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My name is Naveen Sharma. Apologies. I'm not with you in person today. I promise I had put my train and then came to train strikes, meaning I had to deliver this talk virtually. Which being honest as an introvert is the best thing that could have ever happened to me. Now, who am I? And why am I talking to you today? And I am a radiologist. That's why I'm here. I'm not just some guy at the street, but I did start to think about why I did get asked him today. And what is that? That's my biggest achievement. And I had to think about it. Is it having a radiology Instagram account with half a million followers? Please follow out the radiologist patron Instagram cheeky plug. And I thought, no, it's not that is it getting into radiology training? Which these days is more like the Hunger Games? I mean, I don't know if you looked at the application form these days, but now you actually have to deliver the blood of your first ball to even stand a chance of an interview. So for those of you who got in well done and I thought No, it's not that, is it getting through the intimidation and unnecessary bullying during my fr cr to be fiver all those years ago, I mean, I passed, which is just as well as become a consultant has helped pay for the therapy sessions and I still get flashbacks. But no, it's not that my friends, my greatest achievement and the reason I'm here today is this S R T 2015 2nd place prize for educational poster. That's right. You probably thought I was just some guy but little did you know you're in the presence of greatness. Now, I know what you're thinking. That's not your first place, but the first place gets all the glory things go to your head, second place, you know, you're good and you retain your modesty. Bear that in mind for later. But seriously, though I found this when looking for my marriage certificate, which I lost, but this I kept and that shows you just what SRT means to me. And so you'll see it is an honor for me to be giving you this talk today. So I was tasked with giving you a talk on the basics of cardiac radiology and full disclosure. I left it quite late. So I decided to ask our robot pals to give me a hand. I asked Chat G B T to help me write a talk on cardiac radiology. That's Chat GPT right there. So I wrote in the right talk for training radiologist on cardiff radiology in the style of the radiologist, patient Instagram one to make it realistic, put it in the form of bullet points or numbered points. And this is what I got. And you know, I just thought I'd read this out. Welcome radiologist. Today we're going to talk about cardiff radiology and how to improve your skills. Interpreting bit boring, isn't it? So I thought let's make it more fun. And what I got was something I could never dream of creating. Hey, hey, hey, radiologist, welcome to the most epic cardiac radiology training ever. Get ready to have some serious fun as we learn all about the heart and how to become an ultimate cardiac imaging superheroes. I mean, that's just incredible. My favorite bits are the function of the heart, including the ejection fraction. We're not just pumping blood, we're pumping up the party and the presence of any size of the scheme or infarction. Let's find the heart little boo boos and give them some tender loving care. I mean, that's just better than anything I could have come up with, but there are some person lessons to take away from there. Let a I do the dirty work. Now you're going to come across a lot of people who are going to tell you that artificial intelligence is going to take jobs away from radiologist. And the thing about these people is that they really love it. They really want us to lose our jobs. I mean, look at some of the comments I get on social media. This comment is from complete surgeon. I mean, I'm glad he was complete as you can't contrast an incomplete surgeon E day. I see a radiologist like a patient in the face and tell them what their problem is and that they will take care of it. I will call them real physicians. Otherwise the are a tour we conditions used to treat human beings. The data computer brackets. A I can do my job. I will bow to them. Diagnostic radiologist. Brackets. Readers should about two computers who eventually will replace them. Enough. Said no offense. Now, firstly, the first thing this guy should be bound down to is a dictionary and babies, but I'll check facility but you can detect the joy this guy is having in telling us our job is in danger. So, in the distant future, yes. A I could report a scan to a better ability with a radiologist. But right now and in the near future we're that top guy. There are so many ways in which AI is going to make our life a lot easier and scan reads a lot safer. It's a tool in the armory that we can use. So, remember that whenever anyone tries to tell you any different, now there is a lot more nonsense I could speak, but I should probably start talking about what I'm supposed to be actually. Talking to actually supposed to be here to talk about. Now, if I told you there was this thing in the human body disease of which is the biggest killer in the world. If this thing stops working for a few seconds, then you will die. And most regular, just from reviewing a CT scan, don't even look at it. You'd say that doesn't really make sense. Right. So if you leave here today and on the next CT you look at you just even