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 ---
 title: "Aortic Sarcomas"
 docid: "773f978e-3e39-4f1f-9e1e-13d587c11c74"
 authors:
  - key: "b00d2bdb-66e1-41ed-90b4-c52904f4d598"
    value: "Seth Kligerman, MD, MS"
 breadcrumbs:
  -
    name: "Cardiac"
    slug: "cardiac"
    treeNodeId: "860c1cc6-9bd0-44e4-bd29-ed34fc8beebf"
  -
    name: "Diagnosis"
    slug: "diagnosis"
    treeNodeId: "5a1a870b-9c08-4b31-b188-eec7c1676c0a"
  -
    name: "Cardiac Neoplasms"
    slug: "cardiac-neoplasms"
    treeNodeId: "e4570e75-477e-421d-88e4-7820c38b9cff"
  -
    name: "Aortic Sarcomas"
    slug: "aortic-sarcomas"
    treeNodeId: null
 category: "Cardiac"
 documentVersionId: "e27053dd-044b-48f6-b0eb-1399762ddee5"
 imageCount: 4
 lastUpdated: "12/19/24"
 pageDescription: "Aortic Sarcomas"
 pageKeywords: "Cardiac, Diagnosis, Cardiac Neoplasms, Aortic Sarcomas"
 pageTitle: "Aortic Sarcomas | STATdx"
 enhancedTitle: "Aortic Sarcomas"
 type: "DX"
 references: true
 breadcrumbs:
  - "Cardiac"
  - "Diagnosis"
  - "Cardiac Neoplasms"
  - "Aortic Sarcomas"
 ---
 ## KEY FACTS
 - ### Terminology
    - Primary sarcoma arising from intima of aorta
 - ### Imaging
    - Dominant polyploid mass leading to narrowing of aorta
    - Soft tissue may extend beyond aortic wall
    - Proximal and distal to dominant mass, variable degree of irregular aortic wall thickening
    - Areas of intimal thickening can be noncontiguous from dominant mass
    - Tumor extends pathologically beyond where it can be visualized due to intimal spread
    - Enhancement with CT often absent or minimal
    - Enhancement often subtle but present with MR
    - Often limited atherosclerotic disease elsewhere in aorta
    - FDG PET imaging will show noncontiguous uptake along tumor that is often mild
 - ### Top Differential Diagnoses
    - Complex atheroma with mural thrombus
    - Vasculitis
    - Acute aortic syndrome
 - ### Pathology
    - Polyploid endoluminal masses arising from intima but eventually grow into media and adventitia
    - Malignant epithelioid cells extending over thrombus composed of fibrin, tumor, and areas of necrosis
          - Reason for mild uptake on FDG PET
    - Very limited vascularity in mass
          - Reason for little enhancement on CT and MR
 - ### Clinical Issues
    - Embolization of tumor into systemic arteries leading to claudication, abdominal pain, flank pain, etc.
    - ~ 1/2 patients have metastases at time of diagnosis
    - Very poor prognosis, even in absence of metastatic disease
 ## TERMINOLOGY
 - ### Abbreviations
    - Aortic intimal sarcoma (AIS)
 - ### Definitions
    - Primary sarcoma arising from intima of aorta
 ## IMAGING
 - ### General Features
    - #### Best diagnostic clue
          - Irregular polyploid mass in aorta, often in absence of significant atherosclerotic disease
          - Irregular intimal thickening extending proximal and distal to mass
          - Evidence of systemic embolization
    - #### Location
          - Thoracic aorta in 46% of patients
          - Abdominal aorta in 42% of patients
          - Both thoracic and abdominal aorta in 12% of patients
    - #### Size
          - Usually large
    - #### Morphology
          - Variable along course of tumor as described below
 - ### Radiographic Findings
    - Not visible on radiography
    - Pulmonary metastases may be present
 - ### CT Findings
    - Variable CT appearances of AIS along entire tumor
    - Dominant polyploid mass leading to narrowing of aorta
    - Soft tissue may extend beyond aortic wall
    - Variable degree of irregular aortic wall thickening proximal and distal to dominant mass
          - Circumferential or focal thickening
          - Smooth in some areas and irregular/nodular in others
    - Areas of intimal thickening may be discontinuous from dominant mass
    - Enhancement often absent or minimal
    - Often limited atherosclerotic disease elsewhere in aorta
    - Aneurysmal dilation of aorta in region of AIS can occur
    - Metastases may be present
 - ### MR Findings
    - Similar morphology to CT findings
    - Better assessment of possible spread of tumor along aortic wall and outside wall
    - Often mild postcontrast enhancement
 - ### Nuclear Medicine Findings
    - #### PET/CT
          - FDG PET imaging will show noncontiguous uptake along tumor that is often mild; most of tumor is actually fibrin clot
 - ### Imaging Recommendations
    - #### Best imaging tool
          - Initial study is often CTA due to nonspecific symptoms
                  - Given very characteristic AIS morphology, diagnosis can be made by CT alone
                            - However, in one pathology series of 26 cases, AIS was not suspected clinically before surgery
          - PET is best 2nd study to help confirm primary tumor and assess for metastases
          - MR can help confirm diagnosis
 ## DIFFERENTIAL DIAGNOSIS
 - ### Complex Atheroma With Mural Thrombus
    - Diffuse atherosclerosis usually absent in AIS
 - ### Vasculitis
    - Circumferential, enhancing wall thickening without mass
 - [Acute Aortic Syndrome](/document/acute-aortic-syndromes/ef1650b4-fa0d-4031-9cc2-d2852664b401)
    - Large endoluminal mass not seen with acute aortic syndrome
 ## PATHOLOGY
 - ### Gross Pathologic & Surgical Features
    - Polyploid endoluminal masses arising from intima but eventually grow into media and adventitia
    - Contiguous spread of tumor along intima distal to dominant mass
 - ### Microscopic Features
    - Undifferentiated tumors are most common
          - Malignant epithelioid cells extending over thrombus composed of fibrin, tumor, and areas of necrosis
          - Very limited vascularity in mass
    - Myxoid variant is less common
    - Intimal spread of tumor may pathologically extend beyond where it can be visualized on imaging
    - 10% show osteosarcomatous differentiation
 ## CLINICAL ISSUES
 - ### Presentation
    - #### Most common signs/symptoms
          - Nonspecific pain
          - Hypertension
          - Embolization of tumor into systemic arteries leading to claudication, abdominal pain, flank pain, etc.
