Curriculum in cardiac imaging

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

A suggested curriculum in cardiac imaging has been established by the North American Society of Cardiac Imaging.

The original document can be viewed here.

Physiological aspects of cardiac imaging

1. Normal cardiac cycle (systole and diastole)
   • Systole and diastole
   • Ventricular function
   • Atrial function
   • Valvular function
2. Electrocardiography
   • Control of excitation and conduction in the heart
   • Characteristics of normal sinus rhythm
   • Common abnormalities in EKG
     • Premature atrial contraction / premature ventricular contraction
     • Atrial fibrillation / atrial flutter / Atrioventricular block
     • Current of injury (signs of myocardial ischemia and infarction)
3. Physiologic anatomy of cardiac muscle
4. Mechanics of cardiac contraction
5. Physical basis for blood flow, pressure and resistance
   • Ventricular volume and pressure relationship
     • Preload
     • Afterload
   • Practical cardiac measurements
     • Ejection fraction
     • Stroke volume
     • Cardiac Output
     • Left ventricular mass
     • Flow calculation (Q = V x A)
     • Gradient calculation (Bernoulli equation, G = 4 x PV2)
     • Qp/Qs ratio
   • Normal cardiac and pulmonary pressures
   • Vascular regions supplied by the coronary arteries
   • Standard nomenclature for topographic imaging of the heart

Anatomy of the heart and great vessels

1. Normal morphology and structure
   • Embryology
   • Fetal circulation
   • Normal cardiac and peri-cardiac structures to include
     • Eustachian valve
     • Thebesian valve / coronary sinus
     • Right and left atrial appendages
     • Moderator band
     • Endocardial cushion
     • Atrioventricular valves (tricuspid and mitral)
     • Semilunar valves (aortic and pulmonic)
     • Sinus of Valsalva
     • Coronary arteries and major branches
     • Coronary veins including coronary sinus
     • Superior vena cava and deep mediastinal veins (e.g. azygous vein)
     • Pericardium
     • Pulmonary arteries
     • Pulmonary veins
   • Common variants
     • Anomalous coronary artery
     • Persistent left superior vena cava
     • Azygous continuation of the inferior vena cava
2. Segmental Anatomy of the Heart
   • Atrial situs
   • Ventricular situs
   • Identification of great vessels
   • Assess pulmonary arteries and veins
   • Identify systemic venous return
3. Normal Adult Heart Measurements
   • Left ventricular wall thickness, diameter, fractional shortening and end-diastolic volume and volume index
   • Left atrium size
   • Right ventricular wall thickness and size
   • Right atrial size
   • Diameter of the thoracic aorta

Techniques for imaging the heart and great vessels

1. Radiography
2. Computed tomography
   • Indications
     • Coronary calcium scoring
     • Cardiac CT
     • Coronary CTA
   • Physics and cardiac imaging considerations including ECG gating techniques
     • Coronary artery calcium scoring
     • Coronary CTA
     • Aortic CTA
     • Pulmonary CTA
   • Advantages and Limitations
3. Magnetic resonance imaging
   • Indications
   • Physics and imaging considerations, including pulse sequences, ECG-gating techniques, and respiratory compensation strategies
     • Wall motion studies
     • Myocardial perfusion and viability scanning
     • Valvular disease assessment
     • Blood flow quantification
     • Coronary MRA
     • MR of the aorta
     • Pulmonary MRA
     • Atherosclerotic plaque evaluation
   • Advantages, Limitations and contraindications
4. Cardiac Scintigraphy (including PET)
   • Indications
   • Physics and cardiac imaging considerations
     • Multiple-gated acquisition (MUGA)
     • Myocardial perfusion and viability scanning
     • Shunt evaluation
   • Advantages and Limitations
5. Other (working understanding)
   • Echocardiography (transthoracic and transesophageal)
     • Indications
     • Technique including standard views and use of color Doppler
     • Advantages and Limitations
   • Cardiac and coronary catheter angiography
     • Indications
     • Technique including standard views and transcatheter tools (e.g. intraluminal ultrasound)
     • Advantages and Limitations

