The Common Vein 

Ganesh Athappan MD  Ashley Davidoff MD

Definition

The left ventricle , the largest and most muscular of the four chambers of the heart receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve. Structurally it is a hollow muscular conical chamber which can be divided into an inlet , apical trabecular and outlet components. Functionally it receives oxygenated blood from the left atrium and pumps it forward through the aortic valve into the aorta to supply oxygenated blood to the tissues of the body.

Diseases of the left ventricular myocardium lead to systolic or diastolic pump failure characterized by inability of the LV to pump blood at a rate commensurate with the requirements of the metabolizing tissues and/or pumps only from an abnormally elevated diastolic filling pressure.

Diagnosis of LV failure is suspected in patients presenting with symptoms of exertional dyspnea, orthopnea, PND, fatigue, weakness and nocturia. On examination patients may have signs of frank pulmonary edema with bibasilar coarse crackles. BNP levels are raised in the serum and an EKG may show LVH. Chest radiography shows an enlarged cardiac silhouette and alveolar edema with pleural effusions and bilateral infiltrates in a butterfly pattern. 2D echocardiography is the easiest and cost effective method to determine LV systolic and diastolic function.

Medical therapy is the cornerstone for management of LV dysfunction, with heart transplant needed in a few cases.

Principles

Structural Considerations

The left ventricle is a conical muscular chamber which forms a small part of the sternocostal surface but  a considerable part of the diaphragmatic surface of the heart¹.It also forms the apex of the heart.  The left ventricle can be subdivided into three components – inlet , apex and outlet, with a septal surface, and a free wall

Size

The left ventricle is the largest of the 4 chambers.  Echocardiography offers an excellent tool for the measurement of left ventricular size:

Posterior LV thickness:

0.6-1.2 cm (diastole),

Internal diameter

3.5 -5.6 (diastole)

2- 4cms (systole) ,

Mass:

92± 16.0 gm/m2

End-Diastolic Volume:

70 ± 20.0 ml/m2.

Stroke Volume:

45± 13.0 ml/m2

Ejection Fraction:

0.67 ± 0.08 = 50-85%

The Normal LV

This anatomic specimen shows the LV with septal side to the patients right and free wall side to the patients left. Note the relatively smooth walled septal surface and the papillary muscle apparatus attached to the free wall side. There are two groups of papillary muscles neither of which are attached to the septum. The anterior leaflet of the MV is in full view and note that it is in fibrous continuity with the left and non coronary cusps of the aortic valve. Courtesy Ashley Davidoff MD 01817 code normal heart cardiac LV MV anterior leaflet fibrous continuity anatomy

 

Normal Echo

Normal LV,  Pericardial Effusion

This gray scale echo of the heart showing a 4 chamber view, with a normal LV, but demonstrating a large collection of fluid around the heart, characteristic of a pericardial effusion. Courtesy Philips Medical Systems 33140 code cardiac heart echo pericardium effusion imaging cardiac echo

 

Normal CT

Sagittal View of the Normal LV Thickness

The sagittally reconstructed CT study of the heart demonstrates the normal LV thickness, chamber size, mitral valve with continuity to the aortic valve.  The smaller of the two hollow tubes to the left of the aorta represents the left atrial appendage and the larger more superior structure represents the main pulmonary artery. Davidoff MD 47823 copyright 2009 all rights reserved

Normal MRI

MRI Normal

This MRI series demonstrates the heart in systole and diastole. Image 1 demonstrates ventricular systole. The atrial chambers are full, the A-V valves are closed and the ventricular chambers are contracted. Image 3 is a color overlay of the closed A-V valves of image 1. Image 2 demonstrates ventricular diastole. The atrial chambers are emptying, the A-V valves are open and the ventricular chambers are full. Image 4 is a color overlay of the open A-V valves of image 2. Courtesy of Philips Medical Systems and modified by Ashley Davidoff M.D. 32062

Normal MRI Sagittal View

This series of MRI images of the LV and LA are a beautiful sagittal depiction of a normal heart in systole and diastole. Note the changes in LV cavity size as the heart in diastole (a) goes through progressive systole (b,c,d,e,f) and then goes through diastole again. (g,h,i) Courtesy Rebecca Schwartz MD 38132c code

