Cath SAP 5

Anatomy, Anatomic Variants, Anatomic
Pathology
Anatomy, Anatomic Variants, Anatomic Pathology
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Question 1 of 35
#2729
A 55-year-old woman under treatment for recent myocardial infarction (MI) develops acute shortness of breath and
hypotension. She had been admitted 2 days earlier to an outside facility with substernal chest pain and ST-segment
elevation in leads v1-v4. Catheterization demonstrated an acute left anterior descending (LAD) artery occlusion that
was successfully treated with a drug-eluting stent. She was stable until this morning, when upon examination, she is
cold and clammy with a pulse of 110 beats per minute and blood pressure of 90/55 mm Hg. Bilateral rales are
appreciated along with a loud, holosystolic murmur heard best at the apex and left sternal border with a palpable
thrill. Electrocardiogram demonstrates sinus tachycardia and Q-waves in v1-v4 with persistent ST elevation. An
emergent echocardiogram is performed with the findings noted in Figure 1.
What is the diagnosis?
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• Ventricular free wall rupture.
• Left ventricular (LV) pseudoaneurysm.
• Ventricular septal rupture.
• Takotsubo cardiomyopathy.
• Papillary muscle rupture.
Submit Answer
That is incorrect
76% of peers answered this correctly
• Reasoning
• Related Text / Key Point
• References
The echocardiographic findings suggest preserved LV function and anteroapical ventricular septal rupture, which is a
rare but significant complication of acute MI. As the LAD supplies the anterior lateral and septal walls, occlusion of
this vessel may lead to anteroapical septal rupture. Right coronary artery occlusion is associated with postrerobasal
septal rupture. Papillary muscle dysfunction may occur following acute MI, but it is less common following anterior
MI (dual blood supply to the anterolateral papillary muscle) and the echocardiographic findings are not suggestive of
mitral regurgitation. Free wall rupture is another important complication of acute MI, but it generally presents as
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pulseless electrical activity and pericardial tamponade and the echocardiographic findings are not consistent with
the presence of a ventricular pseudoaneurysm or Takotsubo cardiomyopathy, which would show signficant apical
ballooning.
Key Point
The LAD is most frequently a direct continuation of the left main artery, coursing along the anterior interventricular
groove. It gives rise to anterior septal perforating arteries and diagonal branches that supply the septum and
anterolateral free wall of the left ventricle, respectively.
Related Text
Click the title below to read text related to this question in the Cardiac Vascular Anatomy chapter/Coronary Artery
Anomalies module.
Definitions
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Question 2 of 35
#747
A 62-year-old man is referred for upgrade of his dual-chamber pacemaker to a biventricular pacemaker because of
severe heart failure and evidence of left ventricular-right ventricular (LV-RV) dyssynchrony. You have been consulted
by your colleague, an electrophysiologist, who obtained this image (Figure 1) while preparing to install an LV pacing
lead. He has requested your opinion regarding balloon angioplasty of the coronary sinus.
Which of the following is the best course of action at this point?
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• He should not install the left ventricular lead in the setting of a coronary sinus stricture because obstruction
of coronary sinus outflow could cause myocardial edema.
• Place a coronary sinus stent at the site of the narrowing.
• Refer the patient for epicardial lead placement.
• Dilate the stricture with a 5 mm balloon before attempting to install the left ventricular lead.
• No intervention is required.
Submit Answer
That is incorrect
• Reasoning
• References
This image demonstrates normal contractility of the coronary sinus. Your colleague may proceed with LV lead
implantation. Balloon dilatation is not necessary. Balloon-occluded venography can be performed safely, and will
provide more complete visualization of the venous anatomy. To obtain a stable position, it may be necessary to
position the balloon in the great cardiac vein. This would still provide complete visualization of the epicardial venous
system because of vein-to-vein collaterals.
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Key Point
Significant differences exist in the anatomy and electrophysiological properties between the coronary sinus and the
rest of the epicardial coronary venous system. The coronary sinus is a small, tubular contractile cardiac chamber with
valves and a conduction system. It contracts in synchrony with the atria and the contractions are absent in atrial
fibrillation.
Related Text
Click the title below to read text related to this question in the Cardiac Vascular Anatomy chapter/Coronary Venous
and Variant Anatomy module.
Terminology of Coronary Veins: Coronary Sinus
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Question 3 of 35
#2710
A 70-year-old man with longstanding diabetes and end-stage renal disease presents for catheterization in the setting
of a renal transplant evaluation. Coronary angiography is normal except for the image shown in Figure 1.
What is most appropriate next step in this patient's management?
• Cardiac computed tomography angiography.
• Coronary artery bypass or reimplantation surgery.
• No further evaluation is necessary.
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• Nuclear stress test.
• Percutaneous coronary intervention of culprit lesion.
Submit Answer
That is incorrect
• Reasoning
• References
The circumflex coronary artery typically arises from the left main artery at its bifurcation and courses posteriorly to
reach the left atrioventricular groove. Obtuse marginal arteries branch off the circumflex to supply the posterolateral
wall. The circumflex has a variable distribution over the posterior and inferior walls, supplying the myocardium not
supplied by the right coronary artery. In <1% of cases, the circumflex arises from the right sinus of Valsalva. It is the
most common anomalous coronary origin, and it is usually of no significance as the vessel courses posterior to the
aorta and is at low risk for compression.
Key Point
The LCX coronary artery normally arises from the left main artery at its bifurcation and courses posteriorly under the
left atrial appendage to reach the left atrioventricular (AV) groove, to give rise to one or more obtuse marginal
branches. It has a variable distribution over the posterior and inferior walls.
Related Text
Anomalies module.
Definitions
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Question 4 of 35
#2912
A frustrated electrophysiology colleague asks your advice for aid in cannulating a coronary sinus for elective cardiac
resynchronization therapy with defibrillator implantation.
Based on your extensive knowledge of cardiac venous anatomy, you tell the electrophysiologist the most likely
reason for this difficulty is which of the following?
• Severe ostial sinus stenosis.
• Severe angulation of the coronary sinus.
• Thebesian valve.
• Anomalous sinus from the inferior vena cava.
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• Dextrocardia.
Submit Answer
That is incorrect
• Reasoning
• References
The Thebesian valve is at the mouth of the coronary sinus; the valve of Vieussens is at the junction of the coronary
sinus and the great cardiac vein. Potential exists for the valve of Vieussens or the Thebesian valve to interfere with
cannulation of the coronary veins.
Key Point
The Thebesian valve is at the mouth of the CS. The valve of Vieussens is at the junction of the CS and the great
cardiac vein. Potential exists for the valve of Vieussens or the Thebesian valve to interfere with canulation of the
coronary veins.
Related Text
Two Valves of the Coronary Sinus
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Question 5 of 35
#2745
You are asked to see in consultation a 68-year-old man with metastatic non–small-cell lung cancer who has
developed facial and upper extremity swelling over the last few days. He also has a history of nonischemic
cardiomyopathy which has resolved with medical management. On physical examination, his face is swollen and
both external jugular veins are bulging without respiratory variation. The upper extremities are edematous with
prominent hand veins. The hand veins do not collapse when arms are elevated above the shoulder line. There is no
lower extremity peripheral edema. The patient does not wish to undergo chemotherapy, radiation, or surgical
treatment of his malignancy.
What would be the best next step in management for this case?
• Stenting of the superior vena cava.
• Initiate systemic anticoagulation followed by local thrombolytic administration.
• Surgical management with embolectomy and tumor debulking/resection.
• Refer him for home hospice.
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• Urgent radiation therapy to reduce tumor size.
Submit Answer
That is correct!
• Reasoning
• References
Superior vena cava (SVC) syndrome due to obstruction is most commonly seen as a complication from an advanced
malignancy. Classically, surgical treatment or radiation oncology treatment combined with chemotherapy have been
performed. All these treatments, in particular surgical, were associated with high morbidity and mortality and may
not relieve the obstruction in a timely fashion. Endovascular treatment with SVC stent placement affords quick and
consistent resolution of swelling and symptoms and has been shown to be associated with low rates of
complications, morbidity, and mortality. At this time, it is considered first-line treatment for SVC syndrome.
Anticoagulation and thrombolytics may be used but are associated with higher complication rates, bleeding, and less
consistent potency.
Key Point
SVC syndrome is characterized by dyspnea, facial swelling, cough, dysphagia, and airway obstruction. Stenting is an
effective treatment for malignant and nonmalignant SVC obstructions.
Related Text
Click the title below to read text related to this question in the Cardiac Vascular Anatomy chapter/Extracardiac
Anatomy module.
Thoracic Veins
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Question 6 of 35
#2913
You are asked to perform coronary sinus angiography to assess potential enrollment in a research study.
Which of the following is how this is best performed?
• Power injection with an angled pigtail within the coronary sinus.
• A woven endhole catheter.
• Balloon occlusion of the sinus ostium with retrograde distal injection.
• Right atrial injection with a pigtail catheter.
• Left-sided coronary angiography with levophase.
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Submit Answer
That is incorrect
• Reasoning
• References
Balloon-occlusion coronary sinus venography is used to image the cardiac veins.
Key Point
Balloon occlusive CS venography is used to image the cardiac veins.
Related Text
Visualization of Coronary Sinus: Retrograde Balloon Occlusive Coronary Venography
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Question 7 of 35
#2743
A 28-year-old African-American female with known sickle cell disease presents to the emergency department with
acute onset of chest pain and shortness of breath. You are seeing her at bedside, and her cardiac examination is
normal. Electrocardiography demonstrates sinus tachycardia, and the axis is normal. You notice a midline
sternotomy scar, and the patient reports that she had an atrial septal defect (ASD) repaired as a child. Urgent
bedside echocardiography is performed, and representative parasternal long-axis view is shown (Figure 1).
Which of the following is the best next step needed based on the abnormality seen on echocardiography?
• Perform a bubble study to evaluate the ASD and rule out late surgical dehiscence.
• Perform transesophageal echocardiography to better visualize the abnormality.
• Document the finding in your consultation note; however, no further treatment is required at this time.
• Perform emergent pulmonary angiography and consider ultrasound-enhanced thrombolysis.
• Obtain D-dimer and lower-extremity ultrasonography to determine need for anticoagulation.

