• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
23204989
 

23204989

on

  • 3,099 views

ACR Inservice Recall

ACR Inservice Recall

Statistics

Views

Total Views
3,099
Views on SlideShare
3,099
Embed Views
0

Actions

Likes
1
Downloads
306
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Adobe PDF

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    23204989 23204989 Document Transcript

    • Section X – Cardiac Radiology Figure 1A 239. You are shown a posteroanterior (PA) and lateral chest radiograph of a 64-year-old man with chest pain (Figures 1A and 1B). What is the MOST likely diagnosis? A. Congestive heart failure B. Aortic stenosis C. Mitral valve disease D. Pericardial effusion 1 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Figure 1B 2 American College of Radiology
    • Section X – Cardiac Radiology Question #239 Rationales: A. Incorrect. The chest radiograph shows normal heart size and vascularity. There is no evidence of pulmonary edema. B. Correct. The chest radiograph shows normal heart size and vascularity. On the lateral view, there is calcification of the aortic valve, consistent with aortic stenosis. Identification of calcification of the aortic valve on a chest radiograph is usually associated with clinically significant aortic stenosis. C. Incorrect. The chest radiograph shows normal heart size and vascularity. There is no evidence of left atrial enlargement or pulmonary venous hypertension. D. Incorrect. The chest radiograph shows normal heart size and vascularity. There is no evidence of pericardial effusion. 3 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Figure 2A 240. You are shown two images from a non-enhanced CT scan in a 77-year-old woman who has undergone pacemaker placement (arrow) and mitral valve replacement (arrowhead) (Figures 2A and 2B). The calcifications are related to which one of the following? A. Pericarditis B. Pulmonary hypertension C. Rheumatic heart disease D. Coronary atherosclerosis 4 American College of Radiology
    • Section X – Cardiac Radiology Figure 2B 5 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Question #240 Rationales: A. Incorrect. The calcifications are located in the wall of the left atrium. B. Incorrect. Calcification of the pulmonary arteries may occur in patients with longstanding, severe pulmonary arterial hypertension. The calcifications in this case are located in the wall of the left atrium. C. Correct. The calcifications are secondary to endocarditis from rheumatic heart disease. Other caus- es of endocarditis can also cause calcification of the left atrial wall. D. Incorrect. The areas of calcification do not correspond with the anatomic location of the coronary arteries. 6 American College of Radiology
    • Section X – Cardiac Radiology Figure 3A 241. You are shown a posteroanterior (PA) and lateral chest radiograph of a 75-year-old woman (Figures 3A and 3B). What is the MOST likely diagnosis? A. Atrial septal defect B. Chronic pulmonary embolism C. Pulmonary venous hypertension D. Cor pulmonale 7 American College of Radiology
    • Section X – Cardiac Radiology Figure 3B 8 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Question #241 Rationales: A. Incorrect. The chest radiograph shows enlargement of the central pulmonary arteries with diminu- tion of the peripheral vasculature, consistent with pulmonary arterial hypertension. If the left-to- right shunt in atrial septal defect is 2:1 or greater, the chest radiograph will show evidence of over- circulation which is characterized by enlargement of all segments of the pulmonary arteries throughout the lung (shunt vascularity). Right heart enlargement is also a feature of atrial septal defect, a finding which is not present in this case. B. Incorrect. Chronic thromboembolic disease is an uncommon cause of pulmonary arterial hyperten- sion. The chest radiograph in this case demonstrates marked hyperinflation of the lungs and emphy- sema, making pulmonary arterial hypertension secondary to chronic lung disease the most likely diagnosis. C. Incorrect. Early radiographic changes of pulmonary venous hypertension are characterized by pul- monary venous distention, equalization of the size of upper and lower lobe vessels and indistinct vessel margins. This case does not demonstrate these findings. D. Correct. This case shows enlargement of the central pulmonary arteries with diminished size of the peripheral vasculature, characteristic of pulmonary arterial hypertension. In this patient, the pul- monary arterial hypertension is a result of the severe emphysema as manifested by markedly increased lung volumes, flattening of the diaphragm and increase in AP diameter of the chest. Cor pulmonale is defined as pulmonary hypertension secondary to chronic lung disease. 9 American College of Radiology
    • Section X – Cardiac Radiology Figure 4 242. You are shown an axial contrast-enhanced CT scan of the chest (Figure 4). What is the MOST LIKELY diagnosis? A. Ostium primum defect B. Ostium secundum defect C. Sinus venosus defect D. Patent foramen ovale 10 American College of Radiology