 - ### Demographics
    - Average age: 60 years; M > F
 - ### Natural History & Prognosis
    - ~ 1/2 patients have metastases at time of diagnosis
    - Very poor prognosis, even in absence of metastatic disease
 - ### Treatment
    - Surgical resection attempted if possible
          - If entire tumor is removed, long-term survival possible
                  - However, this is rarely achieved
    - Chemotherapy, palliative surgery, and radiation
          - Survival still poor
 ## DIAGNOSTIC CHECKLIST
 - ### Consider
    - AIS in setting of irregular polyploid mass in descending thoracic aorta or abdominal aorta, especially when there is little or no atherosclerotic disease
 4b5b516a-bfde-43f6-a587-cce74b9bcae9
 ## References
 ## Selected References
 1. [Ropp AM et al: Intimal sarcoma of the great vessels. Radiographics. 41(2):361-79, 2021](http://www.ncbi.nlm.nih.gov/pubmed/?term=33646906%5Bpmid%5D)
 1. [Rusthoven CG et al: Sarcomas of the aorta: a systematic review and pooled analysis of published reports. Ann Vasc Surg. 28(2):515-25, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=24485779%5Bpmid%5D)
 1. [Staats P et al: Intimal sarcomas of the aorta and iliofemoral arteries: a clinicopathological study of 26 cases. Pathology. 46(7):596-603, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25393249%5Bpmid%5D)
 1. [Fatima J et al: Primary angiosarcoma of the aorta, great vessels, and the heart. J Vasc Surg. 57(3):756-64, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23312835%5Bpmid%5D)
 ## Images
 ### Selected Images
 ![Axial CTs through the proximal (left), mid (center), and distal (right) descending thoracic aorta (DTA) in a 58-year-old man with intermittent chest pain shows an irregular filling defect <img src='img/arrows/CS.png' alt='cyan solid arrow'/> with diffuse wall thickening proximally, a polyploid mass in the mid-DTA, and shaggy contours in distal DTA.](images/app.statdx.com_image_thumbnail_0c120eba-b4d2-405b-a71b-faba3aaef6dd_annotated_true_size_900_quality_90_3cbd1ec040356c4c58a10310b276833dbc4417e5.jpg)
 *Axial CTs through the proximal (left), mid (center), and distal (right) descending thoracic aorta (DTA) in a 58-year-old man with intermittent chest pain shows an irregular filling defect <img src='img/arrows/CS.png' alt='cyan solid arrow'/> with diffuse wall thickening proximally, a polyploid mass in the mid-DTA, and shaggy contours in distal DTA.*
 ![Axial CTs through the proximal (left), mid (center), and distal (right) descending thoracic aorta (DTA) in a 58-year-old man with intermittent chest pain shows an irregular filling defect <img src='img/arrows/CS.png' alt='cyan solid arrow'/> with diffuse wall thickening proximally, a polyploid mass in the mid-DTA, and shaggy contours in distal DTA.](images/app.statdx.com_image_thumbnail_0c120eba-b4d2-405b-a71b-faba3aaef6dd_size_174_quality_85_9e17fb5d7336ac542a2e0538ba853c297cb9e848.jpg)
 *Axial CTs through the proximal (left), mid (center), and distal (right) descending thoracic aorta (DTA) in a 58-year-old man with intermittent chest pain shows an irregular filling defect <img src='img/arrows/CS.png' alt='cyan solid arrow'/> with diffuse wall thickening proximally, a polyploid mass in the mid-DTA, and shaggy contours in distal DTA.*
 ![CTA in the same patient shows the bizarre polyploid filling defect with irregular intimal thickening extending into the arch. The ascending aorta and abdominal aorta were normal. Surgical biopsy confirmed aortic intimal sarcoma.](images/app.statdx.com_image_thumbnail_efc67a40-a8d1-42bd-96fa-de57105bce28_annotated_true_size_900_quality_90_77cb063b59fa1093aa6b6091fe8eae9bb1eb1823.jpg)
 *CTA in the same patient shows the bizarre polyploid filling defect with irregular intimal thickening extending into the arch. The ascending aorta and abdominal aorta were normal. Surgical biopsy confirmed aortic intimal sarcoma.*
 ![CT images from a 61-year-old with leg and abdominal pain show a polyploid mass in the DTA <img src='img/arrows/CS.png' alt='cyan solid arrow'/>. Surrounding the mass, there is irregular intimal thickening <img src='img/arrows/CC.png' alt='cyan curved arrow'/>. Abdominal pain and leg pain were related to superior mesenteric artery <img src='img/arrows/CO.png' alt='cyan open arrow'/> and posterior tibial artery (not shown) emboli. The remainder of the thoracic and abdominal aorta were normal.](images/app.statdx.com_image_thumbnail_a455b335-108a-4a11-93aa-f79a23f75d6f_annotated_true_size_900_quality_90_0b9de3605d7b512e7a9a2f38070132f7413da6df.jpg)
 *CT images from a 61-year-old with leg and abdominal pain show a polyploid mass in the DTA <img src='img/arrows/CS.png' alt='cyan solid arrow'/>. Surrounding the mass, there is irregular intimal thickening <img src='img/arrows/CC.png' alt='cyan curved arrow'/>. Abdominal pain and leg pain were related to superior mesenteric artery <img src='img/arrows/CO.png' alt='cyan open arrow'/> and posterior tibial artery (not shown) emboli. The remainder of the thoracic and abdominal aorta were normal.*
 ![Gross pathology and CT in the same patient show the polyploid mass in the DTA <img src='img/arrows/CS.png' alt='cyan solid arrow'/> due to intimal sarcoma. The sarcoma extending throughout the entire DTA.](images/app.statdx.com_image_thumbnail_80091e46-04a8-4134-b7f8-0aebb98062da_annotated_true_size_900_quality_90_42f9d37b5198dd50ad79530be23937bf8c4a89a0.jpg)
 *Gross pathology and CT in the same patient show the polyploid mass in the DTA <img src='img/arrows/CS.png' alt='cyan solid arrow'/> due to intimal sarcoma. The sarcoma extending throughout the entire DTA.*
@@ -0,0 +1,560 @@
 ---
 title: "Cardiac Anatomy"
 docid: "c11f5b0b-90b4-4db9-acf9-356af5e5bb00"
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  - key: "9fea2857-d729-4fe4-b4fd-3b7bf1db23cf"
    value: "Mortadha Al-Kinani, MD, MBChB"
  - key: "3d1e4c57-c1cf-4c89-b0f0-5d82b29a31e1"
    value: "Suhny Abbara, MD, FACR, MSCCT, FNASCI"
  - key: "15ee0dfd-031b-40c3-987c-1dae68c01847"
    value: "Christopher M. Walker, MD"
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  -
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  -
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 documentVersionId: "8e3d875d-5277-4f01-b898-1053f7995eb9"
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 lastUpdated: "12/19/24"
 pageDescription: "Cardiac Anatomy"
 pageKeywords: "Cardiac, Anatomy, Cardiac Anatomy"
 pageTitle: "Cardiac Anatomy | STATdx"
 enhancedTitle: "Cardiac Anatomy"
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 ---
 ## GENERAL ANATOMY AND FUNCTION
 - ### Anatomy
    - Cardiac chambers
          - **Right atrium (RA)**, **right ventricle (RV)**, **left atrium (LA)**, **left ventricle (LV)**
    - Cardiac valves
          - Atrioventricular (AV) valves: Tricuspid, mitral
          - Semilunar valves: Pulmonic, aortic
    - Cardiac structure
          - **Epicardium**: Serous visceral pericardium
          - **Myocardium**: Specialized cardiac muscle that forms atrial and ventricular walls
          - **Endocardium**: Thin layer of cells lining internal surfaces of cardiac chambers
 - ### Function
    - Pump action
          - Delivery of deoxygenated blood to alveolar-capillary interface
          - Delivery of oxygenated blood to tissues
    - Cardiac conduction system
          - **Sinoatrial node**
                  - Cardiac pacemaker; atrial contraction
                  - Superior end of **crista terminalis** at **superior vena cava (SVC) orifice**
          - **AV node**
                  - In atrial septum, near coronary sinus orifice, close to attachment of septal cusp of tricuspid valve
                  - Receives impulse generated at sinoatrial node and propagates it to ventricles
                  - Produces ventricular contraction
          - **AV bundle**
