Pericardial cysts are uncommon benign congenital anomalies of the anterior and middle mediastinum.
Usually asymptomatic and discovered incidentally although occasionally may present with chest pain and dyspnoea.
They are thought to often result from aberration...
Pericardial effusions occur when excess fluid collects in the pericardial space (a normal pericardial sac contains approximately 30-50 mL of fluid).
There is no single demographic affected, as there are many underlying causes of a pericardial effusion.
Pericardial haemangioma is a location specific rare subtype of cardiac haemangioma which arises from either the parietal or visceral (commoner 3) pericardial layers.
Treatment and prognosis
It is a benign tumour. Treatment option vary from monitoring to resection.
The pericardial ligaments is a name given to a group of variable fibrous ligaments or adhesions that connect the pericardium to adjacent structures. These ‘ligaments’ tether the fibrous pericardium to it's surrounds, hence movements of the chest wall and diaphragm influence the position of the ...
Pericardial lipoblastomas are rare benign tumours that usually occur in children less than 3 years of age. The originate from embryonic fat cells and are divided into two forms, based on location 1:
superficial form: well circumscribed and well encapsulated
deep form: not well circumscribed an...
Pericardial lipomas are slowly growing benign tumours of the pericardium that are asymptomatic unless large in size, where they can cause pressure symptoms.
Tends to be echogenic structure adjacent or inside the pericardium.
Seen as a fatty attenuat...
Pericardial mesothelioma refers to a mesothelioma arising primarily from the pericardium.
They are rare and are only thought to account for ~ 0.7% of all malignant mesotheliomas. There is male to female predominance of approximately 3:1.
The presentation o...
The pericardial recesses are small spaces in the pericardial cavity arising from the transverse pericardial sinus that are formed by the reflections of the pericardium. Pericardial fluid can pool in these recesses, mimicking mediastinal lymph nodes or pathology. There are several pericardial re...
The pericardial space or cavity is the fluid-filled space in between the parietal and visceral layers of the serous pericardium. In normal conditions it contains only a small amount of serous pericardial fluid, usually 15-20 mL.
A pericardial effusion is the pathological accu...
There are a number of tumours that can involve the pericardium. They include
primary pericardial tumours
primary pericardial mesothelioma
primary pericardial lymphoma
Pericardial window is a procedure performed to create a fistula or "window" from the pericardial space to the pleural space. It is done to allow a pericardial effusion to drain the chest cavity in order to relieve situations with increased pressures such as with cardiac tamponade.
Pericarditis is defined as inflammation of the pericardium. It is normally found in association with cardiac, thoracic or wider systemic pathology and it is unusual to manifest on its own.
In general, infection is the most common cause of pericarditis. Infection accounts for two-thir...
The pericardium is a conical, flask-like, fibroserous sac which contains the heart and the roots of the great vessels and defines the middle mediastinum.
The pericardium is made of two sacs in one. The outer sac is the fibrous pericardium and the inner sac is the double-layered ...
Peri-partum/post-partum cardiomyopathy is a dilated cardiomyopathy that may occur in the last trimester of pregnancy through the first several months post-partum.
The pathogenesis of post-partum cardiomyopathy is uncertain, with genetic factors, sympathetic tone, hormones, and malnut...
PET-CT is a combination of cross-sectional anatomic information provided by CT and the metabolic information provided by positron emission tomography (PET).
PET is most commonly performed with 2-[F-18]fluoro-2-deoxy-D-glucose (FDG). Fluorine-18 (F-18) is an unstable radioisotope and has a half-...
Pink tetralogy of Fallot refers to a tetralogy of Fallot in which the degree of right ventricular outflow obstruction is minimal, resulting no significant right to left shunt, and therefore no cyanosis. Symptoms are mild and presentation may be delayed, even into adulthood.
Pneumopericardium represents air within the pericardium, thus surrounding the heart.
Underlying causes include:
positive pressure ventilation
thoracic surgery/pericardial fluid drainage
blunt trauma (rare)
infectious pericarditis with gas-producing organisms
Porcelain left atrium, also known as coconut left atrium, is a term used when a large part of or the entire left atrial wall becomes calcified. It can occur as a rare consequence of endocarditis (with underlying rheumatic heart disease). It has also been described in the setting of end-stage ren...
The postcaval recess is one of the pericardial recesses forming a small space within the pericardium, which arises from the transverse pericardial sinus. It is located posterior to the superior vena cava and superior to the right superior pulmonary vein.
It may mimic mediastinal lymphadenopathy...
