Heart anatomical images: Ilustration Picture of Anatomical Structures – Heart

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Содержание

Cardiac ultrasound: An Anatomical and Clinical Review

https://doi.org/10.1016/j.tria.2020.100083Get rights and content

Highlights

•: Ultrasound not only provides a diagnosis but allow for the development of treatment modalities.
•: Cardiac images may be obtained via several techniques; some are invasive while most are not.
•: Transthoracic ultrasound may be achieved via several windows in different planes of view.

Abstract

Background

The importance of cardiac examination is supported by the ever-increasing incidence of heart disease. Traditional examination and auscultation techniques may not provide the level of sensitivity required for identifying certain conditions. Development of cardiac ultrasound (echocardiography) techniques has added greatly to the discipline. Ultrasound images do not only provide a means of diagnosis but allow for the development of treatment modalities and easy monitoring of disease progression.

Results

Cardiac images may be obtained via several techniques; some are invasive while most are not. Transthoracic ultrasound may be achieved via several windows in different planes of view and is non-invasive. While it allows for better imaging of all cardiac structures, some parts such as the mitral and aortic valve function can be viewed best by transesophageal echocardiography, a more invasive technique. Each modality and window tend to be more sensitive to certain cardiac structures than others.

Conclusions

This review discusses the different modalities and their advantages and provides a comparison to other imaging modalities.

Keywords

Echocardiography

Ultrasonography

Heart diseases

Heart

Transesophageal echocardiography

Cardiac imaging techniques

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The right ventricle: anatomy, physiology and clinical imaging

Not long ago the right ventricle (RV) was considered an “unnecessary” part of the normal circulation. While factually correct—ablation or replacement of the RV free wall can be well tolerated by experimental animals without reduction in cardiac output, and many surgical algorithms for congenital heart diseases culminate in a circulation devoid of a sub-pulmonary ventricle, a Fontan procedure, for example—it is clear that such circulations are far from normal. Furthermore, recent studies consistently demonstrate a central role for RV dysfunction in the prognosis and outcomes for a wide variety of acquired and congenital cardiac conditions. Consequently there has been a renewed interest in the singular role of the RV, as well as its influence on global function via biventricular interactions. In this review, we will discuss some of the challenges encountered in the measurement of RV volume and function in the context of the RV’s unique anatomic structure and physiology.

ANATOMIC CONSIDERATIONS

The role of both ventricles is to propel blood forward in the circulation. To enable this mechanical role, ventricular function is intimately related to ventricular structure. However, the two ventricles differ. Morphologically, the RV is distinguished from the left ventricle (LV) by having coarser trabeculae, a moderator band, and a lack of fibrous continuity between its inlet and outflow valves. In the RV the pulmonary valve sits on a freestanding muscular infundibulum and the crista supraventricularis courses between it and the tricuspid valve to aid free wall contraction toward the interventricular septum. Because it normally operates at a lower pressure than the LV, the RV has a thinner wall. Its septal contour is indented by the dominant LV, producing a shape that is difficult to model geometrically (fig 1).

Figure 1 Three dimensional reconstructions of the right ventricle (RV) illustrating its complex shape in a normal subject (A). RV remodelling in diseased hearts can result in profound shape change, as in this patient (B) with dilated RV due to severe pulmonary regurgitation following repair of tetralogy of Fallot. The mesh surface is the left ventricle. LV, left ventricle; P, pulmonary valve; RV, right ventricle; T, tricuspid valve. See Sheehan and Bolson14 for explanation of reconstruction method.

Nearly all studies of ventricular fibre structure were performed on the LV.1 Dissection studies showed that its fibres course …

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What is the real cardiac anatomy? – Mori – 2019 – Clinical Anatomy

INTRODUCTION

Cardiac anatomy is usually taught to medical students on the basis of examination of the cadaveric hearts opened and studied in the dissecting room. This approach, despite multiple limitations, has endured over the passage of time (Maresky et al., 2018). Such dissection of the heart, due to the complex three-dimensional interrelations of its component parts, is known to be challenging (Stanford et al., 1994). It is also well recognized that the elements of anatomy taught in the first year of the medical curriculum do not always instill a lasting knowledge (Hołda et al. , 2019). Detailed knowledge of the structure and location of the cardiac components, nonetheless, is essential information for those diagnosing and treating cardiac disease. With the intention of improving the initial acquisition of this knowledge, we have recently emphasized the value of virtual reconstructions of datasets obtained in the clinical setting (Mori et al., 2016a). When using a similar approach, medical students were shown not only to enjoy the exposure to three-dimensional reconstructions, but also significantly to improve their acquisition of the details of cardiac anatomy (Maresky et al., 2018). These developments in the technology of clinical imaging have made it possible to reveal all the details of cardiac anatomy without distorting the relationships to the intrathoracic structures (Mori et al., 2016a). There is no reason, therefore, why the nuances of cardiac anatomy should not now be taught to medical students using the attitudinally appropriate approach. This is more important for those who point to the advantages of virtual reality (Maresky et al., 2018; Anderson et al., 2018a). In this review, we show how such anatomically accurate virtual reconstruction is, indeed, capable of revealing the complex three-dimensional interrelations of its component parts.

IMAGE ACQUISITION AND RECONSTRUCTION

All images were reconstructed from full volume datasets obtained from adult patients. They had undergone electrocardiographically-gated contrast-enhanced cardiac computed tomography using commercially available multidetector-row scanners (SOMATOM Force, Siemens Healthcare, Forchheim, Germany). From the datasets available, we reconstructed selected examples showing normal features in the absence of any significant coronary arterial lesions or abnormal extracardiac findings, aside from the use of one dataset chosen from a patient with a pericardial effusion. Virtual dissections and reconstructions were subsequently performed using a commercially available workstation (Ziostation2 ver. 2.4.2.3.; Ziosoft Inc., Tokyo, Japan).

PLACING THE HEART IN THE CHEST

One of the first rules of human anatomy is that all bodily parts should be described as viewed in the so-called anatomical position (Anderson and Loukas, 2009). This means that the heart should be described as it is normally positioned within the thorax (Fig. 1; Cosío et al., 1999; Anderson et al., 2013). It is difficult in the dissecting room, however, to assess the interrelationships of the cardiac components while the organ itself remains embedded within the mediastinum and encased by the thoracic skeleton and the lungs. It is almost certainly the need to remove the heart from the thorax so as to identify its individual components that has led to its usual description in so-called “Valentine” fashion. In this arrangement, which is currently followed in the greater majority of textbooks used for education of medical students, the organ is shown as positioned on its apex (Fig. 2). In the Valentine approach, the atrial chambers are shown inappropriately directly above the ventricles, with the right-sided structures shown as though truly right-sided relative to their allegedly left-sided counterparts (Anderson et al., 2013). When taking advantage of the images obtained from datasets prepared using the commercially available software used by clinicians, it is now possible to show the heart as it is properly situated within the thorax (Fig. 3).

The heart occupies the middle part of the mediastinum, but its long axis is markedly skewed relative to the long axis of body. Virtual dissection is able to show the heart in the so-called anatomical position. White arrows indicate the acute margin. Regarding the orientation cube attached in all following figures, the letters appeared as A, P, H, F, R, and L indicate anterior, posterior, superior (head), inferior (foot), right, and left, respectively. [Color figure can be viewed at wileyonlinelibrary.com]

A view of the heart from the left anterior oblique 45° and cranial 45°direction. Only in this projection, which is attitudinally inappropriate, can the heart be viewed in the so-called Valentine position. White arrows indicate the acute margin. [Color figure can be viewed at wileyonlinelibrary.com]

This virtual dissection, revealing the thoracic contents, shows reason why echocardiographic windows are limited when using the transthoracic approach. [Color figure can be viewed at wileyonlinelibrary.com]

SEGMENTING THE CARDIAC COMPONENTS

The great advantage of access to the clinical datasets as prepared using computed tomography is that it proves possible to segment not only the different components of the heart, but also the remaining thoracic organs. It is then possible to appropriately replace the significant parts of the heart within the body, and to reveal their attitudinally appropriate relationships (Anderson, 2015). The structures can be placed within the chest radiograph as viewed in frontal orientation, which is how the heart is viewed in the standard clinical examination (Fig. 4). Such virtual dissection shows that, within the middle component of the mediastinum, and directly behind the heart, the descending aorta is located within the left paravertebral gutter, with the azygos vein crossing from left to right (Fig. 4a). The left atrium is the most posterior cardiac component, being located directly in front of the esophagus, with the asymmetric branching pattern of the trachea seen cranially (Fig. 4b,c). When the left ventricle is added to the reconstruction (Fig. 4e), it can be appreciated that its long axis of the ventricular mass is directed from right posterior to left anterior, with an additional inferior tilt (Fig. 5; Mori et al., 2017a). The axis does not run from up to down, as is suggested in the usual Valentine approach (Fig. 2). The addition of the ascending aorta provides the crucial knowledge that its root springs from the centerpiece of the cardiac silhouette (Figs. 4f and 6; Dean et al., 1994; Anderson et al., 2000; Mori et al., 2017b). Completion of the cardiac silhouette with the addition of the so-called “right-sided” chambers shows that, although right-sided in part, they are also anteriorly positioned relative to their left-sided partners (Fig. 4d,g,h). In particular, the reconstruction now shows that the pulmonary root is anterior and leftward relative to the aortic root (Anderson et al., 2004). The intrapericardial component of the aorta can then be seen to ascend through the middle of the cardiac shadow, but with marked spiraling relative to the pulmonary trunk, which extends caudally prior to bifurcating into the right and left pulmonary arteries (Fig. 4h; Anderson et al., 2003a, Anderson et al., 2016).

The step-wise virtual dissection shows the contents of the middle mediastinum as viewed from the frontal direction. By tracking from the left upper (a) to the right lower panels (h), the components constructing and supporting the cardiac contour are demonstrated in order from the posterior direction. [Color figure can be viewed at wileyonlinelibrary.com]

The virtual images, shown in frontal (upper panel) and left lateral (lower panel) projections demonstrate how the branches of the coronary arteries delimit the extent of the left ventricle within the ventricular cone, with branches occupying the atrioventricular and interventricular grooves. The yellow dotted arrows show the long axis of the left ventricle, which runs leftward and inferiorly when traced from posterior to anterior. The images show how the artery occupying the inferior interventricular groove is never posterior to its counterpart in the anterior interventricular groove. It is a mistake to name this artery as being posterior and descending. [Color figure can be viewed at wileyonlinelibrary.com]

When the so-called “five-chamber view” is created at the level of both inferior pulmonary veins, and then viewed from the superior direction, the spatial relationships between the cardiac chambers, as well as the central wedging of the aortic root, can be recognized in attitudinally appropriate fashion. The upper panel shows an endocast image mainly focusing on the relationships among each cavity, with the cavities removed in the lower panel to focus on the walls and septums (virtual dissection image). [Color figure can be viewed at wileyonlinelibrary.com]

As with the left ventricle, the long axis of the right ventricle is similarly running from right posterior to left anterior (Figs. 4h and 6; Mori et al., 2017a). Most significantly, by virtue of its position on the diaphragm, its parietal border, also known as the acute margin, is located inferiorly, rather than rightward as is suggested when the heart is viewed in Valentine orientation (Compare Figs. 1 and 2).

These true relationships, as revealed by segmentation of the cardiac components, combined with the ability of the virtual dissector to place them back within the cardiac silhouette (Fig. 4), show well why it is transesophageal echocardiographic interrogation that best reveals the details of the posteriorly positioned left atrium, as well as the descending aorta and, on occasion, the aortic arch (Willens and Kessler, 2000). It is only the tip of the appendage of the left atrium, located to the left side of the right ventricular infundibulum, which can be seen when the heart is viewed from the frontal direction (Fig. 1; Anderson et al., 2004). Perhaps the most significant feature revealed by virtual dissection, however, is the central location of the aortic root within the base of the ventricular mass (Fig. 6; Anderson, 2000).

