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(BQ) Part 2 book Manual of cardiac diagnosis presentation of content: Intravascular coronary ultrasound and beyond, cardiac computed tomography, cardiovascular magnetic resonance, molecular imaging of vascular disease, cardiac hemodynamics and coronary physiology, cardiac biopsy,...
Intravascular Coronary Ultrasound and Beyond CHAPTER 12 Teruyoshi Kume, Yasuhiro Honda, Peter J Fitzgerald Chapter Outline • Intravascular Ultrasound –– Basics of IVUS and Procedures –– Normal Vessel Morphology –– IVUS Measurements –– Tissue Characterization –– Insights into Plaque Formation and Distribution –– Interventional Applications –– Preinterventional Imaging –– Balloon Angioplasty –– Bare Metal Stent Implantation –– Drug-eluting Stent Implantation –– Safety –– Future Directions • Optical Coherence Tomography –– Imaging Systems and Procedures –– Image Interpretation –– Clinical Experience –– Detection of Vulnerable Plaque –– Safety and Limitations –– Future Directions • Angioscopy –– Imaging Systems and Procedures –– Image Interpretation –– Clinical Experience –– Detection of Vulnerable Plaque –– Safety and Limitations –– Future Directions • Spectroscopy –– Imaging Systems and Procedures –– Experimental Data –– Clinical Experience –– Safety and Limitations –– Future Directions INTRODUCTION Intravascular ultrasound (IVUS) is widely used as a major diagnostic and assessment technique that provides detailed crosssectional imaging of blood vessels in the cardiac catheterization laboratory The first ultrasound imaging catheter system was developed by Bom and his colleagues in Rotterdam, the Netherland, in 1971.1 By the late 1980s, the first images of human vessels were recorded by Yock and his colleagues.2 Since then, IVUS has become a pivotal catheter-based imaging technology that can provide scientific insights into vascular biology and practical guidance for percutaneous coronary interventions (PCIs) in clinical settings In this chapter, IVUS and the other catheter-based imaging devices—optical coherence tomography (OCT), angioscopy and spectroscopy—are described These newly developed imaging technologies provide supplemental and unique insights into vascular biology as well INTRAVASCULAR ULTRASOUND Basics of IVUS and Procedures The IVUS imaging systems use reflected sound waves to visualize the vessel wall in a two-dimensional format analogous to a histologic cross-section In general, higher frequencies of ultrasound limit the scanning depth but improve the axial resolution, and current IVUS catheters used in the coronary arteries have center frequencies ranging 20–45 MHz 434 Manual of Cardiac Diagnosis There are two different types of IVUS transducer systems: (i) the solid-state dynamic aperture system (the electronically switched multi-element array system) and (ii) the mechanically rotating single-transducer system (Table and Figs 1A and B) Several types of artifacts can be observed common or unique to each system (Figs 2A to D) With both systems, still frames and video images can be digitally archived on local storage memory or a remote server using digital imaging and communications in medicine (DICOM) Standard 3.0 Regardless of IVUS system used in the patient, both require preprocedural administration of intravenous heparin (5,000–10,000 U), or equivalent anticoagulation along with intracoronary nitroglycerin (100–300 µg), to reduce the potential for coronary spasm Normal Vessel Morphology The interpretation of IVUS images is possible as the layers of a diseased arterial wall can be identified separately Particularly in muscular arteries, such as the coronary tree, the media of the vessel is characterized by a dark band compared with the intima and adventitia (Figs 3A and B) Differentiation of the layers of elastic arteries, such as the aorta and carotid, can be problematic because media are less distinctly seen by IVUS However, most of the vessels currently treated by catheter techniques are muscular or transitional arteries These include the coronary, iliofemoral, renal and popliteal systems Therefore, it is usually easy to identify the medial layer FIGURES 1A AND B: Diagrams of two basic imaging catheter designs: (A) solid state and (B) mechanical (A: bottom) an image obtained using a solid-state catheter imaging system (B: bottom) an image obtained using a mechanical catheter imaging system Intravascular Coronary Ultrasound and Beyond TABLE 1 Comparison of two IVUS designs Basics Products Features Image quality Artifacts Solid-state dynamic aperture system An electronic solid state catheter system with multiple imaging elements at its distal tip, providing cross-sectional imaging by sequentially activating the imaging elements in a circular way One system is commercially available (Volcano Corporation, Inc., Rancho Cordova, CA) Mechanically rotating single-transducer system A mechanical system that contains a flexible imaging cable which rotates a single transducer at its tip inside an echolucent distal sheath Several systems are commercially available (Boston Scientific Corporation, Natick, MA; Volcano Corporation, Inc., Rancho Cordova, CA; Terumo Corporation, Tokyo, Japan) The imaging catheter has The imaging catheter 64 transducer elements uses a 40- or 45 MHz arranged around the transducer with a distal catheter tip and uses a crossing profile of 3.2 center frequency of 20 Fr (compatible with Fr MHz guide catheters) The outer shaft diameter of IVUS catheters in a rapid-exchange configuration is 2.9 Fr and thus compatible with a Fr guide catheter This imaging catheter has Higher frequencies better scanning depth but