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40 Cards in this Set
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Cardiac sarcoma
Diagnosis: osteosarcoma of the right atrium Case findings: Right atrial mass with irregular, multilobulated borders Mass obstructs the IVC, thrombus throughout IVC Inhomogeneous enhancement of the liver and non-enhancement of hepatic veins consistent with Budd-Chiari syndrome DDX right atrial mass: Angiosarcoma Osteosarcoma (MC left-sided) Myxoma Lymphoma Metastatic disease including metastatic osteosarcoma Large adherent clot Primary cardiac sarcoma: Rare and < 25% of primary cardiac tumors MC angiosarcoma (tend to be right-sided) Additional subtypes: undifferentiated, fibrosarcoma, MFH, leiomyosarcoma, myxosarcoma, synovial sarcoma, neurofibrosarcoma, osteosarcoma |
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Congenital absence of left pericardium
Case findings: Shift of the mediastinum toward the left side Appearance of the heart is unusual 3 large convexities (aortic arch, main pulmonary artery, LV segment) at elongated left heart border Hyperlucent area between the aortic arch and the main PA, due to interposition of lung tissue at this level (arrow) MR: Heart is rotated clockwise (horizontal position of the interventricular septum) Absence of a hypointense line in the epicardial fat along the left heart border Premature atrophy of left cardiac vein (left duct of Cuvier) Leads to a loss of blood supply to the left pleuropericardial membrane (normally persists and forms the left pericardium) Features: Abrupt termination of the right pericardium or total absence of pericardium Cardiac rotation Shift to the left hemithorax Interposition of lung between the aortic arch and MPA Associated with other congenital cardiopulmonary abnormalities in 1/3rd of cases: Atrial or ventricular septal defects Persistent ductus arteriosus Aortic valve anomalies Tetralogy of Fallot Bronchopulmonary sequestration |
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Left atrial appendage thrombus
Case findings: Left atrial appendage is located between the LAD coronary artery and the upper part of the left atrium Curved non-enhanced filling defect is seen inside the left appendage US: fixed left atrial appendage thrombus Left atrial thrombi MC occur in the setting of stagnant blood flow Predisposing conditions: Atrial fibrillation MV disease, MV prostheses Cardiomyopathy |
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Left atrial calcification
Case findings: XR: heart is enlarged, thin oval curvilinear rim of calcification projected through the center of the heart CT: LA wall calcification, MV is calcified LA calcification: result of extensive chronic rheumatoid heart disease Associated with: Atrial fibrillation Long standing congestive cardiac failure Mural thrombus and embolization LC chronic renal failure |
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Left atrial myxoma
Case findings: CT: pedunculated bilobular mass within LA US: mass within the anterior LA , and a 2nd LA mass extends through the MV into the LV Primary cardiac neoplasms are rare, most are benign MC in left atrium (75%) DDX: Because of fibrosis, calcification or iron, myxoma may be dark on GRE images, cine, mimicking the signal drop seen with thrombus Lipoma: bright on T1 and darken with FS, MC in RA Benign tumors are typically well circumscribed, whereas malignant tumors tend to be infiltrative, large, have a broad point of attachment, and are associated with pericardial effusion Clinical presentations: Obstructive symptoms: shortness of breath, orthopnea and PND Embolization: peripheral embolization of tumor fragments Systemic features: fatigue, fever, elevated ESR, hemolytic anemia DDX: Thrombus: MC sessile and of low echogenicity In contrast with myxoma, which is echogenic, mobile, pedunculated and with a point of attachment at the fossa ovalis in most cases |
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Left ventricular thrombus
Case findings: CT: apical myocardium is thin, with an intra-ventricular pedunculated mass suggesting an old infarct complicated by a thrombus US: apical thrombus of in the left ventricle |
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Left ventricular aneurysm
Case findings: Bulging of the left heart border with curvilinear peripheral calcification Lateral CXR demonstrates the relatively anterior position of the calcification Clinical: mitral regurgitation |
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Left ventricular aneurysm
Case findings: Bulging of the left heart border with curvilinear peripheral calcification Lateral CXR demonstrates the relatively anterior position of the calcification Clinical: mitral regurgitation |
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Cor triatriatum (“heart with three atria”)
Case findings: XR: Normal heart size with RV enlargement MR: Membrane at the atrial level with high signal from slow flow Rare congenital anomaly due to a failure of the common pulmonary vein to incorporate normally into left atrium Posterior accessory chamber connects with the true left atrium in an obstruction to the pulmonary venous return Left atrium is pushed against the mitral valve Small atrial appendage |
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Ebstein’s anomaly