The inestimable added value of virtual dissection is that it also permits segmentation of the location of the hingelines of the valves which guard the junctions between the cardiac components, thus showing their relationships to each other (Anderson et al., 2004; Mori et al., 2016b). More importantly, it reveals their specific positions within the base of the ventricular mass (Fig. 7). Once the hinges of the leaflets of the valves have been placed within the cardiac silhouette, they can be viewed not only in frontal projection, which demonstrates their attitudinally appropriate relationships, but also in right and left oblique projections. It is these latter projections that show the structures as typically viewed by clinical cardiologists (Fig. 7—right hand and left-hand panels). Having placed the valvar hinges within the silhouette, the most obvious feature is that, while the leaflets of the atrioventricular valves are hinged in relatively planar fashion, justifying the description of “annulus” for the atrioventricular valves, this is not the case for the arterial valves (Anderson et al., 2004; Mori et al., 2016b). When reconstructed in three-dimensions, the attachments of the arterial valvar leaflets take the form of three-pronged coronets (Fig. 7; Anderson, 2000; Anderson et al., 2004). The pulmonary root is located anteriorly and leftward relative to the aortic root (Fig. 7). Comparison of the three panels of Figure 7 also shows the marked discrepancy between the long axes of the two arterial roots. This reflects the spiraling of the outflow tract of the right ventricle as it swings from the inferiorly located apical component to the superiorly positioned pulmonary valve (Figs. 4 and 7; Anderson et al., 2003a, 2016). The reconstructions also show the problems that have arisen due to the different definitions provided for an “annulus” within the arterial roots (Sievers et al., 2012). The so-called “annulus’ as defined by clinical echocardiographers is no more than a virtual plane, created by joining together the basal attachments of the semilunar hinges (Tretter et al., 2016). It has no anatomical counterpart (Fig. 8).

The upper panels show the external aspect of the heart as viewed from the front (middle panel) and in right and left oblique projections (left-hand and right-hand panels). The middle row panels show the locations of the hinges of the valvar leaflets reconstructed within the cardiac contour, along with the membranous septum, as seen in the comparable projections. The lower panels show the hinges of the valvar leaflets incorporated in the multiplanar reconstruction sections, as seen in the comparable projections. The attachments of the aortic and pulmonary valves take the form of three-pronged coronets. [Color figure can be viewed at wileyonlinelibrary.com]

The reconstructions show the aortic root (upper panel) and pulmonary root (lower panel) as viewed from the same direction. The red dotted lines indicate the sinutubular junction, while the white dotted lines denote the anatomical ventriculo-arterial junction. The yellow dotted lines indicate the plane of the virtual basal ring. [Color figure can be viewed at wileyonlinelibrary.com]

ASSESSING THE ANATOMY OF THE CARDIAC COMPONENTS

Once having segmented the individual components of the heart, it is then an easy matter to assess each component separately, and to identify their individual parts. In this way, it can be shown that each atrial chamber possesses a body, a venous component, an appendage, and a vestibule (Anderson and Cook, 2007). The cavities themselves are separated by the atrial septum (Fig. 9). The atrial component of the developing heart tube forms the body of the developing chamber, which in the postnatal heart is almost exclusively committed to the left atrium (Anderson et al., 2003b; Jensen et al., 2017). The most consistent right atrial component is the appendage, making up the entirety of the anterior wall (Fig. 7). It is distinguished from the remainder of the atrium by its lining of pectinate muscles, which branch from the prominent terminal crest. This internal feature, corresponding to the external terminal groove, marks the border between the appendage and the venous component (Figs. 9-11). The systemic venous component of the atrium receives the superior caval vein at its roof, and the inferior caval vein in its floor (Figs. 10 and 11). Virtual dissection can also reveal the extent of the remnants of the valve of the systemic venous sinus, although not as accurately as true dissection. The remnants persist postnatally as the Eustachian and Thebesian valves. Examination of both true and virtual dissection shows that the so-called sub-Eustachian sinus of the right atrial vestibule is sub-Thebesian when the heart is assessed in attitudinally appropriate position (Fig. 12). The advantage of the virtual approach is that it becomes an easy matter to show the extent of the pectinate muscles which line the inner surface of the walls of the appendages. Such virtual dissection reveals that the pectinate muscles in the left atrium are confined within the tubular appendage. In the right atrium, in contrast, they encircle the vestibule of the tricuspid valve (Fig. 9). It is the morphology of the appendages that is now known to be the distinguishing criterion between the atrial chambers in the setting of congenital cardiac disease (Anderson, 2001). The ability to demonstrate the extent of the pectinate muscles, therefore, achieves particular clinical significance to correctly recognize cardiac isomerism (Uemura et al., 1995; Loomba et al., 2015; Mori et al., 2017c). Although it is also possible to open the hearts in the autopsy room while retaining their attitudinally appropriate positions, the very act of opening them so as to reveal the internal features produces some degree of distortion. This is avoided when using virtual dissection, with the added advantage that the dissected chambers are seen in the form they take during their normal hemodynamic functioning. This virtual approach also reveals that the pulmonary venous component of the left atrium is positioned superiorly rather than posteriorly (Fig. 13). It also serves to emphasize the extensive fold found between the tubular appendage and the termination of the left superior pulmonary vein (Fig. 14).

The reconstruction in the upper panel shows that the pectinate muscles in the left atrium are confined within the tubular appendage, whereas in the right atrium, they encircle the vestibule of the tricuspid valve. When the so-called “four-chamber view” is created at the level of both inferior pulmonary veins, as shown in the lower panel, and then viewed from the superior direction, it is possible to appreciate the extent of the left atrial body. [Color figure can be viewed at wileyonlinelibrary.com]

The reconstruction in the upper panel shows the location of the terminal groove (red arrows), which forms the boundary between the venous component and appendage of the right atrium. When the adipose density is additionally reconstructed, as shown in the lower panel, it is possible also to demonstrate the course of phrenic nerve (red-rimmed white arrows). [Color figure can be viewed at wileyonlinelibrary.com]

Virtual dissection is then able to reveal the internal aspect of the right atrium showing the terminal crest (red arrows) interposed between the venous component and the appendage. Note the pectinate muscles branching at right angles from the terminal crest. [Color figure can be viewed at wileyonlinelibrary.com]

The virtual dissections are viewed from the right anterior oblique 45° direction. The transparency of the surface myocardium is increased in the lower panel to demonstrate the interatrial folds. It also shows the location of the inferior pyramidal space at the septal aspect of the right atrium. The dissection also reveals that the so-called sub-Eustachian sinus is really sub-Thebesian. [Color figure can be viewed at wileyonlinelibrary.com]

The step-wise virtual dissection shows the cardiac components as viewed from the posterior direction. Moving from left to right, and from the upper to the lower panels, it was possible to remove the descending aorta (right upper panel), the esophagus and trachea (left lower panel), and the ascending aorta and right heart (right lower panel). [Color figure can be viewed at wileyonlinelibrary.com]

The dissection reveals the so-called “two-chamber” image as seen from the right anterior oblique direction. It shows well the extensive fold which exists between the tubular left atrial appendage and the orifice of the left pulmonary veins. Note the relationship of the papillary muscles of the mitral valve. [Color figure can be viewed at wileyonlinelibrary.com]

Virtual dissection also reveals the limited extent of the true atrial septum (Mori et al., 2016c; Mori et al., 2018a). The larger parts of the rims of the oval fossa are shown to be no more than folds between the right and left atrial walls. It is the floor of the fossa, derived from the primary atrial septum, along with the antero-inferior buttress, formed by muscularization of the vestibular spine and the mesenchymal cap carried on the leading edge of the primary septum (Jensen et al., 2017), which form the components that can be removed without transgressing on extracavitary space (Fig. 12). The antero-inferior buttress of the septum is itself contiguous with the septal component of the vestibule of the right atrium. It is in this area that there is off-setting of the hinges of the leaflets of the mitral and tricuspid valves (Spicer et al., 2014).

The coronary sinus, having traversed the left atrioventricular groove, opens into the vestibular area forming the floor of this space. It used to be thought that the area of overlap between the atrial wall of the space and the underlying ventricular myocardium formed an atrioventricular muscular septum (Becker and Anderson, 1982). Careful dissection of autopsied hearts showed this not to be the case, with the area between the atrial and ventricular walls being formed by a cranial extension of the fibroadipose tissue from the inferior atrioventricular groove. The same details are shown by virtual dissection (Fig. 15). Such virtual dissection shows that the area is an open sandwich, rather than a true septum (Fig. 9; Dean et al., 1994; Anderson et al., 2000). The area in question is shown to be the inferior pyramidal space (Farré et al., 2010), with its superior extent limited by the atrioventricular component of the membranous septum (Figs. 12 and 15; Mori et al., 2015a). The inferior pyramidal space forms the floor of the triangle of Koch (Figs. 9, 12, 15, and 16; Mori et al., 2015b)

The virtual dissections show that the inferior pyramidal space (red dotted lines) is filled by a cranial extension of the extracardiac fibro-adipose tissue that also occupies the atrioventricular junctions. The upper panel is a cut viewed in right anterior oblique projection, while the lower panel is seen from the left anterior oblique aspect, opening out the orifices of the atrioventricular valves. Pink and blue circles indicate the hinges of the mitral and tricuspid valvar leaflets, respectively. The green area denotes the membranous septum. See also Figure 7. [Color figure can be viewed at wileyonlinelibrary.com]

The virtual dissections have been designed to show that left (upper panel) and right (lower panel) ventricle has inlet, apical trabecular, and outlet components. The triangle of Koch is the area bounded by the tendon of Todaro posteriorly, the central fibrous body (membranous septum and right fibrous trigone) apically, and the tricuspid valvar attachment anteriorly, with the orifice of the coronary sinus forming the inferior base (lower panel). [Color figure can be viewed at wileyonlinelibrary.com]

As is the case with the atrial chambers, both true and virtual dissections are able to demonstrate the extent of the ventricular myocardial cone (Mori et al., 2015c; Mori et al., 2016d). Using either technique, each ventricle within the cone can be shown to have inlet, apical trabecular, and outlet components (Fig. 16). The inlet components surround and support the atrioventricular valves, with their distal limits marked by the origins of the papillary muscles. The apical components have coarse trabeculations within the right ventricle, but fine cross-crossing trabeculations in the left ventricle (Fig. 16). It is the coarseness of the trabeculations that is the final arbiter of morphologically rightness or leftness when the heart is congenitally malformed (Anderson et al., 2004; Jacobs et al., 2007). These features are arguably better seen in cadaveric or autopsied hearts, although they can be distinguished subsequent to appropriate virtual dissection (Fig. 16). The structure of the outflow components also serves to provide another obvious morphological difference between the chambers when the heart itself is normally formed. The outlet is much abbreviated in the left ventricle, by virtue of the fibrous continuity between the leaflets of the mitral and aortic valves (Fig. 16). The right ventricle, in contrast, possesses a long infundibulum, the distal part of which is a free-standing muscular sleeve. This lifts the leaflets of the pulmonary valve away from the base of the ventricular cone (Fig. 17; Lamers and Moorman, 2002; Anderson et al., 2003a,b; Webb et al., 2003; Anderson et al., 2014). It is the presence of the free-standing infundibular sleeve that permits the entirety of the pulmonary root to be removed and used as an aortic autograft in the Ross procedure (Merrick et al., 2000). The inter-relationships of the valves in the two ventricles influence the septal morphology. Because of the deeply wedged location of the aortic root, the inferior part of the muscular ventricular septum separates the inlet of the right ventricle from the outlet of the left (Fig. 18). And, because of the presence of the extensive free-standing infundibular sleeve, there is no muscular septum between the two outlets (Crucean et al., 2014). Thus, the ventricular septum is almost totally composed of the apical muscular septum. In the inner curvature of the heart, however, directly inferior to the aortic root, there is a small part of the septum that is fibrous (Figs. 12 and 17). This is conventionally described as the membranous septum. In many instances, this fibrous part of the septum is crossed by the hinge of the septal leaflet of the tricuspid valve, dividing it into atrioventricular and interventricular components (Fig. 15; Anderson et al., 2004).