                  - Continuation of AV node along interventricular septum; divides into right and left bundle branches
          - **Right bundle branch**
                  - Continues along right side of interventricular septum to reach subendocardial **Purkinje fibers**
          - **Left bundle branch**
                  - Continues along left side of interventricular septum to apex to reach subendocardial **Purkinje fibers**
 ## CARDIAC SHAPE AND ORIENTATION
 - ### Shape
    - Pyramidal
 - ### Orientation
    - Position analogous to pyramid on its side
    - Apex oriented anteriorly, inferiorly, and to left
 ## CARDIAC SURFACES
 - ### Posterior Surface (Base)
    - Faces posteriorly; quadrilateral shape
    - Structures: **LA**, small portion of **RA**, central **great veins**
 - ### Apex
    - Faces anteriorly, inferiorly, and to left
    - Structures: Inferolateral LV
 - ### Anterior Surface
    - Faces anteriorly
    - Structures: **RV (anterior free wall)**, portions of **RA** and **LV**
 - ### Diaphragmatic Surface
    - Faces inferiorly; rests on diaphragm
    - Structures: **LV**, portion of **RV**
 - ### Left Pulmonary Surface
    - Faces left lung
    - Structures: **LV**, portion of **LA**
 - ### Right Pulmonary Surface
    - Faces right lung
    - Structure: **R****A**
 ## CARDIAC BORDERS (MARGINS)
 - ### Upper Border
    - Not well appreciated on imaging
 - ### Inferior (Acute) Border
    - Edge between **anterior** and **diaphragmatic****surfaces**
    - Structures: **RV**, portion of **LV**
 - ### Obtuse (Left) Border
    - Between **anterior**and **left pulmonary surfaces**
    - Curved morphology
    - From **left atrial appendage** to **apex**
    - Structures: **LV**, portion of **LA****appendage**
 - ### Right Border
    - Analogous to **right pulmonary surface**
 ## CARDIAC SULCI OR GROOVES
 - ### General Features
    - Heart divided into chambers
    - Internal cardiac partitions demarcate chamber boundaries
    - **Su****lci**: External grooves related to internal partitions
 - ### Atrioventricular Sulcus or Groove (Coronary Sulcus)
    - Surrounds heart, separates atria from ventricles
    - Structures: Right coronary/circumflex branch of left coronary artery, small cardiac vein, great cardiac vein, coronary sinus
 - ### Anterior & Posterior Interventricular Sulci or Grooves
    - Separate ventricles
    - **Anterior interventricular groove**or**sulcus**
          - Anterior heart surface
          - Structures: Left anterior descending (LAD) coronary artery, anterior interventricular vein
    - **Posterior interventricular groove**or**sulcus**
          - Diaphragmatic heart surface
          - Structures: Posterior descending (interventricular) coronary artery, middle cardiac vein (posterior interventricular vein), occasionally distal wrap-around LAD
    - Anterior and posterior interventricular sulci continuous inferiorly to left of apex
 ## CARDIAC CHAMBERS
 - ### Right Atrium
    - Forms **right cardiac border** and portion of **anterior surface**
    - Receives deoxygenated blood through
          - **SVC**: Superior posterior RA
          - **Inferior vena cava (IVC)**: Inferior posterior RA
          - **Coronary sinus**: Inferior posterior RA
                  - **Thebesian valve**: Prevents reflux of blood back into coronary sinus from RA
          - **Thebesian veins**: Small veins that drain subendocardium
          - **Anterior cardiac vein**: Venous return from anterior RV
    - Blood exits through AV **tricuspid valve**
    - Structures
          - Compartmentalized by external **sulcus terminalis**cordis
                  - From right of SVC to right of IVC
          - Compartmentalized by internal **crista terminalis**
                  - Smooth ridge that begins at roof of atrium anterior to SVC orifice and extends to anterior lip of IVC orifice
          - **Sinus of venae cavae**, posterior to **crista terminalis**
          - **RA** proper
                  - Anterior to crista terminalis
                  - Wall covered by ridges called **pectinate muscles**
                  - **RA appendage** (**auricle**)
          - Vascular orifices
                  - **Orifice of SVC**, **orifices**and**valves of IVC**, and**coronary sinus**
          - **Interatrial septum**
                  - **Fossa ovali****s**: Depression in septum above orifice of IVC
                  - **Limbus fossa oval****is**: Margin of fossa ovalis
                  - **Fossa ovalis** marks location of primitive **foramen ovale**, which allows oxygenated blood to enter LA and bypass lungs in utero
 - ### Right Ventricle
    - Forms **anterior cardiac surface** and small portion of **diaphragmatic surface**
    - Structures
          - **Conus arteriosus**: Smooth-walled RV infundibulum or RV outflow tract (RVOT)
          - RV inflow tract, lined by **trabeculae carneae**, forms ridges and bridges
          - **Papillary muscles** are **trabeculae carneae** attached to ventricular surface and**chordae tendineae**; connect **chordae tendineae** to free edges of **tricuspid valve**
                  - **Anterior papillary muscl****e**: Largest, arises from anterior ventricular wall
                  - **Posterior papillary muscle**: Some chordae tendineae arise directly from ventricular wall
                  - **Septal papillary muscl****e**: Most inconsistent
          - **Septomarginal trabecula** or **moderator band**
                  - Forms bridge **between lower interventricular septum and base of anterior papillary muscle**
 - ### Left Atrium
    - Forms **base** or **posterior cardiac surface**
    - Structures
          - **Posterior**or**inflow portion**: Smooth-walled, receives **pulmonary veins**
          - **Anterior**or**outflow portion**: Continuous with **LA appendage**, lined by **pectinate muscles**
          - **Interatrial septum**
                  - Contains **valve of foramen ovale**, prevents blood from passing from LA to RA
                  - **Valve of foramen ovale** may provide passage between atria during cardiac instrumentation
 - ### Left Ventricle
    - Contributions to **anterior**, **diaphragmatic**, and **left pulmonary cardiac surfaces**; forms **apex**
    - Thickest myocardium
    - Structures
          - Fine, delicate **trabeculae carneae**
          - Papillary muscles larger than in RV
                  - **Anterior papillary muscle**
                  - **Posterior papillary muscle**
          - **Interventricular septum**
                  - **Thick muscular portion** forms major part of septum
                  - **Membranous portion**
 ## CARDIAC VALVES
 - ### Tricuspid Valve
    - 3 cusps attached to fibrous ring
          - **Anterior**, **septal**, **posterior**
    - Anatomy of right AV valve
          - Free margins attached to **chordae tendineae**
                  - Cusps continuous with each other at their bases, forming **commissures**
          - **Chordae tendineae** from 2 papillary muscles attach to each cusp
    - Separated from pulmonic valve by muscular ridge (crista supraventricularis)
 - ### Pulmonic Valve
    - 3 semilunar cusps
          - **Left**, **right**, **anterior**
    - Anatomy of semilunar cusps
          - Free edges project into lumen of pulmonary trunk forming **sinuses**
          - Each cusp has thick central focus (**nodule of semilunar cusp**)
          - Each cusp has thin lateral portion (**lunule of semilunar cusp**)
 - ### Mitral Valve
    - 2 cusps attached to fibrous ring
          - **Anterior**and **posterior**, divided in 3 subdivisions each (A1, A2, A3 and P1, P2, P3; A1 and P1 are superior)
    - Anatomy of left AV valve
          - Cusps continuous with each other at **commissures**
          - **Chordae tendineae** attach papillary muscles to free borders of cusps
    - In fibrous continuity with aortic valve