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Submit Answer
That is incorrect
• Reasoning
• References
Persistent left superior vena cava is a common congenital thoracic abnormality. This embryologic remnant persists in
adulthood, and the left upper vena cava drains into the coronary sinus. The "right" superior vena cava drains
normally into the right atrium. In the adult population, the prevalence is around 0.3%, and it is more commonly seen
in association with other cardiac anomalies (e.g., ASD) and supraventricular cardiac arrhythmias.
The practical implications of this otherwise benign condition are with placement of pacemaker and implantable
cardioverter-defibrillator leads and hemodynamic monitoring (pulmonary artery catheter placement). While access
to the right heart can be successfully accomplished through left subclavian/left internal jugular approach, right-sided
approach has more favorable anatomy.
It is recommended to perform full formal echocardiography to rule out other concomitant congenital heart disease.
Key Point
A benign condition, a persistent left superior vena cava (SVC) can result in a markedly enlarged CS. It can be difficult
to implant pacemakers and achieve desirable placement of the left ventricular pacing leads with this anomaly. When
the left SVC atrophies, it is present as the vein or ligament of Marshall. A persistent left SVC or a vein of Marshall can
be a source of AF.
Related Text
Persistent Left Superior Vena Cava
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Question 8 of 35
#2918
A 28-year-old male comes to your office with complaints of fatigue, dyspnea, and chest pain with exertion. On the
cardiac exam, you hear a loud, continuous, superficial murmur at the lower mid-sternal border.
An echocardiogram was performed, showing an enlarged right atrium (RA) and right ventricle (RV). You suspect a
possible coronary fistula, and arrange for coronary angiography.
Based on historical data, which of the following statements is correct concerning coronary fistula?
• This anomaly rarely occurs in isolation.

