Descriptive anatomy of the dominant septal perforators using Dual Source Coronary CT Angiography.

Although clinical outcomes for septal ablation in treating left ventricular outflow tract obstructions are generally favorable, a variety of complications have been reported including a high incidence of right bundle branch block. These complications may be attributed to anatomic variability of the dominant septal perforator. We used Dual Source CT Coronary Angiography (DS-CTA) to determine the location of the termination point of the dominant septal perforator as well as the distance of the termination point from the mitral annulus in patients undergoing DS-CTA. One-hundred-fourteen DS-CTA scans were retrospectively reviewed by two observers by consensus. The left ventricle was divided into anterior wall, anterioseptum, and inferioseptum. For each segment, the myocardium was divided into three layers (1) right ventricular side, (2) mid portion, and (3) left ventricular side. The zone of termination of the dominant septal perforator was identified as well as the distance of the termination point from the mitral annulus. The dominant septal perforator terminated in the right ventricular side of the anterioseptum in 86 of the 118 visualized terminations (73%) and in the left ventricular anterior wall in 6 visualized terminations (5%). On average, the dominant septal perforator terminated 26.3 +/- 8.6 mm from the mitral annulus. In the majority of cases, the dominant septal perforator terminates in the right ventricular side of anterioseptum. In addition, there is great variability in the distribution of the termination point of the dominant septal perforator from the mitral annulus.

Anatomic assessment of the bifurcation of the left main coronary artery using multidetector computed tomography.

PURPOSE: Multiple techniques for stenting left main coronary artery (LMCA) bifurcation lesions exist, and an accurate understanding of normal LMCA anatomy is essential for proper diagnosis and therapeutic intervention for these lesions. The purpose of this paper is to identify various anatomic LMCA characteristics at the point of bifurcation and draw relevant clinical lessons from these characteristics. METHODS: Two independent observers analyzed 105 cardiac dual-source computed tomography images recording LMCA length, angle of bifurcation, and cross-sectional area of the LMCA, left circumflex artery (LCX), and anterior interventricular artery (AIVA) at the point of LMCA bifurcation. Frequency of left dominance, right dominance, and codominance, as well as LMCA trifurcation was also noted. RESULTS: Average LMCA length was 9.9 ± 4.15 (range 2-21 mm). Average angle of bifurcation between LCX and AIVA was found to be 69.3° ± 33.3° (range 14°-200°). The most frequent division of the LMCA is a bifurcation into the terminal LCX and AIVA. In 20/105 cases (19.0%) a trifurcation pattern was identified. Average cross-sectional areas at point of LMCA bifurcation were as follows for LMCA, LCX, and AIVA respectively: 12.4 ± 4.4 mm(2) (range 2.3-25.9 mm(2)), 7.4 ± 3.5 mm(2) (range 1.2-23 mm(2)), 8.5 ± 3.5 mm(2) (range 1.3-25.9 mm(2)). Frequency of heart dominance was as follows for right dominant, left dominant, and codominant 85.7, 9.5, and 4.8%, respectively. CONCLUSION: Accurate knowledge of the in vivo anatomy of the area of bifurcation of the LMCA is essential for avoiding the misdiagnoses of diseases and for proper stent placement during percutaneous intervention in the area of bifurcation.

Clinical Pulp Fiction: First Multimodality Imaging of Needle Migration From Distal Esophagus Into Ventricular Septum.

A 21-year-old woman self-ingested an 18-gauge needle that perforated the distal esophagus into the left inferior ventricular myocardium, with migration into the septum. Radiography, computed tomography, and echocardiography imaging characterized the needle's location. Following an initial endoscopy and pericardial tamponade drainage, complete needle removal occurred via median sternotomy and cardiopulmonary bypass. (Level of Difficulty: Intermediate.).

Cardiac MR imaging of nonischemic cardiomyopathies.

Cardiomyopathies, diseases of the myocardium associated with cardiac dysfunction, include hypertrophic, restrictive, and dilated forms and rare entities, such as arrhythmogenic right ventricular dysplasia, ventricular noncompaction, and apical ballooning syndrome. Many have similar presentations, but the underlying condition determines prognoses and treatment. Cardiac MR imaging plays a role in characterizing the range of entities and is crucial for evaluation and management. In addition, delayed enhanced imaging can allow differentiation among the forms of cardiomyopathy and offer prognostic information. As the speed and technical ease of cardiac imaging improve, MR imaging will assume an increasing role in the care of patients who have cardiomyopathy.

MR imaging of the pericardium.

Imaging of the pericardium requires understanding of anatomy and the normal and abnormal physiology of the pericardium. MR imaging is well-suited for answering clinical questions regarding suspected pericardial disease. Pericardial diseases that may be effectively imaged with MR imaging include pericarditis, pericardial effusion, cardiac-pericardial tamponade, constrictive pericarditis, pericardial cysts, absence of the pericardium, and pericardial masses. Although benign and malignant primary tumors of the pericardium may be occasionally encountered, the most common etiology of a pericardial mass is metastatic disease.

MR imaging of cardiac masses.

Cardiac MR imaging is the preferred method for assessment of cardiac masses. A comprehensive cardiac MR imaging examination for a cardiac mass consists of static morphologic images using fast spin-echo sequences, including single-shot techniques, with T1 and T2 weighting and fat suppression pulses as well as dynamic imaging with cine steady-state free precession techniques. Further tissue characterization is provided with perfusion and delayed enhancement imaging. Specific cardiac tumoral characterization is possible in many cases. When specific tumor characterization is not possible, MR imaging often can demonstrate aggressive versus nonaggressive features that help in differentiating malignant from benign tumors.

High-speed Shack-Hartmann wavefront sensor design with commercial off-the-shelf optics.

Several trade-offs relevant to the design of a two-dimensional high-speed Shack-Hartmann wavefront sensor are presented. Also outlined are some simple preliminary experiments that can be used to establish critical design specifications not already known. These specifications include angular uncertainty, maximum measurable wavefront tilt, and spatial resolution. A generic design procedure is then introduced to enable the adaptation of a limited selection of CCD cameras and lenslet arrays to the desired design specifications by use of commercial off-the-shelf optics. Although initially developed to aid in the design of high-speed (i.e., megahertz-frame-rate) Shack-Hartmann wavefront sensors, our method also works when used for slower CCD cameras. A design example of our procedure is provided.