 - ### Aortic Valve
    - 3 semilunar cusps
          - **Right**, **left**, and**noncoronary**(or**posterior**)
    - 3 sinuses of Valsalva
          - Right coronary artery originates from right sinus
          - Left coronary artery originates from left sinus
          - Noncoronary sinus always faces interatrial septum
 ## HEART IMAGING
 - ### Radiography
    - Analysis of cardiac borders and surfaces on PA radiograph
          - Right cardiac border: **R****A**
          - Left cardiac border: **LA appendage**and**LV**
    - Analysis of cardiac borders and surfaces on lateral radiograph
          - Anterior cardiac surface: **R****V**
          - Posterior cardiac surface: **LA** and **LV**
    - Variations in cardiac morphology
          - **Infancy**:**P****rominent cardiothymic silhouette**
          - **Childhood**, adolescence, and young adulthood: **Prominent pulmonary trunk**
          - **Adulthood**: **Progressive LV configuration** with dominant left-sided structures and concavity of upper left cardiac border
    - Analysis of cardiac size
          - **Cardiothoracic ratio**
                  - Maximum transverse cardiac diameter to transverse thoracic diameter ≤ **0.55**
                  - Influenced by rotation, lung volume, projection
          - Analysis of individual chamber enlargement
    - Analysis of abnormal cardiac density/calcification
 - ### CT/MR Anatomy
    - **RA**
          - **RA appendage** (trabeculated) anterior and superior to**RV**
          - **Crista terminalis**: Vertical ridge in RA extending from superior to inferior venae cavae
    - **LA**
          - Most superior & posterior cardiac chamber
          - **LA appendage** (trabeculated) anterior & superior to **LV**
          - **Smooth muscle ridge** at junction of **LA appendage** and central **left superior pulmonary vein** (**a.k.a. Coumadin ridge**)
    - **Interatrial septum**
          - Thin structure, difficult identification on CT
          - Increased visibility with fat deposition
                  - Fat spares **fossa ovalis** and may allow its identification
    - **RV**
          - Most anterior cardiac chamber, anterior heart surface
          - Heavy trabeculations, thin wall
                  - **Moderator band**: Connects anterior papillary muscle to interventricular septum near RV apex; contains right bundle branch
          - **Anterior, posterior, septal papillary muscles**
    - **LV**
          - Posterior and diaphragmatic cardiac surfaces
          - Thicker than RV, less trabeculated
          - Anterior and posterior papillary muscles
    - **Interventricular septum**
          - Thicker than interatrial septum
    - **Valves**
          - Imaging in longitudinal and perpendicular planes
                  - CECT and bright-blood cardiac MR: Thin, low-attenuation/signal structures
          - Assessment of function, morphology, calcification
 - ### CT/MR
    - Assessment of cardiac chambers, valves, myocardium
          - Size, morphology, wall thickness, calcification, function
    - **Short**-**axis view**
          - Cross section through short axis of LV cavity and bodies of papillary muscles
    - **Paraseptal long**-**axis (2-chamber) view**
          - Display of LA and LV chambers
          - Evaluation of **mitral** **(****left AV)** **valve**
          - Excellent visualization of anterior and inferior LV myocardium
    - **4-****chamber view**
          - Display of 4 cardiac chambers and AV valves
    - **L****V****outflow tract view**
          - Display of LA, LV, LV outflow tract, and aorta
    - **R****VOT****view**
          - Display of RA, RV, RVOT, and main pulmonary artery
 ## IMAGING CLUES TO IDENTIFY MORPHOLOGIC RIGHT & LEFT VENTRICLES
 - ### Anatomic Right Ventricle
    - Muscular infundibulum separates tricuspid and pulmonic valves
    - Coarse trabeculae with trabeculations along interventricular septum
    - Papillary muscles attached to interventricular septum and free wall
    - Apical moderator band
    - Septal tricuspid valve leaflet inserts more apically than matching mitral valve leaflet
 - ### Anatomic Left Ventricle
    - Fibrous continuity between mitral and aortic valves
    - Thin and delicate trabeculae with smooth septal surface
    - Papillary muscles attached only to free walls
 ## IMAGING CLUES TO IDENTIFY MORPHOLOGIC RIGHT & LEFT ATRIA
 - ### Anatomic Right Atrium
    - RA appendage has broad opening with triangular shape
    - Rule of **venoatrial concordance**
          - Chamber that receives IVC inflow is almost always morphologic RA
    - Generally on same side as morphologic right trilobed lung
 - ### Anatomic Left Atrium
    - Finger-like LA appendage with narrow orifice and pointed appearance
    - Recently described as either of following 4 shapes: Chicken wing (48%), cactus (30%), windsock (19%), and cauliflower (3%)
    - Generally on same side as morphologic left bilobed lung
    - Important to not mistake normal linear pectinate muscle or Coumadin ridge for thrombus
 - ### Cardiac Fibrous Skeleton
    - **Anulus fibrosus**: 4 fibrous rings between atria and ventricles
          - Points of origin of atrial (superior) and ventricular (inferior) myocardia
          - Maintain integrity of orifices
          - Traversed by **AV****bundle**
          - Surround AV valves and aortic/pulmonary trunk orifices
    - Interconnecting fibrous tissue
          - **Right fibrous trigone**: Between aortic and right AV rings
          - **Left fibrous trigone**: Between aortic and left AV rings
 8abd652e-7310-4303-bef5-682e46f4816b
 ## References
 ## Selected References
 1. [Haas NA et al: Normal cardiac anatomy and clinical evaluation. Adv Exp Med Biol. 1441:87-100, 2024](http://www.ncbi.nlm.nih.gov/pubmed/?term=38884706%5Bpmid%5D)
 1. [Malik SB et al: Transthoracic echocardiography: pitfalls and limitations as delineated at cardiac CT and MR imaging. Radiographics. 37(2):383-406, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28212053%5Bpmid%5D)
 1. [Leipsic J et al: SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr. 8(5):342-58, 2014](http://www.ncbi.nlm.nih.gov/pubmed/?term=25301040%5Bpmid%5D)
 1. [Galea N et al: Right ventricular cardiovascular magnetic resonance imaging: normal anatomy and spectrum of pathological findings. Insights Imaging. 4(2):213-23, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23389464%5Bpmid%5D)
 1. [Debonnaire P et al: Contemporary imaging of normal mitral valve anatomy and function. Curr Opin Cardiol. 27(5):455-64, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22820102%5Bpmid%5D)
 1. [Di Biase L et al: Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol. 60(6):531-8, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22858289%5Bpmid%5D)
 1. [Shah SS et al: Imaging of the coronary sinus: normal anatomy and congenital abnormalities. Radiographics. 32(4):991-1008, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22786990%5Bpmid%5D)
 1. [Gopalan D: Right heart on multidetector CT. Br J Radiol. 84 Spec No 3:S306-23, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22723537%5Bpmid%5D)
 1. [Malagò R et al: Coronary artery anatomy and variants. Pediatr Radiol. 41(12):1505-15, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=22127682%5Bpmid%5D)
 1. [Venkatesh V et al: Normal magnetic resonance imaging of the thorax. Magn Reson Imaging Clin N Am. 19(3):489-506, viii, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21816327%5Bpmid%5D)
 1. [O'Leary SM et al: Imaging the pericardium: appearances on ECG-gated 64-detector row cardiac computed tomography. Br J Radiol. 83(987):194-205, 2010](http://www.ncbi.nlm.nih.gov/pubmed/?term=20197434%5Bpmid%5D)
 ## Images
 ### Anatomy of Heart Surfaces, Margins, And Sulci
 ![Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.](images/app.statdx.com_image_e9df470a-161d-4f62-9fa0-c17678bacfc6_61cdd722e2eae7198dea18c790d52c7c99071a8b.jpg)