The posterior vein of the left ventricle is a vein of the heart which courses over the inferior wall of the left ventricle and drains into the coronary sinus to the left of where the middle cardiac vein drains into the sinus. It drains, not unsurprisingly, the inferior wall of the left ventricle.
A Pott shunt is a form of palliative surgery performed in patients with tetralogy of Fallot prior to the ability to repair the defect. It consists of a shunt formed between the descending thoracic aorta and the left pulmonary artery.
This does not relieve the right ventricular outflow obstructi...
Primary benign cardiac tumours are much less common than secondary metastatic deposits. However they are more likely when a cardiac mass is seen outside of the setting of terminal metastatic disease. Tumours include 1-2:
most common in adults
accounts for ~50% of all primary be...
Primary cardiac tumours are uncommon, and comprise only a small minority of all tumour that involve the heart: most are mediastinal or lung tumours which extend through the pericardium and into the heart, or metastases 1.
Primary cardiac tumours have an estimated autopsy prevalenc...
Primary malignant cardiac tumours are rare, and account for only ~25% of primary cardiac tumours, and only a small proportion of all malignant tumours which involve the heart: direct extension of adjacent tumours or metastatic deposits are far more common. Histologcal types include 1:
Prosthetic cardiac valves are a routine finding on chest X-ray. The frequency and degree of exposure is greatest in larger hospitals with cardiothoracic centres, however, prosthetic valves are commonplace universally.
Recognition of which valve has been replaced, any other related cardiothoraci...
Prosthetic heart valves are common. The four valves of the heart may all be surgically replaced. However, aortic and mitral valves are the most commonly replaced.
Replacements may be tissue or metallic valves, only the latter being visualised on imaging investigations. Sometimes the annulus alo...
Pseudocoarctation of the aorta is a very rare anomaly characterised by kinking or buckling of the descending aorta at the level of the ligamentum arteriosum without a pressure gradient across the lesion.
It is thought to be of congenital origin, and characterised by elongation and ki...
Pulmonary artery atresia (or sometimes known as pulmonary atresia) is one of congenital cardiovascular anomaly in which there is complete disruption between the right ventricular outflow tract (RVOT) and the pulmonary trunk.
The estimated incidence is 1 in 10,000 births.
Pulmonary artery banding is a palliative surgical procedure used to decrease excessive pulmonary blood flow. It is usually used for neonates and infants with left-to-right shunts unable to withstand complete surgical correction.
Some indications include:
Pulmonary atresia with intact interventricular septum (PA-IVS) is a subtype of pulmonary atresia that presents as cyanotic congenital heart disease.
PA-IVS is the combination of obstruction of the pulmonary outflow tract from pulmonary valve atresia without a ventricular septal defe...
The classification system for pulmonary hypertension was revised at the 4th World Symposium on Pulmonary Hypertension held in Dana Point, California, in 2008 1.
This system is as follows:
group 1: pulmonary arterial hypertension
1.1: idiopathic pulmonary arterial hypertension
1.2: heritable ...
Pulmonary hypertension has many causes, and these can be divided in many ways. A simple and systematic approach is to proceed along the cardiopulmonary pulmonary circulation, as causes are found at each site (for a more official classification system see 2003 third world symposium on pulmonary a...
The pulmonary valve is one of the four cardiac valves. It is the semilunar valve that allows blood to exit the right ventricle. It opens during systole and closes during diastole. The valve has anterior, left and right cusps, the bases of which attach around the valve orifice to a fibrous ring o...
Pulmonary valve regurgitation, also known as pulmonary valve insufficiency or pulmonary valve incompetence, is a valvulopathy that describes leaking of the pulmonary valve diastole that causes blood to flow in the reverse direction from the pulmonary trunk and into the right ventricle.
Pulmonary valve stenosis, or pulmonic valve stenosis, is a valvulopathy that describes narrowing of the opening of the pulmonary valve between the pulmonary trunk and the right ventricle.
Pulmonary stenosis is nearly always (95%) congenital, and therefore primarily affects the pae...
Pulmonary vein stenosis refers to a spectrum of condition characterised by narrowing to the pulmonary veins. It can be congenital or acquired.
primary pulmonary vein stenosis - occurs in children
secondary pulmonary vein stenosis - occurs in adults and usually associated with some identifiable...
Quadricuspid aortic valve (QAV) is a rare cardiac valvular anomaly where the aortic valve has four cusps, instead of the usual three.
The estimated incidence on necropsy at ~1 in 8,000. While the incidence of QAV on 2D echocardiography has been reported to range between 0.01-0.04%...
Radiation-induced heart disease, also known as radiation cardiotoxicity, describes an uncommon constellation of potential cardiac complications of mediastinal radiotherapy.