glance at the heart and I'll take that as a win because most people don't. So what we're going to do is going to have to a whistle stop tour around the heart and we're gonna go through things that I didn't really have a clue about when I was training. So what do I do in reviewing a post contrast CT scan is too literally follow the contrast around and in doing so and make sure I've checked all the major structures. So we'll start with the S P C. So this has received like in the right and left, breaking balik veins and the strength into the upper half. This strains the upper half of the body and into the right atrium. Usually there's one SPC, but it can be variants that can be a left sided SPC which can drain into the coronary sinus. This is the coronary sinus over here, which to be honest, during my training, I had no idea what that was. Um, and this is draining blood venous blood, the left ventricle into the right atrium. Now, left side SBC that goes into the quarry sinus isn't really a big deal because it's heading into the right atrium, which just as the normal SBC words, the problem comes when it drains into the left side of circulation, such as the left atrium and then you have a left right shun and this, although this is uncommon, now, usually three things strain into the right atrium. The S P C comes in from above, the IBC comes in from below. And we've mentioned the coronary sinus the only. So then after that blood goes through the tricuspid valve, which we can see here. So the name suggests this is three leaflets, unlike the other atrioventricular valve. On the other side, the mitral valve, which has to what pathologies affect the tricuspid valve regurgitation, which is usually functional associated with the right ventricular dilatation in. So, if the right ventricle enlarges, the Tricuspid valve apparatus stretches the leaf that's come apart leading to regurgitation, stenosis or the Tricuspid valve isn't common associated with rheumatic fever and carcinoid. So let's have a look at a case here. We've got a 46 year old male who presents with chest pain and has a cardiac CT. And here is an image from that reach of the following is least likely P B S D or A S D. Now, the thing to spot here is that the right ventricle is larger than the left and this suggests right ventricular dilatation. Now, if you see this on CT, there are few things that you start to think about. Number one, think about the most common cause which will see on CT scan, which is A P S O, check your palmy arteries, looking for acute and chronic peeing to think about a left to right shunt, which will come into more detail. And three think about a condition known as a RBC or arrhythmogenic ventricular cardiomyopathy. This is the likely inherited condition, whether it's fatty replacement of the right ventricular wall. However, we now know the camp also the involvement of the left ventricular wall as well. It's best successful echo and N MRI and we'll see a reduced ejection fraction on the right. Usually now, very occasionally you can see fat density within the wall of the right ventricle on CT, which if you see a dilated right ventricle is an unlikely cause, but it's just worth checking. So a bit more on the left to right shirts. That should really sorry. Now, it took me a while to get my head around this but not all of these can cause white heart dilatations. We can split these up into shots that happen before the tricuspid valve and those that happened after sorry, this should say left to right as that is an error at the top. I will try and add an attendant later. Um So we can split these up into things that calls happened, performs tricuspid valve and happened after the tricuspid valve. Now, the ones that happened um before cause right heart validation and they want to happen after and why that I mean happen at the level of the right ventricle or the parliament archery cause left heart validation. It took me a little while to understand why that was. But the reason is the blood shots from left to right, but the blood doesn't spend long enough in the right ventricle to cause that volume overload because it gets pumped out straight away. And you actually end up with left heart validation with the VSD NPD A which is an abnormal connection, we'll be able to inform the artery. So the key point is that A S D needs to write hart palpitation and BS des need to left heart palpitations. So the answer to our question here is because we have right hart palpitation, you look for an ASD and learn, behold, you have a defect in the region of the inter actual sector. So let's have a think about a stds remain. Types may occur at different parts of the interatrial septum. First is the most common and this is what we have in our case. Ostium secundum, this happens at the mid atrial level, often discovered as an adult. So when you see a dilated right heart on A C T or an adult, don't think about this as we are looking at a CT will have a chance to diagnose it. This was an E C G gated CT scan, but sometimes you can just make it out on a non gated scam austin primum is less common. Uh This occurs more towards the ventricle, so called endocardial cushions effect. Less likely we'll pick this up in adult hurt. And the third is something called a sinus spinosus asd. This is eccentric happening either with the inflow of where the S P C comes in or the I D C comes in. In theory, early SPC is more common like we have in