow velocity curves Early phase of diastolic dysfunction impairment of LV relaxation, with reduced early transmitral flow and a compensatory increase in flow during atrial contraction Pseudonormalization As disease progresses, and ventricular compliance declines, left atrial pressure rises, resulting in a higher early transmitral velocity and shortening of the deceleration of flow in early diastole so that the filling pattern becomes normal Restrictive filling pattern seen in patients with the most severe diastolic dysfunction; there is further elevation of left atrial pressure and early diastolic flow velocity detection of acute mechanical complications (e.g., papillary muscle rupture, ventricular septal defect, myocardial perforation with tamponade, and right ventricular infarction) NUCLEAR CARDIOLOGY injection into the patient of an isotope that emits photons (energy) generally gamma rays generated during radioactive decay when the nucleus of an isotope changes from one energy level to a lower one. uses a special camera that images these photons expressed by using x-rays with colors. Isotopes are used as a dye. Clinical Applications Assessment of ventricular function uses equilibrium radionuclide angiography, also known as multiple-gated blood pool imaging involves the imaging of 99mTc-labeled albumin or red cells that are uniformly distributed throughout the blood volume Resting images of the blood pool of isotopes within the cardiac chambers are obtained by electrocardiographic gating through multiple cycles provides an accurate, reproducible method for assessment of LV function most commonly used when echocardiography is technically difficult or when poor LV function requires accurate quantitation Assessment of myocardial perfusion by gated single-photon emission computed tomography (SPECT) - but too large and more expensive. utilized to assess ejection fraction and regional wall motion usually performed post-stress by gating the acquisition of SPECT myocardial perfusion images using 99mTc- labeled compounds determines the endocardial borders of the LV cavity and calculates the ejection fraction Myocardial Perfusion Two phases Check perfusion during REST Check perfusion during STRESS (again, to diagnose ischemia and cardiac function) Compares the stressed image and the relaxed image of the heart.

Scanning should involve the heart at rest and the heart at stress phases. Normal results show equal color distribution of both phases. What happens? If the isotope is injected during REST isotopes would go to the heart and give it color If theres no problem with the blood distribution isotopes will distribute well and give color to the myocardium making a donut-like shape. Were concerned with the left ventricle more because it is the one pumping blood to the system. Checking is from apical to the base. When you inject the isotopes to a problematic heart it will scan and reveal a blockage by revealing less/no color, since the isotopes stick to the blood. Treatment includes reperfusion by invasive procedures. The heart should accommodate a lot of blood during STRESS. If there is problem of the blood supply as impeded by the obstruction of the coronary arteries, then there will be a problem in perfusion. Abnormal perfusion during rest and stress infarct Decrease perfusion ischemia produce images of myocardial regional uptake proportional to regional blood flow Circular shape of the LV at cross section is imaged as a perfect donut during rest. If there is problem with perfusion, there will be a bite-like appearance of the donut. Maximal exercise myocardial blood flow is increased up to fivefold above the resting condition In the presence of a fixed coronary stenosis, there is an inability to increase myocardial perfusion in the territory supplied by the stenosis creating a flow differential and inhomogeneous distribution of the isotope. patients who are unable to exercise: pharmacologic agents ---> to increase blood flow and create similar in homogeneities preferred pharmacologic (increase blood flow to a similar degree as exercise) adenosine dipyridamole dobutamine (does not increase myocardial blood flow to the same extent) may be used as an alternative in patients with bronchospastic lung disease. First do the stress test. Then inject the isotope and place the patient under the camera. If there are abnormalities in the coronary arteries, then there will be stenosis (plaque). It will then reflect as an abnormality in the image. Blood in the image is colored yellow. Absence of blood flow in the cardiac muscle causes the bite-like image of the ventricle. If the stress image is almost similar to the rest image, then it is normal.

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Orientation

PET cameras are considerably more expensive than conventional nuclear cardiology cameras Rubidium-82 the most commonly used positron emitter available from a generator and does not require a nearby cyclotron pharmacologic stress with dipyridamole, adenosine, or dobutamine is preferred for PET scanning Clinical Applications Assess myocardial blood flow and myocardial metabolism. Myocardial metabolism of the hibernating muscle of the heart. Hibernating to reserve energy for more stressful events. Muscles will regain normal strength when reperfusion/bypass/angioplasty is done Positron emitters or isotopes to assess myocardial blood flow: Nitrogen-13 ammonia Oxygen-15 water Rubidium-82 Positron Emitters permit measurement of absolute regional blood flows, In contrast to the relative blood flows that is assessed with 201Tl- or 99mTc-labeled compounds. This advantage has been utilized for research purposes but has generally not been exploited clinically. For myocardial metabolism fluorine-18 deoxyglucose. permits the detection and quantification of exogenous glucose utilization in areas of hypoperfused myocardium. PET Scan is also used to survey cancer because more metabolism shows the area of metastasis Clinical Uses been best studied clinical application - assessment of myocardial viability. if the myocardium is still viable, you can subject the patient to revascularization procedure to open up arteries angioplasty or bypass surgery. pattern of enhanced fluorodeoxyglucose uptake in regions of decreased perfusion glucose/blood flow "mismatch" even with good blood flow, if the myocardium does not metabolize glucose, it is no longer viable even if the heart is contracting weakly but it still metabolizes glucose, it is still viable (may have hibernating muscles) indicates the presence of ischemic myocardium that has preferentially shifted its metabolic substrate toward glucose rather than fatty acid or lactate. pattern identifies regions of ischemic or hibernating myocardium that are likely to improve in function after revascularization gold standard for the assessment of myocardial viability also the most expensive identify ischemic or hibernating myocardium in 1020% of regions that would be classified as fibrotic (infarcted) by 201Tl- or 99mTc-labeled compounds more advantageous than 201Tl- and 99mTc-labeled compounds for obese patients in assessing myocardial perfusion Patient is not allowed to eat for 4 hours before the procedure to prevent splitting of blood flow and energy/isotope between the stomach and the heart.