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• The most common drainage site is the left atrium.
• The most likely coronary artery involved is the right coronary artery (RCA).
• Catheter closure should be performed only in highly selected cases.
• Fistulas usually require treatment in childhood.
Submit Answer
That is incorrect
• Reasoning
• References
The most popular site for drainage is the RV, RA, and then the pulmonary artery. The major origin sites are the RCA
(52%), the left anterior descending (30%), the left circumflex (18%), and on occasion, both coronaries. They are
usually asymptomatic in childhood, but large fistulas can lead to coronary steal, aneurysmal dilatation, and
embolization. This is usually an isolated anomaly.
There is no text related to this question.
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Question 9 of 35
#2914
A 60-year-old man with advanced coronary artery disease and a history of supraventricular tachycardia undergoes
coronary sinus angiography (Figure 1) as part of a stem cell study.
Which of the following statements is most accurate?
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• This is often associated with coarctation of the aorta.
• This is an incidental finding of undefined significance.
• A covered stent is indicated.
• Therapeutic anticoagulation is indicated.
• He is at risk for malignant rhythm abnormalities.
Submit Answer
That is incorrect
• Reasoning
• References
Diverticula of the coronary sinus are rare and can be associated with arrhythmias, including pre-excitation
syndromes and sudden cardiac death. There is no established endovascular treatment. Epicardial approaches,
including surgical ligation, may be necessary.
Key Point
Diverticula of the CS are associated with arrhythmias, including pre-excitation syndromes and sudden cardiac death.
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Related Text
Malformations of the Coronary Sinus and Association With Arrhythmias
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Question 10 of 35
#2911
A coronary sinus venogram is obtained as part of a stem cell research study (Figure 1).
The arrow is pointing to which of the following structures?
• Middle cardiac vein.
• Anterior interventricular vein.
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• Coronary sinus.
• Thebesian vein.
• Great cardiac vein.
Submit Answer
That is incorrect
• Reasoning
• References
In this balloon occlusion sinus venogram taken from the right anterior oblique view, this structure is the anterior
interventricular vein. It courses adjacent to the left anterior descending, and drains into the great cardiac vein and
then into the coronary sinus. The middle cardiac vein courses adjacent to the posterior interventricular septum. The
Thebesian veins are variable and located in many cardiac chambers.
Key Point
While CS anatomy is consistent, the anatomical course of the epicardial venous anatomy is often variable. The most
consistent veins are the anterior interventricular vein, coursing adjacent to the left anterior descending coronary
artery, and the middle cardiac vein that courses adjacent to the posterior descending artery. The other veins are
variable in size and location.
Related Text
Terminology of Coronary Veins: Branch Epicardial Veins
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Question 11 of 35
#2917
A 70-year-old patient is referred to you for chest pain and anteroseptal defect on nuclear stress imaging. He is
medically refractory, and you elect to take him to the cardiac catheterization laboratory. The coronary angiogram is
shown in Video 1.
Which of the following statements is correct regarding the diagnosis and treatment?
Figure 1
• Stenting is safe, and is associated with low rates of target lesion revascularization (TLR).
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• Surgery is of unlikely benefit in treatment of this disease.
• This condition is associated with significant atherosclerotic burden.
• Nitrates are first-line therapy for this condition.
• The preferred medical therapy includes beta-blockers and nondihydropyridine calcium channel blockers
(CCB).
Submit Answer
That is incorrect
• Reasoning
• References
Myocardial bridging can be debilitating, and the use of nitrates exacerbates symptoms due to its lowering of the
intraluminal pressure.
Beta-blockers and nondihydropyridine CCB are the preferred choices. Stenting of these lesions is associated with
increased late TLR and perforation. In patients with hypertrophic cardiomyopathy, there appears to be more
myocardial bridging present. Surgery is an option in patients with refractory ischemia, with optimum medical
therapy or associated sudden cardiac death.
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Question 12 of 35
#2714
A 45-year-old woman with a history of Raynaud's phemenenom presents for evaluation of substernal chest pain. The
pain occurs both on exertion and at rest, and is associated with shortness of breath and diaphoresis. She believes the
pain is worse at times of stress and when the weather is cold. Blood pressure, examination and electrocardiogram
(ECG) is normal, and a nuclear stress test demonstrates normal left ventricular (LV) function and normal perfusion.
Despite reassurance, the pain syndrome has continued, prompting multiple Emergency Room presentations. ECG's
obtained during times of pain have been unremarkable as has ambulatory monitoring. Catheterization demonstrates
normal coronary angiography.
What is the next best step in this patient's management?
• Ranolazine.
• Long-acting nitroglycerin.
• High-intensity statin therapy.
• Propanolol.
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• Intracoronary acetylcholine challenge.
Submit Answer
That is incorrect
• Reasoning
• References
The patient likely has vasospastic (Prinzemetal's) angina, and it is best evaluated provocatively by acetylcholine
challenge as all noninvasive tests have been negative to date. In this setting, provocative testing may be useful in
order to elicit spasm and make the definitive diagnosis. Nitroglycerin may be used for symptoms, but it will not alter
disease course. Ranolazine does not have a defined role in treatment. Statins may be of benefit, as may calcium
channel blockers. Nonselective beta-blockers should be avoided.
Key Point
Abnormal variations in autonomic vasomotor tone are frequent and may result in Prinzmetal’s angina, Syndrome X,
or Takotsubo cardiomyopathy. Acetylcholine testing is the best method to evaluate endothelial dysfunction.
Related Text
Anomalies module.
Coronary Artery Structure and Function
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Question 13 of 35
#2740
A 57-year-old woman underwent aortography after presenting with acute chest pain. The angiogram is shown in
Figure 1.
This patient’s anatomy is consistent with which one the following?
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• A right-sided aorta with an isolated left subclavian and left common carotid artery.
• Aberrant right subclavian artery.
• Aortic dissection.
• Truncus arteriosus.
• Bovine aortic arch.
Submit Answer
That is incorrect
• Reasoning
• References
The aorta gives rise to the three great vessels: the brachiocephalic, left common carotid, and left subclavian arteries.
Bovine arch is the most common variant of the aortic arch (approximately 15%; range 8-25%), and occurs when the
brachiocephalic (innominate) artery shares a common origin with the left common carotid artery. This common
variant is asymptomatic most of the time. In rare cases of head and neck surgery, for example, tracheostomy, it can
be a risk factor for injury and cause complications.
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Aberrant right subclavian arteries, also known as arteria lusoria, are the most common of the aortic arch anomalies.
The estimated incidence is 0.5-2%. They are often asymptomatic, but around 10% of people may complain of
tracheoesophageal symptoms, almost always as dysphagia, termed dysphagia lusoria. Instead of being the first
branch (with the right common carotid as the brachiocephalic artery), it arises on its own as the fourth branch, after
the left subclavian artery. It then hooks back to reach the right side. Its relationship to the esophagus is variable: 80%
posterior to the esophagus, 15% between the esophagus and trachea, and 5% anterior to the trachea.
Truncus arteriosus is a rare congenital anomaly in which a single blood vessel (truncus arteriosus) comes out of the
right and left ventricles, instead of the normal vessels (pulmonary artery and aorta).
A right-sided aorta with an isolated left subclavian and left common carotid artery is a rare anomaly. This patient’s
left common carotid artery clearly does not branch from the aorta.
This aorta is smooth walled without evidence of dissection.
Key Point
The aorta gives rise to the three great vessels: the brachiocephalic, left common carotid, and left subclavian arteries.
Related Text
Anatomy module.
Aortic Anatomy
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Question 14 of 35
#2919
A 55-year-old man is referred to you from one of your partners to revascularize a chronically total occluded (CTO)
right coronary artery (RCA). The patient has significant medically refractory symptoms of dyspnea on exertion and
chest pressure. Your partner has tried an anterograde approach, which was not successful. He would like you to