this case in the picture over here. Now, over 80% are associated with something called partial anomalous pommery venous return, which is something that we will come onto. So to summarize when you see a dilated ventricle, one, check the poem, the arteries to look for a shunt. The main things you need to do have a look at the interracial septum. Can you see an asd and check the poly veins which is something will come on two and three, just have a look at the right ventricular wall. Can you see in your practice city on the wall and a CT scan? One last thing about the right ventricle is that's the most anterior heart chamber and sometimes a congenital heart disease. It can be really difficult to tell what the morphological right ventricle is. So we look at something called the moderator band should always be there. And this is a virus band which extends from the septum to the are be free wall. We can see it just over here. Now, if we follow the contrast up into poli artery, something we should all be familiar with acute P here. You've got the Polo mint sign which signifying acute P as a walls of the vessel is spared. If you do see A P, the best marker for right heart strain that correlates with 30 day mortality and echo findings is measuring your R V E L V actual dimension ratio. So in a standard CTP A measured from the endocardium to the endocardium on the left and the right in the basil third of the ventricles. So that's the part that's closest to the valves. You don't necessarily have to do it on the same axiom slice. And if the right ventricle is larger than the left, we can say there is right heart strain on CT on this gonna ratio is around once once we are okay. If the right ventricle is dilated, this has prognostic implications and can help risk stratified patient's that you may be eligible systemic or captor directed on license. So next, let's think about pottery hypertension. Here. There was a mean palmy arterial pressure impact of more than 25 millimeters of mercury officially measured by right heart capitalization. But can we tell if there's problems hypertension CT, well, we can get some information from our CT scans. We can look at the palm tree trunk and that can give us some information if we measure the ascending aorta and compare it with the palm tree trunk, if the pulmonary artery is larger. And this is a good sign that there is palm hypertension. Alternatively, we can measure the palmy trunk and the larger is the more likely it is that they've got palmy hypertension over 33 millimeters. And we can be fairly certain with, with an over 95% specificity. So contrast has gone out of the palm, the arteries gets oxygenated comes back in via the pommery veins. And we've got this schematic diagram here. Now, in normal circumstances, there should be at least two pommery veins on each side. What we call is pretty easy, right and left, superior and inferior. Now, I say at least two on each side is normal as it can be additional accessory pommery veins, for example, a separate vein draining the middle lobe. What shouldn't happen is what we mentioned before and a palm yvaine plugging into the right side of circulation rather than going into the left atrium as then you have a left to right, a left right shunt. Now, in total anomalous pommery venous return, nothing at all, drains into the left atrium. All the pommery veins drain into the systemic circulation. This is a cyanotic congenital heart anomaly presents of birth, you get the classic snowman appearance on the chest X ray, right? People won't be seeing this incidentally on an adult ct now, whether partial anonymous palm ravines returns quite different here. At least one palmy vein, but not all of them drain into the systemic circulation. Rather than that patriot. There were different variations of this, but eventually the blood will end up in the right atrium. And what we have here is the case from before with the sinus been osis asd which remember I said could be associated with the right sided partial numbers, palmy venous return. And here we can see the right superior palmy vein draining into the S P C as well as the sinus pain osis asd on the same case. Another common configuration of this is left sided. And here we've pointed out the left superior palmy vein draining instead of going into the left atrium is heading upwards and it's going into your left break hepatic vein there. This doesn't always prevent the symptoms. So you may well see this incidentally on CT. And for me, this is very easy to spot on just this image. Here on the left sided image. We know there's a problem here because the important lesson here is in normal circumstances on actual spices, you shouldn't have a vessel that is to the left or the aortic arch. If you do, you need to think about left sided partial normal's problem units return training into the left breaking valid veins will be seen or a left side SBC that we mentioned for can look like this as well. If you have a right side of one, like the previous case, we already know this can be associated as I said with a sinus for notice, a sti which means you've got a lot more left to right shunting more volume overload on those right side of the heart chambers progressing to pommery hypertension that it's really important to look for on CT as we don't see partying on this palm, a venous return well echo. So it's up to us as radiologist to look for it on just everyday general CT that