Size – LV Enlargement

LV Hypertrophy

LV Hypertrophy LV Thickness = 2cms

The post mortem specimen shows a short axis transverse view through the right and left ventricle showing hypertrophy of the left ventricle. The ventricular septum measures about 2cms. code heart cardiac left ventricle hypertrophy enlarged growth thick normal right ventricle gross pathology Courtesy Ashley DAvidoff copyright 2009 all rights reserved 08028c03.8s

Mild LV Hypertrophy – Congenital VSD

The left ventricle that has been opened along the ventricular septum shows the septal wall to your left and the free wall with the papillary muscles to your right. Note the glistening endothelium which has a whitish sheen. The myocardium lies directly under the endocardium.. Note also the two sets of papillary muscles, and the fibrous continuity of the mitral valve with the aortic valve. A VSD is noted on the superior aspect of the septum. Courtesy Ashley Davidoff all rights reserved copyright 2009 08345b.8

Size – LV Hypertrophy by CXR

LVE on CXR

76788c02.8s The PA and lateral chest x-ray shows evidence of cardiomegaly with the left ventricle pointing down and out in the PA examination (white arrow c) and taking up more than a third of the diaphragmatic space on the lateral, with posterior bulging so that the IVC (blue arrow) is anterior to the IVC. The method is to draw a vertical, 2,5cms line up from the junction of IVC with diaphragm and then if the border of the LV is greater than 2.5 cms from the vertical line then LVH is diagnosed. Most the time the posterior positioning of the LV in relation to the IVC suffices to enable the diagnosis. These findings are characteristic of LVH – with the change mostly in shape on the PA rather than an overt change in size. code CXR heart cardiac left ventricle size hypertrophy shape LVH left ventricular hypertrophy CXR chest X-ray plain film of the chest Copyright 2009 Courtesy Ashley Davidoff M

Size – LV Hypertrophy by Angiography

07969c06 heart aorta left ventricle LV normal anatomy fx hypercontractile ballet slipper ejection fraction = 80% AV aortic valve thickened doming ejection click jet turbulence shear stress post stenotic dilatation  LV angiogram angiography Courtesy Ashley Davidoff MD aortic valve 07969c03 07969c02 07969c04

 Size – LV Hypertrophy by CT

Coronal reformats through the chests of two different patients. They are approximately at the same level of the RVOT. The left image (a) is normal, while image b shows concentric thickening of the LV. Courtesy Ashley Davidoff MD 39088c01 code cardiac heart normal LVH LV hypertrophy

39699.800 aorta aortic valve aortic annulus calcified calcification aortic sclerosis aortic stenosis LVH left ventricle hypertrophy CT scan volume rendering Courtesy Ashley Davidoff MD

Size – LV Hypertrophy by MRI

16906.800 heart LV left ventricle aorta coarctation left ventricular hypertrophy fx LVH concentric hypertrophy dx coarctation imaging radiology T1 weighted MRI Courtesy Ashley Davidoff MD

Size – LV Idiopathic Hypertrophic Subaortic Stenosis (IHSS)

CT scan

Normal and  IHSS

This series of CTscans shows a normal Left ventricular outflow tract overlayed in bright red in a, with normal septum in green (c) contrasted to a patient with IHSS, where the LVOT is narrowed (b and bright red in d) with a thickened septum with overlay in green (d). Courtesy Ashley DAvidoff MD 39208c01 code cardiac heart CTscan interventricular septum thickened IHSS imaging radiology CTscan

 Size – LV Dilatation

 

Size – LV Dilatation – Echocardiography

Dilated LV in a Patient with  a Cardiomyopathy This gray scale echo of the heart shows a 4 chamber view revealing a dilated chambers including the left ventricle, right ventricle left atrium and right atrium. The mitral and tricuspid valves are both well seen and are closed in this diastolic phase. The patient has a cardiomyopathy. Courtesy Philips Medical Systems 33130 code cardiac heart echo dilated LV RV LA RA MV TV cardiomyopathy see image 33137 imaging cardiac echo

Size – LV Dilatation CT

Ischemic Cardiomyopathy Dilated LV

The CTscan is from a 76 year old man in whom the dominant finding is of left ventricular enlargement. The RA and RV are also enlarged based on this image, and LA was enlarged as well suggesting global cardiomegaly consistent with a cardiomyopathy. The clue to the cause of the enlargement is the segmental nature of the disease characterized by the asymmetry of the free wall and septum and the presence of fat (yellow overlay) in the thinned and probably scarred myocardium making ischemic cardiomyopathy the diagnosis. At the apex, there is there is a subtle calcification as well. Courtesy Ashley Davidoff Copyright 2009 All rights reserved 86984c05.8s01