 *Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.*
 ![Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.](images/app.statdx.com_image_thumbnail_e9df470a-161d-4f62-9fa0-c17678bacfc6_annotated_false_size_900_quality_90_d623216512e3ee057471e095277939ec46a25e99.jpg)
 *Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.*
 ![Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.](images/app.statdx.com_image_thumbnail_e9df470a-161d-4f62-9fa0-c17678bacfc6_size_168_quality_85_7827e897862070e80821bb7c35f16a1bd559875d.jpg)
 *Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.*
 ![Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.](images/app.statdx.com_image_thumbnail_e9df470a-161d-4f62-9fa0-c17678bacfc6_size_174_quality_85_0b9a4df3b67b9bc9df5bca11403c955b234cc1fd.jpg)
 *Graphic shows the posterior heart surface, or base of the heart, which is formed by the left atrium, a small portion of the right atrium, the paired superior and inferior pulmonary veins, and the superior and inferior venae cavae, which fix the heart base to the pericardium. The left atrioventricular groove is seen at the junction of the left atrium and ventricle.*
 ![Graphic shows the diaphragmatic heart surface, which is formed by the right and left ventricles and is separated from the heart base by the coronary sulcus (atrioventricular groove). The inferior (acute) cardiac border separates the diaphragmatic surface from the anterior heart surface. The posterior interventricular sulcus (or groove) marks the location of the interventricular septum.](images/app.statdx.com_image_fd3ef8c6-ed58-4eb1-9180-3e9fd6f6a919_dd2220ca1543f8b19eed8e3a960c11c8215d5871.jpg)
 *Graphic shows the diaphragmatic heart surface, which is formed by the right and left ventricles and is separated from the heart base by the coronary sulcus (atrioventricular groove). The inferior (acute) cardiac border separates the diaphragmatic surface from the anterior heart surface. The posterior interventricular sulcus (or groove) marks the location of the interventricular septum.*
 ![Graphic shows the diaphragmatic heart surface, which is formed by the right and left ventricles and is separated from the heart base by the coronary sulcus (atrioventricular groove). The inferior (acute) cardiac border separates the diaphragmatic surface from the anterior heart surface. The posterior interventricular sulcus (or groove) marks the location of the interventricular septum.](images/app.statdx.com_image_thumbnail_fd3ef8c6-ed58-4eb1-9180-3e9fd6f6a919_annotated_false_size_900_quality_90_54e90eab32371d31780c9facf76dedd5645d810b.jpg)
 *Graphic shows the diaphragmatic heart surface, which is formed by the right and left ventricles and is separated from the heart base by the coronary sulcus (atrioventricular groove). The inferior (acute) cardiac border separates the diaphragmatic surface from the anterior heart surface. The posterior interventricular sulcus (or groove) marks the location of the interventricular septum.*
 ![Graphic shows the diaphragmatic heart surface, which is formed by the right and left ventricles and is separated from the heart base by the coronary sulcus (atrioventricular groove). The inferior (acute) cardiac border separates the diaphragmatic surface from the anterior heart surface. The posterior interventricular sulcus (or groove) marks the location of the interventricular septum.](images/app.statdx.com_image_thumbnail_fd3ef8c6-ed58-4eb1-9180-3e9fd6f6a919_size_168_quality_85_af4a551b34fa4f7d5fa09473cf51bd3e84bdfd8c.jpg)
 *Graphic shows the diaphragmatic heart surface, which is formed by the right and left ventricles and is separated from the heart base by the coronary sulcus (atrioventricular groove). The inferior (acute) cardiac border separates the diaphragmatic surface from the anterior heart surface. The posterior interventricular sulcus (or groove) marks the location of the interventricular septum.*
 ### CT of Left Atrium
 ![Axial CT shows the nodular appearance of the ridge at the junction of the left atrium and left superior pulmonary vein adjacent to the left atrial appendage, which is also known as the Coumadin ridge as it can be mistaken for thrombus at transesophageal echocardiography. This image through the superior aspect of the left atrium demonstrates the constant relationship between the left superior pulmonary vein and the adjacent left atrial appendage. The left atrial appendage is always anterior and inferior to the left superior pulmonary vein.](images/app.statdx.com_image_thumbnail_438d8166-5c87-41a0-96f8-2eab60559be1_annotated_false_size_900_quality_90_1f4c6af0ddd66d8bb0d4089e41b3e4468ff8229e.jpg)
 *Axial CT shows the nodular appearance of the ridge at the junction of the left atrium and left superior pulmonary vein adjacent to the left atrial appendage, which is also known as the Coumadin ridge as it can be mistaken for thrombus at transesophageal echocardiography. This image through the superior aspect of the left atrium demonstrates the constant relationship between the left superior pulmonary vein and the adjacent left atrial appendage. The left atrial appendage is always anterior and inferior to the left superior pulmonary vein.*
 ![Axial CT shows the nodular appearance of the ridge at the junction of the left atrium and left superior pulmonary vein adjacent to the left atrial appendage, which is also known as the Coumadin ridge as it can be mistaken for thrombus at transesophageal echocardiography. This image through the superior aspect of the left atrium demonstrates the constant relationship between the left superior pulmonary vein and the adjacent left atrial appendage. The left atrial appendage is always anterior and inferior to the left superior pulmonary vein.](images/app.statdx.com_image_thumbnail_438d8166-5c87-41a0-96f8-2eab60559be1_size_168_quality_85_9f84a543bbc97f9d3de17170e4ef34fd32688930.jpg)
 *Axial CT shows the nodular appearance of the ridge at the junction of the left atrium and left superior pulmonary vein adjacent to the left atrial appendage, which is also known as the Coumadin ridge as it can be mistaken for thrombus at transesophageal echocardiography. This image through the superior aspect of the left atrium demonstrates the constant relationship between the left superior pulmonary vein and the adjacent left atrial appendage. The left atrial appendage is always anterior and inferior to the left superior pulmonary vein.*
 ![Coronal CT through the left atrial appendage in the same patient demonstrates the normal soft tissue ridge that occurs at the junction of the left atrium with the left superior pulmonary vein adjacent to the left atrial appendage.](images/app.statdx.com_image_thumbnail_36e815c4-f8ad-4973-ae1b-b952d9488777_annotated_false_size_900_quality_90_2b375ccb87836ac693906da4d0efa454f4f8971b.jpg)
 *Coronal CT through the left atrial appendage in the same patient demonstrates the normal soft tissue ridge that occurs at the junction of the left atrium with the left superior pulmonary vein adjacent to the left atrial appendage.*
 ![Coronal CT through the left atrial appendage in the same patient demonstrates the normal soft tissue ridge that occurs at the junction of the left atrium with the left superior pulmonary vein adjacent to the left atrial appendage.](images/app.statdx.com_image_thumbnail_36e815c4-f8ad-4973-ae1b-b952d9488777_size_168_quality_85_bf43c07d34f4dbedc369f9037b7ff272bd611ab9.jpg)
 *Coronal CT through the left atrial appendage in the same patient demonstrates the normal soft tissue ridge that occurs at the junction of the left atrium with the left superior pulmonary vein adjacent to the left atrial appendage.*