Congenital heart disease: Basic

1. Cyanotic versus acyanotic presentations
2. Most common lesions:
   • Ventricular septal defect
   • Patent ductus arteriosus
   • Atrial septal defect
   • Tetralogy of Fallot
   • Pulmonary stenosis
   • Obstruction of the aorta (aortic coarctation and interruption of the aorta)
   • Transposition of the great vessels (D- vs. L-transposition)
   • Endocardial cushion defect
   • Aortic valvular disease
   • Total anomalous pulmonary venous connection and Partial anomalous pulmonary venous connection
   • Truncus arteriosus
   • Vascular rings
3. Situs Anomalies and (asplenia and polysplenia)

Unusual congenital heart disease: Advanced

1. Double outlet right ventricle
2. Single ventricle
3. Cor Triatriatum
4. Hypoplastic left heart syndrome
   • Aortic atresia
   • Mitral atresia
5. Hyopoplastic right heart syndrome
   • Tricuspid atresia
   • Uhl’s anomaly
   • Right ventricular dysplasia
   • Pulmonary valve atresia
   • Ebstein’s anomaly
6. Congenital absence of the pericardium
7. Indications for and post-operative assessment of
   • Mustard
   • Senning
   • Rastelli
   • Fontan
   • Norwood
   • Jatene
   • Blalock-Taussig
   • Potts
   • Waterston-Cooley
   • Glenn
   • Rashkind
   • Ross Procedure
8. Late or Adult presentations of congenital heart disease
   • Mitral valve prolapse
   • Aortic stenosis (e.g. valvular and subvalvular)
   • Sinus of Valsalva aneurysm
   • Marfan’s syndrome
   • Bicuspid aortic valve

Ischemic heart disease

1. Risk factors, primary prevention and screening
2. Inducible myocardial ischemia
3. Acute MI
4. Chronic MI
5. Post-MI complications
   • Cardiac rupture
   • LV aneurysm
   • Papillary muscle rupture
   • Congestive heart failure
   • Dressler’s syndrome
6. Myocardial viability
   • Stunned myocardium
   • Hibernating myocardium
   • Therapeutic and interventional options

Valvular Heart Disease

1. Aortic stenosis
   • Valvular aortic stenosis
   • Subvalvular aortic stenosis
   • Supravalvular aortic stenosis
     • William’s syndrome
2. Aortic insufficiency
3. Mitral stenosis / mitral insufficiency
   • Parachute mitral valve
4. Tricuspid stenosis / tricuspid regurgitation
5. Miscellaneous:
   • Degenerative calcification
     • Calcified aortic stenosis
     • Mitral annular calcification
   • Myxomatous degeneration
   • Carcinoid syndrome
   • Infective endocarditis
   • Rheumatic heart disease
6. Therapeutic and interventional options

Cardiac and pericardial masses

1. Primary lesions
   • Myxoma
   • Lipoma
   • Angiosarcoma
   • Rhabdomyoma
2. Metastasis
3. Therapeutic and interventional options

Acquired diseases of the thoracic aorta

1. Aneurysms
   • Atherosclerotic
   • Marfan’s syndrome
   • Ehlers-Danlos syndrome
2. Pseudoaneurysms
   • Mycotic
3. Post-traumatic and post-surgical
   • Dissection
     • Intramural hematoma
   • Aortitis
   • Atherosclerosis
     • Plaque
     • Penetrating ulcer
   • Therapeutic and interventional options

Cardiomyopathy

1. Hypertrophic cardiomyopathy
   • Idiopathic hypertrophic subaortic stenosis
2. Dilated Cardiomyopathy
   • • Ischemic
     • Non-ischemic

1. Restrictive (also infiltrative) cardiomyopathy
   • Amyloidosis
     • Sarcoidosis
     • Storage diseases
     • Infection
     • Radiation
   • Therapeutic and interventional options

Diseases of the Pericardium

1. Acute pericarditis
2. Constrictive pericarditis
3. Pericardial effusion
4. Pericardial cyst
5. Pericardial defect
6. Therapeutic and interventional options

Miscellaneous

1. Arrhythmogenic Right Ventricular Dysplasia (ARVD)
2. Coronary artery / sinus of Valsalva aneurysm and fistula
3. Pulmonary arterial hypertension
4. Pulmonary embolism
5. Cardiac transplantation
6. Automatic Inplantable Cardioverter Defibrillator (AICD)
7. Pacemakers
8. RF ablation for atrial fibrillation

Cardiovascular Protocols

• MR Angiography for Pulmonary Embolism
• Acute Chest Pain Imaging