evaluate the angiogram.
Which of the following statements concerning CTO revascularization is correct?
• Hybrid algorithm to chronically total occluded (CTO) vessel treatment has increased CTO success rate from
50% to 70%.
• Bridging collaterals suggest a higher chance of success.
• Septal collaterals are the preferred route for retrograde access.
• The anterograde approach is preferred over the retrograde approach.
• Perforation of an epicardial collateral can be managed unidirectionally.
Submit Answer
That is incorrect
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• Reasoning
• References
The length and duration of the CTO vessel, along with severity of vessel calcium are predictors of CTO success.
The epicardial collaterals are not preferred approaches since perforations of these vessels will likely lead to severe
cardiac tamponade and other major complications. These frequently must be managed with bidirectional occlusion
of flow.
There has not been a randomized trial comparing the success rate of the antegrade versus retrograde approach in
CTO. In this particular patient in which an antegrade approach has failed, a retrograde approach may be more
anatomically favored depending on lesion characteristics. In experienced hands, upward of 90% success rate has
been achieved in selected CTO revascularization with a modern techniques and hybrid approaches.
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Question 15 of 35
#2910
A coronary sinus venogram is obtained as part of a research study.
Which of the following is true regarding the coronary sinus?
• Contraction of the coronary sinus persists in atrial fibrillation.
• The coronary sinus has independent contractile properties associated with electrical conduction.
• Contraction of the sinus on venography represents artifact from left circumflex motion.
• The coronary sinus is a stationary structure.
• Each of the cardiac veins demonstrates contraction associated with myocardial contraction.
Submit Answer
That is incorrect
• Reasoning
• References
Significant differences exist in the anatomy and electrophysiological properties between the coronary sinus and the
rest of the epicardial coronary venous system. The coronary sinus is a small, tubular contractile cardiac chamber with
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valves and a conduction system. It contracts in synchrony with the atria, and the contractions are absent in atrial
fibrillation.
Key Point
Significant differences exist in the anatomy and electrophysiologic properties between the coronary sinus (CS) and
the rest of the epicardial coronary venous system. The CS is a small, tubular contractile cardiac chamber with valves
and a conduction system. It contracts in synchrony with the atria, and the contractions are absent in AF.
Related Text
Terminology of Coronary Veins: Coronary Sinus
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Question 16 of 35
#2907
A 62-year-old male with no significant cardiac history presents to the emergency department with a 2-hour history
of left-sided chest pain that radiates to his neck and jaw. Associated symptoms include diaphoresis and nausea. His
pulse is 70, and blood pressure is 125/75 mg Hg. There are no signs of congestive heart failure on examination. An
electrocardiogram (ECG) is obtained, and the catheterization laboratory is alerted.
Expected findings on catheterization include which of the following?
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• Nonobstructive coronary artery disease.
• Proximal circumflex occlusion.
• Proximal right coronary artery occlusion.
• Mid left anterior descending occlusion.
• Severe multivessel coronary artery disease.
Submit Answer
That is incorrect
• Reasoning
• References
The injury pattern in this ECG suggests an occlusion of a dominant circumflex artery. Specifically, the inferior ST-
segment elevation is of similar height in both lead II and lead III, and there is no ST-segment depression in lead I. An
inferior ST-segment elevation myocardial infarction involving the right coronary artery often has ST-segment
elevation greater in lead III than in lead II, and there is reciprocal ST depression often noted. A distal "wrap-around"
left anterior descending (LAD) occlusion can manifest as isolated inferior ST-segment elevation, but a mid-LAD
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occlusion should have anterolateral ST-segment elevation as well. While the patient may have nonobstructive or
multivessel disease, the lack of Q waves elsewhere and localizing pattern of injury suggest circumflex occlusion.
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Question 17 of 35
#691
You are performing an oximetry run during a right- heart catheterization. While attempting to obtain a “high
superior vena cava (SVC)” blood sample, the catheter takes an unusual course, and angiograms are obtained (Figures
1a, b). The left panel is an anteroposterior projection, and the right panel is a left anterior oblique (right) projection.
Which of the following explains the angiogram shown?
• A normal azygos vein.
• Persistent left superior vena cava.
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• A hemiazygos vein.
• Anomalous pulmonary venous connection.
• A dilated internal mammary vein.
Submit Answer
That is correct!
• Reasoning
• References
This is the azygos vein. The left anterior oblique projection clearly demonstrates that it descends posteriorly, along
the spine. The azygos vein transports deoxygenated blood from the posterior walls of the thorax and abdomen into
the SVC vein. The anatomy of this blood vessel can be quite variable. In some rare variations, for example, it also
drains thoracic veins, bronchial veins, and even gonadal veins. The vein is so-named because it has no symmetrically
equivalent vein on the left side of the body. The hemiazygos vein receives blood from the lower half of the left
thoracic wall and the left abdominal wall, ascends along the left side of the spinal column, and empties into the
azygos vein near the middle of the thorax. The internal mammary vein is an anterior structure, located behind the
sternum. A persistent left SVC would enter the coronary sinus, which would occupy the lower right corner of these
images and drain into the right atrium from below.
Key Point
The azygos vein and the pericardiophrenic vein may be entered inadvertently during right-heart catheterization,
placement of central venous catheters, or insertion of pacing leads.
Related Text
Anatomy module.
Thoracic Veins
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Question 18 of 35
#2908
A 62-year-old female with longstanding diabetes and end-stage renal disease undergoes catheterization as part of a
preoperative evaluation for renal transplant. She has no significant obstructive disease, but was told she had an
unusual finding. She brings with her representative images that she was given. Two years later, following the
transplant, she returns with concerns about her long-term prognosis.
Which of the following is most consistent with the image in the figure?
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• This anomaly is associated with sudden cardiac death.
• This anomaly is best treated with surgical revascularization.
• This anomaly is benign.
• This anomaly is best assessed by fractional flow reserve.
• This anomaly is associated with accelerated atherosclerosis.
Submit Answer
That is incorrect
• Reasoning
• References
Congenital coronary artery anomalies in the absence of other cardiac congenital anomalies have been described in
approximately 1% of patients undergoing coronary angiography, and approximately 0.3% of patients at autopsy. An
anomalous left circumflex off the right coronary cusp generally courses posterior, and it is not associated with
increased cardiovascular events.
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Question 19 of 35
#2746
Your patient in the cardiac catheterization laboratory has an anterior ST-segment elevation myocardial infarction
(STEMI), and you plan to perform primary percutaneous coronary intervention. You have just successfully obtained
right radial access with a 6 Fr sheath. After multiple attempts, the J-wire cannot advance past the level of the elbow.
The most likely explanation is which of the following?
• Radial artery occlusion from previous radial access.
• Brachial artery occlusion.
• High radial artery bifurcation.
• Radial artery loops.
• Radial artery spasm.
Submit Answer
That is incorrect
• Reasoning
• References
Radial arterial access has been associated with lower mortality in patients with STEMI. Radial artery anomalies are
relatively common, but can be negotiated with skill and knowledge.
The patient most likely has a radial loop that can, in most cases, be negotiated with hydrophobic and coronary 0.014
inch wires. Radial artery occlusion most commonly occurs at the site of access, and is unlikely to be diagnosed after
successful insertion of a radial artery sheath.
Brachial artery occlusion is extremely rare. A high radial artery take-off would cause issues in the upper arm, and is
rarely associated with difficulty with wire passage.
Key Point
Radial loops, high radial bifurcations, and accessory radial arteries occur in up to 10% of patients and complicate
transradial access.
Related Text
Anatomy module.
Vascular Access: Radial Arterial Anatomy