 ![Posterior 3D volume-rendered CTA shows the normal appearance of the pulmonary veins.](images/app.statdx.com_image_thumbnail_69d49b09-ae65-431b-a096-015720b5d3b6_annotated_false_size_900_quality_90_66f63259d8e7ebe42d72e5ff82fd99bf4e2b4910.jpg)
 *Posterior 3D volume-rendered CTA shows the normal appearance of the pulmonary veins.*
 ![Posterior 3D volume-rendered CTA shows the normal appearance of the pulmonary veins.](images/app.statdx.com_image_thumbnail_69d49b09-ae65-431b-a096-015720b5d3b6_size_168_quality_85_bb689143d0a8828f9640f71b62044d987de2da2f.jpg)
 *Posterior 3D volume-rendered CTA shows the normal appearance of the pulmonary veins.*
 ### CT, 4-Chamber View
 ![Gated 4-chamber cardiac CECT allows simultaneous evaluation of the 4 cardiac chambers. The right chambers are projected anterolateral to the left heart chambers and are less opacified with contrast. The mitral valve leaflets manifest as thin, linear soft tissue structures between the left atrium and left ventricle.](images/app.statdx.com_image_thumbnail_cae8e036-1910-4321-8edd-f9205e028a4e_annotated_false_size_900_quality_90_7e9baf3f25995927d39d6f8142a231c7f6033c1e.jpg)
 *Gated 4-chamber cardiac CECT allows simultaneous evaluation of the 4 cardiac chambers. The right chambers are projected anterolateral to the left heart chambers and are less opacified with contrast. The mitral valve leaflets manifest as thin, linear soft tissue structures between the left atrium and left ventricle.*
 ![Gated 4-chamber cardiac CECT allows simultaneous evaluation of the 4 cardiac chambers. The right chambers are projected anterolateral to the left heart chambers and are less opacified with contrast. The mitral valve leaflets manifest as thin, linear soft tissue structures between the left atrium and left ventricle.](images/app.statdx.com_image_thumbnail_cae8e036-1910-4321-8edd-f9205e028a4e_size_168_quality_85_8cbb94c2d692fa74c0ecd9b12721bd8a99e973e8.jpg)
 *Gated 4-chamber cardiac CECT allows simultaneous evaluation of the 4 cardiac chambers. The right chambers are projected anterolateral to the left heart chambers and are less opacified with contrast. The mitral valve leaflets manifest as thin, linear soft tissue structures between the left atrium and left ventricle.*
 ![Gated 4-chamber cardiac CECT in the same patient demonstrates a normal mitral valve. The 4 cardiac chambers and the coronary (atrioventricular) and interventricular sulci (grooves) are demonstrated. The interventricular groove is located slightly to the right of the cardiac apex.](images/app.statdx.com_image_thumbnail_77b58981-538e-4b76-877d-32cae61dc15d_annotated_false_size_900_quality_90_20d9d3ff16a51444088b9a922b85dab4b6ee1e1d.jpg)
 *Gated 4-chamber cardiac CECT in the same patient demonstrates a normal mitral valve. The 4 cardiac chambers and the coronary (atrioventricular) and interventricular sulci (grooves) are demonstrated. The interventricular groove is located slightly to the right of the cardiac apex.*
 ### CT, 2-Chamber View
 ![Paraseptal long-axis (2-chamber) gated cardiac CECT shows the anatomy of the left ventricle and left atrium. Note the intimate relationship of the left superior pulmonary vein and left atrial appendage with an intervening nodular soft tissue ridge, which is also known as the Coumadin ridge. The left atrial appendage exhibits a trabeculated internal surface produced by the pectinate muscles. The left ventricle, the thickness of its wall, and its papillary muscles are well visualized.](images/app.statdx.com_image_thumbnail_035a4a3f-8b12-4bf2-96cb-4d3f39f0c130_annotated_false_size_900_quality_90_56beb018c1d2e02682a2d680007e0179bc53f15c.jpg)
 *Paraseptal long-axis (2-chamber) gated cardiac CECT shows the anatomy of the left ventricle and left atrium. Note the intimate relationship of the left superior pulmonary vein and left atrial appendage with an intervening nodular soft tissue ridge, which is also known as the Coumadin ridge. The left atrial appendage exhibits a trabeculated internal surface produced by the pectinate muscles. The left ventricle, the thickness of its wall, and its papillary muscles are well visualized.*
 ![Paraseptal long-axis (2-chamber) gated cardiac CECT through the mitral valve obtained during systole in the same patient  demonstrates coaptation of the thin anterior and posterior valve cusps. The papillary muscles manifest as rounded filling defects within the contrast-filled left ventricular chamber.](images/app.statdx.com_image_thumbnail_f1838c2a-6c92-4700-9aab-e4a6a1a326a7_annotated_false_size_900_quality_90_645fa22aa0b783b8757fcd7b5668d5de31555366.jpg)
 *Paraseptal long-axis (2-chamber) gated cardiac CECT through the mitral valve obtained during systole in the same patient  demonstrates coaptation of the thin anterior and posterior valve cusps. The papillary muscles manifest as rounded filling defects within the contrast-filled left ventricular chamber.*
 ### CT, Short-Axis View
 ![Short-axis gated cardiac CECT shows the ventricular chambers. The right ventricle is located anteriorly and has a thin wall. The right ventricular outflow tract courses superiorly and posteriorly to give off the pulmonary trunk. The left ventricle is posterior and has a thicker myocardium than the right ventricle. The 2 chambers are separated by the interventricular sulcus (or groove).](images/app.statdx.com_image_thumbnail_57a3bff2-4b4d-4e4b-9e77-ef5aa55d2203_annotated_false_size_900_quality_90_bd5cc40eeb7bfc63475735c22cf85553fea829fa.jpg)
 *Short-axis gated cardiac CECT shows the ventricular chambers. The right ventricle is located anteriorly and has a thin wall. The right ventricular outflow tract courses superiorly and posteriorly to give off the pulmonary trunk. The left ventricle is posterior and has a thicker myocardium than the right ventricle. The 2 chambers are separated by the interventricular sulcus (or groove).*
 ![Short-axis gated cardiac CECT through the midheart in the same patient shows the anatomy of the left ventricular chamber. The papillary muscles manifest as filling defects within the contrast-filled left ventricular lumen.](images/app.statdx.com_image_thumbnail_ca688b64-2c31-4078-a8d6-72f7cd9bc058_annotated_false_size_900_quality_90_9f5996e9c284e4477da4dcabe2b94e25170659a2.jpg)
 *Short-axis gated cardiac CECT through the midheart in the same patient shows the anatomy of the left ventricular chamber. The papillary muscles manifest as filling defects within the contrast-filled left ventricular lumen.*
 ![Short-axis gated cardiac CECT obtained just medial to the left apex in the same patient demonstrates trabeculations in both ventricular chambers produced by trabeculae carneae. The right ventricle forms the anterior heart surface.](images/app.statdx.com_image_thumbnail_d44800a0-e283-4987-8ace-815744cc6219_annotated_false_size_900_quality_90_a7bc8f16b4fc1a3595033ed1b0bc25234cf05dfb.jpg)
 *Short-axis gated cardiac CECT obtained just medial to the left apex in the same patient demonstrates trabeculations in both ventricular chambers produced by trabeculae carneae. The right ventricle forms the anterior heart surface.*
 ### MR of Normal Heart, Short-Axis View
 ![Short-axis T2-weighted double inversion-recovery black-blood MR shows the basal aspect of the heart, which is made up of the right and left atria.](images/app.statdx.com_image_thumbnail_e7a486a7-4717-445d-bc3a-d969ac592653_annotated_false_size_900_quality_90_bc176cf70079af6cc9fc804647b0b232887497b7.jpg)
 *Short-axis T2-weighted double inversion-recovery black-blood MR shows the basal aspect of the heart, which is made up of the right and left atria.*
 ![Short-axis T2-weighted double inversion-recovery black-blood MR slightly more apically in the same patient shows the pulmonic valve and right ventricular outflow tract.](images/app.statdx.com_image_thumbnail_8227bea2-a3e8-44cb-be64-c0a554ef7b0e_annotated_false_size_900_quality_90_f2584aaab812b86272f354839e345bf33ab9bfea.jpg)