The cuts of the heart show the arrangement as viewed from the right anterior and left anterior oblique projections in the upper and lower panels, respectively. The black-rimmed arrows in the upper panel indicate the crest of the muscular ventricular septum, which is the anticipated location of the atrioventricular conduction axis. The red rimmed arrows in the lower panel show the fibro-adipose tissue plane extending from the left ventricular free wall to the crest of the muscular ventricular septum, thus creating the free-standing pulmonary infundibulum. [Color figure can be viewed at wileyonlinelibrary.com]

The images show how it is views of the heart taken from the right anterior oblique direction that produce the Valentine position, along with rotation so as to place the apex downward. The upper panel is the endocast image, while the lower panel is the virtual dissection including the walls. [Color figure can be viewed at wileyonlinelibrary.com]

Virtual dissection shows particularly well the make-up of the third, or outlet, compartment of the heart. This is composed of the arterial roots, along with the intrapericardial components of the arterial trunks (Fig. 19; Anderson et al., 2016). The proximal border of each arterial root is the virtual basal ring formed by joining together the nadirs of the three semilunar leaflets of the arterial valves (Fig. 8; Anderson, 2000; Anderson et al., 2004; Anderson et al., 2018b). As already discussed, this plane has no anatomic counterpart, but is described by echocardiographers as the valvar annulus (Mori et al., 2017d). The distal extent of the roots is the sinutubular junction, where the semilunar hinges meet together at their circumference (Fig. 8). The proximal boundary of each root is the virtual basal plane. This line itself is proximal to the anatomic junction between the myocardium of the ventricular cone and the fibro-elastic sinuses of the roots which support the greater part of the semilunar hinges of the valvar leaflets. This potential paradox is explained by the fact that the basal hinges of some of the leaflets extend proximally relative to the anatomic ventriculo-arterial junction (Fig. 8). By virtue of this arrangement, crescents of myocardium are incorporated at the bases of each of the sinuses of the pulmonary root (Fig. 20; Anderson et al., 2018b, c). In the aortic root, however, because of the fibrous continuity found posteriorly between the leaflets of the aortic and mitral valves, myocardium is incorporated into the bases of only the two valvar sinuses that give rise to the coronary arteries (Figs. 8 and 20; Mori et al., 2016a). The spaces on the ventricular aspect of the attachments of the valvar leaflets to the sinutubular junction are themselves filled by fibrous tissue, even though they are the distal parts of the ventricular chambers. These are the interleaflet triangles (Fig. 8; Sutton et al., 1995). The apical parts of these triangles separate the ventricular cavities from the pericardial space (Anderson, 2000; Mori et al., 2016d). The triangle between the non-coronary and right coronary sinuses of the aortic root is particularly significant (Tretter et al., 2018; Mori et al., 2018b), since it is continuous proximally with the membranous part of the septum (Fig. 15).

The virtual dissections show how it is also possible to demonstrate the extent of the pericardial cavity, with the upper panel showing the heart as seen from the front. The arrows in the lower panel denote the pericardial reflections. These images were reconstructed from a patient with a pericardial effusion. [Color figure can be viewed at wileyonlinelibrary.com]

The dissections are made to show the crescents of myocardium found at the bases of the arterial sinuses (white stars). The crescents are found at the base of each valvar sinus in the pulmonary root (upper panels), whereas they are found only at the bottom of the right coronary aortic sinus and anterior half of the left coronary aortic sinus in the aortic root (lower panels). The white dashed lines indicate the extent of muscular support on the virtual basal ring plane. The red dashed line denotes the aortic-to-mitral continuity. See also Figure 8. [Color figure can be viewed at wileyonlinelibrary.com]

THE CORONARY VASCULATURE

The ability to segment the various cardiac components also extends to the branches of the coronary arteries and veins. The advantage of virtual dissection in this context is that it then shows these cardiac components as they are visualized by clinicians studying angiograms, and nowadays by using computed tomographic interrogation or magnetic resonance imaging. As already emphasized, when using virtual dissection, it proves possible not only to show the location of the various structures as seen relative to the frontal cardiac silhouette, but also in the oblique projections as used by clinicians to distinguish the various vessels (Figs. 21 and 22). The images show how the coronary arteries are the initial branches of the aortic root, while the major venous tributaries drain to the coronary sinus (Figs. 21 and 22). Although there are three aortic valvar sinuses, the coronary arteries take origin only from the two that are adjacent to the pulmonary root (Fig. 21). It is customary, nonetheless, to describe three major arteries. This is because the left coronary artery divides almost immediately into the anterior interventricular and circumflex arteries (Fig. 21). The circumflex and right coronary arteries then occupy the atrioventricular grooves, while the anterior interventricular artery, usually described as the left anterior descending artery, occupies the anterior interventricular groove (Figs. 1 and 2). Another prominent artery then occupies the interventricular groove found on the diaphragmatic aspect of the ventricular mass. This groove, and the coronary artery it contains, is located inferiorly (Fig. 1). Only when the heart is spuriously described in Valentine fashion can the artery be considered to be posterior and descending (Fig. 2). In reality, it is inferior and interventricular (Anderson and Loukas, 2009). It is accompanied by a coronary vein that would, in similar fashion, best be described as the inferior interventricular vein (Fig. 22). The great cardiac vein accompanies the anterior interventricular and circumflex arteries. It is the union of this vein with the oblique vein of the left atrium, also known as the vein of Marshall, which marks the beginning of the coronary sinus.

The reconstructions show the coronary arteries as viewed from the frontal and right and left anterior oblique 45° directions. [Color figure can be viewed at wileyonlinelibrary.com]

Comparable reconstructions to those shown in Figure 21 show the coronary veins viewed from the frontal and right and left anterior oblique 45° directions. [Color figure can be viewed at wileyonlinelibrary.com]

THE NEED FOR ATTITUDINALLY APPROPRIATE DESCRIPTION

The basic rules of human anatomy dictate that cranial, caudal, left, right, ventral, and dorsal directions should be referred to as superior, inferior, left, right, anterior, and posterior directions, respectively (Cosío et al., 1999; Anderson and Loukas, 2009; Anderson et al., 2013). This is the essence of description relative to the anatomical position. As we have already emphasized, it is this rule that should underscore the terms used to described all bodily components. As with every other structure within the body, this attitudinally appropriate nomenclature should have traditionally been used to account for the detailed anatomy of cardiac structures. It is unfortunate that for centuries the heart has been described as if removed from the thorax and positioned on its apex, producing the so-called Valentine arrangement (Figs. 2 and 18). It is equally unfortunate that this inappropriate use of “Valentine” nomenclature remains the standard for current teaching of medical students, and continues to retain its currency by most of those practicing clinical cardiology. The increasing use of three-dimensional imaging techniques now serves to emphasize the deficiencies of the non-attitudinal approach (Anderson, 2015). The deficiencies are now painfully obvious when images are viewed as prepared using the virtual dissection of computed tomographic datasets.

Perhaps the most egregious ongoing deficiency of the Valentine approach is the naming of the inferior interventricular artery. When imaging the heart in its correct anatomical location, the course of this artery is certainly not posterior, and it is barely descending. Instead, the vessel, along with its accompanying vein, runs more-or-less horizontally on the inferior, or diaphragmatic, surface of the ventricular cone (Fig. 1). It is this location that explains why blockage of the artery produces inferior, and not posterior, myocardial infarction (Anderson and Loukas, 2009). The logic underscoring knowledge of the electrocardiogram, furthermore, is based firmly on the fact that the recordings are made and analyzed with the subject occupying the anatomical position (Mori et al., 2016a). Renaming the vessel as the inferior interventricular artery will surely facilitate the understanding of its actual location for medical students (Figs. 1, 5, and 21), which will be more important for them as they proceed to their clinical training.

The medical students, when they become clinical trainees, unfortunately, will encounter further problems. It is only when the heart is described on the basis of the Valentine position that it becomes possible to understand the current names given to the papillary muscles of the mitral valve. When observing the valve itself as it is positioned within the thorax, its leaflets are best described as being aortic and mural, although “anterior” and “posterior” are approximately accurate (Figs. 17, 23, and 24). Assessment of the locations of the papillary muscles, in contrast, leaves no question but they are located infero-medially and supero-laterally (Figs. 14, 23, and 24). In similar fashion, it becomes obvious that the so-called “posterior” leaflet of the tricuspid valve is, in reality, the inferior leaflet (Anderson et al., 2013; Spicer et al., 2014; Mori et al., 2016b). It is the septal leaflet of the tricuspid valve that is located leftward and posteriorly within the right atrioventricular junction (Figs. 9 and 23).

The dissection made to show a short axis cut across the ventricular cone viewed in attitudinally appropriate fashion from the left anterior oblique 45° direction shows that the papillary muscles of the mitral valve are located infero-medially and supero-laterally. The leaflets of the tricuspid valve are positioned antero-superiorly, inferiorly, and septally. [Color figure can be viewed at wileyonlinelibrary.com]

As is demonstrated in the panels, which are sagittal cuts taken at apical (left hand), middle (middle panel), and basal (right hand) level of the anterior interventricular artery, the septal wall is always anterior to its lateral counterpart. It can also be seen that the anterior interventricular artery is always located superiorly relative to the inferior interventricular artery, and that it takes an antero-inferior course as it descends. It is also evident that describing the mitral leaflet as having anterior and posterior leaflets is not incorrect. The papillary muscles of the left ventricle, however, are not positioned “postero-septally” and antero-laterally”, as they are frequently described at the moment. It is also clear that the wall opposite the inferior quadrant of the ventricular cone is positioned superiorly, and not anteriorly. [Color figure can be viewed at wileyonlinelibrary.com]

INCONSISTENCIES IN THE SEGMENTATION OF THE LEFT VENTRICULAR CONE

Comparison of Figures 1 and 2 shows that the superior and inferior walls of the left ventricular cone, as seen in attitudinally appropriate orientation, are equivalent to those described as being anterior and posterior by those using the Valentine approach. The inappropriate use of “posterior” in this regard has been recognized when accounting for the inferior wall of the left ventricle by those using echocardiography (Cerqueira et al., 2002; Lang et al., 2015). It is difficult to understand, therefore, why those accepting the inappropriate use of “posterior” should continue to be use anterior rather than superior when describing the opposite wall (Lang et al., 2015). The antonym of “inferior” must surely be “superior”? The situation, however, is not as clear cut as it might seem. This is because the long axis of the left ventricle is not directly anterior relative to the spine and sternum, but rather is directed in left anterior and slightly inferior fashion (Figs. 5 and 6; Loukas et al., 2016; Mori et al., 2017a). Thus, when assessing short axis images of the ventricular cone in left anterior oblique projection, the side of the cone seen to the left hand is directed not only anteriorly but also rightward. The component of the wall seen to the right hand is similarly located posteriorly and leftward, rather than being directly posterior, as we have suggested in our previous papers (Cosío et al., 1999; Anderson and Mori, 2016). When we then consider the walls of the ventricular cone themselves, nonetheless, it remains the case that, in any given sagittal cut through the ventricular cone, the septal wall is always anterior to its lateral counterpart (Fig. 24). If, in this context, we assess the course of the interventricular coronary artery universally described as being “anterior”, we find that the vessel, as it extends anteriorly and leftward from its aortic sinus origin, is consistently positioned superiorly relative to its partner occupying the inferior interventricular groove. The latter artery, as discussed, is located inferiorly rather than posteriorly. Its blockage produces inferior myocardial infarction. Blockage of the artery occupying the superior interventricular groove, nonetheless, does lead to antero-septal infarction. Proposals to rename this vessel as being the superior interventricular artery, with the consequence of correcting “antero-septal infarction” to “supero-septal infarction”, might be considered a step too far. But we cannot disguise the fact that the antonym of the inferior is superior. And, even though the long axis of the ventricular cone is tilted inferiorly and leftward when traced from posterior to anterior (Fig. 5), it is always the case that the septal wall is always anterior to its lateral counterpart in any given sagittal cut through the ventricular cone (Fig. 24). The current inconsistencies in nomenclature of the echocardiographic ventricular segments, therefore, can be made anatomically accurate simply by describing septal and lateral quadrants in addition to those which, on direct observation, are self-evidently seen to be located superiorly and inferiorly (Fig. 25).