The demographics of patients affected by radiation-induced heart disease are those of the underlying conditi...
Raghib syndrome is a rare developmental complex, which consists of
persistence of the left superior vena cava along with
coronary sinus ostial atresia and
atrial septal defect.
It has also been associated with other congenital malformations including ventricular septal defects, enlargement o...
The Rapid ultrasound in shock (RUSH) protocol is a structured point-of-care ultrasound examination performed at the time of presentation of a shocked patient. It is a more detailed and longer exam than the FAST scan, with the aim to differentiate between hypovolemic, cardiogenic, obstructive and...
RASopathies are a class of developmental disorders caused by germline mutations in genes that encode for components or regulators of the Ras/mitogen activated protein kinase (MAPK) pathway.
As a group, RASopathies represent one of the most common malformation syndromes, with an in...
The Rastelli procedure is a surgical procedure to correct certain combinations of cardiovascular defects in patients with cyanotic congenital heart disease.
The operation is based on a redirection of ventricular outflows using an intracardiac baffle that tunnels the left ventricle to...
Restrictive cardiomyopathy is the least common subtype of cardiomyopathy and is characterised by a marked decrease in ventricular compliance.
Patients can present with symptoms and signs of left ventricular failure and/or right ventricular failure 9.
It is p...
Cardiac rhabdomyosarcoma is a muscular tumour that arises in the heart.
They account for only 4-7% of cardiac sarcomas overall but are the most common cardiac malignancy in infants and children. There is a slight male predilection.
Cardiac rhabdomyosarcoma ha...
Rheumatic heart disease (not to be confused with rheumatoid heart disease) may refer to either the acute cardiac involvement or chronic cardiac sequelae following rheumatic fever. Carditis is a major Jones criterion of rheumatic fever.
An increased prevalence in females have been ...
Rheumatoid arthritis (RA) is a chronic autoimmune multisystemic inflammatory disease which affects many organs but predominantly attacks the synovial tissues and joints.
RA has an overall prevalence of 0.5-1%. There is a female predominance, with the disease being 2-3 times more c...
Right atrial enlargement is less common, and harder to delineate on chest radiograph, than left atrial enlargement.
Enlargement of the right atrium can result from a number of conditions, including:
raised right ventricular pressures
pulmonary arterial hypertension
The right atrial (RA) line monitors RA pressure and is indicative of right ventricular function, preload and afterload. The RA line enters the right atrium through the right atrial appendage, and always exits the right side of the chest medial to the left atrial line. It is typically a double lu...
The right atrium (RA) is one of the four chambers of the human heart, and is the first chamber to receive deoxygenated blood returning from the body. It plays an important role in originating and regulating the conduction of the heart.
The right atrium receives deoxygenated blood...
The right coronary artery (RCA) is one of the two main coronary arteries that supply the heart with oxygenated blood.
It is a branch of the ascending aorta, with its normal origin in the right aortic sinus, just superior to the aortic valve
The RCA courses to th...
Right heart strain (or more precisely right ventricular strain) is a term given to denote the presence of right ventricular dysfunction usually in the absence of an underlying cardiomyopathy. It can manifest as an acute right heart syndrome.
Right heart strain can often occur as a re...
The right pulmonary venous recess is one of the pericardial recesses forming a small space within the pericardium. It arises from the pericardial cavity proper located between the right superior and inferior pulmonary veins, posterior to the left atrium. It invaginates towards the oblique perica...
The right pulmonic recess is one of the pericardial recesses forming a small space within the pericardium, which arises from the transverse pericardial sinus. It is located posterior to the right pulmonary artery and anterior to the oesophagus.
It may mimic mediastinal lymphadenopathy or a bron...
The right ventricle is the most anterior of the 4 heart chambers. It receives deoxygenated blood from the right atrium and pumps it into the pulmonary circulation. Blood enters the right ventricle through the atrioventricular orifice containing the tricuspid valve during diastole and in systole ...
Right ventricular dysfunction usually results from either pressure overload, volume overload, or a combination.
It occur in a number of clinical scenarios, including:
cardiomyopathies: ischemic, congenital
valvular heart disease
It can manifest as r...
Right ventricular enlargement can be the result of a number of conditions, including:
pulmonary valve stenosis
pulmonary arterial hypertension
atrial septal defect (ASD)
ventricular septal defect (VSD)
anomalous pulmonary venous drainage
The right ventricular outflow tract (RVOT) view (or three vessel view/3VV) is one of the standard views in a fetal echocardiogram.