Abnormal Perfusion Image

Isotopes 201Tl (thallium) - first isotope used for this purpose 99mTc, largely replaced 201Tl higher photon energy shorter half-life, permitting the injection of larger doses resulting in scans of higher quality. Two technetium-labeled in common use: tetrofosmin sestamibi both distributes to the myocardium in relation to blood flow, and their uptake requires an intact cell membrane and a viable myocardial cell POSITRON EMISSION TOMOGRAPHY a type of beta-decay of an unstable isotope. this unstable isotope, a proton undergoes spontaneous decay into a neutron, a neutrino, and a (+) particle (positron). positrons interact with electrons release of gamma-radiation (photons) upon collision with tissue. gamma emission detected by the gamma camera in the PET scanner. high energy of the photons results in far less scatter than with conventional nuclear cardiology techniques.

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MAGNETIC RESONANCE IMAGING Basic Principles a technique based on the magnetic properties of hydrogen nuclei. magnetic field induce nuclear spin transitions from the ground state to excited states as the nuclei relax and return to their ground state, they release energy in the form of electromagnetic radiation that is detected and processed into an image Gadolinium, a contrast medium, frequently employed to produce magnetic resonance angiograms (MRAs). provide enhanced soft tissue contrast as well as the opportunity to obtain rapid angiographic images during the first pass of contrast through the vascular system static and cine images can be obtained using electrocardiographic triggering images can be used to quantify ejection fraction, end-systolic and end-diastolic volumes, and cardiac mass with high accuracy, reliability, and reproducibility Normal Cardiac MRI Cardiac MRI is challenging due to rapid physiologic motion of the heart and coronary arteries

Clinical Applications defining anatomic relationships in patients with complex congenital heart disease and cardiomyopathies characterize cardiac masses and their relationship to normal anatomic structures defined allow characterization of the severity of valvular disease as well as quantification of shunt volumes examination of choice to determine whether a mediastinal or pulmonary mass has invaded the pericardium or heart characterizing pericardial effusions or pericardial thickening in patients with indeterminate results on echocardiography Specialized pulse sequences measure the velocity of blood in each pixel of the image for accurate determination of flow across valves and within blood vessels standard technique for imaging the aorta and large vessels of the chest and abdomen coronary MRA is not yet an accurate and reliable clinical technique Assessment of ventricular function and wall motion at rest and during infusion of inotropic agents by injecting a bolus of gadolinium contrast relative perfusion deficits - reflected as regions of low signal intensity within the myocardium. for detecting subendocardial ischemia cardiac MRI is more sensitive than SPECT imaging due to its enhanced spatial resolution. myocardial viability by imaging the heart 1020 min after gadolinium injection Limitations Relative contraindications presence of pacemakers or internal defibrillators cerebral aneurysm clips claustrophobic and unable to tolerate the examination within the relatively confined quarters of the magnet bore. However, open-bore magnets are now available to deal with this problem. clinically unstable patients, since close monitoring is difficult. image quality in patients with significant arrhythmias is often limited. COMPUTED TOMOGRAPHIC IMAGING Basic Principles CT is fast, simple, noninvasive, and provides images with excellent spatial resolution and good soft tissue contrast. conventional CT was too long to freeze cardiac motion. electron-beam CT and multislice spiral (helical) CT have improved temporal resolution and routine imaging of the beating heart It uses the principle of x-ray; better imaging of structures with calcium (ex. bones, atheroma, calcified pericardium) Clinical Applications constrictive pericarditis is easily detected by CT characterizing pericardial thickening, cardiac masses, particularly those containing fat or calcium.