The virtual dissection is made to show a short axis cut across the ventricular cone as viewed from the left anterior oblique 45° direction. As shown, the four quadrants of the cone can accurately be described as being superior, inferior, septal, and lateral. Note we have labeled the interventricular artery occupying the superior interior interventricular groove as being anterior, since it does run anteriorly as it extends to the ventricular apex, and its blockage does produce antero-septal myocardial infarction. The artery within the inferior interventricular groove, however, is correctly identified as being inferior, with its blockage producing inferior myocardial infarction. [Color figure can be viewed at wileyonlinelibrary.com]

CONCLUSIONS

Careful virtual dissection of three-dimensional datasets obtained from living patients now permits demonstration of all the necessary details of cardiac anatomy, paralleling the information that can be revealed by true dissection of cadaveric or autopsied hearts. Since the datasets are obtained with the individuals in the anatomical position, however, the components are readily described following the basic rules of human anatomy, in other words, in attitudinally appropriate fashion. These subtle features of the cardiac structural anatomy, furthermore, are demonstrated without distortion of their spatial relationships within the thorax. There is now no reason why images such as we have produced should not be used to illustrate cardiac anatomy in all standard textbooks as used for the teaching of medical students and clinical trainees. This, in turn, should serve to emphasize the need also for anatomy to be taught using attitudinally appropriate nomenclature. When combined with the accumulated basic anatomical information, such approaches will surely bridge the gap currently existing between the dissection room and the clinical setting, helping to persuade clinicians also to adopt the attitudinal nomenclature.

ACKNOWLEDGMENTS

The authors thank Professor Ken-ichi Hirata, from the Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, for providing an opportunity for continuous investigation of living cardiac anatomy. We also thank all of our colleagues in the cardiac imaging group (Shinsuke Shimoyama, Yu Izawa, Takayoshi Toba, Daisuke Tsuda, Hiroyuki Toh, Masataka Suzuki, Yu Takahashi, Takuro Nishio, Tomoki Maebayashi, Wakiko Tani, Kiyosumi Kagawa, and Noriyuki Negi) of Kobe University Graduate School of Medicine, without whose help it would have been impossible to produce the virtual dissections as shown in our review.

CONFLICTS OF INTEREST

The authors have no conflicts of interest.

REFERENCES

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Cosío FG, Anderson RH, Kuck KH, Becker A, Borggrefe M, Campbell RW, Gaita F, Guiraudon GM, Haïssaguerre M, Rufilanchas JJ, Thiene G, Wellens HJ, Langberg J, Benditt DG, Bharati S, Klein G, Marchlinski F, Saksena S. 1999. Living anatomy of the atrioventricular junctions. A guide to electrophysiologic mapping. A Consensus Statement from the Cardiac Nomenclature Study Group, Working Group of Arrhythmias, European Society of Cardiology, and the task force on cardiac nomenclature from NASPE. Circulation 100: e31– e37.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU. 2015. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28: 1– 39.

[00:00:00] During this lesson, we’re going to learn how to identify the normal heart structures on a cardiac CT scan. We are going to start at the top of the heart, at the level of the main pulmonary artery and work our way down to the inferior aspect of the heart. Let us first consider the overall anatomy of the heart. Here, we can see that the right atrium is connected to the right ventricle, and the right ventricle transitions into the right ventricular outflow tract before passing blood through

[00:00:30] the pulmonary valve and through into the main pulmonary artery. Here, we can see the left ventricle. Please pay note to the various coronary arteries that can be seen on the scan. We can see that the right coronary artery emerges from the aortic root, before it becomes the ascending aorta, and the right coronary artery passes down the right-sided atrioventricular groove. Here, we can see the left anterior descending artery, which emerges from behind the main pulmonary artery and is connected to the aortic

[00:01:30] Let’s start at the beginning, at the level of the main pulmonary artery. On this side, we can see using multiplanar imaging, with the axial dataset in the top left-hand image, the coronal CT dataset in the bottom left-hand image, and the sagittal plane in the bottom right-hand window. We’re now looking at the dataset at the level of the main pulmonary artery. Let us first look at the structures in the axial plane. Here, we can see, at the

[00:02:00] level of the main pulmonary artery, a number of different structures. We can see that the main pulmonary artery bifurcates into the right pulmonary artery and also the left pulmonary artery. We can see one of the pulmonary veins, the tip of the left atrial appendage, and also the ascending and descending aorta. In the coronal views and the sagittal views, we are starting to see more structures. Notice that the right ventricular outflow tract and the right heart is closest to the sternum. We can also see

[00:02:30] the left atrium, the mitral valve, and the left ventricle, and also the descending aorta. In the coronal view, we can also see the right atrium and the main pulmonary artery. And we’re now looking at the left ventricle on FAST. So, we see the left ventricle, the aortic valve, and the ascending aorta. To remind yourself, this is the level at which this image is taken. Let us now move down to the level of the aortic root. At this particular level, we can start to see a number of

[00:03:00] different structures that weren’t seen at the level of the main pulmonary artery. The images in the coronal and also sagittal plane, however, remain the same because we’re still able to image the length of the heart. Let us now take a closer look at this axial image. We can now see a number of different structures. We can see the tip of the right atrial appendage, the aortic root, from which the left main stem arises, the right ventricular outflow tract, and more of the pulmonary veins. We can see the left superior pulmonary vein,

[00:03:30] the left inferior pulmonary vein, the descending aorta. In addition, we can also see the left anterior descending artery. In the coronal plane, we see the same images that were seen at the level of the main pulmonary artery. Because the length of the scan is still incorporating the length of the heart. We can see once again the right atrium, the left ventricle, the aortic valve, and the ascending aorta, along with the main pulmonary artery, as we’re looking front on to the heart. In the sagittal plane, in other words,

[00:04:00] the plane looking from one of the sides of the heart, we can see the right ventricular outflow tract, the pulmonary valve, and the main pulmonary artery lying closest to the sternum, along with the left atrium, the mitral valve, and the descending aorta, which is the structure the furthest distance away from the sternum. Let us now move to the level of the ventricular outflow tract. We can now see, on the axial image, even more structures being included on our imaging plane. We can see all

[00:04:30] three of the coronary arteries: the right coronary artery, the left anterior descending artery, and also the left circumflex artery. We can now see also the left atrium, the right inferior pulmonary vein, and the left inferior pulmonary vein. We can also see the most superior portion of the left ventricle, the transition into the left ventricular outflow tract, and also the cusps of the aortic valve. We can also see the right ventricular outflow tract, as the most anteriorly located structure. To remind ourselves,

[00:05:00] we can see the same structures in the coronal and sagittal views and this picture only changes if the axial crosshair position changes in the axial plane. Let us now move further down the image to the level of the four chambers. To remind ourselves, we can see the axial plane on the top left-hand image, the coronal plane on the bottom left-hand image, and the sagittal on the bottom right-hand image. Let us now look at the various structures that we can see at the midportion of the left ventricle. We can now see

[00:05:30] what we call the four-chamber view. We can see the left atrium, the mitral valve, and the left ventricle, the wall of the left ventricle, the right atrium, and the right ventricle. And we can also see the three coronary arteries: the right coronary artery, the left anterior descending artery, and also the left circumflex artery. This thin gray line, that you can see outside of the heart, is known as the parietal pericardium, whilst the visceral pericardium lies in closer position to the myocardium.

[00:06:00] The space between the visceral and the parietal pericardium is known as epicardial fat. As we move further down into the left ventricle, we can start to see a number above the different structures emerging. We can still see our right coronary artery, our left anterior descending artery, and our left circumflex artery but we now also see the inferior part of the left atrium. We can still see the left ventricle, the right ventricle, and the right atrium, and also the inferior vena cava, and the descending aorta.

[00:06:30] As before, the coronal and sagittal views remain unchanged. Here, we can focus more on the axial view at this plane, to remind ourselves the inferior part of the left atrium, the left ventricle, the right ventricle, and also the right atrium. As we move to the very bottom of the heart, we’re now starting to see the inferior aspect of the right ventricle and also that of the left ventricle. We can see the axial plane, the coronal plane, and also

[00:07:00] the sagittal plane. And then the axial view, we can now see a number of different structures in closer detail. We can see the very bottom of the right atrium and the right ventricle. We can also see the bottom of the left ventricle. Connected to the right atrium is the coronary sinus, through which the coronary veins drain back into the right atrium. We can see the thoracic spine, the liver, and also the sternum. Now, that we have been through all of the cardiac structures, are you able to identify these from the axial dataset alone?

If the sinus node fails, which can happen, for example, with a heart attack, then the AV node, without waiting for signals from its fellow, takes over its functions – in this case, the atria, left without electricity from the dead sinus node, begin receive impulses from the AV node according to the residual principle (retrograde).That is, although the system is bad, it continues to work and the person survives, but his pulse will not exceed 30-40 beats per minute and an implantation of a cardiac stimulator will be required, which will become the new main driver.

There is also another protection system. For example, with cardiac fibrillation (as an option, as a result of the same heart attack), the sinus node begins to generate 400-700 impulses per minute. If the AV node listened to its fellow man and forced the ventricles to contract with such a tremendous frequency, then the owner of the heart would inevitably and quickly die.You can’t do that with the ventricles. The maximum they can endure is 200-220 beats per minute. This is how many impulses the AV node begins to give them, giving a person a chance to wait for the cardio team.

Imaging in cardiology and cardiac surgery is an important part of the diagnosis and treatment of patients with cardiovascular diseases.Currently, the main imaging methods are electrocardiographic (ECG), echocardiographic (EchoCG), angiographic and nuclear examination methods. Over the past years, each of these techniques has become a testament to the rapid technological development. All techniques can now provide comprehensive information about the functioning of the heart and its blood supply. All of them are widely used in the Department of Non-invasive Arrhythmology and Surgical Treatment of Combined Pathology of the N.N.A.N. Bakuleva RAMS, under the leadership of Elena Zelikovna Golukhova.

Ultrasound (ultrasound) methods. Echocardiography (EchoCG) is the most commonly used non-invasive imaging technique in clinical cardiology. Echocardiography provides the most comprehensive information about the anatomy and function of the heart, including the pericardium, myocardium, and heart valves. Recently, echocardiography has been developing in the direction of three-dimensional (3D) imaging in real time, which provides very valuable information about cardiac structures, and also increases the accuracy of assessing LV volumes and ejection fraction, myocardial function (deformation and rate of myocardial deformation).With the help of 3D visualization and the MVQ (mitral valve quatfification) technique, it becomes possible to obtain the best information about valvular pathology, in particular about the anatomy of the mitral valve (MV), which is extremely useful for cardiac surgeons in planning MV reconstructive surgery.

Nuclear techniques include single photon emission computed tomography (SPECT) and positron emission tomography (PET), magnetic resonance imaging (MRI), and multispiral computed tomography (MSCT). Nuclear imaging techniques predominantly assess function rather than anatomy, and provide detailed information about myocardial blood supply (ischemia) and its viability (and the presence of a scar).This technique has evolved significantly in recent years. The main breakthrough was the ability to obtain ECG-gated images, which expanded the information received from myocardial perfusion to a comprehensive assessment of blood supply and heart function.

Minor anomalies in the development of the heart (or MARS) is one of the manifestations of not entirely correct development of connective tissue.Connective tissue is found in all organs. It forms the frame of the heart, valves and walls of large vessels. Due to this, the heart tissue is elastic, but rather strong. Small anomalies in the development of the heart are considered the presence of anatomical congenital changes in the heart and its large vessels. In this condition, the connective tissue is either too weak, or is formed in excess, not in those places where it is necessary in the norm. MARS is mainly detected in children in the first 2 to 3 years of life and has no tendency to progression.Many MARS disappear as the child grows.