improve the axial poorer axial resolution resolution Therefore, compared with the mechanical transducers mechanical systems have traditionally offered advantages in image quality compared with the solid-state systems The guidewire runs inside The guidewire runs the IVUS catheter thereby outside the IVUS catheter, preventing guidewire parallel to the imaging artifact segment, resulting in guidewire artifact This system does not This system requires require flushing with flushing with saline before saline insertion to eliminate any air in the path of the beam Incomplete flushing artifact may result in poor image quality Contd 435 436 Manual of Cardiac Diagnosis Contd Solid-state dynamic aperture system Mechanically rotating single-transducer system This system eliminates nonuniform rotational distortion (NURD) Others The NURD can occur when bending of the drive cable interferes with uniform transducer rotation, causing a wedgeshaped, smeared image to appear in one or more segments of the image Since the solid-state The imaging catheters transducer has a zone have excellent near-field of “ring-down artifact” resolution and not encircling the catheter, an require the subtraction of extra step is required to form a mask a mask of the artifact and subtract this from the image Short transducer-toThe pullback trajectory is tip distance (10.5 mm) stabilized and it reduces facilitates visualization of the risk of a nonuniform distal coronary anatomy speed in a continuous pullback The relative echolucency of media compared with intima and adventitia gives rise to a three-layered appearance (bright-dark-bright), first described in vitro by Meyer and his colleagues.3 Due to the lack of collagen and elastin compared to neighboring layers, the media displays lower ultrasound reflection “Blooming”, a spillover effect, is seen in the IVUS image because the intimal layer reflects ultrasound more strongly than the media This results in a slight overestimation of the thickness of the intima and a corresponding underestimation of the medial thickness On the other hand, the media/adventitia border is accurately rendered, because a step-up in echo reflectivity occurs at this boundary and no blooming appears The adventitial and periadventitial tissues are similar enough in echoreflectivity that a clear outer adventitial border cannot be defined Several deviations from the classic three-layered appearance are encountered in clinical practice The echoreflectivity of the intima and internal lamina may not be sufficient to resolve a clear inner layer in truly normal coronary arteries from young patients This is particularly true when the media has a relatively high content of elastin However, most adults seen in the cardiac catheterization laboratory have enough intimal thickening to show a three-layered appearance, even in angiographically normal segments At the other extreme, patients with a significant plaque burden have thinning of the media underlying the plaque As a result, the media is often indistinct or undetectable in at least some part of the IVUS Intravascular Coronary Ultrasound and Beyond FIGURES 2A TO D: Common IVUS image artifacts: (A) A “halo” or a series of bright rings immediately around the mechanical IVUS catheter is usually caused by air bubbles that need to be flushed out (B) Radiofrequency noise appears as alternating radial spokes or random white dots in the far-field The interference is usually caused by other electrical equipment in the cardiac catheterization laboratory (C) Nonuniform rotational distortion (NURD) results in a wedge-shaped, smeared appearance in one or more segments of the image (between 12 O’clock and O’clock in this example) This may be corrected by straightening the catheter and motor drive assembly, lessening tension on the guide catheter, or loosening the hemostatic valve of the Y-adapter (D) Circumferential calcification causes reverberation artifact between 10 O’clock and O’clock cross-section This problem is exacerbated by the blooming phenomenon Even in these cases, however, the inner adventitial boundary (at the level of the external elastic lamina) is always clearly defined For this reason, most IVUS studies measure and report the plaque-plus-media area as a surrogate measure for plaque area alone The addition of the media represents only a tiny percentage increase in the total area of the plaque The determination of the position of the imaging plane within the artery is one important aspect of image interpretation For example, an IVUS beam penetrates beyond the coronary artery, providing images of perivascular structures, including the cardiac veins, myocardium and pericardium (Figs 4A to C) These structures provide useful landmarks regarding the position of the imaging plane because they have a characteristic appearance when viewed from various positions within the arterial tree The branching patterns of the arteries are also 437 438 Manual of Cardiac Diagnosis FIGURES 3A AND B: Cross-sectional format of a representative IVUS image The bright-dark-bright, three-layered appearance is seen in the image with corresponding anatomy as defined The “IVUS” represents the imaging catheter in the vessel lumen Histologic correlation with intima, media and adventitia are shown The media has lower ultrasound reflectance owing to less collagen and elastin compared with neighboring layers Since the intimal layer reflects ultrasound more strongly than the media, there is a spillover in the image, resulting in slight overestimation of the thickness of the intima and a corresponding underestimation of the medial thickness distinctive and help to identify the position