    • Section X – Cardiac Radiology Question #242 Rationales: A. Incorrect. Ostium primum defects are the second most common atrial septal defects (ASD), accounting for about 15 percent of all ASDs. The primum portion of the atrial septum is located inferiorly at the level of the mitral and tricuspid valves. Ostium primum defects are often associated with atrioventricular defects. The abnormality on the image is not in this location. B. Incorrect. Ostium secundum defects are the most common ASD, accounting for approximately 75 percent of all ASDs, and are located near the fossa ovalis, in the middle of the atrial septum. The abnormality on the image is not in this location. C. Correct. Sinus venosus defects are the third most common ASD accounting for approximately 10 percent of all cases. The sinus venosus portion of the atrial septum separates the left atrium from the superior vena cava. The defect in this case is located in the superolateral aspect of the atrial septum at the junction of the superior vena cava and right atrium, near the insertion of the right pulmonary veins, consistent with a sinus venosus ASD. D. Incorrect. Patent foramen ovale occurs in up to 25 percent of adults. The flap of tissue covering the foramen ovale typically closes the defect since the left atrial pressure is higher than the right atrial pressure. Normally, this flap of tissue fuses with the septum after the first year of life. The abnor- mality on the image is not in the location of the foramen ovale. 11 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Figure 5 243. You are shown an oblique coronal reformatted image from a contrast-enhanced CT (Figure 5). Which coronary artery is depicted by the arrow? A. Diagonal branch B. Obtuse marginal branch C. Ramus intermedius D. Septal branch 12 American College of Radiology
    • Section X – Cardiac Radiology Question #243 Rationales: A. Incorrect. The left anterior descending artery gives off epicardial diagonal branches over the antero- lateral wall. The artery shown in this image does not arise from the left anterior descending artery. Instead, it arises between the left anterior descending artery and the left circumflex artery. B. Incorrect. The left circumflex artery arises from the left main artery and gives off obtuse marginal branches which supply the lateral wall of the left ventricle. The artery shown in this image does not arise from the left circumflex artery. Instead, it arises between the left anterior descending artery and the left circumflex artery. C. Correct. The left main coronary artery may trifurcate giving off the left anterior descending artery, the left circumflex artery and the ramus intermedius, or intermediate artery, which arises between the left anterior descending and left circumflex arteries as shown in this case. D. Incorrect. The left anterior descending coronary artery gives off septal branches that supply the interventricular septum. The artery shown in this image does not arise from the left anterior descending artery. Instead, it arises between the left anterior descending artery and the left circum- flex artery. 13 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Figure 6A Figure 6B 14 American College of Radiology
    • Section X – Cardiac Radiology Figure 6C 244. You are shown axial (see Figures 6A and 6B) and sagittally-reconstructed (Figure 6C) images from a contrast-enhanced CT scan of the chest obtained after a motor vehicle collision. What is the MOST LIKELY diagnosis? A. Patent ductus arteriosus B. Traumatic aortic tear C. Ductus diverticulum D. Penetrating ulcer 15 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Question #244 Rationales: A. Incorrect. There is only a tiny strand of soft tissue density material connecting the proximal descending aorta and the left pulmonary artery. This represents the ligamentum arteriosum. B. Incorrect. The bulge along the underside of the aorta is smooth and there is no evidence of any flap or periaortic hematoma. These findings make traumatic laceration highly unlikely. C. Correct. The combination of a small, smooth bump along the bottom edge of the aorta along with the lack of any evidence of flap or mediastinal hematoma is typical of a ductus diverticulum. The soft tissue strand joining the bump to the pulmonary artery represents the ligamentum arteriosum, the remnant of the ductus arteriosus. D. Incorrect. The bump has none of the hallmarks of penetrating atherosclerotic ulcer 16 American College of Radiology