The most famous and common MARS is mitral valve prolapse (MVP).MVP is the sagging of the bicuspid valve at the time of contraction of the heart into the cavity of the left ventricle, due to which a slight swirl of blood flow in the heart occurs. Only the first degree of prolapse is referred to MARS. All other degrees are accompanied by severe circulatory disorders and should be considered heart defects.

A fairly common second MARS, these are additional chords in the left ventricular cavity (LVPD) or in another way abnormal chords (LVAP). This MARS, which manifests itself in the presence of additional cords of connective tissue or muscles inside the cavity of the ventricle, attached to the walls of the ventricle or the interventricular septum.They normally attach to the valve flaps. Most often, false (additional) chords are found in boys. False chords are single, multiple, occur both separately and in combination with other anomalies. The location can be along the blood stream, across it, or diagonally. The severity of the heart murmur will depend on this. Chords can give a rhythm disturbance, therefore, patients require special supervision of a cardiologist.

A close examination of the child can reveal scoliosis (curvature of the spine), various forms of flat feet, hypermobility (excessive joint mobility). The most common combinations of MARS are the gastroesophageal reflex (reverse reflux of the contents of the stomach into the esophagus), kink of the gallbladder, megaureter (expansion of the ureter).In addition, MARS is often accompanied by neurovegetative disorders – the peripheral and central nervous systems work unbalancedly. This can be manifested by urinary incontinence, speech impairment, vegetative-vascular dystonia, and behavioral disturbances. All these combinations do not lead to severe dysfunctions of organs and systems and do not worsen the child’s life.

MARS is a syndrome, this is not a sentence, it is a special condition of a child that requires observation and minor correction. This is not a reason to restrict your child from physical activity. There is no need to treat a child diagnosed with MARS as sick. Most of MARS proceeds favorably and does not interfere with the child in any way.You only need to change your lifestyle and be regularly monitored by a cardiologist.

For example, cardiac resynchronization treatment relies on the implantation of two ventricular pacemaker wires in the cavity of the right and left sides of the heart.To synchronize the heartbeat, the position of the left ventricular conductor is controlled within the coronary anatomy to position the electrode tip within the region of greatest mechanical delay. 3D vein models derived from rotational phlebograms help clinicians identify prospective vein branches for guidewire navigation, while asynchrony assessment based on 3D ultrasound imaging helps identify the target location for electrode tip placement.To use X-ray and ultrasound information effectively, alignment (eg, spatial alignment) between the X-ray and ultrasound images must be computed. One endocardial imaging technology for aligning X-ray and ultrasound images uses ventriculography-derived anatomy of the LV (left ventricle) cavity in conjunction with the same ultrasound imaged cavity to align. However, patients undergoing cardiac resynchronization treatment are usually extremely frail and prone to heart failure, and therefore are often unable to tolerate the high volume contrast agent injections that are usually required for procedures such as ventriculography.Ventriculographic alignment of X-ray and ultrasound imaging is therefore problematic for CRT patients with poor cardiac and renal function.

One form of the present invention is a method of aligning a ventricular epicardium, comprising (1) presenting one or more anatomical features not visible within ultrasound images of the ventricular epicardium of the heart, (2) identifying anatomical feature (s) visible within an X-ray image ventricular epicardium, and (3) aligning ultrasound images and X-ray images of the ventricular epicardium based on presenting an anatomical feature (s) not visible within the ultrasound images and identifying the anatomical feature (s) visible within the X-ray images.

A second form of the present invention is a complex registration system comprising a processor and memory associated with the processor, the memory storing program execution instructions executed by the processor to (1) represent one or more anatomical features not visible within ultrasound images of the ventricular epicardium of the heart, (2) identifying the anatomical feature (s) visible within the X-ray images of the ventricular epicardium of the heart, and (3) aligning the ultrasound images and the X-ray images of the ventricular epicardium based on the presentation of the anatomical feature (s) not visible within the ultrasound images and identifying the anatomical feature (s) visible within X-ray images.

The foregoing form and other forms of the present invention, as well as various features and advantages of the present invention, will become further apparent from the following detailed description of various embodiments of the present invention, read in conjunction with the accompanying drawings. The detailed description and drawings are merely illustrative of the present invention rather than limiting the scope of the present invention as defined by the appended claims and their equivalents.

The present invention is based on the recognition that instead of using ventriculography to delineate the endocardial surfaces of the left and / or right ventricles of the heart, the ventricular epicardium can be used to locate the left and / or right ventricles of the heart.More specifically, X-ray images of the ventricular epicardium can be automatically, semi-automatically, or manually segmented to form a surface model that can indicate the position of a viable anatomical feature that is visualized by the X-ray images. Additionally, large volume imaging may be employed for 3D ultrasound, or multiple smaller volumes may be fused together to capture the profile of the complete ventricular epicardium, whereby the viable anatomical feature is magnified many times and possibly visible on ultrasound imaging.The position of the anatomical feature can be automatically, semi-automatically or manually indicated on the ultrasound image if it is visible on the ultrasound image.

As stated above, the X-ray / ultrasound combining strategy according to the present invention is based on combining common features. For example, as shown in FIG. 2, the location 25 of the right ventricular (RV) conductor tip and the location 26 of the coronary vein centerline identified from the ultrasound data were transformed to match the location of the centerlines of the coronary vein model obtained from rotational x-ray.In some cases, these signs may not be readily discernible in the ultrasound data. The present invention is further based on the derivation and use of statistical models to determine three-dimensional probability plots for the locations of invisible anatomical features relative to other structures that are visible in the acquired ultrasound data. In particular, statistical models of the anatomy of interest may be derived from a library of cardiac computed topography datasets, with each statistical model being used to infer the position of the same trait in ultrasound space, and then performing alignment to convert the inferred position to the actual position of the trait as seen in X-ray dataset.Following this sequence of operations, a successful fusion of the ultrasound and X-ray data will be achieved despite the absence of an actual anatomical feature used for fusion in the ultrasound data.

For example, with reference to FIG. 1, X-ray images of the ventricular epicardium of the heart 10 may be segmented to form a surface model onto which the position of the epicardial surface 11 of the left ventricle of the heart 10, the position of the epicardial surface 12 of the right ventricle of the heart 10 and / or the position veins 13 of the coronary sinus, which are visualized in the posterior projections of the heart with 10 x-ray images.Additionally, large volume imaging may be employed for 3D ultrasound, or multiple smaller volumes may be fused together to capture the profile of the complete ventricular epicardium of the heart 10, whereby the coronary sinus vein 13 is invisible in ultrasound imaging but is capable of being represented by statistical modeling. according to the present invention. Essentially, the position of the epicardial surface 11 of the left ventricle of the heart 10, the position of the epicardial surface 12 of the right ventricle of the heart 10 and / or the position of the coronary sinus vein 13 can be automatically, semi-automatically or manually applied to the ultrasound images.

An end result of the present invention is to combine ultrasound and X-ray images to produce an epicardial surface / coronary vein fusion for surgical purposes, such as the epicardial surface / coronary vein fusion 20 shown in FIG. 1, for example. In this example, pooling 20 includes an endocardial surface 21 having a coronary sinus vein 22 spaced from surface 21, and reference points 23 and 24 (e.g., a catheter tip) associated with surface 21.

With reference to FIG. 3, an x-ray system 30 is an x-ray system structurally configured to generate x-ray images 31 for a vessel imaging the heart 10 and to transmit x-ray imaging data 32 indicative of x-ray images 31 to a system 50.Additionally, the ultrasound system 40 is any ultrasound system structurally configured to generate 3D ultrasound images 41 of full 3D or multi-volume 3D imaging of the heart 10 and to transmit ultrasound imaging data 42 indicative of the ultrasound images 41 to the system 50. The complex registration system 50 is structurally configured with instructions stored in memory 52 and executed by processor 51 to process X-ray phlebography data 32 and ultrasound data 42 to implement flowchart 60.

More specifically, the ultrasound imaging phase P61 of flowchart 60 involves a processor 51 executing instructions to represent one or more anatomical features not present in the ultrasound images 41. The X-ray imaging phase P62 of flowchart 60 involves a processor 51, executing instructions for identifying one or more anatomical features shown in X-ray images 31.And, the image registration phase P63 of flowchart 60 involves a processor 51 executing instructions for displaying images 31 and 41 based on X-ray identification and ultrasound representation of anatomical features. Again, examples of anatomical features include, but are not limited to, the epicardial surfaces 11 and 12 and the coronary sinus vein 13 as shown in FIGS. 1 and 2.

The flowchart 70 shown in FIG. 5 is an exemplary embodiment of the ultrasound imaging phase P61, taking into account the epicardial surfaces 11 and 12 as well as the coronary sinus vein 13 serving as anatomical features. With reference to FIG.5, step S71 of the flowchart 70 involves a processor 51 generating a three-dimensional epicardial membrane from the ultrasound data 42, whereby one or more anatomical features may not be visible in the ultrasound images 41 (i.e., anatomical feature (2) undetectable or is an inadmissible positive identification). Essentially optional step S72 of flowchart 70 involves a processor 51 generating a statistical model of the invisible anatomical feature (s), and optional step S73 of flowchart 70 involves a processor 51 displaying a statistical model of the invisible anatomical feature (s). on a three-dimensional epicardial membrane.The statistical model generation of step S72 is obtained from a library containing many X cardiac datasets of any type (eg, computer topography and magnetic resonance imaging), where X ≥ 1. Moreover, the statistical model display of step S74 inferences the position of the invisible anatomical feature (s) on three-dimensional epicardial membrane.

Upon completion of steps S72 and S73, if applicable, step S74 of flowchart 70 involves processor 51 defining one or more 3D epicardial segments that can be used to display convex membrane segment (s) determined during step S83 of flowchart 80, and step S75 of flowchart 70 involves a processor 51 indicating the position of the coronary sinus vein 13 on the three-dimensional epicardial membrane.Again, the position of the coronary sinus vein 13 includes the coordinates of the spatial location of the coronary sinus vein 13 and / or the coordinates of the angular orientation of the coronary sinus vein 13.

The flowchart 80 shown in FIG. 6 is an exemplary embodiment of the X-ray imaging phase P62, taking into account the epicardial surfaces 11 and 12 as well as the coronary sinus vein 13 serving as anatomical features.Referring to FIG. 6, step S81 of flowchart 80 involves a processor 51 generating a 3D vein model from X-ray phlebography data 32, and step S82 of flowchart 80 involves a processor 51 generating a 3D convex hull from the 3D model. veins for the purpose of approximating the complete ventricular epicardium of the heart 10. In view of the fact that the three-dimensional convex membrane may be accurate on a limited portion of the epicardial surfaces 11 and 12 (for example, the shape of the apical membrane may not be accurate), step S83 of flowchart 80 involves a processor 51 defining one or more segments of a three-dimensional convex membrane that accurately reflects the ventricular epicardium of the heart 10, whereby this segment (s) of the convex membrane can be used to display the formation of ultrasound images of the ventricular epicardium of the heart 10, as will be further explained in mater ials of the present application.Step S84 of the flowchart 80 involves a processor 51 annotating the position of the coronary sinus vein 13 on the 3D convex hull. The position includes the coordinates of the spatial location of the vein 13 of the coronary sinus and / or coordinates of the angular orientation of the vein 13 of the coronary sinus.

The flowchart 90 shown in FIG. 7 is an exemplary embodiment of the image registration phase P63, taking into account the epicardial surfaces 11 and 12 as well as the coronary sinus vein 13 serving as anatomical features.With reference to FIG. 7, step S91 of flowchart 90 involves a processor 91 evaluating one or more alignment parameters as needed to thereby obtain a minimum total distance between the convex hull and epicardial surface segments during step S92. diagrams 90 of the sequence of operations of the method, and to thereby obtain the minimum total distance between the positions of the vein 13 of the coronary sinus in the 3D convex hull and the 3D hull of the epicardial surface during step S93 of the flow diagram 90 of the sequence of operations.Once such minimum total distances are obtained, step S94 of flowchart 90 involves a processor 51 displaying X-ray images 31 and ultrasound images 41 based on the minimum overall distance metric in steps S92 and S93. Alternatively, step S94 of flowchart 90 may involve a processor 51 displaying X-ray images 31 and ultrasound images 41 based on the determination of the minimum total distance in step S92 or step S93, as indicated by the dashed lines.