of the transducer In the left anterior descending (LAD) coronary artery system, for example, the septal perforators usually branch at a wider angle than the diagonals On the IVUS scan, the septals appear to bud away from the LAD much more abruptly than the diagonals (Figs 5A to D) The branching pattern and perivascular landmarks, once understood, can provide a reference to the actual orientation of the image in space IVUS Measurements The IVUS images have an intrinsic distance calibration, which is usually displayed as a grid in the image Electronic caliper (diameter) and tracing (area) measurements can be performed at the tightest cross section, as well as at reference segments located proximal and distal to the lesion In everyday clinical practice, where accurate sizing of devices is needed, vessel and lumen diameter measurements are important The maximum and minimum diameters (i.e the major and minor axes of an elliptical cross-section) are the most widely used dimensions The ratio of maximum to minimum diameter defines a measure of symmetry Area measurements are performed with computer planimetry; lumen area is determined FIGURES 4A TO C: Perivascular landmarks: (A) The great cardiac vein (GCV), running superiorly to the left circumflex coronary artery (LCx), appears as a large, low-echoic structure with fine blood speckle Recurrent atrial branches emerge from the LCx in an orientation directed toward the GCV, whereas the obtuse marginal branches emerge opposite the GCV and course inferiorly to cover the lateral myocardial wall (B) In the proximal portion of the left main coronary artery, a clear echo-free space filled with pericardial fluid, called the transverse sinus, is found adjacent to the artery, immediately outside of the left lateral aspect of the aortic root (C) At the level of the middle right coronary artery, the veins arc over the artery, typically at a position just adjacent to the right ventricular marginal branches Intravascular Coronary Ultrasound and Beyond 439 440 Manual of Cardiac Diagnosis FIGURES 5A TO D: Pullback imaging sequence from mid to proximal portion of the left anterior descending (LAD) artery: (A) The mid and distal portions of the LAD often lie deeper in the sulcus than the proximal LAD and myocardium may be observed The pericardium is seen at the opposite site of myocardium (B and C) The septal branches emerge opposite to the pericardium, but the diagonal branches take off more superiorly The angle between the septal and the diagonal branches usually increases to as much as 180 degrees (D) The left circumflex artery emerges on the same side as the emergence of the diagonal branches by tracing the leading edge of the blood/intima border, whereas vessel or external elastic membrane (EEM) area is defined as the area enclosed by the outermost interface between media and adventitia Plaque area or plaque-plus-media area is calculated as the difference between the vessel and lumen areas; the ratio of plaque to vessel area is termed percent plaque area, plaque Intravascular Coronary Ultrasound and Beyond burden or percent cross-sectional narrowing Area measurements can be added to calculate volumes using Simpson’s rule with the use of motorized pullback In general, the investigator selects the most normal-looking cross-section (i.e largest lumen with smallest plaque burden) occurring within 10 mm of the lesion with no intervening major side branches as the reference segment.4 Tissue Characterization The IVUS can provide detailed information about plaque composition Regions of calcification are very brightly echoreflective and create a dense shadow more peripherally from the catheter, a phenomenon known as “acoustic shadowing” (Figs 6A to C) Shadowing prevents determination of the true thickness of a calcific deposit and precludes visualization of structures in the tissue beyond the calcium Reverberation is another characteristic finding with calcification It causes the appearance of multiple ghost images of the leading calcium interface, spaced at regular intervals radially (Fig 2D) Like calcium, densely fibrotic tissue appears bright on the ultrasound scan Fatty plaque is less echogenic than fibrous plaque The brightness of the adventitia can be used as a gauge to discriminate between predominantly fatty from fibrous plaque Therefore, an area of plaque that appears darker than the adventitia is fatty In an image of extremely good quality, the presence of a lipid pool can be inferred from the appearance of a dark region within the plaque (Figs 7A and B) Furthermore, the “hot” lesions like ruptured plaques responsible for unstable angina or acute coronary syndromes can be observed by IVUS (Figs 8A and B) Recently, the clinical impact of attenuated plaques characteri zed as hypoechoic plaque with ultrasound attenuation despite little evidence of calcium has been reported (Figs 9A to C) These specific plaques are more often seen in patients with acute coronary syndromes than in those with stable angina and are characterized by positive remodeling and nearby calcifica tion.5 Clinical studies have indicated that attenuated plaques are associated with no reflow and creatine kinase-MB elevation after PCI because of distal embolization.6,7 This novel defined plaque may contain microcalcification, thrombus or cholesterol crystals.8 Visual interpretation of conventional grayscale IVUS images is limited in the detection and quantification of specific plaque components Therefore, computer-assisted analysis of raw radiofrequency (RF) signals in the reflected ultrasound beam has recently been developed (Figs 10A to C) Virtual Histology™ (VH) IVUS (Volcano Corporation, Rancho 441 FIGURES 6A TO C: Examples of coronary calcification: (A) Superficial calcification is seen between O’clock and 10 O’clock The deeper vessel structure is obscured by the shadowing of the calcium layer (acoustic shadowing: asterisk) (B) Deep deposit of calcium is seen in a rim of fibrous plaque (C) There are superficial and deep calcium deposits with acoustic shadowing 442 Manual of Cardiac Diagnosis Index.indd 886 886 Manual of Cardiac Diagnosis physiology 498 plaques molecular imaging 481 revascularization 507 risk 522 spasm 434 steal 501 stenosis 498, 500 stent 573 TREE 446 Cumulative risk of heart failure 192f CW Doppler of mitral regurgitation 198f Cyanosis 22 D Degenerated saphenous vein grafts 828 Dense cavitary photopenia 519 Detection of ischemia in asymptomatic diabetics 168 Detection of stenoses 606 Determinants of arterial oxygen content 154 left ventricular performance 233 velocity 387 venous oxygen content 154 Diabetes mellitus 177, 203 type 2 522 Diagnostic and assessment technique 433 prognostic parameter 501 Diastolic dysfunction calculation 512 murmurs early aortic regurgitation 62 pulmonic 65 velocity 393, 395 Digital imaging and communications in medicine 434, 512 Dilated cardiomyopathic heart 93 coronary artery stenoses 608 etiology 607 myocarditis 608 prognosis idiopathic dilated cardiomyopathy 611 ischemic dilated cardiomyopathy 610 Dip-and-plateau configuration 700f Dipyridamole stress echocardiography 333t Directional coronary atherectomy 855 Diseases acquired valvular heart 71 aortic root 21, 68 valve 28, 36, 66, 88, 89, 766, 822 arterial 346, 355, 446, 820, 824 atherosclerotic cardiovascular 8, 9, 56, 669 carcinoid heart 22, 61, 66, 693, 695 cardiac 168, 361, 676, 740, 747, 771 cardiovascular 9, 22, 56, 71, 349, 395, 553, 599, 637, 669, 734, 744 chronic lung 197 obstructive lung pulmonary 10 congenital heart 21, 88, 135, 261, 397, 427, 566, 577, 580, 592, 681, 780, 822 coronary artery 9, 138, 174, 222, 322, 350, 473, 503, 515, 516, 551, 552 cyanotic heart 23, 68 davies 205 heart 9, 11, 20, ischemic heart 60, 99, 118, 206, 243, 354, 390, 473, 576, 580, 725, 833 LV 206 Lyme 21, 22 mitochondrials 205 mitral valve 23, 87, 248, 361, 428, 429, 685, 767, 774 multivessel coronary artery 497, 517 11-02-2014 16:04:43 Index.indd 887 Index myocardial hearts 11 Naxos 20, 68 pulmonary embolic 83 rheumatic heart 88, 90, 290, 406, 411 severe angiographic 165 severe ischemic 500 structural heart 122, 303 valvular heart 11, 159, 261, 620, 634, 679, 681, 693, 707, 708, 754, 780 Dobutamine perfusion scintigraphy 505 stress echocardiography 505 stress echo 343 Doppler derived diastolic measurements 216t echocardiographic features 285f indices of diastolic function 277t myocardial imaging 238, 257 TEE 357 tissue imaging 221 velocity ratio 286 Drug-eluting stent implantation procedures 456, 457 Drug toxicity 734 Duett, vascular closure device 820 Duke activity status index 321t treadmill score 165, 338t Dynamic exercise testing 501 Dysfunctional myocardium 526, 529 Dyspnea cardiac and pulmonary causes of cardiac or noncardiac physical examination 12 presence of cardiac pathology 12 Chest X-ray 12 ECG 12 causes of episodes of severe 11 diagnosing causes of 12 differential diagnosis stiff heart syndrome 11 887 Dysrhythmias 13, 31, 769 Dyssynchronous myocardium 387 Dyssynchrony assessment 392 determination 390 presence 392 E Ebstein’s anomaly 61 Echocardiographic exercise contraindications to exercise testing 142 exercise test modalities 144 methodology of exercise testing 142 pretest preparations 143 safety precautions and equipment 142 testing after the test 160 before the test diagnosis 138 prognosis 138 class i (definitely appropriate) 138 class iib (may be appropriate) 138 indications for exercise testing 138 patients after myocardial infarction 141 patients presenting with acute coronary syndromes 140 during the test 147 acute cardiopulmonary response to exercise 150 11-02-2014 16:04:43 Index.indd 888 888 Manual of Cardiac Diagnosis autonomic control 154 central command 155 muscle afferents 155 neural control mechanisms 154 metabolic equivalents term 150 oxygen consumption 147 physiology review 147 interpretation 160 patient selection 138 prognostic utilization of exercise testing 164 screening 166 ST-segment analysis 160 features 177, 202, 203 findings 177, 200 laboratory 421 methods 396 modalities 406 stress study 605 indication 387 laboratory 505 Echo contrast agents 305 Doppler methods 250 right heart catheterization 279f Ehler–Danlos syndrome 21 Einthoven triangle 101 Eisenmenger’s syndrome 19 Ejection fraction 177, 178, 185, 233, 242, 387 Electrocardiogram basis of 96 characterization of QRS complex 121 common electrode misplacements 103 left arm 104 right leg electrode 106 component parts of 100 identification of atrial activity 107 leads orientation and vector forces 102 leads systems used to record 100 other lead systems 107 QT interval 134 ST-T wave abnormalities 131 “u” wave 134 Electrocardiographic rhythm 711 procedures 381 Electrophysiologic conditions 498 laboratory 392 Embolic protection devices for venous bypass graft PCI distal embolic filters 856 distal occlusion devices 857 proximal occlusion devices 857 End-diastolic short-axis trueFISP image 627 End-diastolic volume (EDV) 178, 240, 242 Endocardial segmentation 387 volume 396 Endoluminal morphology 476 Endomyocardial biopsy 417, 709, 717t contraction 392 fibrosis 177, 204, 726 Endoscopic technology 475 Endpoints for stress echocardiography 325t End-systolic dimension 183f left atrial (LA) volum 271f volume 153, 185, 178, 188, 390 index 191t Energy level 564 Enoxaparin 