we're reporting and we do see patient's down the line with right heart failure upon your hypertension years before they've had a CT. And in retrospect, you can see there was a shunt there. So key point is to make sure at least to palmy veins, drains the left atrium on each side. So next, the blood heads into the left atrium and contrast to pacify the left atrial appendage, which is a finger like projection, which comes off the left atrium gives us part of the contour of the left side, a hard border and chest X ray. And this is really important because from this likes the form here and then fly off and cause strokes. Now, it can be really tricky to assess on CT is sometimes contrast doesn't fill the whole appendage. So it's really difficult to differentiate between genuine from this and contrast stasis. Now, transthoracic echo doesn't assess the appendage very well. And the gold standard is T O. We trying to stop the deal echo, which is quite an invasive procedure. However, radiology, we do have a few tricks up our sleeve. So what we can do is a laid phase ct. So have a look at this case and we've got a patient has had a previous known from this in the left atrial appendage on T O E was anticoagulated, didn't want another T O E. So the cardiologist asked whether we could do a CT scan. So first on the initial phase, we've got an apparent filling defect here in the left atrial appendage, we prick peter the scan at one minute and then you can see that there is still something going on at the tip and we've done it again at three minutes and you can see all homogenize is. So here that, that means on the initial sequence, this was all just contrast stasis rather than real from this. And the evidence for this is good, meaning we can be fairly certain with this appearance three minutes, but there's no remaining from this. This correlates. Well, with T are we, so we're going to move on to the mitral valve? This has two leaflets, anterior, posterior unlikely tricuspid, which has three, this attaches to a fibrous ring known as the mitral valve annuus. Now, you may see calcification in this area. Calcification of valve itself isn't common and it may point to usually rheumatic heart disease. In which case, you may get a really dilated calcified left atrium, which is usually a nice exam case. Calcification of the annual list itself is a lot more common and you'll see it barely often doesn't usually cause any problems. It can be quite florid. Now, it's quite rare but sometimes this calcification can what we call Casey eight and liquefy like this case over here. Now, these are sometimes mislabeled as tumor's and usually however thought of as leave alone lesion's the optimal management when it Casey eight is a bit unclear because surgery is usually high risk and sometimes this case, a thing calcification can just on its own revert back to regular calcification saying that when there is caseation, there is a risk of embolization and stroke. So unfortunately, that's what happens to this patient who scanners is a few weeks later, they had a stroke. So the lesson here is most much Manulis calcification is fine and you wouldn't do much about it. In rare cases, this can liquify and can be confused the tumor. But most cases again, you don't need to do much unless usually if there were mbali later like this case. Now, below the mitral valve, you have the subvalvular apparatus connecting it to the left ventricle, you have the cord a tendency which are thin fibrous cause which you can sometimes see on CT and they connect onto these, which are the papillary muscles. During systole, these contract to close the valve and present them from, from prolapsing in the left ventricle. You've got the, the anterior, the posterior papillary muscles and here on the left, we've got what we call a short axis view. And we know we're cutting through the mid birds of the left ventricle because we can see these, these preparing muscles. So they're a nice market that in the mid third of the, of the ventricle. So going on to the left ventricle in more detail, in terms of anatomy, we can think about it in 17 different segments. So this looks quite daunting, quite confusing. And I don't think that your stage, you need to memorize all of this for exams, but it's good to learn the basic principles. What we can do is we can firstly split this ventricle up as we mentioned for into third. So you've got the basil third, which is closest to the valve, the mid third, you can use the papillary muscles here as a marker of that and then the eighth called third distance to that. Now, let's cut through the left ventricle, give it a donut shape. This is reproducing something called a short axis view which we can see on the cardiac MRI. Now, if we draw in our right ventricle, this will attach to two points called the RV insertion points. Now over the basil midnight from segments, it gives us 17 segments in total. But let's let's simplify it really what I want you to think of it as is the septal part, which is defined as the two insertion points by the to insertion point. Sorry, the anterior part which is at the top, the inferior part at the bottom and the lateral wall which is over here. So the bread and butter of cardiac imaging is assessing ischemic heart disease, which given this is the biggest killer in the world is no surprise. So we need to think about which coronary artery supply, which part of the left ventricle, the L