In further alternative embodiments, additional intrinsic focal points (eg, anatomical fiducial point 21 shown in FIG. 2) and / or intrinsic focal points (eg, catheter / electrode tip 22 shown in FIG. 2) may be used to annotate and / or minimizing the distance between the X-ray and ultrasound images. Additionally, the total distance metric or any other appropriate degree of fit parameter technology may be used during step S92 and / or S93.

FIG. 8 illustrates a flow diagram 100 of a method for facilitating a further understanding of statistical model generation / mapping in accordance with the present invention.With reference to FIG. 8, step S101 of flowchart 100 involves a processor 51 displaying one or more fiducials shown in ultrasound images 41 in a statistical model, and step S102 of flowchart 100 involves a processor 51 calculating the middle position of an invisible anatomical feature.

For example, FIG. 9 illustrates the generation of a 100 statistical model based on delineating the nearest 3 cm coronary vein centerline to the insertion site relative to four (4) mitral fiducials visible on cardiac computed tomography and ultrasound.The three-dimensional locations of the four (4) mitral fiducials (112 in the lower left diagram) are determined from multilayer reformatted thin slices of twelve (12) cardiac computed tomography volumes. The location of the central line of the nearest 3 cm coronary vein to the insertion site was also determined 113 for each patient. All of these markers are mapped to a common baseline space and the mean position of the 3D centerline 114 of the coronary veins is calculated. Centerline 114 represents the inferred closest to the attachment location of the vein centerline relative to mitral fiducials that are readily identifiable in 3D ultrasound datasets.

For example, with reference to FIG. 9, the statistical model display 101 uses the same mitral fiducials measured in cardiac computed tomography volumes and readily identifiable in the ultrasound volume data 42, whereby mitral fiducials are used to align the left ventricular sheath from the cardiac echo with a statistical model of the coronary vein closest to the attachment site.Again coronary vein measurements in 12 patients were averaged to construct the model shown. The center line of the vein model (the dashed green line in the left diagram, the red curved segment in the 3D imaging on the right) is the mean 3D position for 12 patients, while the diameter of the model represents one standard deviation of the position of the center line at the location of each segment. Fig. 10 illustrates the alignment of ultrasound and X-ray space based on the spatial transformation of the model of the vein closest to the attachment site in the ultrasound space with the corresponding segment of the coronary vein present in the X-ray space with the end result showing the rotational X-ray projection at the bottom left and the corresponding connected LV sheath (from 3DUS ) and vein model (from rotary x-ray) at the bottom right.

With reference to FIGS. 1-10, those of ordinary skill in the art will take into account the various effects of the present invention, including, but not limited to, reducing or eliminating external tracking systems, resulting in low clinical overhead. and allows / requires very small contrast boluses. Additionally, in practice, different technologies for the application, segmentation and alignment needs of the present invention may be used depending on the particular cardiac procedure being performed and the particular equipment used to perform the cardiac procedure.Preferred: (1) 3D convex membrane segmentation derived from Elco Oost, et.al, “Automated contour detection in X-ray left ventricular angiograms using multiview active appearance models and dynamic programming” multi-projection active models of appearance and dynamic programming ”), IEEE Trans Med Imaging, September 2006; (2) segmentation of the three-dimensional membrane of the epicardial surface derived from Alison Noble, et.al, “Ultrasound image segmentation: a survey”, IEEE Trans Med Imaging, August 2006, and (3) X-ray and ultrasound image fusion derived from Audette et. al, Medical Image Analysis, 2000.