    • Section X – Cardiac Radiology 245. Concerning the morphologic right ventricle, which of the following is the MOST reliable indicator? A. Anterior location of the ventricle B. Trabeculation of the ventricular wall C. Separation of the inflow and outflow valves by a muscular infundibulum D. The ventricle receives blood from the right atrium Question #245 Rationales: A. Incorrect. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is more trabeculated than the left ventricle. The inflow and outflow valves of the right ventricle are separated by the muscular infundibulum in contrast to the left ventricle where the valves are con- tiguous. In complex congenital cardiac anomalies, the separation of the inflow and outflow valves is the most reliable indicator of the morphologic right ventricle. B. Incorrect. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is more trabeculated than the left ventricle. The inflow and outflow valves of the right ventricle are separated by the muscular infundibulum in contrast to the left ventricle where the valves are con- tiguous. In complex congenital cardiac anomalies, the separation of the inflow and outflow valves is the most reliable indicator of the morphologic right ventricle. C. Correct. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is more trabeculated than the left ventricle. The inflow and outflow valves of the right ventricle are separated by the muscular infundibulum in contrast to the left ventricle where the valves are con- tiguous. In complex congenital cardiac anomalies, the separation of the inflow and outflow valves is the most reliable indicator of the morphologic right ventricle. D. Incorrect. Normally, the right ventricle receives blood from the right atrium, lies anterior to and is more trabeculated than the left ventricle. The inflow and outflow valves of the right ventricle are separated by the muscular infundibulum in contrast to the left ventricle where the valves are con- tiguous. In complex congenital cardiac anomalies, the separation of the inflow and outflow valves is the most reliable indicator of the morphologic right ventricle. 17 American College of Radiology
    • Section X – Cardiac Radiology 246. Concerning the location of cardiac valves on a posteroanterior (PA) and lateral chest radiograph, which one is TRUE? A. The aortic valve is located superior to the other valves. B. The tricuspid valve is the most anteriorly located valve. C. The mitral valve lies inferior to the other valves. D. The aortic valve lies closest to the pulmonary valve. Question #246 Rationales: A. Incorrect. The aortic valve lies inferior to the pulmonary valve. The pulmonary valve is the most superiorly located valve. B. Correct. The tricuspid valve is the most anteriorly located valve. C. Incorrect. The mitral valve is the most posteriorly located valve. The tricuspid valve lies inferior to the mitral valve. D. Incorrect. The aortic valve is contiguous with the mitral valve and shares a common fibrous skele- ton. 18 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology 247. Concerning the position of the interventricular septum on short axis images of the heart, which one is TRUE? A. It has a normal convexity toward the right ventricle. B. It has a sinusoid shape. C. It has a straight course separating the right and left ventricles. D. Its convexity varies in position during the cardiac cycle. Question #247 Rationales: A. Correct. On short axis images, the interventricular septum is curved with the convexity toward the right ventricle. This appearance is maintained during systole and diastole. Straightening, bowing with convexity toward the left ventricle and sinusoidal appearance of the interventricular septum are abnormal. B. Incorrect. On short axis images, the interventricular septum is curved with the convexity toward the right ventricle. This appearance is maintained during systole and diastole. Straightening, bowing with convexity toward the left ventricle and sinusoidal appearance of the interventricular septum are abnormal. C. Incorrect. On short axis images, the interventricular septum is curved with the convexity toward the right ventricle. This appearance is maintained during systole and diastole. Straightening, bowing with convexity toward the left ventricle and sinusoidal appearance of the interventricular septum are abnormal. D. Incorrect. On short axis images, the interventricular septum is curved with the convexity toward the right ventricle. This appearance is maintained during systole and diastole. Straightening, bowing with convexity toward the left ventricle and sinusoidal appearance of the interventricular septum are abnormal. 19 American College of Radiology