It is a long axis view of the heart, highlighting the path from the right ventricle into the pulmonary trunk (right ventricular outflow tract).
In this view, the r...
Ritscher-Schinzel syndrome (RTSC), also known as 3C (cranio-cerebello-cardiac) syndrome, is a rare entity with a variable spectrum of CNS (primarily cerebellar), craniofacial, and congenital heart defects.
Ross procedure involves the use of a pulmonary homograft for surgical aortic valve replacement.
It can be used to treat a broad array of aortic valve pathologies, often aortic stenosis.
multivessel coronary artery disease
multiple valvular pathologies in which...
The Sano shunt is a palliative surgical technique sometimes used as a step in Norwood procedure for hypoplastic left heart syndrome.
The procedure involves placement of an extracardiac conduit between the right ventricle and main pulmonary artery stump. This technique prevents the reduced diast...
Cardiac manifestations of sarcoidosis are present in up to 25% of patients with sarcoidosis, but only 5-10% of patients are symptomatic 1-2.
Sarcoidosis is a multisystem disorder characterised by the presence of non-caseating granulomas. For a general discussion of this condition please refer t...
Scleroderma, also known as systemic sclerosis, is a multisystem autoimmune connective tissue disorder. As such, it affects many separate organ systems, which are discussed separately:
musculoskeletal manifestations of scleroderma
pulmonary manifestations of scleroderma
cardiac manifestations ...
Secondary cardiac neoplasms or cardiac metastasis/es refer to a secondary malignant tumour of the heart, arising by lymphatic or haematogenous spread of a primary neoplasm 3,5.
Overall cardiac malignancy is an infrequent finding. Metastatic spread is much more common than primary ...
The Senning repair is one of two "atrial switch" procedures used to functionally correct transposition of the great arteries (the other being the Mustard repair).
The two repairs share a similar fundamental principle. Systemic blood flow is redirected away from the right ventricle and toward t...
Septal bounce is a sign of ventricular interdependence on echocardiography, cardiac CT, and cardiac MRI, manifested by reduced or paradoxical interventricular septal movement during diastole (i.e. initial septal movement towards and then away from the left ventricle) during early diastole second...
The septal branches of the left anterior descending artery supply blood flow to the interventricular septum of the heart.
These are branches from the left anterior descending artery
They provide the main blood supply to the anterior interventricular septum. A smaller posterior ...
Shmoo sign refers to the appearance of a prominent, rounded left ventricle and dilated aorta on a plain AP chest radiograph giving the appearance of Shmoo, a fictional cartoon character in the comic strip Li'l Abner in the 1940s. This sign is indicative of left ventricular enlargement.
Single coronary arteries are rare (incidence 0.03-0.07%), with a higher incidence in patients with congenital heart disease (in particular truncus arteriosus and pulmonary atresia). They occur when there is a single ostia arising from the aorta with no ectopic ostia. There is a wide variety of c...
The sinoatrial (SA) nodal artery is the small artery that supplies the sinoatrial (SA) node of the heart (the pacemaker).
Right coronary artery in 60% of cases and the left coronary artery in 40% of cases.
The artery turns posteriorly below the superior vena cav...
Sinus of Valsalva aneurysms are a cause of thoracic aortic dilatation. They can be either congenital or acquired (mycotic).
There is a male predilection (M:F ratio being around 3-4:1). They are relatively more common in eastern and Asian populations and can occur in any age group ...
The small cardiac vein is a vein of the heart which accompanies the acute marginal artery from the RCA. It courses in the right posterior atrioventricular groove and drains into the coronary sinus close to it’s termination but may drain directly into the right atrium. It drains the right ventric...
Snowman sign refers to the configuration of the heart and the superior mediastinal borders resembling a snowman. This is seen in total anomalous pulmonary venous return (TAPVR) type I (supracardiac type).
It is an abnormality of the fetal circulation wherein the entire pulmonary venous flow is ...
This mnemonic will help with the sonographic approach to the critically ill patient with dyspnoea:
C: collapsed lung (pneumothorax)
absent anterior lung sliding / anterior B lines
lung point present 1
H: heart failure (acute pulmonary oedema)
diffuse bilateral anterior B ...
Speckle tracking echocardiography is a new player in the cardiac arena which is rapidly making its mark in cardiac and radiology circles alike. It is an objective, robust, semiautomatic and reproducible technique with a short post processing time.
Traditionally, left ventricular function is mea...
Stunned myocardium refers to a situation in which an acute transient myocardial ischemic event results in a prolonged wall motion abnormality which eventually resolves.