 *Short-axis T2-weighted double inversion-recovery black-blood MR slightly more apically in the same patient shows the pulmonic valve and right ventricular outflow tract.*
 ![Short-axis T2-weighted double inversion-recovery black-blood MR through the midventricular level in the same patient shows a papillary muscle of the left ventricle. The midventricular level is best identified on the short-axis view by identifying the papillary muscles. The left ventricular interventricular septum is typically smooth, whereas the right ventricular interventricular septum is trabeculated.](images/app.statdx.com_image_thumbnail_95ab1bba-c048-4036-bb75-b8ed5e342c51_annotated_false_size_900_quality_90_371b44993b0707456e49260797ec4661ce9f5a41.jpg)
 *Short-axis T2-weighted double inversion-recovery black-blood MR through the midventricular level in the same patient shows a papillary muscle of the left ventricle. The midventricular level is best identified on the short-axis view by identifying the papillary muscles. The left ventricular interventricular septum is typically smooth, whereas the right ventricular interventricular septum is trabeculated.*
 ### Anatomy of Cardiac Skeleton and Heart Valves
 ![Graphic demonstrates the anatomy of the cardiac skeleton located between the atria and ventricles. The cardiac skeleton consists of thick, fibrous connective tissue and provides support for the valve orifices and the areas of attachment for the valve cusps. Here, the atria have been &quot;removed&quot; to expose the cardiac skeleton and heart valves seen from above. The 4 fibrous rings that surround the valves are known as the anulus fibrosus. The right fibrous trigone is the connective tissue bridge between the aortic valve and right atrioventricular (tricuspid) valve rings. The left fibrous trigone is the connective tissue bridge between the aortic valve and the left atrioventricular (mitral) valve rings. The yellow dot represents the atrioventricular bundle seen in cross section as it courses caudally from the atria to the ventricles.](images/app.statdx.com_image_thumbnail_799ff8ba-28cc-4a64-9b21-7f9c78cdda07_annotated_false_size_900_quality_90_50add974a1ec7e70f3756177f2cab136bd1fadba.jpg)
 *Graphic demonstrates the anatomy of the cardiac skeleton located between the atria and ventricles. The cardiac skeleton consists of thick, fibrous connective tissue and provides support for the valve orifices and the areas of attachment for the valve cusps. Here, the atria have been &quot;removed&quot; to expose the cardiac skeleton and heart valves seen from above. The 4 fibrous rings that surround the valves are known as the anulus fibrosus. The right fibrous trigone is the connective tissue bridge between the aortic valve and right atrioventricular (tricuspid) valve rings. The left fibrous trigone is the connective tissue bridge between the aortic valve and the left atrioventricular (mitral) valve rings. The yellow dot represents the atrioventricular bundle seen in cross section as it courses caudally from the atria to the ventricles.*
 ### Anatomy of Left Heart Valves
 ![Graphic depicts the close relationship between the aortic and mitral valves. These valves are supported by fibrous valve rings connected by the left fibrous trigone. Thus, the anterior cusp of the mitral valve is closely related to the left coronary cusp of the aortic valve. The aortic valve right coronary, left coronary, and noncoronary cusps are shown. The semilunar cusps form sinuses during valve closure, which occurs by coaptation of the free cusp edges. Each valve has a fibrous nodule on the central portion of its free edge that is called the nodulus arantii. The mitral valve cusps are continuous along the left atrioventricular fibrous valve ring and are connected at the valve cusp commissures. The free edges of the mitral valve cusps attach to the anterior and posterior papillary muscles via chordae tendineae.](images/app.statdx.com_image_thumbnail_83f7b4cd-70bb-46cb-86f1-dc5e7d42e276_annotated_false_size_900_quality_90_57115fdcee6f5e968c50a82cf021eaf4a26f6f77.jpg)
 *Graphic depicts the close relationship between the aortic and mitral valves. These valves are supported by fibrous valve rings connected by the left fibrous trigone. Thus, the anterior cusp of the mitral valve is closely related to the left coronary cusp of the aortic valve. The aortic valve right coronary, left coronary, and noncoronary cusps are shown. The semilunar cusps form sinuses during valve closure, which occurs by coaptation of the free cusp edges. Each valve has a fibrous nodule on the central portion of its free edge that is called the nodulus arantii. The mitral valve cusps are continuous along the left atrioventricular fibrous valve ring and are connected at the valve cusp commissures. The free edges of the mitral valve cusps attach to the anterior and posterior papillary muscles via chordae tendineae.*
 ### Echocardiography of Aortic and Mitral Valves
 ![Three-chamber transthoracic echocardiogram in diastole shows the left atrium, open mitral valve, left ventricle cavity, left ventricular outflow tract, and the aortic root with a closed aortic valve. Note that the &quot;3rd chamber&quot; near the probe is the right ventricle and its outflow tract.](images/app.statdx.com_image_thumbnail_14da7ca2-1204-4b20-ae79-3a794d562a3b_annotated_false_size_900_quality_90_8c5924e0dadc1252b1bd5d0bebfec7cd35d79009.jpg)
 *Three-chamber transthoracic echocardiogram in diastole shows the left atrium, open mitral valve, left ventricle cavity, left ventricular outflow tract, and the aortic root with a closed aortic valve. Note that the &quot;3rd chamber&quot; near the probe is the right ventricle and its outflow tract.*
 ![Short-axis transthoracic echocardiogram of the closed aortic valve in diastole shows normal coaptation of all 3 cusps without regurgitant orifice. The cusps can be identified by the interatrial septum always pointing to the noncoronary cusp and by the right atrium, right ventricle, and right ventricular outflow tract &quot;wrapping&quot; around the right coronary cusp.](images/app.statdx.com_image_thumbnail_98f73e87-24c3-47cc-94dc-7cd36f9db61c_annotated_false_size_900_quality_90_3266a4289351315514ee45019446c1986ba53fb6.jpg)
 *Short-axis transthoracic echocardiogram of the closed aortic valve in diastole shows normal coaptation of all 3 cusps without regurgitant orifice. The cusps can be identified by the interatrial septum always pointing to the noncoronary cusp and by the right atrium, right ventricle, and right ventricular outflow tract &quot;wrapping&quot; around the right coronary cusp.*
 ![Short-axis transthoracic echocardiogram of the open aortic valve in systole shows unrestricted opening of the cusp and confirms that it indeed has an unobstructed tricuspid configuration. Fusion along cusp edges can lead to bicuspid or unicuspid configuration and obstruction.](images/app.statdx.com_image_thumbnail_e97a7ab5-9c96-4f7a-ae1a-44aab7249acd_annotated_false_size_900_quality_90_b3f86ed07ea84fa66fc0a27575afc4d065d63950.jpg)
 *Short-axis transthoracic echocardiogram of the open aortic valve in systole shows unrestricted opening of the cusp and confirms that it indeed has an unobstructed tricuspid configuration. Fusion along cusp edges can lead to bicuspid or unicuspid configuration and obstruction.*
 ### Anatomy and CT of Left Heart Valves
 ![Graphic illustrates a 3-chamber (left ventricular outflow tract) view of the heart and the relationship between the mitral and aortic valves. The fibrous rings that support these valves share a common fibrous bridge called the left fibrous trigone. The fibrous bridge forms a connection between the anterior cusp of the mitral valve and the left coronary cusp of the aortic valve.](images/app.statdx.com_image_thumbnail_cfeef036-5485-4b8a-aaa4-0e353599814e_annotated_false_size_900_quality_90_6ed487f721068e10b1460c03846785701492c3de.jpg)