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Question 20 of 35
#2731
A 60-year-old man is referred for catheterization in the setting of angina and an abnormal stress test. Catheterization
is shown in Figure 1.
Which of the following is most appropriate?
• The left main coronary artery (LMCA) has an anomalous takeoff from the right sinus.
• The circumflex has an anomalous takeoff from the right coronary sinus.
• The left main coronary artery (LMCA) is absent with dual coronary ostia in the left sinus.
• The left anterior descending (LAD) has an anomalous takeoff from the right coronary sinus.
• The right coronary artery has an anomalous takeoff from the left sinus.
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Submit Answer
That is incorrect
• Reasoning
• References
In this case, there is no LMCA and the LAD and circumflex arteries have dual ostia (Figure 2). Although not
necessarily an anomaly, it is a common variation of normal coronary anatomy. The other answers are incorrect as
the arteries originate from their respective cusps.
(Figure 2)
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Question 21 of 35
#2915
A 47-year-old male with Wolff-Parkinson-White syndrome undergoing radiofrequency ablation for supraventricular
tachycardia develops inferior ST-segment elevation during the procedure. Pulse remains regular and stable, but
blood pressure drops to 100/60 mm Hg from 130/80 mm Hg. Emergent catheterization is performed, and is
significant for an occluded circumflex (Figure 1).
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Which of the following is the most likely cause of this lesion?
• Coronary plaque rupture and thrombus.
• Spontaneous coronary dissection.
• Thermal injury from coronary sinus ablation.
• Coronary vasospasm.
• Coronary embolization from left atrial thrombus.
Submit Answer
That is incorrect
• Reasoning
• References
The coronary sinus courses through the posterior interventricular groove adjacent to the left circumflex vessel. The
sinus is increasingly used as a conduit for drug and/or device delivery during invasive cardiovascular therapeutics,
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including radiofrequency ablation. Care should be taken to avoid and recognize local complications, including
compromise of the circumflex.
Key Point
The coronary venous system is a potential route for delivering drugs, growth factors, stem cells, and genes to the
myocardium. It is also a structure that may be used for achieving percutaneous alterations of mitral valve geometry
as part of therapy for mitral regurgitation.
Related Text
Coronary Venous System for Novel Therapies
Submit and Exit
Question 22 of 35
#2737
A 76-year-old male with history of hypertension and alcohol abuse presents for catheterization in the setting of chest
pain and elevated biomarkers. His left coronary system is free of significant disease, and a representative image of
the right coronary artery is shown in Figure 1.
Which of the following is the most appropriate next step in management?
29
• Percutaneous revascularization with drug-eluting stents.
• Percutaneous revascularization with bare-metal stents.
• Coronary artery bypass surgery.
• Medical therapy, including antithrombotic therapy.
• Catheter-directed thrombolytic therapy.
Submit Answer
That is incorrect
• Reasoning
• References
Coronary artery ectasia/aneurysm may occur in congenital disease, Kawasaki's disease, or as a manifestation of
atherosclerosis (often in the absence of occlusive stenosis). Aneurysmal disease has been associated with myocardial
infarction, presumably secondary to in situ thrombosis and/or embolism. In this case, there is no definitive occlusive
disease, so percutaneous or surgical revascularization is not necessary. Catheter-directed thrombolytics have not
been evaluated for this indication. Medical therapy is most appropriate, while the optimal antithrombotic therapy in
this condition is not established.
30
Key Point
Coronary artery aneurysms can be congenital (rare) or acquired from atherosclerosis or Kawasaki disease (most
frequently).
Related Text
Anomalies module.
Definitions
Submit and Exit
Question 23 of 35
#2744
You are seeing a 68-year-old female with angina and a high-risk stress test, and you are discussing risks and benefits
of coronary angiography. A prior computed tomography of the chest has revealed a bovine arch.
Which of the following is the most appropriate arterial access site regarding risk of stroke?
31
32
• Left radial access has a lower rate of stroke compared with right radial access.
• Vertebral artery distribution strokes are less common with radial access compared with femoral access.
• Right radial access and bovine arch are associated with the highest rate of procedure-related stroke.
• There is no difference in stroke rates between radial and femoral approach.
• Femoral access would be preferred given the presence of a bovine arch.
Submit Answer
That is incorrect
• Reasoning
• References
One of the most widely used misnomers in the medical literature is that of the “bovine aortic arch” in humans. This
term refers to a common anatomic configuration of the aortic arch. The bovine aortic arch in humans would
presumably resemble the aortic arch branching pattern found in the family of ruminant animals, including cattle and
buffalo. However, the bovine aortic arch configuration ascribed to the most common human aortic arch variants
bears no resemblance to the aortic arch branching pattern found in cattle. In cattle, a single great vessel originates
from the aortic arch. This large brachiocephalic trunk gives rise to both subclavian arteries and a bicarotid trunk.
Radial access-site utilization for cardiac catheterization is not associated with an increased risk of stroke events.
There is no evidence that aortic arch anatomy variants correlate with stroke risk, or that one access site should be
preferred over another. These data provide reassurance, and should remove another potential barrier to conversion
to a “default” radial practice among those who are currently predominantly femoral operators.
Key Point
The left common carotid artery can arise from the brachiocephalic artery in a variant sometimes misnamed a
“bovine arch.”
Related Text
Anatomy module.
Aortic Anatomy
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Question 25 of 35
#2742
A 63-year-old man was taken to the catheterization laboratory after presenting with exertional angina, and having a
positive nuclear stress test finding of anterior ischemia. The operator chose to use the femoral artery approach.
33
Which of the following is true about the femoral arterial approach to cardiac catheterization?
• In patients with a high bifurcation, it is reasonable to obtain access above the inguinal ligament.
• A safe access zone for common femoral artery is well defined by fluoroscopy of the femoral head.
• The groin crease is a reliable marker to determine the correct entry site for femoral artery approach.
• Ultrasound guidance lowers the risk of access above the inguinal ligament.
• Access above the inguinal ligament is associated with a high risk of retroperitoneal bleeding.
Submit Answer
That is incorrect
• Reasoning
• References
The femoral artery crosses the inguinal ligament at approximately its mid point. Use of the bony landmarks of the
iliac crest and the symphysis pubis help to define the path of the inguinal ligament. Although the inguinal (groin) skin
crease is usually where the inguinal ligament and femoral artery should be, in some obese patients, there may be
several skin folds below and above the presumed line of the inguinal ligament, making it at times impossible to
locate the access site correctly. The target for femoral puncture is the mid point of the common femoral artery,
defined as the segment between the inferior epigastric artery and the bifurcation of the superficial and profunda
branches, and is usually at the level of the center of the femoral head.
Key Point
The common femoral artery is bounded superiorly by the inguinal ligament, and inferiorly by its bifurcation into the
superficial femoral and profunda femoral arteries.
Related Text
Anatomy module.
Vascular Access: Femoral Arterial Anatomy
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Question 26 of 35
#750