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imaging patients with suspected arrhythmogenic right ventricular dysplasia ---> ability to detect small amounts of fat Cine images can evaluate wall motion and determine ejection fraction, end-diastolic and end-systolic volumes, and cardiac mass. calcium is shown as white densities Calcified Pericardium Calcification is hypodense May be caused by tuberculosis

"noninvasive coronary angiography" concept has generated great interest in the widespread utility of CTA. major well-accepted indications for coronary CTA evaluation of suspected coronary anomalies patients with chest pain syndromes intermediate pretest probability of CAD unable to exercise uninterpretable or equivocal stress test. Limitations dependence on ionizing radiation (in contrast to MRI) problematic in patients with renal insufficiency or contrast allergy. radiation doses tend to increase as the spatial resolution improves doses for coronary CTA exceed those delivered during standard diagnostic cardiac catheterization. SELECTION OF IMAGING TESTS LV Function and Size 2D echocardiography primary imaging modality for assessment of LV cavity size, systolic function, and wall thickness low cost and portable provides ancillary structural and hemodynamic information MRI and CT highest quality resolution of endocardial border the most accurate of all modalities However, expensive, lack portability, and do not provide concomitant hemodynamic information as echocardiography does Valvular Heart Disease 2D and Doppler echocardiography the first test of choice provides images for valve motion provide both anatomic and hemodynamic information regarding valve disease MRI can also visualize valve motion and determine abnormal flow velocities across valves but there is less validation of quantitative hemodynamic measurements in comparison to echocardiography. Pericardial Disease Echocardiography first imaging modality of choice (suspected pericardial effusion and tamponade) hemodynamic analysis that occurs in pericardial constriction (Doppler echocardiography) MRI or CT scanning suspected constrictive pericarditis visualizes pericardial thickening Aortic Disease CT scanning and MRI provides images of the entire aorta imaging modalities of choice for stable patients with suspected aortic aneurysm or aortic dissection. TEE or CT scanning for rapid diagnosis for the acutely ill patients with suspected aortic dissection definitive diagnosis of a suspected aortic dissection usually requires a TEE, which can rapidly provide high-resolution images of the proximal ascending and descending thoracic aorta Cardiac Masses 2D TTE first test to rule out an intracardiac mass masses >1.0 cm in diameter - well visualized

CT Angiography accuracy similar to MRA in imaging the aorta and great vessels the examination of choice in the evaluation of patients with suspected pulmonary embolus. excellent imaging modality for the diagnosis of aortic dissection or penetrating ulcers. initial diagnosis as well as follow-up of patients with aortic aneurysmal disease can be done. number 3 sign coarctation of the aorta similar to the MRI except that CT uses x-ray Coronary Calcification Calcium in the coronary arteries occurs in atherosclerosis and is absent in the normal coronary artery CT is very sensitive for the detection of coronary artery calcification CA Calcium Scoring counting the number of calcified coronary arteries very sensitive for the detection of coronary artery calcification promoted as a noninvasive modality for the screening and diagnosis of CAD. Detects patients with high risk for CAD quantity of coronary calcification (coronary calcium score) is related to the severity of CAD. Mild, moderate or severe moderate and severe indicates more than 50% calcification very high sensitivity but low specificity. should not be used for the diagnosis of obstructive coronary disease Score = Area x Hn x-factor Hn x-factor (Agatston Scoring) Peak CT 130-199 1 200-299 2 300-399 3 >400 4 Contrast-Enhanced CT Angiography accurate assessment of luminal narrowing in the major branches of the coronary arteries (high temporal and spatial resolution of multislice spiral CT) high sensitivity (>85%), and specificity (>90%) of CTA as compared to cardiac catheterization. a very high negative predictive value of 98-99% highest accuracy - noted in the left main and the proximal portions of the left anterior descending and left circumflex arteries fast, irregular heart rates and body motion limit the accuracy of CTA.

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Solid masses appear as echo-dense structures, which can be located inside the cardiac chambers or infiltrating into the myocardium or pericardium TEE smaller size may be visualized. provides high resolution images required for further delineation of myocardial masses, especially those <1cm in diameter CT scanning and MRI masses extrinsic to the heart or involving the myocardium IMPORTANT FOR THE EXAM (accdg to Dr Jimenez): Remember the use of the tests and the principles behind each test. Take note of the limitations of the MRI END of LECTURE PS. Dr. Jimenez was not able to lecture Roentgenography or X-Ray Radiography and also Cardiac Surgery. We are not sure if these topics are included in the exams. Please read on it if you have time. 4 Long Exams next week and I know most of us have not yet studied most of the trans due to the late influx of most transes. But i believe we can all still do good in the exams... because God is with us. Christmas is just around the corner. I hope despite our busy schedules, the hustle and bustle of the Christmas rush, Christmas shopping and gift-giving, we do not forget the real meaning of CHRISTmas the birth of our Lord, Jesus Christ. Let us give thanks to Him for coming down to earth more than 2000 years ago to sacrifice His life for the forgiveness of our sins. MERRY CHRISTMAS 2012! Maligayang Pasko sa lahat. And may we enjoy the remaining months of our academic life. Again let me thank the medicine trans committee: Vincent Reolalas, Taktak Santos, Hayzle Mallari, Abby Maralit, Rors Reyes, Den Palines, Vin Sanchez, James Rondal, Virra Rosales, Jessa Marapao, Armi Menchavez, Pepin Mendieta, Trish Navarro, Marth Tarroza, Co-Neil Relato, Joie Silva, Glen Ventanilla, Khei Villanueva, Yvonne Vias, Emma Sinco, Car Real, Jess Prego and Nats Quan. Warm thanks to Gayle Limos, Nizh Mapandi and Trish Navarro for the audio recordings CARLO BENJAMIN Z. TAADA
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