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Would you like to make a romantic cherry-filled chocolate biscuit dessert for your loved ones, but there is no shape? See how to make a heart shaped cake without a mold.It’s simple and beautiful!
Volumetric heart
The most unusual is a volumetric heart:
You need to take a square of white or colored paper and fold it in half, carefully pressing on the fold;
Expand and bend the top a couple of millimeters;
Fold the piece of paper in half and put the lower corners to the top so that a triangle is formed on the table;
Its sides must be slightly bent down, but without pressing hard, but bend the upper corners to the resulting marks;
“Ears”, which turned out on top, bend and fasten in the resulting pocket;
There is a hole at the bottom of the shape.It needs to be filled with air so that the product becomes voluminous;
A voluminous heart made of paper is ready
Making an anatomical heart from polymer clay
Small introduction. The thought of a master class lurked in my head for a long time. Starting to study the technique of modeling and working with polymer clay, I was also looking for high-quality master classes that would explain to me in as much detail as possible how to make “just such a thing.” There were good and understandable ones, and there were none at all
Therefore, now I decided to share my not very original, but living and popular idea of creating such a heart:
So, for work we need:
Polymer clay of two colors – cherry and ultramarine.
Toothpicks.
Pliers.
Round nose pliers.
Nippers.
Matt varnish for polymer clay (maybe not matt, who likes which one better).
Varnish brush.
Rubber gloves.
Blade for office knives.
Hammer.
Foil.
Stove.
Wire.
To begin with, I want to say: this work is rather painstaking, so assess your strength correctly so as not to give up everything at the last stage.If you nevertheless decide to continue, proceed:
Step number 1
Take a roll of foil and cut off about 40 cm.
Step number 2
Without unnecessary movements, smoothly form a lump out of foil that will fit into your hand. Important! When folding such a large sheet of foil, remember that all the edges later do not come off, do not stick out, do not bump, etc. You should get a homogeneous mass. Do not squeeze it too tightly in your fist, we will use a hammer to compact the foil later.
Step # 3
Loose foil wad needs to be leveled and compacted. For these purposes, we take a hammer (I have a small one) and begin to “knock out” all the protruding, uneven places, compacting and leveling our lump. Important! To make the future heart as similar as possible to the real one – the lower part can be made a little conical, not round, and the upper part – vice versa. I would advise you to find a good picture on the Internet and see which shape is better to give our lump.
This is what we should get:
Step # 4
Take 1/4 of a pack of cherry-colored clay, cut it into about the following pieces:
Step # 5
Roll out the largest piece into a fairly thin layer.
Step 6
We begin to wrap our dense lump in polymer clay. This should be done evenly, smoothly, so that the clay does not break during the application on the foil, otherwise there is a possibility that small pieces of foil will come off the lump and fall into the clay.It will be extremely difficult to pull out such pieces …
This is what we should get:
Step 7
We begin to form the arteries. To do this, you need to roll out 3 clay sausages of different thicknesses. The middle one is the thickest, the right one is the thinnest, it is single, and the left one is a little thicker, because it will be double. Then attach them to the place where they should be located (look at the picture from the Internet).
Then the edge of the sausage, which is adjacent to the base, must be drowned in the base with very smooth movements, smeared and made a uniform consistency.So it is with the rest of the arteries. Like this:
Step number 8
After the larger parts are made, you can move on to the small ones. On the thickest artery on top, we have three holes. We form them using small balls or small plump sausages. With a toothpick, smooth out the clay at the junction of the ball and the main artery to get a homogeneous mass.
Step # 9
After all 3 balls are in place, make holes in them with a toothpick:
Next, you can make the same holes in all the main arteries.Here’s what you should get:
Do not forget to make a hole for the future ring, into which a chain or rope will then be threaded for suspension:
Step 10
Take a toothpick and start making grooves for the main veins. There are so many of them – 2 or 3 pieces (photo from the Internet).
This is what you should get:
Step 11
Mix the clay for the veins. To do this, you literally need to tint our main cherry color a little – with blue or ultramarine.
This is what you should get:
Step 12
Roll out a very thin sausage from the resulting color.
Step No. 13
First we lay the main veins along the grooves, and then turn on the imagination and branch off smaller ones from each in several places, and from them even smaller ones, etc., as far as your patience is enough.
Here’s what you should get:
Step No. 14
If you are satisfied with the general appearance of the product, then you can safely bake it in accordance with the instructions on the polymer clay packaging. Since we have a foil frame, the total thickness of the clay on the surface and on the walls of the arteries is quite thin.
Step 15
After baking and cooling the product, cover it with varnish. The varnish will give the product a darker color and will also revive it a little. Important! The varnish should be applied without unnecessary movements, smoothly, preferably in the direction of the grooves and veins. It is better to take varnish from a can in small quantities and without raising bubbles. This can further spoil the “presentation” of the product.
Step 16
If the varnish has dried, using pliers, round-nose pliers and wire cutters we make a ring that we insert into the holes made in advance:
That’s it, you’re done!
Now you can hang this jewelry on a chain or string and wear it as a pendant or keychain.
Thank you for your attention! Until the new master classes
Heart-bookmark
You can make not only beautiful, but also practical things from paper – “heart-bookmark”
A square paper sheet must be folded in half diagonally;
Then you need to roll the sides of the triangle to the center and turn the future product;
The upper corner is folded down and then there are two parts from above that need to be folded down and the corners removed into the pockets formed;
The corners located in the center must be bent down;
To form the side pieces, they must be bent and sharp corners rolled inward.
Bookmark ready. The original design will help you easily complement your creative notebook or put it on the pages of your favorite book.
Paper hearts. Original and simple
A heart as a gift can not only be sewn, but also made of paper. To make the gift look more thoughtful and elegant, make a paper craft in the shape of a heart.
Box-heart
We make:
Paper
Scissors
Ruler
Draw the shape of a box, that is, 2 hearts, a partition between the sides and flaps for fastening.Cut out the shape, insert along the lines. We glue the desired part and let it dry. On the front side, you can write a few words and put a surprise in the box.
The box is ready.
Original modular heart as a gift
An unusual and beautiful gift will be appreciated by everyone, in addition, modular origami can serve as a table for a romantic dinner or holidays. It looks very atmospheric and creative.
The essence of this Chinese technique is to create any shape from many triangular modules.In our case, it will be the heart.
Combined composition
If there is a little more time in stock and there is a desire, then you should try to create an interesting composition from a large number of hearts, or even make a picture, it is enough to cut out many hearts of different sizes from red paper, cut each of them into center and glue it together – you get a volumetric figure, and a couple of dozen of these next to it will create an interesting composition.
Modular versions
The modular origami version impresses with its sophistication and imagination.
It is suitable for a gift for all kinds of holidays.
It is interesting to watch a video lesson on creating voluminous hearts:
If you want to surprise your family and loved ones, watch a video lesson on the 3D hearts class:
An elegant gift will be a voluminous heart with wings. Such origami will not go unnoticed and your work and skill will be rewarded. Video tutorials on how to make a heart with different wings can be found here:
Valentine’s envelopes
If you already have cut paper hearts, you can make an envelope out of them – a great solution for a romantic letter or note.On one side of the heart, you can write a wish, and then by opening the envelope, the person will also receive a valentine card as a gift.
To make such a product, you need to bend the sides of the heart inward towards each other, but so that they do not join, bend the part with the cutout in the same direction – it will serve as the bottom of the envelope, as if I recall two rounded parts, and they hearts have turned into a triangle and will serve as the top, classic, folded part of the envelope.
How to make origami “Heart”
Divide a square sheet into 3 identical parts;
Fold the lower right corner to point A on the left line;
Fold the right and bottom sides to point A;
Rotate the sheet so that the fold angle is at the bottom;
Fold back the top corner;
Fold the edges to make them rounded.
You can come up with other ideas for original volumetric hearts by using your own skills: you can knit hearts, decorate fabrics with embroidery, lace, decoupage on a plywood blank.
You will enjoy the very process of creating a gift with your own hands, and the person to whom it is intended will feel your love.
Tips and conclusions
In addition to the above options, there are many more different schemes, videos and photos of how to make a heart.More complex designs allow you to build a whole heart of the box, but you will have to use a ready-made template, printed or drawn yourself.
Hearts on sticks will look nice to decorate dishes. Using the most elementary materials – paper, scissors, glue – you can easily, quickly and truly decorate any holiday in an original way.
DIY photo of hearts
Read here: How to make a doll: manufacturing technology, patterns and step-by-step instructions for sewing.85 photos of the best ideas
Preparation
Before starting work on the product, you need to prepare the materials at hand. Regardless of the complexity of the workpiece, there are no requirements for the list:
Colored paper (single-sided, double-sided).
Scissors, ruler, pencil.
Schemes according to which you will fold
Any metal object with a sharp rounded end (knitting needle, nail file, rod from a used pen, etc.).
Using the tools from point 4, you can fold the craft out of thick cardboard without much difficulty. When using thin paper sheets, this item can be omitted.
Heart in quilling technique
Do you know what this unique and at first glance interesting word means, quilling? In fact, a technique that makes it very funny to fold paper into little funny things. I think all those who love creativity and crafts are familiar with this type of work, or have you ever seen such cute souvenirs.
If you know how to use and make such valentines, please share your work with us, I can only offer you these ideas that I liked myself.
I suggest you make a photo frame and something else, take a look and decide for yourself what is closer to your soul.
Or make such a small but pleasant thing from strips:
We need:
Work steps:
Take a ready-made heart template or make it by hand using a compass, or something then round.Then attach the stencil to thick cardboard and cut out the blank. Next, attach the blank on colored paper and make some more stock, as shown in the figure.
Paste this green cover. Then cut a heart out of red colored paper and glue it on the back of the blank. On this side, you can write a love note or a poem.
After making figures for quilling, wind the strips of paper on a pencil, use a special ruler and a toothpick.
When the washer works, leave it in the circle of the same engineering ruler.
Take your love photo and trace it to the desired shape, and then glue it onto double-sided tape or tape.
Now it remains to glue all the elements. And this is how wonderful and magical it looks.
And you can also build such a red pendant, a symbol of love.
Cream heart cake, recipe
Another option for making a “hearty” dessert is cream cake “Heart”.For those who have ever made a cream-based cake, this recipe will be familiar.
The cakes can be made biscuit. But the cream needs more attention.
It will consist of:
The chocolate and butter will need to be melted. Add the rest of the ingredients. Put on low heat and bring the mixture to medium consistency.
Each layer should be greased with this cream. Using a piping bag, you can make pretty creamy flowers on the surface of the cake.
Dessert must be allowed to soak before serving.
Application “heart with roses” from rolled paper
An interesting paper heart is obtained using the application technique from rolled paper. We need to twist the colored paper into a tube, then cut the tube into small curly pieces.
Cut the tube into curl pieces
Fix the ends of the curls with glue so that the curl is loose enough.We glue the curls onto a paper base.
Glue the curls to the paper base
Glue small green curls to the base. Before us is an applique “heart” decorated with a bouquet of roses!
Application “heart with roses”
Cake with mastic
A cake in the shape of a heart can be made from anything. Sweet mastic dishes are gaining popularity. The material allows you to create stunning culinary masterpieces. Why not make a dessert in your own kitchen and present the treat as a gift.
Ingredients:
For mastic:
marshmallow – 120 g;
butter – 20 g;
lemon juice – 5 ml;
icing sugar – 350 g;
food coloring – 3 pcs.
For dough:
vanilla sugar – 10 g;
sour cream – 180 g;
sugar – 180 g;
cocoa – 50 g;
baking powder – 10 g;
eggs – 2 pcs.;
flour – 250 g.
For meringues:
sugar – 180 g;
egg whites – 2 pcs.;
salt – a pinch.
For cream:
icing sugar – 100 g;
boiled condensed milk – 300 g;
butter – 250 g;
cream – 450 ml;
peanuts – 150 g.
Preparation:
Let’s start making mastic. Doing it yourself is easy. The only thing to consider is that you need to sculpt decorations a few days before preparing the dessert. Throw marshmallows into a bowl, add lemon juice and oil.We put the dishes in the microwave for 30 seconds. This time is enough for the mass to increase in size. Pour icing sugar into the resulting mixture, mix everything.
Divide the mastic into several parts, paint each in a different color. We wrap the mass in cling film.
We start to sculpt decorations. We tear off a small piece of mastic, make a thin cake out of it. We fold the resulting element into a tube.
In the same way we make the next petal, put it on the first one.The petals should only touch at the base.
Form the rest of the parts to a larger size, alternately attaching them around the core. We cut off all the excess, wrap the petals outward.
In the same way we form the rest of the roses. We make leaves, for this we cut them out of the mastic using cutting. Put the decorations on a tray with powdered sugar, put them in a dry place. The photo shows the finished flowers.
Let’s start making meringues.Combine egg whites, salt and sugar in a bowl. Beat the mixture with a mixer.
Place the meringue on a baking sheet lined with parchment. We bake them in the oven at 100 degrees for an hour. At the end of the allotted time, we take out the baking sheet from the oven, let the meringue cool.
Prepare the dough. Grind eggs with sugar, add sour cream. We mix everything.
We send cocoa, vanilla sugar, baking powder to the total mass.
Pour flour in small portions, knead the dough.
Prepare a round baking dish. Cover it with paper, grease it with oil, spread the dough.
Bake the biscuit at a temperature of 200 degrees, set aside for about 40 minutes. Cut the finished cake into 2 parts.
Put the peanuts in the pan, lightly fry, set aside.
Let’s prepare the cream.In a deep plate, mix the melted butter, boiled condensed milk. For convenience, we will use a mixer.
Add peanuts to the rest of the components, mix everything. This cream is perfect for making children’s desserts.
Let’s make another cream. Combine cream and icing sugar in a separate bowl. Divide the mixture into parts, put it in the refrigerator for a few minutes.
We take thick cardboard, cut out the heart from it.We apply the template to the biscuit, transfer the shape to the cake. Cut off the excess, we get 2 cakes in the form of a heart.
Let’s start assembling the cake. We coat the bottom cake with butter cream, apply a paste with nuts.
Put the meringue in the shape of a heart, coat with cream. This time we apply the cream formulations in reverse order.
Cover with a second cake layer, grease the surface with whipped cream.
Fill the pastry bag with cream, install the toothed nozzle.We plant the cream on the cake in the form of decorations.
Put the sugar flowers on the dessert.
Put the pastries in the refrigerator for a few hours, let them soak.
The treat is ready. It will take a lot of free time to prepare it, but the result is worth it. Why not please your loved one and make him such a surprise.
Tip! If mastic remains after cooking, do not throw it away.It can be kept in the refrigerator for up to a week.
Send your photos
Do you also make beautiful crafts? Send photos of your work. We will publish the best photos and send you a diploma of the participant of the competition. In order not to forget the page address and share with your friends, add to yourself in social networks:
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Tags: Valentines with your own hands
Discussion: there is 1 comment
LuzaraFar:
September 1, 2019 at 19:10
Cool hearts, it’s good that there are many options, you can choose to your taste and color. I would make some more out of patterned and velvet paper.
Answer
Heart mousse cake, recipe
Heart mousse cake can amaze with its appearance and taste characteristics.
This recipe can be divided into the following stages:
preparation of the cake;
receiving mousse;
preparation of a gelatinous layer.
If you do everything correctly, then in the cut, the cake will look like this:
The culinary specialist will need the following products:
Cooking a mousse “heart” cake takes place in several stages:
Now you need to form a cake: lay out cake, mousse on it, and a jelly layer on top.Send cake to refrigerator overnight.
Assembly diagram
Below is a diagram of assembling an origami heart from the famous Japanese origami master Fumiaki Shingu. If you follow the instructions carefully, assembling the origami heart will not take much time, and the result will be the same as in the picture. After doing the described in the diagram several times, you will understand how to make origami a heart quickly and without peeping into the diagram.
Cooking steps
Let’s start by making the cakes.To do this, take 6 eggs and beat them until the volume doubles. After that, add 180 g of granulated sugar and beat for another 2-3 minutes. Sift flour and mix with baking powder, and then combine with egg-sugar mass. Pour in the poppy seeds and stir gently again. In the shape of a heart, bake 3 biscuit-poppy cakes, preheating the oven to 180 degrees. Each crust is baked for about 15 minutes.
In the meantime, prepare the custard. First, in a refractory container, mix milk with 120 g of granulated sugar, 3 egg yolks, 2 ½ tbsp.l. flour and 2 tbsp. l. starch (better than corn).
Put the container on the stove or in the microwave and heat the mixture over medium-high heat, stirring regularly.
The finished cream should thicken well. After that, it can be removed from the stove and cooled, and if there are lumps, it can also be rubbed through a sieve.
Interrupt the cooled homogeneous custard with a mixer to get the smoothest texture possible.
Separately beat the softened butter.
Then add it to the custard and interrupt everything together until it puffs.
Defrost the cherries and combine with the remaining sugar and starch residues diluted with water.
Boil the mixture until thick and cool.
Now we collect the cake. To do this, cover each cake with custard, and then sandwich with a cherry mass.
Thoroughly interrupt the heavy cream with powdered sugar and a thickener.
Cover the cake with the resulting mixture.
We do the same on the sides.
If you wish, you can set aside some of the creamy mass, add a dye (the same cherry juice) to it and deposit it through a pastry syringe to get a more effective decor.
Have a pleasant and romantic tea party!
Valentine’s Day is coming soon! And no matter how old we are – 15 or 50, or 85, let’s love and be loved !!! And let’s bake delicious cakes to delight our loved ones. And of course there will be this one!
Even if you don’t have a special baking dish, nothing! The cake is a heart and without a mold you can bake! But as? I’ll tell you now!
As a base for the cake, I took a recipe for a very tasty chocolate honey cake with Nutella custard from the Marie’s Recipes website.I just divided the ingredients in half, but made the cream a little differently. Thank you, Marinochka, for a delicious recipe !!!
Original card Heart for February 14 with the scheme
While preparing for this note, I found several ways of how you can beautifully and unexpectedly surprise your beloved or beloved. Indeed, on this day you really want something that will make your head spin. For example, if your betrothed will give you a ring, but not just like that, but in a purse. It will look dignified and romantic at the same time.
You will need to cut out two of these shapes from paper using ordinary sharp scissors:
And then connect them together, but in advance you will need to fold them in half, where you see symmetry, make a small incision where the antennae are at butterflies.
It turns out something like the following:
Now it remains to glue the ribbon or make it out of paper and put the cherished gift with wishes or a bill.
It is more difficult to offer such a craft, who is familiar with the technique of cutting stencils, it will be easy for that, this is a method of poking out with a special knife, as the people say vytynanka.You can get the stencil itself completely free of charge, if you write a comment below, I will definitely send it to you.
Also, in a hurry, you can build such a masterpiece using your palms. I think that the process of making such a product is already clear.
Looks gentle and of course with love. The beloved will definitely be delighted and smile and give you a kiss.
In America and other countries, they very often give their loved ones pictures related to this topic, you can use newspaper publications, you do not need to be an artist to create such a work, see for yourself.
Well, one more type is vytynanka, they are also appropriate to use here. And I will write about them below. To be honest, such a souvenir can be attributed to a competition in a kindergarten or school.
Here is its template, cut with a cutter or a special sharp knife.
Cake with mascarpone
Honey dessert is considered one of the easiest to prepare, it will take a minimum of time to prepare. You can choose anything as a decor: nuts, chocolate, berries, flowers, sweets, cookies.
Ingredients:
For the dough:
egg – 1 pc .;
sugar – 130 g;
honey – 55 g;
butter – 100 g;
flour – 300 g;
soda – a pinch;
salt – a pinch.
For cream:
mascarpone cheese – 500 g;
condensed milk – 200 g.
For decoration:
meringue – to taste;
berries – 100 g;
flowers – to taste;
pistachio greens – 100 g.
Preparation:
In one bowl, mix honey, sugar, salt, butter and egg. Beat the mixture with a mixer.
Pour flour and soda in small portions. Gently knead the dough.
Put the parchment on the table, roll out the dough. Its thickness should be no more than 3 mm.
Let’s prepare a paper template in the shape of a heart, you will need 2 blanks. We spread the dough on them.
We bake the cakes in the oven at 180 degrees for 15 minutes. As a result, we get soft, ruddy cakes.
Let’s prepare the cream. Combine cheese with condensed milk in one bowl. Beat the mass with a mixer until smooth. The cream turns out to be lush, light in color.
Prepare a pastry bag, put the cream in it, choose a round nozzle.
We plant the cream on the cake along the contour, then fill in the voids.
Place the second cake on top, plant the cream in the same way.
Put the baked goods in the refrigerator, set aside at least 5 hours for impregnation.
Before serving the dessert on the table, let’s decorate it. For this we use berries, meringues, flowers, pistachio greens.
Even without mastic we can get an amazing treat. You have to show a little imagination and the result will amaze all expectations.The cake will be a wonderful gift for the holiday and will help to please a loved one.