    • Section X – Cardiac Radiology Concerning cardiac aneurysms, which one is TRUE? 248. A. True aneurysms of saphenous vein grafts are a manifestation of atherosclerosis. B. Rupture of a sinus of Valsalva aneurysm occurs more commonly on the left. C. Left ventricular pseudoaneurysms typically occur at the cardiac apex. D. The neck of a left ventricular aneurysm is typically narrow. Question #248 Rationales: A. Correct. It is thought that atherosclerosis of saphenous vein bypass grafts results in decreased wall elasticity and resulting dilatation of the graft lumen over time. B. Incorrect. Rupture of a sinus of Valsalva aneurysm typically involves the right sinus. Rupture of the left sinus is rare. C. Incorrect. True aneurysms of the left ventricle most commonly occur in the anterolateral and apical wall. In contrast, false aneurysms are most commonly located in the posterolateral and diaphragmat- ic aspect of the left ventricle. D. Incorrect. Left ventricular pseudoaneurysms typically have a narrow communication between the pseudoaneurysm and the left ventricular cavity. In contrast, the neck of a left ventricular true aneurysm is typically broad. 20 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Concerning coronary artery atherosclerosis, which one is TRUE? 249. A. Coronary artery calcification is strongly associated with coronary atherosclerosis. B. On angiography, a stenosis greater than 40 percent of the luminal diameter is considered to be significant. C. On angiography, a stenosis greater than 60 percent of the luminal diameter is considered to be severe. D. When present, coronary artery calcifications make up about 50 percent of the total plaque burden. Question #249 Rationales: A. Correct. Coronary artery calcification is almost always associated with coronary atherosclerosis. B. Incorrect. On angiography, a significant stenosis is one in which there is obstruction of at least 50 percent of the diameter or 75 percent of the cross-sectional area of the vessel lumen. C. Incorrect. On angiography, a severe stenosis is one in which there is obstruction of at least 75 per- cent of the diameter or 90 percent of the cross-sectional area of the vessel lumen. D. Incorrect. Coronary artery calcification, when present, accounts for approximately 20 percent of the total plaque burden. 21 American College of Radiology
    • Section X – Cardiac Radiology Which one of the following congenital anomalies is MOST commonly associated with 250. anomalous pulmonary venous drainage? A. Ostium primum atrial septal defect B. Ostium secundum atrial septal defect C. Ventricular septal defect D. Sinus venosus atrial septal defect Question #250 Rationales: A. Incorrect. Drainage of the pulmonary veins should be assessed in all patients with congenital anom- alies. Nearly all patients with sinus venosus atrial septal defect have anomalous pulmonary venous drainage, most commonly drainage of the right upper lobe to the superior vena cava. Approximately 10 percent of patients with an ostium secundum atrial septal defect will have anomalous pulmonary venous drainage. B. Incorrect. Drainage of the pulmonary veins should be assessed in all patients with congenital anom- alies. Nearly all patients with sinus venosus atrial septal defect have anomalous pulmonary venous drainage, most commonly drainage of the right upper lobe to the superior vena cava. Approximately 10 percent of patients with an ostium secundum atrial septal defect will have anomalous pulmonary venous drainage. C. Incorrect. Drainage of the pulmonary veins should be assessed in all patients with congenital anom- alies. Nearly all patients with sinus venosus atrial septal defect have anomalous pulmonary venous drainage, most commonly drainage of the right upper lobe to the superior vena cava. Approximately 10 percent of patients with an ostium secundum atrial septal defect will have anomalous pulmonary venous drainage. D. Correct. Drainage of the pulmonary veins should be assessed in all patients with congenital anom- alies. Nearly all patients with sinus venosus atrial septal defect have anomalous pulmonary venous drainage, most commonly drainage of the right upper lobe to the superior vena cava. Approximately 10 percent of patients with an ostium secundum atrial septal defect will have anomalous pulmonary venous drainage. 22 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology 251. What is the greatest advantage of conventional CR imaging systems over DR imaging systems? A. Better detective quantum efficiency with lower dose B. Positioning flexibility C. Instantaneous readout of the latent image D. Better intrinsic spatial resolution Question #251 Rationales: A. Incorrect. CR typically exhibits lower detection effiency and lower detective quantum efficiency (a measure of the information transfer from the input x-rays to the information content of the output image), chiefly due to thinner screens (compared to CsI structured phosphors) or lower atomic num- ber (compared to Gd2O2S screens : Gd, Z=53 versus BaFBr CR screens : Br, Z=35) B. Correct. This is the main advantage of CR…. A passive, cassette-based imaging detector that emu- lates the screen-film paradigm, allowing use of conventional imaging equipment and providing excellent positioning flexibility that active, DR detectors in their current technology state cannot provide. C. Incorrect. This is the advantage of DR over conventional CR (not including the newer line-scan and mechanical CR automatic readers) D. Incorrect. The intrinsic (prior to sampling) resolution of CR is lower than that of scintillator and photoconductor-based DR units. This is easily discerned by the MTF curves of each modality. The reasons are chiefly due to the use of a structured scintillator (CsI) used for most DR indirect detec- tor systems, which confines the emitted light without spreading, and the use of high voltage placed across the semiconductor materials of DR direct detector, which actively collects the electron/hole pairs from spreading out during acquisition. Of all detector converters, the semiconductor detector has the highest intrinsic spatial resolution. 23 American College of Radiology