A D usually supply the anterior and septal walls and most of the apex, the circumflex supplies the lateral wall and the right coronary supplies in variable. It can be a little bit of variation depending on which vestments dominant, whether it's the right coronary of the left circumflex artery, what vessels doc is whatever vessel supply is a vessel called the P D A, which is the vessel that runs the base of the heart. But this diagram usually gives us a fairly good guide as to what territory supply by which artery. And this can be really helpful when it comes to interpreting cardiac MRI studies, CT studies and also your Micardis perfusion scans. Now thinking about scheming heart disease, there are loads of different tests we can do. The gold standard is invasive coronary angiogram, which can give us the anatomy of the coronary arteries also can give us some idea of the function as well. Now, remember, not all Corey stenosis are functionally important and it can be especially difficult to know whether the moderate stenosis, the ones between 50 and 69% are functionally important. What you can do during invasive angio is measure something called the FFR fractional flow reserved and put a wire across the stenosis test the pressures either side and see if it's functionally significant stenosis, then you can go on to treat stenosis with sensing or blue invasive angio then gives us, gives us anatomical info, gives us functional info and it also gives us therapeutic options. Now, CT is increasingly done. And if you've been anywhere near radiology department, you've probably seen we're now doing absolute shed load of cardiac CT. That's because it's not invasive. It's quick, it's safe. It's just really good. It gives us so much information about the anatomy instructor of the coronary arteries that's prognostically important. The disadvantage is it doesn't give us functional information, especially regarding those moderate stenosis. However, there is a new technique called CT FFR where we can get some function information as well by mathematically model inquiry flow below before and after stenosis. Although it isn't implemented everywhere just yet, you then have your standard functional studies and this middle column. So equity IV C G been superseded by things like stress echo Mark Cardell profusion scans. And then you've got Mark Cardiac MRI, which does a bit of everything. It gives you so much information about the function of the left ventricle, much like an echo. But more detailed, you've got perfusion aspect, we can stress the patient with adenosine. See if there's inducible scheme here much like nuclear medicine perfusion studies. But when it gets really interesting is you can give gadolinium contrast and get tissue characterization and that information you don't really get on any other studies, which is why I think cardiac MRI is such a great test. The downside is it takes a long time to do so. Ct takes a few minutes. Cardiac MRI can take anywhere between half an hour to an hour or the demands on MRI scanners across the country. It's a struggle sometimes to put them in. So how do we perform tissue characterization? Simple way to think about it is we inject gadolinium which we know accumulates in the extracellular space. So in pathologies that cause my sight necrosis or fibrosis such as infarction, there's increased exercise, other space, meaning increased gadolinium. So what we can do is choose the timing of the scan, whether my card it becomes mulled or those black and accumulation of gadolinium cause t one shortening and looks bright. Uh So what we can do then is distinguished between what we call ischemic causes of lake an enhancement and non ischemic cause of lake an enhancement. What we do is we split the myocardium says the wall of the left ventricle into different layers. So we've got the subendocardial layer, which is the inner part, the mid wall and the outer part of the epicardial layer. What we know in the ischemia when the quarries are blocked, the subendocardial part of the wall is the business affected. First, this is a bit that's most vulnerable and then it spreads to involve the mid wall than the whole wall, so called transmural. So, whereas a non ischemic cause of lake and enhancement including cardio mark, the mark carditis affect the mid wall or the epicardial layer and they usually spare the subendocardial layer, ischemic causes started the subendocardial layer and work their way through. So let's have a look at this case here. Here, we're dealing with 76 year olds coming with chest pain and we're cutting through the basil third of left ventricle, I can't see the papillary muscles. So I don't think I'm in the mid part of the left ventricle. Here, we have the RV insertion points which I've just marked in over here. And then let's mark in each part of the ventricle. So we've got the sector war in between the RV insertion points. We've got anterior at the top in here at the bottom and on the side, we've got the lateral wall. But if you look at the lateral wall carefully, you'll see you've got this ring of sub endocardial enhancement. Now, remember that means we've probably got an ischemic cause of Lake Allen Huntsman. Remember the lateral supplied by the circumflex artery. So this looks like an iron farts caused by obstruction of the circumflex. It's worth. So what CMR can do if you can tell us if the heart vessel is what we call viable? So is it worth