Openwork valentines
Openwork paper hearts look delicate, like a weightless cloud or a pattern of a skilled artist. It is very easy to do them, and the result exceeds all expectations. Here are several options for openwork hearts.
Option 1
First, cut strips about 1 cm wide from pink paper. Their number must be even.
Now we put all the blanks one on top of the other, in a stack. On one side, we fix the stripes with a stapler or PVA glue. And on the reverse side, we shorten them trampled. 2 long ones remain in the center, each subsequent one (symmetrically on both sides) becomes shorter by 1.5 cm.
Divide the strips in half and bend downwards so that the fixed ends remain in the center of the work. We trim all the edges and again fix them with a stapler or glue. An openwork heart comes out of stripes.
If you connect the upper edge of the strips with the lower one, an equally beautiful heart will come out.
Option 2
Cut a heart out of colored paper using a stencil. Fold it in half and draw a beautiful pattern. You can depict a tree with fruits in the form of miniature hearts. Cut out with sharp scissors according to the graphic pattern.
Open the resulting blank and see that the pattern on the left and right is the same. In general, it is a branched tree. This technique is called vytynanka.
It remains only to glue the openwork heart on a sheet of colored cardboard in a contrasting shade.The valentine card is ready.
Option 3
Using a stencil, cut out a blank from white paper and a heart of the same size from red. Draw openwork patterns on white paper that are closely intertwined.
Now fold the red and white hearts and begin to cut out the extra fragments of the pattern with sharp scissors.
This is how a heart with a beautiful pattern looks so beautiful.
We glue it on a yellow rectangle to make the drawing look even better.
Option 4
Draw a small heart on a sheet of pink paper using a stencil. The paper must be double-sided.
In this heart we draw a spiral line following the contours of the image.
Fold the sheet in half and cut out two hearts according to the graphic pattern. They turn out like a long spiral.
Fold the white sheet of paper in half and circle the palm so that the little finger is on the fold line of the paper. We cut out and get such a blank.
In the center we glue two openwork hearts, glued together with the middle. A valentine is coming out entitled “Our hearts are in your hands.”
Option 5
Again, cut out the heart on a stencil on a sheet of double-sided colored paper.
Fold it in half.
And starting from the bottom corner we make cuts, trying not to reach the upper edge by 0.5 cm. The distance between the cuts should not be too large (up to 1 cm, depending on the size of the base).When we come to the semicircle of hearts, you need to make an additional fold and make incisions.
Then we turn the workpiece to its original position. It turns out a heart with horizontal stripes.
Now all the stripes need to be bent alternately to the right and left sides so that the heart gains volume.
Weightless clouds in the form of openwork hearts are obtained. Smaller hearts look no less original.
If you attach a pink thread or fishing line to them, then the crafts can be hung on the chandelier.Such openwork hearts are quite easily made from ordinary colored paper.
Heart attacks | Memorial Sloan Kettering Cancer Center
This information will help you learn about heart attacks, including their signs and how they can be diagnosed and treated.
to come back to the beginning
About heart attacks
A heart attack, also known as myocardial infarction (MI), occurs when one of the coronary arteries (blood vessels that carry blood to the heart muscle) is blocked.This can weaken part of the heart muscle as there is no blood flow to it (see Figure 1). If part of the heart muscle is weakened, that muscle will not work as well as it used to.
Figure 1. Cardiac muscle damaged by blockage of a coronary artery
to come back to the beginning
Common signs of a heart attack
The following are signs of a heart attack.You may have one or more of these symptoms.
Pain, pressure or discomfort in the chest.
Pain, tingling, or discomfort in the hands, back, neck, jaw, or stomach.
Difficulty breathing at rest and during mild exertion, such as walking several blocks or climbing one flight of stairs.
Wheezing (wheezing or wheezing when breathing).
Sweating.
Rapid or irregular heartbeat.
dizziness or lightheadedness.
Indigestion (burning or discomfort in the upper abdomen (belly)).
Nausea (feeling of approaching vomiting) with or without vomiting. This is a common symptom of heart attacks in women.
If you think you are having a heart attack, call 911 immediately. You do not need to drive to the hospital yourself. Emergency medical technicians (EMTs) can start your treatment on the way to the nearest emergency room.
to come back to the beginning
Diagnosis of a heart attack
There are many different studies that can diagnose a heart attack. When you arrive at the emergency room, you may have one or more of the tests listed below.
Electrocardiogram (EKG)
An electrocardiogram measures the electrical activity of your heart. This means how often your heart beats is determined and many other parameters are measured.During this test, your healthcare professional will place sensors (electrodes) on your chest, arms, and legs, or in all three positions. These sensors will show you how your heart is working.
Blood test
This test determines the presence of a protein in the blood such as troponin, which is released into the bloodstream if the heart muscle is damaged.
Echocardiogram
An echocardiogram is an imaging test that uses ultrasound (sound waves) to take pictures of your heart.It allows you to see how your heart is beating, how it pumps blood, and can also show if there are abnormalities in the work of the heart muscle and heart valves.
Cardiogram with stress
Exercise cardiogram allows doctors to see if your heart is getting enough blood when you exercise, or when you do something that makes your heart work harder. For this test, you may be given medication through an intravenous (IV) line (a needle placed in a vein to deliver medication) to increase your heart rate and blood pressure as if you were exercising, or you may be asked to do physical exercises.
Cardiac catheterization and coronary angiography
This is a procedure that helps you see if your coronary arteries are blocked.
You will be given medication to help you relax before your procedure. During the procedure, your doctor will insert a thin catheter (long, flexible tube) into a blood vessel in your arm or leg and advance it toward your heart. This process is called cardiac catheterization.
When the end of the catheter is in your heart, the doctor will inject a special dye into your heart through the catheter.Using an X-ray machine, the doctor will observe how the dye leaves the heart and travels through the coronary arteries. This is called coronary angiography.
to come back to the beginning
Treatment and prevention of heart attacks
Medicines, cardiac catheterization, or surgery can be used to treat heart attacks. Many of the treatments described below can also prevent future heart attacks.
Medicines
There are many medicines used to treat and prevent heart attacks. These medicines work in different ways. The following are examples of some drugs, but there are others as well. Your cardiologist (doctor who treats heart disease) will talk with you about which one is best for you.
OTC drugs
Aspirin. This medicine helps prevent platelets from clumping together (blood clots) and reduces the risk of death from heart attack.
Prescription drugs
ACE inhibitors relax the blood vessels. It helps improve heart function after a heart attack and lowers blood pressure. Examples of such drugs include enalapril (Vasotec ^®) and lisinopril (Prinivil ^®).
Anticoagulants (medicines that thin the blood) such as heparin and enoxaparin (Lovenox ^®) thin your blood and prevent blood clots.
Antiplatelet drugs (like aspirin) prevent blood clots in the arteries. These drugs include clopidogrel (Plavix ^®), prasugrel (Effient ^®), and ticagrelor (Brilinta ^®). They can prevent re-blockage if you have stents in place. For more information on stents, see the Cardiac Catheterization section below.
Beta blockers slow heart rate and lower blood pressure.This helps to reduce the amount of work the heart has to do. Examples include carvedilol (Coreg ^®) and metoprolol (Lopressor ^®).
Nitrates dilate your coronary arteries. This allows more blood to flow into the heart muscle and relieves chest pain. Examples of such drugs include nitroglycerin and isosorbide mononitrate (Imdur ^®).
Statins lower cholesterol levels. If you have too much cholesterol (high cholesterol) in your blood, it can clog your arteries, making you more likely to have a heart attack.Statins reduce the amount of fatty deposits (plaque) inside the arteries, reducing the risk of future heart attacks. In addition, statins help anchor existing fatty deposits on the walls of the arteries, preventing them from coming off and blocking the arteries. Examples of such drugs include atorvastatin (Lipitor ^®) and rosuvastatin (Crestor ^®).
Procedures and Operations
Sometimes, after a heart attack, you may need more specialized care, including angioplasty, stent placement, or surgery.If you have a heart attack during your stay at Memorial Sloan Kettering (MSK) and need specialized care, you may need to be transferred to another hospital. Your doctor will talk with you about the most effective treatment for you.
The following are procedures that may be performed after a heart attack.
Cardiac catheterization and coronary angiography
During your cardiac catheterization procedure, a small catheter is placed in your artery.It is placed in one of the arteries in the wrist (radial artery) or in one of the arteries in the upper thigh (femoral artery).
Figure 2. Unblocked and blocked arteries.
Through a catheter, your doctor will inject contrast agent (a dye that makes your arteries more visible) into your coronary arteries to check for blockages (see Figure 2). If the doctor sees that the arteries are blocked, they may perform angioplasty.
Coronary angioplasty and stenting
During an angioplasty (also known as coronary angioplasty), your doctor will insert a thin balloon catheter into your blocked artery. When the catheter reaches the blocked site, the doctor will inflate the balloon so that it rests against the walls of the artery (see Figure 3). As a result, the artery will widen and blood flow to the heart will improve.
Figure 3. Artery dilator balloon
At the same time, the doctor can insert a stent into the artery.A stent is a hollow metal tube that keeps an artery open (see Figure 4).
Figure 4. Stent in an artery
Coronary artery bypass surgery
Figure 5. Coronary artery bypass graft
During coronary artery bypass surgery, your doctor will remove a blood vessel from another part of your body (such as an arm or leg) and connect it to a coronary artery before and after the site of the obstruction.Figure 5). This allows the blood to bypass the blocked area of the artery.
to come back to the beginning
Lifestyle changes after a heart attack
The following are steps you can take to take care of yourself after a heart attack. Some of them involve lifestyle changes and may prevent future heart attacks from occurring.
If you smoke, try to break the habit.If you would like to help you quit smoking, please contact our Tobacco Addiction Treatment Program at 212-610-0507 or ask your nurse for information about this program.
If you are overweight, try to lose weight. Talk to your doctor about safe ways to lose weight.
Eat a healthy diet by including plenty of fruits and vegetables in your diet. For more information, read our resource How to Improve Your Health Through Nutrition, or consult a clinical dietitian nutritionist.
Talk to your primary healthcare provider or cardiologist (doctor who treats heart disease) about how to manage other health problems (such as high blood pressure, high cholesterol, and diabetes) if you have any.
Take part in a cardiac rehabilitation program (a program designed to improve the health and well-being of people with heart problems). It includes:
safe exercise to strengthen the heart;
Communicating on how the risk of other heart problems can be reduced;
Counseling on ways to reduce stress, as stress can increase the risk of heart disease.
Additional information and resources are also available on the American Heart Association website www.

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Highlights

Abstract

Background

Results

Conclusions

Keywords

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ANATOMIC CONSIDERATIONS

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IMAGE ACQUISITION AND RECONSTRUCTION

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THE CORONARY VASCULATURE

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INCONSISTENCIES IN THE SEGMENTATION OF THE LEFT VENTRICULAR CONE

CONCLUSIONS

ACKNOWLEDGMENTS

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