    • Section X – Cardiac Radiology Which one of the following structures directly communicates with the transverse sinus? 252. A. Oblique sinus B. Postcaval recess C. Superior aortic recess D. Posterior pericardial recess Question #252 Rationales: A. Incorrect. The oblique sinus is separated from the transverse sinus by a pericardial reflection. B. Incorrect. The postcaval recess arises from the pericardial cavity proper and is separated from the transverse sinus by a pericardial reflection C. Correct. The superior aortic recess arises from the transverse sinus and extends superiorly to sur- round the posterior, right lateral and anterior aspect of the ascending aorta. D. Incorrect. The posterior pericardial recess is a superior extension of the oblique sinus, which does not communicate directly with the transverse sinus. 24 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Concerning coronary artery dominance, which one is TRUE? 253. A. It is determined by which coronary artery supplies the majority of the heart. B. 85 percent of patients have a codominant system. C. It is determined by which artery supplies the posterior descending artery. D. 70 percent of patients have a left dominant system. Question #253 Rationales: A. Incorrect. Coronary dominance is determined by which artery supplies the posterior descending artery (PDA). In most patients (85%), the PDA is supplied by the right coronary artery and there- fore is a right dominant system. If the PDA is supplied by the circumflex coronary artery, it is con- sidered to be a left dominant system. A codominant system is one in which both the right coronary artery and circumflex coronary artery supply the PDA or when the right coronary artery supplies the PDA and the left circumflex coronary artery supplies the inferior left ventricular wall. B. Incorrect. Dominance is determined by which artery supplies the posterior descending artery (PDA). In most patients (85%), the PDA is supplied by the right coronary artery and therefore is a right dominant system. If the PDA is supplies by the circumflex coronary artery, it is considered to be a left dominant system. A codominant system is one in which both the right coronary artery and circumflex coronary artery supply the PDA or when the right coronary artery supplies the PDA and the left circumflex coronary artery supplies the inferior left ventricular wall. C. Correct. Dominance is determined by which artery supplies the posterior descending artery (PDA). In most patients (85%), the PDA is supplied by the right coronary artery and therefore is a right dominant system. If the PDA is supplies by the circumflex coronary artery, it is considered to be a left dominant system. A codominant system is one in which both the right coronary artery and cir- cumflex coronary artery supply the PDA or when the right coronary artery supplies the PDA and the left circumflex coronary artery supplies the inferior left ventricular wall. D. Incorrect. Dominance is determined by which artery supplies the posterior descending artery (PDA). In most patients (85%), the PDA is supplied by the right coronary artery and therefore is a right dominant system. If the PDA is supplies by the circumflex coronary artery, it is considered to be a left dominant system. A codominant system is one in which both the right coronary artery and circumflex coronary artery supply the PDA or when the right coronary artery supplies the PDA and the left circumflex coronary artery supplies the inferior left ventricular wall. 25 American College of Radiology
    • Section X – Cardiac Radiology 254. Concerning a patient presenting with an acute myocardial infarction accompanied by severe bradycardia, which coronary artery or branch is MOST LIKELY involved? A. Diagonal branch B. Left anterior descending coronary artery C. Right coronary artery D. Circumflex artery Question #254 Rationales: A. Incorrect. The diagonal artery is a branch of the left anterior descending coronary artery. The atri- oventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery. B. Incorrect. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery. C. Correct. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery. D. Incorrect. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery. A branch of the circumflex artery supplies the AV node in the remaining cases. 