847 Entricular filling 46 Epicardial coronary artery stenosis diagnosis 603 segmentation 387 volume 396 E-point to septal separation 185 11-02-2014 16:04:43 Index.indd 889 Index Equilibrium gated imaging 538 radionuclide angiography 533, 541 Equipment for coronary interventions guide catheters 848 guidewire 849 Estimation of myocardial deformation 387 Evaluation of CAD in women 522 Everolimus-eluting stent 859 Everolimus, paclitaxel 858 Exercise score 338t stress echocardiography 318t, 335 testing guideline recommendation 171 testing 320t Extensive myocardium 501t External elastic membrane 440 Extraluminal contrast staining 864 Eyeballing 387 F Fabry’s disease 617 Failing heart 93 False-positive ST responses 160 FDA black box 325t Fiberoptic-based raman system 485 Fiberoptic catheter 475 Fick principle 151 First heart sound clinical conditions 44t First pass curve analysis 535 radionuclide angiography guidelines 533 Fluorescence angioscopy 481 measurements 484 spectroscopy 482, 483, 485 Fluorodeoxyglucose 648 Fluoroscopic imaging bioptome 712f system basic principle of 814 system X-ray tube 814 889 Fourier transform techniques 466 Fractional area change 270f flow reserve 829 shortening 185 Framingham risk scoring 570 Frank pulmonary edema 11 rupture 864 Functional imaging value 540 G Gallavardin sign 54 Gastrointestinal angioscopy 476 Gated blood-pool scintigraphy 254f Generation of catheters 463 Geometric assumptions 390 Giant cell myocarditis 609 Global LV systolic function 178, 198 Glomerular filtration 816 Goldberger’s 102 Grading diastolic dysfunction 277f Graham steell murmur 66 Guidelines for diagnosing cardiac sarcoidosis 729t Guidewire-based imaging catheter 465 H Hazard ratio plot for risk 195f Heart attack 519 failure 397, 498, 523 rate 152, 226, 247 activation 97 structures 381 sounds artificial valve sounds 52 early diastolic high frequency sounds 50 ejection sounds 48 first heart sound 44t fourth 46 midsystolic click 49 pericardial knock 48 second heart sound 47 third 46 Hemochromatosis 730, 732f 11-02-2014 16:04:43 Index.indd 890 890 Manual of Cardiac Diagnosis Hemodynamic classification of pulmonary arterial hypertension 768 complications 821 instability 778 parameters 700t pulmonary edema 11, 16 Hemodynamics in cardiomyopathy cardiac tamponade 702 constrictive pericarditis 701 hypertrophic obstructive cardiomyopathy 696 restrictive cardiomyopathy 697 Hemodynamics in valvular heart disease aortic regurgitation 688 stenosis 686 mitral regurgitation 691 stenosis 690 pulmonic regurgitation 693 stenosis 692 tricuspid regurgitation 695 stenosis 693 Heparin 847 Heparin-induced thrombocytopenia 848 Hepatojugular reflux 32 Heterogeneity map 532 Hibernation 526 Higher density 564, 565 High-interobserver variability 391 High lateral myocardial infarction 124 Histologic cross-section 433 History analysis of symptoms chest pain or discomfort cough 16 dyspnea 9 edema 15 general approach hemoptysis 16 palpitation 12 syncope 13 Holt-Oram syndrome 21 Human carotid endoatherectomy 484 coronary arteries 485 Hybrid nuclear 590 Hyperemic flow response 503t Hypereosinophilia 618 Hyperlipidemia 477 Hypertrophic cardiomyopathy causes 395 correlative findings 615 diagnosis 612 prognosis 613 Hypertrophic obstructive cardiomyopathy 49, 56, 397 I Identify dyssynchrony 391 Imaging acquisition protocols 505 analysis 557, 563 modalities 512 myocardial sympathetic innervation 545 viability 526 basis 527t principles 526 perfusion 530 quality and artifacts 557, 567 recording system 475 Implantable cardiac defibrillator 612 Infective endocarditis 261, 303, 362f Inflammation 647 Initial acs evaluation strategy 521 Inotrope dobutamine 604 Interatrial septal aneurysm 364f Interventional applications 449 devices 478 procedures 463 Interventricular septum 97 Intracardiac beating-heart procedures 422 echocardiography 417 masses 261, 304 shunt 621 structures 386 volumes 10 Intracoronary angioscopy 475 nitroglycerin 835 11-02-2014 16:04:43 Index.indd 891 Index thrombus 866 Intractable ischemia 606 Intraobserver and interobserver variabilities 406, 390 Intraoperative transesophageal echocardiography 372 Intravascular chemogram 485 coronary ultrasound 433 imaging catheters 463 investigation 486 Raman scattering 484 ultrasound 433, 433 basics 433 future directions 463 imaging systems 433 procedures 433 safety 463 Intravenous anticoagulation 846 Invasive mitral orifice 406 Ischemic burden 500 cardiomyopathy 201, 523 cascade 500, 501 dysfunction 528 heart disease 390 mitral regurgitation 401 risk 501t stress agent 505 Isolated cardiac myocyte 236 pulmonic stenosis 302 tricuspid stenosis 298 exercise 144 Isovolumic systole 40 Iterative method for atrioventricular optimization 312f IVUS (intravascular ultrasound) basics of 435 designs comparison 435t measurements 438 J Jaundice 20, 22 Judkins right catheter 788 type coronary catheters 786 Jugular veins 29 venous pressure 25 venous pulsations 24, 27 891 K Kawasaki disease 606, 833 Kerberos embolic protection system 857 Kerley lines 11, 81 Kinematics and tissue characterization 602 Kirchhoff’s 101 Konno-Sakakibara bioptome 709 Korotkoff sounds 24 Kussamul’s sign 33 Kyphoscoliosis 21 L Laminar flow encounters 274f Lancisi sign 30 Laser speckle analysis 475 Late gadolinium enhancement 607 Left anterior descending 438 artery 790, 565f hemiblock 124 Left atrial assessment 397 appendage 399 enlargement 79f volume 222 Left bundle branch block 516, 123f Left circumflex artery 790 Left heart in normal adults 184t Left main coronary artery 790 Left-to-right shunt analysis 537 Left ventricle ejection fraction 177 end diastolic pressure 686f pressure waveform 678f