P1254325714ONitZ

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A Cardiac Quiz by John Partridge
In anatomy, it is better to have learned
and lost than to have never learned at all
W Somerset Maughan
www.cardiacradiology.co.uk
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Welcome to the quiz All the slides have a clue,
either text or another image, which will appear
when you mouse click. some have two
clues. score two points for a correct answer
without using a clue, one point with the
clues. The next mouse click will bring in the
answer in white text have fun!
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A practice question
The Trojan Horse Analysis of eyewitness reports
have allowed a determination of the exact number
of Trojans in the Trojan Horse. How many were
there?
You do know the answer
none, they were all Greeks
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Answer Both have an upturned cardiac apex, but
the one on the right is a genuine boot heart of
tetralogy of Fallot (note right aortic arch)
whereas the left has left ventricular hypertrophy
due to coarctation (flat aortic knuckle).
One of these has severe LVH, the other severe
RVH. Which is which?
look at the upper mediastinum
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5
who matches the film?
B
A
The valve is a Starr ball and cage, and C is
Ringo Starr
D
C
2
6
Who matches the 3D CT recon?
C
A
So the heterotopic transplant gives you two
hearts, just like Dr Who (C). A is Spock, who
has green blood but only one heart, D is
Superman who still only has one, and B is James T
Kirk, who probably doesnt have one at all.
D
The CT is of a heterotopic (piggy-back) cardiac
transplant
B
3
7
What's missing?
There is complete absence of the left
pericardium. The clue is in the sulcus between
the aorta and the main pulmonary artery. The
plain film is diagnostic with an angular left
heart border and cardiac displacement to the
left. One of my favourite films!
4
8
What's missing?
The left upper pulmonary vein is not in its
usual position in front of the left main
bronchus. The clue images show that it turns
upward to drain anomalously into the left
brachiocephalic vein. The bottom left image
could well be mistaken for a persistent left
superior vena cava.
5
same malformation, different case
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Odd
One
Out
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B
A
which of these is the odd one out and why?
B is an Eisenmenger ASD with large main and hilar
pulmonary arteries. The others all show a large
main and left hilar artery and a small or normal
right hilar pulmonary artery, the classic
appearance of valvar pulmonary stenosis.
C
D
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one of these is not pulmonary stenosis
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B
A
which of these is the odd one out and why?
All these have a flattened left upper mediastinal
shadow. In C it is because the aortic arch is on
the right. All the others have a deformed aortic
knuckle due to coarctation.
C
D
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one of these is not a coarctation
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What Is it?
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What is this vessel?
This is a right superior septal perforator, or
cristal artery- passing along the crista
superventricularis to end as upper septal vessels
Where are its terminal branches?
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Kugels artery, forming an anastomosis though
the atrial septum from the proximal right
coronary artery to the inferior left ventricular
branches
What is this and who named it?
Starts with a K
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Odd
One
Out
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A
B
which one is the odd one out and why?
A shows the spotty enhancement of foci of
myocarditis, the others show transmural
enhancement of thinned myocardium, due to full
thickness infarction.
D
C
one of these late gadolinium studies is not the
result of coronary disease
10
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What Is it?
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There is a small patent ductus arteriosus
(persistent arterial duct) in the usual place,
running from the anterior upper descending
aorta to the posterior end of the main
pulmonary artery. I assume that the plaque of
calcification nearby is dystrophic rather than
atheromatous.
There is a continuous murmur
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Anomalous drainage of the left upper pulmonary
vein to the left brachiocephalic vein (and yes
you did see one in question 5 already!)
What is this?
It gives a shunt
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20
Whats the link?
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which T-shirt belongs to the pathology on
the angio?
B
A
C is team Williams - A Ferrari, B Toyota, D
Renault. ( but a bonus point for saying D
because of elfin facies in Williams syndrome!)
C
D
the angio shows supra-aortic stenosis in Williams
Syndrome
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Which bike fits?