 *Graphic illustrates a 3-chamber (left ventricular outflow tract) view of the heart and the relationship between the mitral and aortic valves. The fibrous rings that support these valves share a common fibrous bridge called the left fibrous trigone. The fibrous bridge forms a connection between the anterior cusp of the mitral valve and the left coronary cusp of the aortic valve.*
 ![Gated cardiac CECT demonstrates the anatomic relationship between the aortic and mitral valves. The left coronary cusp of the aortic valve shares a common fibrous attachment with the anterior cusp of the mitral valve.](images/app.statdx.com_image_thumbnail_606b6d07-4ad7-463c-b1eb-dbc3ad85c9c8_annotated_false_size_900_quality_90_4d9b172a4fd7effb98883db04517210ff70b86a4.jpg)
 *Gated cardiac CECT demonstrates the anatomic relationship between the aortic and mitral valves. The left coronary cusp of the aortic valve shares a common fibrous attachment with the anterior cusp of the mitral valve.*
 ![Four-chamber gated cardiac CECT demonstrates the close relationship between the anterior cusp of the mitral valve and the left coronary cusp of the aortic valve. The left coronary cusp is only partially visualized on this image.](images/app.statdx.com_image_thumbnail_8c787178-3e58-4d90-8095-2ffe6ddf0524_annotated_false_size_900_quality_90_60cd17b860b681da952704a384f80839b5c2011f.jpg)
 *Four-chamber gated cardiac CECT demonstrates the close relationship between the anterior cusp of the mitral valve and the left coronary cusp of the aortic valve. The left coronary cusp is only partially visualized on this image.*
 ### CT And MR of Aortic Valve
 ![Coronal gated cardiac CECT demonstrates the cross-sectional imaging appearance of the aortic valve. The aortic valve cusps are in coaptation, manifesting as thin, curvilinear soft tissue structures located at the apex of the left ventricular outflow tract. The sinuses of Valsalva are located above the valve cusps and are visible during diastole.](images/app.statdx.com_image_thumbnail_9106fb08-69fb-4d03-9ac4-00b725d6787a_annotated_false_size_900_quality_90_d4941b00e9f81b21ba8a8d7e0276496b7408a371.jpg)
 *Coronal gated cardiac CECT demonstrates the cross-sectional imaging appearance of the aortic valve. The aortic valve cusps are in coaptation, manifesting as thin, curvilinear soft tissue structures located at the apex of the left ventricular outflow tract. The sinuses of Valsalva are located above the valve cusps and are visible during diastole.*
 ![Axial gated CECT through the aortic valve in coaptation shows right coronary, left coronary, and noncoronary sinuses of Valsalva bound by the aortic wall and the corresponding valve cusps. The noncoronary sinus of Valsalva always faces the interatrial septum.](images/app.statdx.com_image_thumbnail_6c8ba4ff-bcb7-436a-8ace-68d9a7b134be_annotated_false_size_900_quality_90_8f3de6f7668d29d573ac7d2ad45c021b1c3f35f5.jpg)
 *Axial gated CECT through the aortic valve in coaptation shows right coronary, left coronary, and noncoronary sinuses of Valsalva bound by the aortic wall and the corresponding valve cusps. The noncoronary sinus of Valsalva always faces the interatrial septum.*
 ![Axial SSFP MR through the aortic valve in coaptation shows right coronary, left coronary, and noncoronary sinuses of Valsalva bound by the aortic wall and the corresponding valve cusps.](images/app.statdx.com_image_thumbnail_0b66917e-8aa3-40bc-8a56-367e5c380732_annotated_false_size_900_quality_90_16a551517a7206aa4cb0e9d59a1a1dce8a5cca30.jpg)
 *Axial SSFP MR through the aortic valve in coaptation shows right coronary, left coronary, and noncoronary sinuses of Valsalva bound by the aortic wall and the corresponding valve cusps.*
 ### MR, Valve Function
 ![Four-chamber gated cardiac SSFP MR through the heart demonstrates the function of the heart valves. This view, obtained during ventricular systole, shows that the atrioventricular valve cusps are coapted or closed, allowing blood to be pumped in an antegrade direction into the pulmonary and systemic arteries by the contracting myocardium without regurgitation or retrograde flow into the atria.](images/app.statdx.com_image_thumbnail_7e253504-bf15-4a7a-8133-686d8f7396a7_annotated_false_size_900_quality_90_e32441a07308ea8273c95d4cd8dee694126c7b1f.jpg)
 *Four-chamber gated cardiac SSFP MR through the heart demonstrates the function of the heart valves. This view, obtained during ventricular systole, shows that the atrioventricular valve cusps are coapted or closed, allowing blood to be pumped in an antegrade direction into the pulmonary and systemic arteries by the contracting myocardium without regurgitation or retrograde flow into the atria.*
 ![Four-chamber gated cardiac SSFP MR obtained during diastole in the same patient demonstrates that the cusps of the atrioventricular valves are open, allowing blood to flow in an antegrade direction from the atria to fill the bilateral ventricles. The papillary muscles where the chordae tendineae attach are also visualized. There are small, bilateral pleural effusions, larger on the right.](images/app.statdx.com_image_thumbnail_d3271d49-d796-4e8b-8495-1920afbb12fc_annotated_false_size_900_quality_90_5c47b6ef5ed212d66970a3f3c4d865e7e50e464c.jpg)
 *Four-chamber gated cardiac SSFP MR obtained during diastole in the same patient demonstrates that the cusps of the atrioventricular valves are open, allowing blood to flow in an antegrade direction from the atria to fill the bilateral ventricles. The papillary muscles where the chordae tendineae attach are also visualized. There are small, bilateral pleural effusions, larger on the right.*
 ![Three-chamber gated cardiac SSFP MR demonstrates the function of the mitral and aortic valves. Left ventricular outflow tract view obtained during ventricular systole demonstrates that the aortic valve cusps are not visible at the aortic root distal to the right ventricular outflow tract, indicating that the aortic valve is open to allow antegrade flow of blood into the aorta. The mitral valve cusps are closed or coapted to prevent regurgitation of ventricular blood into the left atrium.](images/app.statdx.com_image_thumbnail_46cd7452-8513-4aab-bb77-cba347c68fe2_annotated_false_size_900_quality_90_c707bec7ac85ee9443254c5fd76e385d40812c0a.jpg)
 *Three-chamber gated cardiac SSFP MR demonstrates the function of the mitral and aortic valves. Left ventricular outflow tract view obtained during ventricular systole demonstrates that the aortic valve cusps are not visible at the aortic root distal to the right ventricular outflow tract, indicating that the aortic valve is open to allow antegrade flow of blood into the aorta. The mitral valve cusps are closed or coapted to prevent regurgitation of ventricular blood into the left atrium.*
 ![Three-chamber gated cardiac SSFP MR obtained during diastole in the same patient shows that the mitral valve cusps are open to allow blood to flow into the left ventricle. The aortic valve cusps are closed, preventing retrograde flow of blood from the aorta. The papillary muscles of the left ventricle and moderator band of the right ventricle are also visualized.](images/app.statdx.com_image_thumbnail_51f23442-1dcb-4d1c-b947-16dbb0f78664_annotated_false_size_900_quality_90_2190f3ef635b7897ae22424249dfacfe9ddd1a8c.jpg)
 *Three-chamber gated cardiac SSFP MR obtained during diastole in the same patient shows that the mitral valve cusps are open to allow blood to flow into the left ventricle. The aortic valve cusps are closed, preventing retrograde flow of blood from the aorta. The papillary muscles of the left ventricle and moderator band of the right ventricle are also visualized.*
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