26 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Concerning pulmonary vein ablation, which one is TRUE? 255. A. Accessory pulmonary veins are more common on the left. B. Myocardial sleeves are longest and thickest in the inferior pulmonary veins. C. The presence of left atrial thrombus is a contraindication. D. A common pulmonary vein is more common on the right. Question #255 Rationales: A. Incorrect. Accessory pulmonary veins are more common on the right. B. Incorrect. Myocardium extends 2-17 mm into the pulmonary veins and is called the myocardial sleeve. The myocardial sleeve is thickest at the atriopulmonary venous junction of the left superior vein. The myocardial sleeves are longer in the superior pulmonary veins than in the inferior pul- monary veins. C. Correct. Due to the risk of stroke following manipulation of the left atrium, the presence of left atrial thrombus is a contraindication to pulmonary vein ablation. D. Incorrect. Pulmonary venous anatomy varies widely. A common variation is a common pulmonary vein draining the entire lung, which typically occurs on the left. 27 American College of Radiology
    • Section X – Cardiac Radiology Concerning the Ross procedure, which one is TRUE? 256. A. It is suitable for children because the pulmonary autograft grows with the child. B. Patients undergoing the Ross procedure require lifelong anticoagulation. C. It is preferred because it is technically easier to perform than standard valve replacement. D. The procedure is performed to correct pulmonary valve stenosis. Question #256 Rationales: A. Correct. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Follow-up studies have shown interval growth of the aortic valve graft in children and infants. B. Incorrect. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Because a homo- graft is used, anticoagulation is not necessary. C. Incorrect. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Because both the pulmonary and aortic valves are replaced, the Ross procedure is a more extensive operation com- pared to conventional aortic valve replacement. D. Incorrect. The Ross procedure is performed to correct aortic valve disease. 28 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology Concerning the Blalock-Taussig shunt, which one is TRUE? 257. A. It connects the subclavian artery to the pulmonary artery. B. It creates a conduit between the right atrium and the pulmonary artery. C. It creates an atrial switch using an intra-atrial baffle made of pericardium. D. It connects the superior vena cava with the pulmonary artery. Question #257 Rationales: A. Correct. The Blalock-Taussig shunt creates a connection between the systemic and arterial systems and is a palliative procedure that increases systemic arterial oxygenation by increasing blood flow to the pulmonary artery. B. Incorrect. The Fontan procedure creates a conduit between the right atrium and the pulmonary artery. C. Incorrect. The Mustard procedure creates an atrial switch using an intra-atrial baffle made of peri- cardium D. Incorrect. The Glenn procedure connects the superior vena cava with the pulmonary artery. 29 American College of Radiology
    • Section X – Cardiac Radiology 258. What is the MOST common congenital heart defect? A. Tetralogy of Fallot B. Atrial septal defect C. Bicuspid aortic valve D. Ventricular septal defect Question #258 Rationales: A. Incorrect. Tetralogy of Fallot is the most common cyanotic heart disease occurring at a rate of 3.53 per 10,000 live births. B. Incorrect. Atrial septal defect is the most common congenital heart disease to remain undetected until adulthood. The occurrence rate is 3.78 per 10,000 live births. C. Correct. Bicuspid aortic valve is the most common congenital heart defect and occurs at a rate of 50-200 per 10,000 live births. D. Incorrect. Ventricular septal defect occurs at a rate of 14.8 per 10,000 live births. 30 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology 259. Regarding cardiac CT scans, keeping all scan parameters the same, the dose to the patient with retrospective ECG gating when compared to prospective ECG triggering. A. Increases B. Decreases C. Remains the same Question #259 Rationales: A. Correct. During retrospective ecg gating with multidetector CT (MDCT), the x-rays are ON throughout the cardiac cycle, however, only part of the data is used for reconstruction to achieve high temporal resolution with minimal motion artifacts. Whereas in prospective ecg triggering, the x-rays are ON only during certain part of the ecg signals, there by yielding lower radiation dose to the patient. B. Incorrect. See correct answer. C. Incorrect. See correct answer. 31 American College of Radiology