Ischemic Cardiomyopathy

The CTscan through the LV in this non gated examination shows an enlarged LV with a particularly prominent LV apex with thinned myocardium  suggestive of a dyskinetic segment. 42394.800 CTscan Davidoff MD copyright 2009

Globular Heart Recent MI

This elderly female recently sustained an acute MI and the resulting functional myocardial loss has resulted in a globular deformity of the heart as seen on this non gated CT through the chest.  Note the malorientation of the posterior papillary muscle that prohibits normal function of the mitral valve and results in mitral regurgitation.  A Small pericardial effusion is present. Courtesy Ashley Davidoff MD copyright TCV 2008 75517

Congenital Hypoplastic Left Heart Syndrome Diminutive Cavity with LV Hypertrophy

This pathological specimen is from a patient with hypoplastic left heart syndrome, (HLHS) (a) show a diminutive LV cavity (about 5mm in diameter)and MV elements with a relatively thick LV wall. (about 9mms in diameter) Both these findings are characteristic of the disease. a close-up of the MV (b)shows an atretic MV with unformed and poorly formed elements including the chordae and papillary muscles. No lumen could be identified. Courtesy Ashley Davidoff MD. 01813c01 copyright 2009

Shape

The overall shape of the left ventricle is conical.

Shape LV Fetal Ultrasound

Fetal Ultrasound

This is a fetal US with an oblique coronal projection revealing a normal thick walled LV with its football shape (red overlay). The RV which has a rounded shape in this projection, is overlaid in blue. The anterolateral papillary muscle can be seen projecting into the RV chamber (sinus). Courtesy of Ashley Davidoff M.D.

Shape LV Angiography

Shape LV – CT Scan

Diastolic Shape RAO  CTscan

The oblique sagittal reconstructed LV is a diastolic reconstruction showing a rounded apex.  The apparent thinning of the apex is caused by the obliquity of the cut and is an artifact since this was an otherwise normal study.  The elongated LV outflow tract is well demonstrated in this view.  Additionally the normal SVC with high density contrast is well seen. 45193 vein SVC superior vena cava RA right atrium right ventricular inflow RV LV left ventricle LVOT sinus of Valsalva aortic valve heart cardiac normal anatomy CTscan Courtesy Ashley Davidoff MD

31235c.81s The CT scan of the heart has been reconstructed in the coronal view with image a being slightly anterior to image b. In image a, the triangular nature of the RV is noted and inimage b the ovoid nature of the LV is noted heart cardiac CTscan RV LV Ao PA right ventricle left ventricle aorta pulmonary artery RCA right coronary artery shape normal anatomy CTscan coronal reformat Courtesy Ashley Davidoff copyright 2009 all rights reserved

Shape LV – Posterior Wall

06559b03c01.8s The post mortem specimen was distended with fixatives including formalin under gravitational pressure, and then fixed in wax. The heart is viewed in a lateral projection tipped slightly to show the lateral and posterior wall of the LV. The main pulmonary artery (MPA), right ventricular outflow tract (RVOT), left atrial appendage (LAA) aorta(Ao), superior vena cava (SVC) pulmonary vein (PV) left atrium (LA) left ventricle (LV) and inferior vena cava (IVC) are shown. The distensible nature of the heart is demonstrated. code heart cardiac anatomy normal fixed heart right ventricular outflow tract left ventricle main pulmonary artery aorta left atrial appendage pulmonary vein left atrium inferior vena cava superior vena cava RVOT LV MPA Ao PV IVC SVC LA LAA gross pathology wax specimen anatomy Courtesy Ashley Davidoff copyright 2009 all rights reserved

 Shape LV – Enlargement by CXR

 

 

Shape LV – Enlarged Angiography

Image 1 on the left, is the normal ventriculogram shown previously in the “Mitral Valve – Imaging” page. Contrast is injected directly into the LV, via a catheter which passes from the aorta through the aortic valve into the LV, and hence no contrast should pass into the LA. In contrast the ventriculogram in the same RAO projection in image 2, shows the posteriorly positioned LA filled with contrast. This is regurgitation of contrast called mitral regurgitation, the same condition as the previous two echocardiograms. Courtesy of Ashley Davidoff M.D. 32124