A 35-year-old woman with a history of migraine headaches and transient extremity weakness was referred for
evaluation of a possible patent foramen ovale (PFO). During exploration of the fossa ovalis, the catheter position
shown in Figure 1 was obtained.
34
Which of the following is the most likely explanation for this catheter position and the oxygen saturation obtained
from the catheter in this location?
• The catheter has crossed the patent foramen ovale and entered a left superior pulmonary vein; the
saturation expected would be 99%.
• The catheter has crossed the patent foramen ovale and entered a left superior pulmonary vein; the
saturation expected would be 56%.
• The catheter has entered the coronary sinus; the saturation expected would be 56%.
• The catheter has entered the hemiazygos vein; the saturation expected would be 56%.
• The catheter has passed through the right ventricle into the pulmonary artery, and has crossed into the
aorta via a patent ductus, and the tip is in the aorta; the saturation expected would be 95%.
Submit Answer
That is incorrect
• Reasoning
• References
35
The catheter has entered a persistent left superior vena cava (PLSVC) by way of the coronary sinus. Normally, it
would be unusual to inadvertently enter the coronary sinus during a right-heart catheterization procedure from the
femoral vein. However, with the marked enlargement of the coronary sinus associated with PLSVC, a catheter may
enter the coronary sinus more readily than the right ventricle. This PLSVC might have been suspected from the
echocardiographic studies, where a dilated coronary sinus would have been expected. The diagnosis could have
been confirmed by advancing the catheter into the subclavian and internal jugular veins, or by injecting contrast.
Oximetry samples from the PLSVC would indicate normal venous blood.
Submit and Exit
Question 27 of 35
#2747
Your patient in the cardiac catheterization laboratory has a non–ST-segment elevation myocardial infarction, and
you plan to perform angiography/ad hoc percutaneous coronary intervention. The patient has a functioning left
upper extremity arteriovenous fistula for hemodialysis. The right subclavian artery is known to be occluded. You plan
to obtain femoral access.
Which of the following is the most important consideration when obtaining femoral access?
• Ultrasound guidance delays time to common femoral artery access.
• High femoral artery bifurcation occurs more often in thin females.
• Ultrasound guidance improves common femoral artery cannulation only in patients with high common
femoral artery bifurcations.
• Ultrasound guidance for femoral access reduces the number of "high sticks."
• The common femoral artery bifurcation occurs above the middle one-third of the femoral head in 95% of
patients.
Submit Answer
That is incorrect
• Reasoning
• References
The common femoral artery (CFA) bifurcation occurs below the middle one-third of the femoral head in 95% of
patients. No patient factors are predictive of a high bifurcation. Ultrasound guidance improves CFA cannulation only
in patients with high CFA bifurcations; however, not in other anatomic variants. Contrary to general belief, the
number of high sticks is not reduced by ultrasound guidance. Ultrasound guidance, in fact, reduces time to femoral
artery access.
Key Point
The common femoral artery has a moderately consistent relationship with the femoral head, with 66% of
36
bifurcations occurring inferior to the femoral head and 95% below the center of the femoral head.
Related Text
Anatomy module.
Vascular Access: Femoral Arterial Anatomy
Submit and Exit
Question 28 of 35
#2741
A 65-year-old man underwent cardiac catheterization after presenting with exertional angina. He has no neurologic
symptoms. Prior to the procedure, it was noted that the arterial blood pressure differed between both arms. The
patient was found to have multivessel disease, and was referred for coronary artery bypass grafting (CABG). At the
time of his catheterization, the cardiologist performed arteriography shown in Figure 1.
Which of the following statements is most accurate about the findings on arteriography?
37
• Fifty percent of patients with this lesion will have concomitant coronary artery disease.
• Routine subclavian arteriography in patients being considered for coronary artery bypass grafting.
• Subclavian arteriography is indicated when the brachial artery cuff pressure differs >30 mm Hg between
both arms.
• The lesion is four times more common on the right side than the left side.
• The patient has a severe left carotid artery stenosis.
Submit Answer
That is correct!
• Reasoning
• References
This patient has a left subclavian artery stenosis. The incidence of subclavian stenosis in the general population
ranges from 3% to 4%, and can be as high as 11-18% in patients with documented peripheral artery disease. It is
estimated that 50% of patients with stenosis of the brachiocephalic arteries will have concomitant coronary artery
disease.
38
Current guidelines do not recommend subclavian arteriography routinely at the time of catheterization in patients
being considered for CABG. Left subclavian artery stenosis is four times more common than right subclavian
stenosis.
Those scheduled to undergo CABG with internal mammary artery grafting should have screening subclavian
angiography when a >10 mm Hg bilateral arm blood pressure differential is found, if they have a history of radiation
therapy to the chest, a history of vasculitis, or if they have known peripheral artery disease (including those who are
asymptomatic with angiographic aortic or iliofemoral atheromatous disease found incidentally during initial coronary
angiography.
Key Point
Subclavian stenosis occurs in only 5% of asymptomatic patients undergoing coronary angiography for coronary
artery bypass graft (CABG).
Related Text
Anatomy module.
Aortic Anatomy
Submit and Exit
Question 29 of 35
#3020
A 75-year-old male with hypertension, coronary artery disease, and symptomatic drug refractory paroxysmal atrial
fibrillation (AF) who underwent radiofrequency ablation 4 months earlier presents with progressive fatigue, dyspnea,
and hemoptysis. The patient is in sinus rhythm. Chest X-ray demonstrates pulmonary congestion.
Which of the following is the most appropriate next step in management?
• Right- and left-heart catheterization.
• Nuclear stress test.
• Transthoracic echocardiogram.
• Chest computed tomography (CT) angiography.
• Cardiac event monitor.
Submit Answer
That is incorrect
• Reasoning
• References
39
This patient most likely has pulmonary vein stenosis as a complication of AF ablation. AF usually originates in the
pulmonary veins, and pulmonary vein isolation is the cornerstone of ablation therapy. The procedure previously
involved individual isolation of the pulmonary vein ostium, and pulmonary vein stenosis occurred in almost one-third
of patients. With refined techniques involving wide circumferential ablation, the injury to the pulmonary vein ostia is
considerably less, and the incidence of significant stenosis is <1% in current series. The complication can still occur,
and typical presentation is about 4 months following ablation with symptoms of fatigue, dyspnea, and hemoptysis.
Diagnosis is best made by CT or magnetic resonance imaging. Treatment includes pulmonary vein angioplasty.
Key Point
The pulmonary veins (PVs) drain oxygenated blood into the left atrium (LA). Sleeves of myocardium extend into the
PVs and can be a source of triggers for AF. Electrically isolating the PVs from the LA is the cornerstone of AF ablation.
Related Text
Pulmonary Veins
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Question 30 of 35
#2909
A 55-year-old male with history of hypertension and diet-controlled diabetes presents to the emergency department
(ED) with an acute onset of substernal, nonexertional, and nonradiating pain that woke him up from sleep. It had
largely resolved by the time he arrived at the ED. Vitals and examination are unremarkable. Electrocardiogram (ECG)
and cardiac biomarkers are negative. A computed tomography angiography is performed, with a representative
image shown Figure 1.
Which of the following is the most appropriate next step?
40
• Beta-blocker.
• No further management.
• Exercise stress testing.
• Surgical revascularization.
• Cardiac catheterization.
Submit Answer
That is incorrect
• Reasoning
• References
