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Cardiac Imaging Section Competency Requirements

Thoracic aorta and great vessels

• State the normal dimensions of the thoracic aorta.
• Describe the classifications of aortic dissection (De-Bakey I, II, III; Stanford A, B) and implications for classification on medical vs. surgical management.
• Describe and recognize the findings of, and distinguish between each of the following on CT and MR:
  • aortic aneurysm
  • aortic dissection
  • aortic intramural hematoma
  • penetrating atherosclerotic ulcer
  • ulcerated plaque
  • ruptured aortic aneurysm
  • sinus of Valsalva aneurysm
  • subclavian or brachiocephalic artery aneurysm
  • aortic coarctation
  • aortic pseudocoarctation
  • pulsation artifact at aortic root
• Recognize a right aortic arch and a double aortic arch on chest CT, and chest MRI.
• State the significance of a right aortic arch with mirror image branching versus with an aberrant subclavian artery.
• Recognize a cervical aortic arch on a chest radiograph and CT.
• Recognize an aberrant subclavian artery on chest CT.
• Recognize normal variants of aortic arch branching, including common origin of brachiocephalic and left common carotid arteries (“bovine arch”), and separate origin of vertebral artery from arch on CT and MRI/MRA.
• Define the terms aneurysm and pseudoaneurysm.
• Describe the cardiac anomalies commonly associated with aortic coarctation.
• Describe and identify the findings of Takayasu arteritis on chest CT and chest MRI.
• Describe the advantages and disadvantages of CT, MRI/MRA, and transesophageal echocardiography in the evaluation of the thoracic aorta.

Ischemic heart disease

• Describe the anatomy of the coronary arteries and identify the following on a coronary arteriogram, MRI, and CT:
  • right coronary artery
  • left main coronary artery
  • left anterior descending coronary artery
  • left circumflex coronary artery
  • obtuse marginal
  • diagonals
  • acute marginals
  • septal perforators
• Describe the clinical significance of coronary arterial calcification on a chest radiograph.
• Recognize coronary arterial calcification on CT and describe the current role of coronary artery calcium scoring with helical or electron beam CT.
• Name the coronary artery that is usually diseased when there is papillary muscle dysfunction.
• Describe the common acute complications of myocardial infarction, including left ventricular failure, myocardial rupture, and papillary muscle rupture, and recognize radiologic findings indicating each.
• Describe the common late complications of myocardial infarction, including ischemic cardiomyopathy, left ventricular aneurysm, left ventricular pseudoaneurysm, coronary-cameral fistula, dyskinesis, and akinesis, and recognize radiologic findings indicating each.
• Identify signs of left heart failure on a chest radiograph and CT.
• Define ejection fraction, including the normal value for left ventricular ejection fraction.
• Identify myocardial calcification on CT and describe the etiology and significance of this finding.
• Describe the difference between a left ventricular aneurysm and pseudoaneurysm.
• Define and identify myocardial bridging on CT.
• Define the role of angiography, echocardiography, stress perfusion scintigraphy, chest CT, and chest MRI in the evaluation of a patient with suspected ischemic heart disease as well as stunned myocardium and hibernating myocardium versus areas of infarction, including the advantages and limitations of each modality.
• Differentiate viable from nonviable myocardium on MRI.
• Identify myocardial perfusion defects on MRI.
• Calculate right and left ventricular volumes, including ejection fraction, stroke volume, end-diastolic volume, and end-systolic volume using MRI and CT. Academic Radiology, Vol 12, No 2, February 2005 CARDIOTHORACIC RADIOLOGY

Myocardial disease

• Define the types of cardiomyopathy (dilated, hypertrophic, restrictive) and list the common causes of each.
• Define right ventricular dysplasia, describe the role of MRI in its diagnosis, and identify MRI findings that support the diagnosis.
• Name the most common benign primary cardiac tumors, including myxoma, lipoma, fibroma, and rhabdomyoma.
• Name the most common malignant primary cardiac tumors, including angiosarcoma, rhabdomyosarcoma and lymphoma.
• Distinguish cardiac tumor from thrombus on CT and MRI.
• Name the most common malignancies to metastasize to the heart, and describe the appearance on a chest radiograph, chest CT and chest MR.
• Describe the advantages and disadvantages of echocardiography, CT, and MRI for evaluation of cardiomyopathy and cardiac tumors.
• Recognize calcification of papillary muscles as distinct from myocardial calcifications and describe the significance of each.