rescuing with intervention? And the ball here is that if there's less than 50% of the L V wall thickness involved with us, let with this lake and enhancement, then it is viable. In this case, I think we're just going more than 50% here in the lateral wall suggesting it's not viable. This patient also had a CT scan and the left circumflex artery runs in between your left atrium and ventricle and we can see it's not well a pacified here. This is a severe sin osis that's led to a left circumflex artery impasse. This is what chat G B T would have referred to as a sign of infection or more specifically, a little Boo boo have a look at this case. This patient came in with breathlessness and like every patient who has any hint of respiratory symptom, they go on to an STD pee wee show, you know, peeing but have a look at the left ventricle. It's not, well, it pacifies we time the scan to look at the right heart and the arteries but still have a look at it, one thing I want you to go away from this talk with is if the left ventricle Luminal diameter, even on a non gated CT is more than 5.5 centimeters, then they likely have a dilated left ventricle. And on this case, we've got way more than 5.5 centimeters and 7.8 centimeters. So this is definitely some it's worth mentioning in the CT report. Now, the most common cause of LV dysfunction is scheming heart disease and cardiac MRI can be really helpful here because because of the tissue characterization, we can differentiate between ischemic versus non ischemic late enhancement. So, firstly, cardiac MRI in this case, confirmed a low lb ejection fraction. And then let's have another look at this late garden image through the basil third. Again, we've got no papillary muscles. We think we're in the basal third instead of subendocardial enhancement. You can see the subendocardial layer is spared. Here, we've got enhancement of the mid wall. So this is a pattern of non ischemic lake and enhancements. So we don't think this is because of the level will be dysfunction is because of diseases that cory arteries. The diagnosis here was a non ischemic dilated cardiomyopathy thing. One more thing to review the left ventricle, look at the cavity and looked at filling defects which could represent from this homicides perform in places where there hasn't where there's been previous infarction is this part of the heart, is it moving properly in their spaces? So have a look at this cardiac MRI image. And here we can see, well, usually in Cardiff right early got images are usually the best for looking from this. Here. We've got lake and images but we can see there's been a transmural apical influx all this stuff here. This right stuff here is a thinned lb apical wallets all embarked and it's all lighting up with gas. This dark stuff here is a normal LV war. This is actually a filling defect. This is actually thrombus. Now remember Thrombus doesn't enhance unlike certain tumors. So even really important general CT is look at things like your left ankle appendage, look at your left ventricle, in particular, looking for Thrombus as if down the line, this causes a stroke, then what we could have seen that we could have prevented that and that's our job. So we'll finish up with the aortic valve in normal circumstances. This has three leaflets like this picture on the left. Now, this I know is the noncoronary cusp because it's a putting that into atrial septum. So there's three leaflets, the noncoronary cusp here abuts the, the intellectual septum. You got the left atrium over here, right atrium over here. This over here is the right coronary cusp. And over here is the left coronary cusp and you've got the left side economy arteries over here. Now, if you see a calcified aortic valve in a patient under the age of 55. This raises the possibility of a bicuspid aortic valve. And we've got a classic example of that on the right over here, this in the systolic phase looks a little bit like a fish mouth. These can be associated with a dilated defending, able to, as well as cooptation. So if you see a dilated tumor ascending, able to reconstruct your aortic valve, if you have a gay to study in particular. Now, sometimes like the middle image can be really tricky. This is a bicuspid valve. We look at it insistently you've got a fish mouth kind of appearance, but it can be really tricky, especially if you catch it in the diastolic phase because you've got fusion of the right and the left coronary cusps. So I will leave you with a shameless plug for more cases and nonsense memes. Please do follow me on Instagram. You can always use your iphone to scan that QR code or if you have psychopathic tendencies, you can use your android device as well. I'll leave you with this something not about Cardiff radiology, about your training in general. For those of you who've already got into radio already training already. Congratulations. Honestly, you've made such a good decision. I was a bit unsure about radiology training when it first started having come from medicine, but looking back at it, it was the best thing I ever did its job so much better. Than every other specialty. So just remember to be grateful for the position you're in. Once you get into training, if you work hard or a normalish person, you'll do great. And if you're really lucky, you'll get second prize for Best Educational Poster and live off the glory for the next eight years. Thank you very much.