systolic function 178, 197 trabeculations and noncompaction 625 Left ventricular determination 387 ejection fraction 177, 178, 233, 242, 264, 512 time 238 end-diastolic dimensions 263 volume 182t, 188f 11-02-2014 16:04:43 Index.indd 892 892 Manual of Cardiac Diagnosis filling pressures 177, 225 function 387 assessment 233, 251 data 523 rest and during inotropic stress assessment of global and regional 604 hypertrophy 206, 395 linear dimensions 261 cavitary dilation 519 mass 177, 206 determination 395 index 208f noncompaction 205, 231, 613 pump function 233, 240 regional wall analysis 267 volume 237f, 387 Lesion calcification coronary perfusion 829 thrombus 828 total occlusion 828 quantification angulated lesions 827 bifurcation lesions 827 lesion complexity 825 lesion length 827 ostial lesions 827 quantitative angiography 824 Libman-Sachs endocarditis 20 Linear dimensions 182 dissection 864 Livido reticularis 20 Low-pressure occlusion balloon catheter 465 Luminal haziness 864 Luminescent emission 483 M Macrophages 654 Magnetic resonance imaging 390 Major epicardial vessels 790 Malignant arrhythmia 606 Malignant cardiac neoplasm 557, 586 Marfan’s syndrome 21 Maximal cardiac output 151 hyperemia 830 test for return to normal activities 142 Maximum intensity projection (MIP) 564 Measurement of diastolic parameters 177, 213 Mechanically rotating singletransducer system 434 Mediastinal emphysema 52 Medtronic vascular 857 Metaiodobenzylguanidine 545 Metastatic cardiac tumors 586 Methemoglobinemia 20 Microbeamformer 379 Midaxillary line 103 Mid-diastolic flow murmur 60 murmurs 65 Mild pulmonic regurgitation 303 Minimum lumen area 449 stent area 453 Mitral annular calcification 87f motion in diastole 221 inflow in response 276f pattern 225f regurgitation 261, 294, 692f severity 296t stenosis assessment 405, 406 quantification 406 valve calcification 91f closure 402 insufficiency 91f obstruction 44 orifice 406 repair 403, 417 stenosis 90f M-mode echocardiogram 309f Mobitz 120 Modified discrete cosine transform 549 Molecular imaging of vascular disease modalities 643 molecular imaging fundamentals 637 11-02-2014 16:04:43 Index.indd 893 Index processes aneurysm 665 atherosclerosis 646 thrombosis 662 vascular injury 668 Multicenter ultrasound-guided stent implantation in coronaries 453 Multidetector cct 243, 255 Multidirectional myocardial strain 392 Multimodality stress imaging 395 Multiple cutaneous lentigines 20 Multivessel coronary artery disease indicators 517 risk 517 Mural thrombi 625 Murmurs, various types of diastolic continuous murmurs 53 early diastolic 53 mid diastolic 53 presystolic 53 systolic 53 Muscle cell components 475 Myocardial compliance 699 contrast imaging 395 flow demands 514 infarction 390, 451, 457, 498, 778, 821, 829 pathophysiology spectrum 526t perfusion analysis 575 defects 507 echocardiography 421 imaging 498, 513, 516, 520 cost effectiveness 514 diagnostic accuracy 514 interpretation 513 studies 497 scaring 576f synchrony 498 tissue density 396 viability 316, 347 arises 526 assessment 523 893 determination 528 evaluation 524 scintigraphic evidence 527t Myocarditis 719f Myocardium at ischemic risk 500 demonstrates systolic dysfunction 526 during fetal development 625 quantification 395 Myocyte hypercontraction 715 Myxomas 363f N National Heart Lung and Blood Institute 864 Naxos disease 20 Neointimal hyperplasia 455, 858 Neoplasms 735 Neovascularization 657 Nir spectroscopy system 486 Nitrogen (13N) ammonia 531 Nonatherosclerotic coronary artery disease and transplant vasculopathy 831 Noncancerous masses 557, 586 Noncardiac surgery cardiovascular evaluation 522 preoperative evaluation 521 procedures 522 Noncontrast CT 570 Non-coronary sinus 585f Nondiabetic population 522 Noninvasive cardiac imaging 523 technique 387 Nonischemic cardiomyopathy 523 Non-occlusive technique 473 Nonperfusion indicators 518 Nonscintigraphic imaging options 528 Non-viral lymphocytic myocarditis 609 Normal coronary anatomy co-dominant or balanced coronary circulation 800 11-02-2014 16:04:43 Index.indd 894 894 Manual of Cardiac Diagnosis coronary collateral circulation 800 left anterior descending artery 794 circumflex artery 797 dominant coronary circulation 799 main coronary artery 793 right coronary artery 797 dominant coronary circulation 799 Normal values for CMR using true-FISP acquisition 603 Nuclear cardiology 497, 513 studies 497 medicine 497, 512 laboratory 505 methods 497 scintigraphy 244, 251 O Obesity epidemic 522 Obstructive hypertrophic cardiomyopathy 289f Oligopeptides 638 Optical coherence tomography clinical experience 468 future directions 473 image interpretation 466 imaging systems 464 limitations 473 procedures 464 safety 473 frequency-domain imaging 466 Orthopnea 10 Osler-Weber-Rendu syndrome 20 Oxidative stress 656 P Paradoxical septal motion 513 splitting of S2 46 embolization 363 Parenteral anticoagulant therapy bivalirudin 848 enoxaparin 847 heparin 847 Parkinsonian gait 19 Partial thromboplastin time 847 Participants with adverse cardiovascular outcomes 192f Pathophysiology of coronary lesions 475 Patient populations general 521 principles 521 risk assessment 521 specific 521 with acute coronary syndrome 172 with rhythm disorders 173 with valvular heart disease 173 Peak contraction 391 Perclose 820 Percutaneous coronary applications 483 intervention 433, 838 femoral arterial catheterization 782 intervention 501 in patients with prior coronary bypass surgery 843 procedures 417 revascularization 838 transluminal coronary angioplasty 851, 852 Perforation of heart chamber 821 Perfusion balloon catheter 851 image display 506 imaging appropriateness