Cardiac valvular disease

• Identify and describe the findings of each on a chest radiograph:
  • ]enlarged right atrium
  • enlarged left atrium
  • enlarged right ventricle
  • enlarged left ventricle
• Describe and recognize the chest radiograph findings associated with each of the following valvular diseases:
  • mitral regurgitation
  • mitral stenosis
  • aortic regurgitation
  • aortic stenosis
  • tricuspid regurgitation
• Recognize an enlarged ascending aorta and aortic valve calcification on a chest radiograph and suggest the diagnosis of aortic stenosis when these findings are present.
• Recognize an enlarged left atrium, vascular redistribution, and mitral valve calcification on a chest radiograph and suggest the diagnosis of mitral stenosis when these findings are present.
• State the most common etiologies of the following:
  • aortic stenosis
  • aortic regurgitation
  • mitral stenosis
  • mitral regurgitation
  • tricuspid regurgitation
  • pulmonary stenosis
• Name the cardiac diseases associated with mitral annulus calcification.
• Identify endocarditis or complications of endocarditis on a chest radiograph, CT, and MRI.
• Describe the advantages and disadvantages of echocardiography and MRI for evaluation of valvular heart disease.
• Describe the pulse sequences and appropriate planes for evaluating cardiac valvular disease and making quantitative measurements, including pressure gradients, regurgitant fractions and valve areas.

Pericardial disease

• Recognize pericardial calcification on a chest radiograph and CT and name the most common causes.
• Describe and identify two chest radiographic signs of a pericardial effusion.
• Name five causes of a pericardial effusion.
• Describe and recognize the findings of each of the following on a chest radiograph,
  • CT, and MR:
  • pericardial cyst
  • constrictive pericarditis
  • pericardial hematoma
  • pericardial metastases
  • partial and complete absence of the pericardium
  • pneumopericardium

• Describe the role of MRI in diagnosing constrictive pericarditis and differentiating constrictive pericarditis from restrictive cardiomyopathy.

Congenital heart disease in adults

• Recognize increased vascularity and decreased vascularity on a chest radiograph and name the common causes of each.
• Describe and recognize the following on a chest radiograph, CT, or MRI.

Heart disease presenting during adulthood

• Left-to-right shunts and Eisenmenger physiology
• Atrial septal defect
• Ventricular septal defect
• Partial anomalous pulmonary venous connection
• Patent ductus arteriosus
• Coarctation of the aorta
• Tetralogy of Fallot and pulmonary atresia with ventricular septal defect
• Congenitally corrected transposition of the great arteries
• Persistent left superior vena cava
• Truncus arteriosus
• Ebstein anomaly
• Cardiac malposition, including abnormal situs
• Coronary artery anomalies

Heart disease originally treated in childhood

• Coarctation of the aorta
• Tetralogy of Fallot and pulmonary atresia with ventricular septal defect
• Complete transposition of the great arteries
• Congenitally corrected transposition of the great arteries
• Truncus arteriosus
• Commonly performed surgical corrections for congenital heart disease

Define the role of angiography, echocardiography, chest CT and chest MRI in the evaluation of an adult patient with congenital heart disease, including the advantages and limitations of each modality depending on patient presentation.

Monitoring and support devices - tubes and lines

• Describe and identify on chest radiography the normal appearance and complications associated with each of the following:
  • endotracheal tube
  • central venous catheter
  • peripherally inserted central venous catheter
  • pulmonary artery catheter
  • intra-aortic balloon pump
  • pacemaker generator and leads (including triple lead devices)
  • automatic implantable cardiac defibrillator
  • left ventricular assist device
  • atrial septal defect closure device
  • pericardial drain
  • extracorporeal life support cannulae
• Explain how an intra-aortic balloon pump works.
• Describe the venous anatomy and expected course of veins from the axillary vein to the right atrium relative to anatomic landmarks.

Post-operative thorax

• Identify normal postoperative findings and complications of the following procedures on chest radiography, CT, and MRI:
  • coronary artery bypass graft surgery
  • cardiac valve replacement
  • aortic graft
  • aortic stent
  • heart transplantation