Shape LV – Enlarged MRI

We now place a normal MRI on the left alongside an hypertrophied right ventricle (right). Note the thickening and heavy trabeculation of the anterior wall of the right ventricle. Note also the ovoid shape of the LV and the triangular shape of the RV. Courtesy of Ashley Davidoff M.D. 32076

Shape LV – Aneurysm

The first image on the left is a normal axial MRI of the LV. In the image on the right, the LV cavity is too large, has a rounded and rather full apex, and has thinned septal apical walls. The color overlay shows the expanded LV cavity in the images on the right with the thrombus in the LV apex (green overlay) Courtesy of Ashley Davidoff M.D. 32131

Position

The left ventricle lies in the middle mediastinum and is enclosed in the pericardium. It sits obliquely in the chest, behind the body of the sternum and the left inferior costochondral junctions, and projects from the midline into the left half of the thoracic cavity.

If we were to “crack open” the chest of the chest X-ray, the structures that would dominate this bloody black and white scene, would be the right sided chambers. The right ventricle (RV) would be the dominant anterior chamber. The right atrium (RA) would form the border with the right lung, and the RV would form the dominant interface with the diaphragm. The RA would of course be slightly posterior to the RV. The left border would be formed by the left ventricle. Courtesy Ashley Davidoff M.D. 32064 code cardiac heart normal RA RV RVOT LV AO RPA LPA normal anatomy imaging CXR chest X-ray plain film

 LV Character

  

This series of non contrast CT scans through the inferior aspect of the LV shows a thin lucency of fat density which is located on the endocardial side of the myocardium. This suggests that there is significant associated thinning of the myocardium. There are a few punctate dystrophic calcifications in the septal component of the lucency. (a,b) The lucent abnormality also extends to the apex and the free wall of the LV. In images c and d the apex bulges forming an apical aneurysm. The findings are consistent with previous infarction with fatty changes in the infarcted region. Courtesy Ashley Davidoff MD. 38325c code cardiac heart LV apex septum free wall lucent fat calcification MI aneurysm CAD IHD imaging radiology CTscan

This tissue doppler echo of the heart showing a long axis view, and demonstrating a normal left ventricle, mitral valve and aorta. Courtesy Philips Medical Systems 33182b normal cardiac heart echo tissue doppler MV LV AOimaging cardiac echo

This is a CT of the chest at the level of the heart demonstrating a curvilinear calcification at the apex of the left ventricle. This calcification is most likely in the myocardium of the apex of the left ventricle, caused by dystrophic calcification of infarcted myocardial tissue. Alternatively it may be within thrombus in the LV apex, secondary to an aneurysm of the apex. The shape of the calcifcation medially as it courses up the septum, makes pericardial calcification unlikely. In addition a faint soft tissue density of normal pericardiium can be seen anterior to the curvilinear calcification. Pericardial calcification is usually present more commonly over the right ventricle. Courtesy Ashley Davidoff MD. 25708 code heart LV apex curvilinear calcification probable remote myocardial infarction cardiac imaging radiology CTscan

This cross sectional CT image of the heart shows calcified apex of the left ventricle associated with thrombus, characteristic of an LV aneurysm. The cause is almost certainly secondary to coronary artery disease and ischemic heart disease with secondary myocardial infarction. Courtesy Ashley Davidoff MD. 30472 code heart LV apex IHD CAD aneurysm calcification calcified MI cardiac imaging radiology CTscan

This series of CT image shows a faint curvilinear lucency in the apical myocardium (a,b) as well as myocardial calcification. The lucency identified by red lines in b, is thought to be a fatty deposition in infarcted myocardial tissue, and the calcification represents dystrophic calcification in the necrotic tissue. Note that the calcification is not in the pericardium which is identified by the red markers in c. The pericardium is surrounded by pericardial at on the outside and epicardial fat on the inside. Included in the differential diagnosis is an apical aneurysm with calcification in clot. The calcification in the annulus is premature and unusual for this 56 year old male patient. Note the small bilateral pleural effusions. Courtesy Ashley Davidoff MD. 29601c01 code CVS cardiac heart MAC apical fat MI calcium myocardium apex cardiac imaging radiology CTscan radiologists and detectives

References and Links

TCV

Cardiomyopathies

003 Non Compaction Heart Failure and Pacemaker