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Ebook Manual of cardiac diagnosis Part 2

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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

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