The patient has an anomalous circumflex off the right cusp. The circumflex courses posterior to reach the posterior
atrioventricular groove. This is the most common anomaly of coronary arterial origin in adults, with an incidence of
about 0.3% when assessed by coronary angiography or autopsy, and it is benign. No further management is
necessary.
41
Submit and Exit
Question 31 of 35
#2709
A 56-year-old man presents to a non-percutaneous coronary intervention (PCI) facility with chest pain and inferior
ST-segment elevation on electrocardiogram (ECG). He is hemodynamically stable. Due to weather considerations,
transfer for primary PCI is not possible. The patient is treated with thrombolytics, unfractionated heparin, aspirin and
clopidogrel with resolution of ST-segment elevation. He is subsequently transferred in stable condition for further
management. The following morning, he develops acute onset of shortness of breath. Examination is significant for
bilateral rales and a holosystolic murmur heard best at the apex with no thrill. ECG is unchanged.
What is the most likely diagnosis?
• Apical ventricular septal rupture.
• Acute systolic dysfunction.
• Ventricular free wall rupture.
• Papillary muscle rupture.
• Left ventricular outflow tract obstruction.
Submit Answer
That is incorrect
• Reasoning
• References
The findings in this case most likely represent papillary muscle rupture and acute mitral regurgitation. The
posteromedial papillary muscle has a single blood supply from the dominant vessel (usually the right coronary
artery; RCA). The anterolateral papillary muscle generally has a dual blood supply and is less likely to rupture
following myocardial infarction. Septal rupture may occur following RCA occlusion, but such rupture is located in the
basal septum. The findings and acute murmur are not consistent with free wall rupture, acute systolic dysfunction or
left ventricular outflow tract obstruction.
Key Point
The dominant coronary artery is the one from which the posterior descending coronary artery arises. The RCA is the
dominant artery in 85- 90% of patients.
Related Text
Anomalies module.
Definitions
42
Submit and Exit
Question 32 of 35
#2739
A 52-year-old woman underwent atrial fibrillation (AF) ablation. Three months later, the patient presented with
cough and hemoptysis. A chest X-ray showed pneumonitis. Computed tomography (CT) suggested possible right
superior pulmonary vein stenosis (PVS).
Which of the following is true about PVS developing after AF ablation?
• Catheter-based interventions can effectively provide symptomatic relief.
• The rate of PVS has remained constant over time.
• The most widely used imaging tool to diagnose PVS is magnetic resonance imaging (MRI).
• Routine surveillance is not indicated after successful catheter-based intervention, as restenosis is rare given
the size of the vessel.
• Antithrombotic therapy with antiplatelet agents will prevent progression of disease.
Submit Answer
That is correct!
• Reasoning
• References
The prevalence of PVS is approximately 1.3%. This has been attributed to abandoning ablation within the PV, the use
of lower-power ablation and intracardiac ultrasound guidance, and image enhancements including CT or MRI for
more accurate delineation of the relevant anatomy for ablation. Patients are maintained on full-dose warfarin to
achieve an international normalized ratio of 2-3 because pulmonary arterial thrombosis in the distribution of the
affected PV has been documented. Catheter-based therapies have been successful in some patients, but recurrence
is frequent.
Key Point
Pulmonary vein stenosis can develop in <1% of patients after ablation for AF. Catheter-based interventions can
provide relief.
Related Text
Pulmonary Vein Stenosis as a Consequence of Atrial Fibrillation Ablation
43
Submit and Exit
Question 33 of 35
#2906
A 57-year-old diabetic female presents for catheterization in the setting of new-onset crescendo angina. Coronary
angiography demonstrates an intermediate lesion in the mid left anterior descending. The left circumflex and right
coronary artery are free of significant disease. Fractional flow reserve (FFR) is performed, and the lesion is found to
be nonphysiologically significant with a value of 0.85. Treatment is deferred, and medical management is
recommended.
The mechanism underlying FFR is best descibed as which of the following?
• Endothelium-independent vasodilation at the arteriolar level.
• Postcapillary cardiac venous dilation.
• Combined endothelium-dependent and independent epicardial and capillary vasodilation.
• Cardiac barorecpetor inhibition.
• Endothelium-dependent vasodilation at the epicardial level.
Submit Answer
That is correct!
• Reasoning
• References
Coronary flow is regulated at the arteriolar level. The hyperemic effect that allows for measurement of FFR occurs at
the arteriolar level via endothelium-independent vasodilation.
Submit and Exit
Question 34 of 35
#2916
A 30-year-old woman comes to your office as a referral. She has been having some exertional chest pain; most
recently, she was in the emergency department at the local hospital, and as part of her workup for chest pain, a rule-
out pulmonary embolism (PE) protocol was initiated. She carries with her a report from a contrast chest computed
44
tomography, which showed no PE and coronary arteries without obstruction. A representative image is seen in
Figure 1.
Which of the following statements is most consistent with the image?
• Initiate medical therapy with beta-blockers, nitrates, and/or calcium channel blocker.
• Refer for cardiac magnetic resonance imaging.
• Refer for surgical revascularization.
• Refer for stress testing.
• No further management is necessary.
Submit Answer
That is incorrect
• Reasoning
• References
45
Surgical intervention is recommended in symptomatic patients with anomalous aortic origin of the coronary artery,
particularly when the left coronary originates from the right coronary cusp. Both the acute angle of the origin of the
coronary and its course between the pulmonary artery and aorta predispose these patients to ischemia and sudden
cardiac death. The other imaging strategy would not add value in this case.
Submit and Exit
Question 35 of 35
#2735
A 65-year-old diabetic male is referred for catheterization in the setting of typical angina and a high-risk stress test
demonstrating a severe and reversible anterior perfusion defect. Coronary angiography demonstrated severe calcific
disease of the proximal left anterior descending artery. The patient underwent successful rotational atherectomy
and drug-eluting stent implantation with preserved TIMI III flow.
Which of the following most appropriately describes coronary microcirculation in this patient?
• Angiographic coronary no-reflow occurs from microembolization, and is common following atherectomy.
• The microparticles generated by rotational atherectomy are small enough to pass through the coronary
capillary bed without causing obstruction.
• Distal embolic protection should be considered as an adjunct to rotational atherectomy.
• The coronary capillaries are <20 microns in diameter in the absence of vasodilator therapy.
• Endothelium-dependent vasodilators are the primary therapy for no-reflow.
Submit Answer
That is incorrect
• Reasoning
• References
The coronary capillary bed is approximately 30-40 microns in diameter. As a white blood cell is about 25 microns in
diameter, this allows for passage of such cells without obstruction. Distal embolization is one mechanism
contributing to no-reflow, and is best managed by prevention (optimal techniques) and the use of an endothelium-
independent vasodilator (verapamil, nitroprusside, adenosine, nicardiopine), when present. With rotational
atherectomy, there is the potential for microembolization, but the particles generated are typically <10 microns.
When preformed correctly, atherectomy should not lead to no-flow. Distal embolic protection generally does not
protect embolization of particles <40 microns, and it has not been shown to be of benefit in native coronary arteries
for any indication.
Key Point
Coronary arteries normally end into the capillary segment of the circulation that lacks smooth muscular media.
46
These vessels normally have diameters of about 20-50 mcm.
Related Text
Anomalies module.
Coronary Collateral Branches
47