criteria 524 visual method 532 ischemic indicator 501 quantification 395 calcifications 88 visualized 583f Pericardial cyst 93, 94f disease 261, 279, 625 11-02-2014 16:04:44 Index.indd 895 Index disorders congenital absence of the pericardium 94 cysts 93 effusion 92, 93f, 278, 281, 282f fat 93 sac 93 Perioperative cardiac risk stratification 522 Peripartum cardiomyopathy 206 Periprocedural hypoglycemia 781 Perivascular landmarks 438 Petechiae and purpuric skin rash 22 Pharmacologic interventions 478 stress 505, 523 agents 504t echo 326, 329, 331 imaging 505 testing 327t, 502 therapy 395 Pharmacotherapy 648 Phase analysis 545 image analysis 545 Photoluminescence 483 Photonic spectroscopy 482 Plaque formation and distribution 446 Platelet receptor inhibitors 845 Pompe’s disease 733f Poor prognosis 501t Positron emission tomography metabolism 524 perfusion 524 technology 524 Postpericardiotomy identification 512 Postrevascularization 523 Preclinical aneurysm imaging investigations 666 thrombus imaging strategies 664 Precordial leads 103 Predischarge submaximal test 142 Preinterventional imaging 449 Premature ventricular contraction 697f 895 Pressure development 233, 236 volume loop 189f, 212 Pretest score 323t Primary HCM 201 Primitive computer technology 557 Procedural adjunct 372 success after PCI measured 862 Prognosis in coronary artery disease 316, 334, 335, 343 value 507 Prominent trabecular band 97 Promising molecular imaging agents 639t Prosthetic valve complications 403, 413 Proteases 654 Prototype computed tomography 557 Proximal convergence method 298f Pseudohypertrophic muscular dystrophy 60 Pseudonormal filling 224 Pulmonary arterial hypertension hemodynamic classification of 768 Pulmonary artery hypertension 277 catheterization 764 catheters 761t, 762 hypertension 622 wedge pressure 822 capillary wedge pressure 226, 234, 240, 241, 246, 252, 279 hypertension 261, 280f, 766, 822 outflow obstruction regurgitant murmurs 58 valve stenosis 45, 92f vascular resistance 755 vein pulse Doppler imaging 367f venous anatomy 578f flow 218 11-02-2014 16:04:44 Index.indd 896 896 Manual of Cardiac Diagnosis Pulmonic regurgitation 65, 261, 303 stenosis 261, 302, 694f Pulsed alternans 695 Doppler measurement 274 tissue Doppler 310f Purkinje cells coating 98 Purkinje fibers 97 Q QRS analysis 121 complex 98, 100, 107, 121 diagnoses 121 QT interval abnormalities suggesting right 135 dilatation 135 hypertrophy 135 left atrial enlargement 135 Quantitative angiography 824 colorimetric analysis 481 methods 477, 481 Q waves 126, 127 R Radial endomyocardial velocity 392 Radiation concerns 547 dosage 549t modulation 562f with CT 563t Radiofrequency 441 Radionuclide injection 520 ventriculography 251, 253 Radiopharmaceutical 648 Raman spectroscopy 483 Regional anatomy 711f contraction 391 coronary flow 532 reserve 532 quantitation 532 deformation 391 endocardial contraction 391 function 391 myocardial perfusion 513 perfusion maintenance 528 ventricular function 395 volume 391 wall motion assessment 390 determination 390 identification 391 Regular non-rapid heart rate 382 Regurgitant murmurs mitral regurgitation 58 tricuspid regurgitation 60 Restrictive cardiomyopathy diagnosis 616 etiology 616 physical findings 34 filling 224 Revascularization after coronary interventions 449 Rheolytic thrombectomy 854 Rheumatic heart disease 406 Rheumatic mitral stenosis 406 Rhythm disorders 173 Right atria assessment 397 atrial pressure waveform 685f, 758f bundle branch block 122 gastroepiploic artery 812 ventricular diameters measured 269f ejection fraction 536 enlargement 78f function assessment 396 hypertrophy 31, 128 morphology 620 volumes assessment 396 Rotational methods of data collection 378f Rubidium (82Rb) chloride 530 S Sarcoidosis 727 Scar tissue 392 Scintigraphic evidence 501t imaging options 528, 529 methods 498 11-02-2014 16:04:44 Index.indd 897 Index Secondary hypertrophic cardiomyopathy 177, 202 left ventricular hypertrophy 202 Segmental parameters 392 techniques 390 visualized 307f volumes 391 Seldinger 777 Selective coronary angiography 507 Semi-automated segmentation techniques 391 Semiinvasive and invasive tests 1 Semi-quantitative scoring system 507 Septal myocardial infarcts 126 Serial angioscopy 478 Severe chronic obstructive lung disease 822 Short-axis true-FISP images 624 Shy-Drager syndrome 19 Simvastatin therapy 652f Single photon emission computed tomography 390, 421, 497, 524, 525 perfusion imaging 501t Sinoatrial node 98, 99 Sirolimus-eluting stent implantation 471 Sites and techniques of vascular access brachial artery approach 785 femoral artery approach 782 transradial approach 783 Small animal molecular imaging modalities 644t Solid-state dynamic aperture system 434 Spatiotemporal resolution 421 Spectroscopic analysis 474 assessment of coronary lipid 485 clinical experience 485 experimental data 484 future directions 486 imaging systems 483 897 limitations 486 procedures 483 safety 486 Spiral dissection 864 Spontaneous coronary artery dissection 832 Stable angina clinical features of 6t Stanford bioptome 710f Starclose 820 Stenosis severity 286, 293 Stenotic epicardial artery 395 orifice area 286 Stent deployment techniques 457 everolimus-eluting 859 platform 859 thrombosis anatomic variables 867 procedural factors 867 zotarolimus-eluting 859 Stereoscopic vision display 422 Still’s murmur 57 Stokes–Adams–Morgagni syndrome 14 Storage diseases and myopathy 732 Strain derived indices 199 parameters 395 Stress echocardiograms 421 Echocardiography 316 Stress echocardiography clinical decisions 316, 317 future 316 myocardial viability 347 pathophysiology involved 317 imaging