The term is usually distinguished from "hibernating" myocardium, in which a chronic ischaemic process leads to chronic left ve...
The superior aortic recess is one of the pericardial recesses forming a small space within the pericardium, which arises from the superior margin of the transverse pericardial sinus and surrounds the root of the ascending aorta.
Its components are variable and may be further subdivided into:
A mnemonic for surgically-created cardiac shunts for congenital heart disease is:
great flow really would be perfect
The mnemonic is ordered by the position of the shunt antegrade to normal blood flow through the heart, proceeding from the systemic venous system into the right heart, and then...
Syphilis is the result of infection with the gram negative spirochete Treponema pallidum, subspecies pallidum. It results in a heterogeneous spectrum of disease with many systems that can potentially be involved, which are discussed separately.
Despite the discovery of penicillin...
Tachycardia induced cardiomyopathy (TIC) (or tachycardiomyopathy) is considered a reversible form of acquired cardiomyopathy where there is impaired left ventricular systolic dysfunction precipitated by a tachycardia or a tachyarrhythmia.
Typically there is an impairment left ventricular systol...
The Takeuchi procedure refers to a direct anastomosis of the anomalous left coronary artery from the pulmonary artery directly to the aorta was described in the 1970s and currently remains the procedure of choice.
An intrapulmonary aortocoronary tunnel or baffle was performed by Takeuchi prior ...
Takotsubo cardiomyopathy (TC) is a condition which has been described predominantly in postmenopausal women following exposure to sudden, unexpected emotional or physical stress.
There is a transient left ventricular dysfunction and there is no evidence of obstructive epicardial cor...
Taussig-Bing anomaly is a rare congenital heart malformation and is one of the variants of double outlet right ventricle. It consists of transposition of the aorta to the right ventricle and malposition of the pulmonary artery with subpulmonary ventricular septal defect.
History and etymology
Tetralogy of Fallot (TOF) is the second most common cyanotic congenital heart condition and has been classically characterised by the combination of ventricular septal defect (VSD), right ventricular outflow tract obstruction (RVOTO), overriding aorta, and a late right ventricular hypertrophy.
A mnemonic for the underlying anatomic defects in tetralogy of Fallot is:
P: pulmonary stenosis
R: right ventricular hypertrophy
O: overriding aorta
V: ventricular septal defect
Thallium 201 Chloride is a radiopharmaceutical used in cardiac imaging.
photon energy: 80 keV
physical half life: 55 hours
biological half life
rest: 3 minutes
exercise: 30 seconds
normal distribution: myocardium, skeletal muscle, GI tract, liver, kidneys
The third mogul sign can be seen on frontal chest radiograph in the presence of left atrial enlargement. It refers to an extra mogul or bump along the upper left cardiac silhouette just below the left main bronchus.
The third mogul sign commonly represents the enlarged left atrial appendage, pa...
The thoracic aorta is the most superior division of the aorta and is divided into three sections:
The thoracic aorta begins at the aortic valve, located obliquely just to the left of the midline at the level of the the third intercostal space. It ...
The thrombolysis in myocardial infarction (TIMI) risk score is a prognostic risk stratification system that categorises the risk of death and ischemic events in patients with unstable angina / NSTEMI and provides a basis for therapeutic decision making. It is thought to have potential to improve...
Total anomalous pulmonary venous return (TAPVR) is a cyanotic congenital heart anomaly with an abnormal drainage anatomy of the entire pulmonary venous system. This contrasts with partial anomalous pulmonary venous return (PAPVR) where only part of the pulmonary venous anatomy is abnormal.
Total repair of tetralogy of Fallot is a corrective surgical procedure that involves closure of the ventricular septal defect (VSD) and relief of right ventricular outflow tract (RVOT) obstruction.
Most patients with tetralogy of Fallot (TOF) undergo elective surgical repair between ...
Transcatheter aortic valve implantation or replacement (TAVI/TAVR) is a technique to replace the aortic valve through a transvascular or transapical approach. Compared to traditional open aortic valve replacement with sternotomy and a heart-lung bypass machine, the TAVI technique is less invasiv...
Transient ischaemic dilatation is a paradoxical phenomenon seen in myocardial perfusion SPECT imaging.
With severe balanced coronary artery disease, myocardial ischaemia may result in apparent enlargement of the left ventricular cavity during stress. The cause of this is not entirely clear, b...
Transposition of the great arteries (TGA) is the most common cyanotic congenital cardiac anomaly with cyanosis in the first 24 hours of life. It accounts for up to 7% of all congenital cardiac anomalies 1 and can be assessed with echocardiography, gated cardiac CT, or cardiac MRI.