    • Section X – Cardiac Radiology 260. Concerning isolated aortic valve stenosis, what is the MOST likely cause in an adult? A. Rheumatic heart disease B. Calcific degeneration C. Congenitally stenotic aortic valve D. Infective endocarditis Question #260 Rationales: A. Incorrect. Almost all patients with rheumatic aortic valve involvement also have mitral valve stenosis. B. Correct. Congenital aortic stenosis implies that the valve is stenotic at birth. Congenital bicuspid aortic valves are usually not stenotic at birth. Due to increased turbulence, the valve becomes trau- matized leading to fibrosis and calcification. C. Incorrect. Although most adults with aortic valve stenosis who are under age 65 will have a bicus- pid aortic valve, the cause is calcification of the valve, not the bicuspid nature per se. Furthermore, patients over the age of 65 years of age with aortic stenosis typically have a tricuspid valve. D. Incorrect. Endocarditis results in aortic regurgitation, not stenosis. 32 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology 261. What is the MOST likely explanation for enlargement of the right atrium in a patient with mitral valve stenosis? A. Tricuspid valve regurgitation B. Pulmonary valve stenosis C. Tricuspid valve stenosis D. Tricuspid valve prolapse Question #261 Rationales: A. Correct. Chronic pulmonary venous hypertension in patients with mitral stenosis leads to elevated pulmonary arterial and right ventricular pressures. If severe, these will result in failure of the right ventricle, usually with tricuspid regurgitation. B. Incorrect. The most frequent cause of pulmonary valve stenosis is a congenital valvular defect. Pulmonary valve stenosis secondary to rheumatic heart disease is very rare. C. Incorrect. Rheumatic heart disease is the predominant cause of mitral stenosis. The tricuspid valve is primarily affected in only 5% of patients with rheumatic heart disease. D. Incorrect. Tricuspid valve prolapse is associated with mitral valve prolapse and can result in tricus- pid regurgitation and subsequent right atrial enlargement. Tricuspid valve prolapse is not associated with mitral stenosis. 33 American College of Radiology
    • Section X – Cardiac Radiology 262. Concerning differentiation of pseudoaneurysms from true aneurysms of the left ventricle, what is the MOST reliable imaging finding? A. Identification of the number of myocardial layers in the wall of the aneurysm B. Involvement of the posterior or inferior walls of the left ventricle C. Size of aneurysm neck or mouth D. Thrombus lining the aneurysm. Question #262 Rationales: A. Incorrect. One cannot determine scarred myocardium from thickened pericardium containing a myocardial rupture with any imaging technique. B. Incorrect. Although pseudoaneurysms of the left ventricle almost always occur in these locations, true ventricular aneurysms also may occur inferiorly or posteriorly. C. Correct. Regardless of the imaging technique employed or the vascular structure involved, the sine qua non of a pseudoaneurysm is a narrow neck or mouth. D. Incorrect. Clot may line the wall of either type of aneurysm. 34 Diagnostic In-Training Exam 2006
    • Section X – Cardiac Radiology 263. Concerning left atrial enlargement in a patient with dilated (congestive) cardiomyopathy, what cause is MOST LIKELY? A. Mitral valve regurgitation secondary to displacement of the papillary muscles B. Mitral valve regurgitation secondary to fusion and shortening of the chordae tendinae C. High left ventricular end-diastolic pressure resulting in left atrial hypertension D. Mitral valve regurgitation secondary to ischemic papillary muscle dysfunction Question #263 Rationales: A. Correct. Left ventricular dilatation results in lateral displacement of the papillary muscles rendering them less efficient and resulting in mitral regurgitation. B. Incorrect. Rheumatic endocarditis can cause fusion and shortening of the chordae tendinae leading to mitral regurgitation. Shortening and fusion of the chordae tendinae is not a feature of dilated car- diomyopathy. C. Incorrect. Most patients with dilated cardiomyopathy are relatively well compensated and tend to have fairly normal LV end-diastolic and thus left atrial and pulmonary venous pressures. D. Incorrect. Patients with dilated (congestive) cardiomyopathy by definition do not have myocardial ischemia as the cause of their dysfunction. 35 American College of Radiology
    • Section X – Cardiac Radiology 264. Concerning tricuspid valve regurgitation in adults, what is the MOST common etiology? A. Infective endocarditis B. Right ventricular hypertension C. Ebstein’s’ anomaly of the tricuspid valve D. Rheumatic heart disease Question #264 Rationales: A. Incorrect. Although tricuspid regurgitation frequently occurs in intravenous drug abusers with bacter- ial endocarditis, it is not as common as tricuspid regurgitation secondary to pulmonary hypertension. B. Correct. The majority of cases of tricuspid regurgitation in adults result from high right sided pres- sures with or without right ventricular failure. C. Incorrect. Ebstein’s anomaly may result in tricuspid regurgitation, but is a rare disease. D. Incorrect. Although patients with rheumatic valvular heart disease frequently have tricuspid regurgi- tation, it almost always results from high right sided pressures related to mitral stenosis. Primary involvement of the tricuspid valve occurs in only about 5% of patients with rheumatic heart disease. 36 Diagnostic In-Training Exam 2006