A
B
A is BMW, B Harley Davidson, and C is Honda. D,
by elimination, is Kawasaki (1400GTR actually)
D
C
the angio is of Kawasaki disease
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What Is it?
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What is the arrow pointing at?
Persistent left caval vein (left superior vena
cava)
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What is the arrow pointing at?
It is the IVC, with contrast from the SVC
baffled away from it by the combination of the
Eustachian valve and its own, unopacified flow
it is a normal structure
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26
Nuclear diagnosis
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23 yr old man, three months post op- what
operation?
these are MIBG scans
Orthotopic cardiac transplantation the
transplanted heart is separated from its
sympathetic nervous supply and so fails to
accumulate MIBG. It can regain sympathetic
function in time. Half point for cardiac
sympathectomy, but not really likely in a 23 yr
old patient.
this is a normal scan
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28
There is evidence of right to left shunt as the
kidneys are active, but as the brain is not
active, the shunt must have been beyond the
brachiocephalic vessels, and can only be a
patent arterial duct (PDA)
23 yr old female, loud P2
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Odd
One
Out
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which of these coronary anomalies is the odd one
out?
B
A
In A B and C, an anomalous vessel runs down and
back around the posterior rim of the aortic root.
In D it is much higher,going between the great
vessels. In C the first image is the LV angio and
the anomalous vessel can be seen just posterior
to the aortic ring.
D
C
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What Is it?
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where and what is this?
it is where it should be
This is an LV pacing lead, going through the
coronary sinus on its way to one of the left
ventricular veins.
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Acute haemopericardium, showing increased
density due to clot retraction.
what is this?
PTCA hours earlier
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Odd
One
Out
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A
B
which of these is the odd one out?
B is a diffusely thickened aortic root due to
chronic aortitis
D
C
one of these is not an acute intramural aortic
haematoma
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36
A
B
D is a pseudo-dissection due to movement overlap
of the aortic and pulmonary arterial shadows.
one of these is not an aortic dissection
C
D
which is the odd one out?
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The initial images show mediastinal and
intercostal collateral arteries. As cyanois is
not the cause, they are probably due to
coarctation. The last reveal shows large internal
thoracic arteries.
this is an acyanotic teenager
two clues
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Circumferential aortic dissection.
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Two breathless patients
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Typical occlusions, stenoses and semi-occlusive
flaps of chronic thromboembolic pulmonary
hypertension.
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Large pulmonary veins (arrowed) and main
pulmonary artery, due to an atrial septal defect.
28 yr old female, soft ejection murmur in
pulmonary area
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Odd
One
Out
difficult
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A
B
one of these does not have transposition of the
great arteries
D is an Eisenmenger ASD. The bulge of the main
pulmonary artery is in the usual position it is
not seen in the other cases, despite significant
pulmonary hypertension, as the vessel is not in
its usual position. A normal MPA contour is
strong evidence against a major positional
anomaly of the great vessels. (A has severe
pulmonary hypertension as well as TGA, hence the
large hilar vessels)
C
D
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44
No 1 is a left arch with aberrant right
subclavian artery. All the others are a right
arch with aberrant left subclavian artery.
1
2
one of these does not have an aberrant left
subclavian artery
3
4
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45
What Is it?
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3 month old, dyspnoea and stridor
Pulmonary artery sling syndrome - note the
anterior impression on the oesophagus
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47
The lead has been introduced through the carotid
artery and has entered the left ventricle
Whats wrong here?
had a stroke shortly after the lead was introduced
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48
Constriction of the right ventricular outflow
tract, and thickening and immobility of the
tricuspid valve. Hepatic metastases from a
malignant cacinoid
Whats this?
a lady with abdominal problems
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49
whats this?
Lymphoma/lymphoprolifertative disease of the
right ventricular outflow tract.
Orthotopic heart transplant, unwell, anaemia
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50
well done for getting through to the end, hope
you enjoyed the trip! 33 questions so a max
possible of 66 points. I have made the quiz
quite challenging by taking the images out of
context, so I think anything over 50 score is
good going. over 45 points is pretty
impressive Keep well JP