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Anatomy, Anatomic Variants, Anatomic

Anatomy, Anatomic Variants, Anatomic Pathology

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What is the diagnosis?

• Left ventricular (LV) pseudoaneurysm.

• Ventricular septal rupture.

• Papillary muscle rupture.

76% of peers answered this correctly

• Related Text / Key Point

Anatomy, Anatomic Variants, Anatomic Pathology

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Which of the following is the best course of action at this point?

• Place a coronary sinus stent at the site of the narrowing.

• Refer the patient for epicardial lead placement.

53% of peers answered this correctly

• Related Text / Key Point

Terminology of Coronary Veins: Coronary Sinus

Anatomy, Anatomic Variants, Anatomic Pathology

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What is most appropriate next step in this patient's management?

• Cardiac computed tomography angiography.

• Coronary artery bypass or reimplantation surgery.

• No further evaluation is necessary.

• Percutaneous coronary intervention of culprit lesion.

65% of peers answered this correctly

• Related Text / Key Point

Anatomy, Anatomic Variants, Anatomic Pathology

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• Severe ostial sinus stenosis.

• Severe angulation of the coronary sinus.

• Anomalous sinus from the inferior vena cava.

53% of peers answered this correctly

• Related Text / Key Point

Two Valves of the Coronary Sinus

Anatomy, Anatomic Variants, Anatomic Pathology

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• Stenting of the superior vena cava.

• Initiate systemic anticoagulation followed by local thrombolytic administration.

• Surgical management with embolectomy and tumor debulking/resection.

• Refer him for home hospice.

58% of peers answered this correctly

• Related Text / Key Point

Anatomy, Anatomic Variants, Anatomic Pathology

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Which of the following is how this is best performed?

• Power injection with an angled pigtail within the coronary sinus.

• A woven endhole catheter.

• Balloon occlusion of the sinus ostium with retrograde distal injection.

• Right atrial injection with a pigtail catheter.

• Left-sided coronary angiography with levophase.

62% of peers answered this correctly

• Related Text / Key Point

Balloon-occlusion coronary sinus venography is used to image the cardiac veins.

Visualization of Coronary Sinus: Retrograde Balloon Occlusive Coronary Venography

Anatomy, Anatomic Variants, Anatomic Pathology

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• Perform transesophageal echocardiography to better visualize the abnormality.

• Perform emergent pulmonary angiography and consider ultrasound-enhanced thrombolysis.

• Obtain D-dimer and lower-extremity ultrasonography to determine need for anticoagulation.

42% of peers answered this correctly