applications 393 induced diastolic dysfunction 395 inotrope 606 testing deficiencies 500 mechanism 503 vasodilator 606 Stroke volume 152 Structural valve assessment 357, 366 11-02-2014 16:04:44 Index.indd 898 898 Manual of Cardiac Diagnosis Strut intussusceptions 463 separation 463 subluxation 463 Subarachnoid hemorrhage 131 Subclavian steal 15 Subendocardial ischemia 160 Subintimal hemorrhage 477 Suboptimal acoustic access 605 Subselective delivery catheter system 475 Subxiphoid impulse 38 Sudden cardiac death 604 Summed difference or reversibility scores 507 rest scores 507 stress scores 507 Superior vena cava 414 Suprasternal notch 38 Supraventricular rhythms 110 tachycardia 110 Surgical revascularization 457 treatment for ischemic heart failure 608 Swan-Ganz catheters abnormal pressures and waveforms 758 clinical applications acute coronary syndromes 759 cardiac catheterization laboratory 759 chronic heart failure 764 non-acute coronary syndrome 763 complications 769 evolution 750 historical perspective 750 indications for pulmonary artery catheterization 768, 769 normal pressures and waveforms 754 placement of balloon flotation 751 Switched multi-element array system 434 Symptomatic postrevascularization 523 Syndromes acute chest pain 497 acute coronary 18, 35, 174, 446, 485, 487 apical ballooning 57 Barlow’s 60, 405 Blue toes 20 brady-tachy 14 carcinoid 412 chest pain 86, 318, 319 coronary 2, 3, 5, 6, CREST 21, 22 Down 21, 23 EhlerDanlos 21, 23 Eisenmenger’s 16, 19, 46 Holt–Oram 21, 23 ischemia 321, 323, 337, 338, 339, 350, 352 Leopard 20, 22, 68 long QT 134 Marfan’s 21, 23 metabolic 9, 18, 648, 650, 670 mitral valve prolapse 23 neurologic 68 Ortner’s 16 Osler-Weber-Rendu 20 paroxysmal orthostatic tachycardia 14 Shy-Drager 19 Stiff heart 11 Stokes–Adams–Morgagni 14 subclavian steal 15, 17 Turner’s 21, 23 Uhl’s 61 Wolff–Parkinson–White 140 System for coronary segments classification of 791t Systolic blood pressure 501 dysfunction 205, 390, 501,526, 533 dyssynchrony index 391 function 523 heart failure 608 wall stress 235 T Tamponade 44 Technique of real-time three-dimensional echocardiography (Rt3DE) 378 TEE imaging 357 Thienopyridine therapy 845 11-02-2014 16:04:44 Index.indd 899 Index Thin-cap fibroatheroma 446 Threatened or acute closure 863 Three-dimensional echocardiography clinical applications 387 future directions 420 limitations 423 technique 379 structure 377 wall motion tracking 389f Thrombectomy 854 Thrombus formation 473 Tissue characterization 441 Transapical aortic valve implantation 417 Transatrial septal puncture 417 Transesophageal echocardiography guidelines 358 history 357 performance 358 safety 359 views 359 transducer 377 Transient ischemic dilation 517, 518 postischemic dysfunction 526 Translesional physiologic measurements 830 coronary angioplasty 450 Transmitral flow 214f, 223f, 214f velocities 227f Transplant rejection 738f vasculopathy 833 Transthoracic echocardiography 234, 242, 243, 247, 253, 357 two-dimensional echocardiography 255f Traumatic ruptured chordae 61 Tricuspid regurgitation severity 302t stenosis physical findings 66t signs of 66f valve closes 28, 40 valve obstruction 31 Tumor plop 51, 67 899 Two-dimensional echocardiography (2DE) 377 U Uhl’s syndrome 61 Ultrasound contrast agents 325t imaging catheter system 433 Unfractionated heparin 848 United States Food and Drug Administration 859 Unrecognized myocardial infarction 607 Unstable angina 520 V Valsalva maneuver 60 Valvular disease 580 disorders assessment 401 heart disease valve stenosis 619 valvular regurgitation 619 Variability of LVESV 187f Vascular biology 433 closure devices 820 closure devices advantages or disadvantages of 820 complications 821 Vasculitis 833 Vasodilator pharmacological stress 517, 520 Vasoseal 820 Velocity contractile element 233, 239 encoding 621 relation 239f time integral 387 Ventricular arterial coupling 233 fibrillation 473 function assessment 233 clinical application 233 curve 233, 240, 241 measurements 523 pacing 516 papillary muscle strips 248 11-02-2014 16:04:44 Index.indd 900 900 Manual of Cardiac Diagnosis perspective 406 septal defect 57, 381, 417, 577f synchrony 533 tachyarrhythmias 11 tachycardia 31, 473 thrombus 587 Vessel morphology 434 Visual assessment 391 interpretation 441 qualitative indicators 205 Volume curves 391 determination 395 pressure loops 213 rendering technique 566f Vulnerable plaque detection 472, 478 W Wall motion abnormalities 527t tracking methods 387 Wide and “fixed” splitting of S2 47 Wide splitting atrial septal defect 44 premature ventricular contractions 44 right bundle branch block 44 ventricular tachycardia 44 Wolff-Parkinson-White syndrome 162 X Xanthelasma 22 Xanthomatosis 22 “x” descent 28 Y Yellow intensity 476 mesh 511 plaque 476, 480f saturation 479 surface color 478 Z Zones, types of zone 1, above the level of the left atrium 754 zone 2, below the level of left atrium 754 zone 3, not verified by obtaining a lateral chest radiography 754 Zotarolimus-eluting stent, second generation DES 859 11-02-2014 16:04:44 ... performed based on IVUS measurements of media-to-media diameter at the lesion site. 32, 33 Angiographic or clinical follow-up of these 451 4 52 Manual of Cardiac Diagnosis studies also showed long-term... 440 Manual of Cardiac Diagnosis FIGURES 5A TO D: Pullback imaging sequence from mid to proximal portion of the left anterior descending (LAD) artery: (A) The mid and distal portions of the LAD often... asterisk) (B) Deep deposit of calcium is seen in a rim of fibrous plaque (C) There are superficial and deep calcium deposits with acoustic shadowing 4 42 Manual of Cardiac Diagnosis Intravascular