Case findings: Septal leaflet and inferior leaflet of the tricuspid valve are plastered to the right ventricular wall near the cardiac apex Anterior leaflet of the tricuspid valve is present in the normal location at the atrioventricular groove RA and atrialized portion of RV are markedly enlarged Malformation of the tricuspid valve leaflets where one or more leaflets arise from the right ventricle wall (septal leaflet is always involved, and inferior leaflet is commonly involved) Atrialized portion or inlet portion of RV: RV proximal to the septal leaflet Thin walled and poorly contractile Functional portion of the RV remains trabeculated Results in severe tricuspid insufficiency DDX cyanosis with decreased vascularity: Tetralogy of Fallot Truncus arteriosus (type IV) Tricuspid atresia (*) TGV (*) Ebstein’s anomaly (*) Also in DDX cyanosis with increased vascularity |
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TAPVR
Diagnosis: TAPVR, supracardiac (type 1) DDX cyanosis with increased vascularity: Truncus arteriosus (type I, II, III) TAPVR Single ventricle Tricuspid atresia (*) TGV (*) (*) Also in DDX cyanosis with decreased vascularity |
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Viral myorcarditis
DDX cardiomegaly with normal vascularity: Viral myocarditis Endocardial fibroelastosis Aberrant left coronary artery Cystic medial necrosis Diabetic mother |
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Hypoplastic left heart syndrome
DDX CHF in newborn (impede return of flow to left heart): Infantile coarctation Congenital aortic stenosis Hypoplastic left heart syndrome Cor triatriatum TAPVR, infracardiac (type 3) |
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Atrial septal defect (ASD)
Case findings: RA is slightly dilated RV, LV, LA are normal in size L-R shunt at atrial level Types: Ostium secundum: MC (60-70%), large defect of 1-3cm in the region of the fossa ovalis Ostium primum (30%): associated with an ECD Sinus venosus (5%): defect of the superior inlet portion of the atrial septum ASD primum with PAH Atrial septal defect (ostium secundum) |
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Ventricular septal defect (VSD)
Membranous/perimembranous (80% of VSD) Defect is below the crista supraventricularis of the RV and 1 cm caudal to the base of the aorta Muscular (10% VSD) Tend to be small and multiple Supracristal or outlet VSD (5% of VSD) Located beneath pulmonary valve with upper border of the defect beneath right coronary cusp of the aortic valve in the LV MR: defect in the muscular ring at the level of the pulmonary valve in the right ventricular outflow tract Inlet or atrioventricular canal (5% of VSD) Represents a component of atrioventricular septal defect along with an ostium primum ASD and common atrioventricular valve Associated with trisomy 21 VSD, membranous VSD, supracristal |
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Patent ductus arteriosus (PDA)
Case findings: MR: aorta focally dilated at site of ductal attachment, consistent with an aortic spindle PDA: persistence of the distal aspect of the primitive 6th aortic arch MC in premature infants, females, and in individuals living at high altitudes Prostaglandins maintain patency, whereas prostaglandin inhibitors (indomethacin) cause its closure Features: Aortic spindle (His’ spindle): dilated part of aorta just below the isthmus Large aortic arch Dilated left atrium |
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Marfan’s syndrome
Case findings: Aortic root aneurysm including enlargement of the sinuses of Valsalva Aortic caliber is normal distal to the sinotubular junction Marfan’s syndrome: Annuloaortic ectasia (complication of aortic regurgitation) Down’s syndrome Atrioventricular canal (endocardial cushion defect) William’s syndrome Supravalvular aortic stenosis, idiopathic hypercalcemia, elfin facies Neurofibromatosis Coarctation of the descending aorta |
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Tetralogy of Fallot
Components of tetralogy of Fallot: Pulmonic stenosis Result of infundibular musculature hypertrophy (above crista supraventricularis and below pulmonary valve) VSD Overriding aorta Right ventricular hypertrophy Pulmonary atresia with VSD: Variant of tetralogy of Fallot Instead of pulmonary stenosis, pulmonary artery is atretic Pulmonary blood flow is derived from the aorta through PDA Pulmonary artery is present, although hypoplastic |
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Truncus arteriosus
Single trunk arising from right and left ventricles, aligned over a VSD Type I: main pulmonary artery arises from truncus Type II and type III: individual right and left pulmonary arteries arise from truncus Rastelli conduit: Treatment for truncus arteriosus, pulmonary atresia Right ventricle to pulmonary artery DDX: Pulmonary atresia: small infundibular chamber that is not seen in truncus Truncus arteriosus (type 1) |
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Hypertrophic cardiomyopathy
Case findings: Severely hypertrophied RV and narrowing of the right ventricular outflow tract Hypertrophied LV with near-obliteration of the left ventricular cavity Left ventricular hypertrophy without chamber enlargement Variants: MC diffuse hypertrophy of the ventricular septum and the anterolateral free wall (70%) Basal septal hypertrophy (10%-15%) Concentric hypertrophy (5%) Apical hypertrophy (< 5%) Posterolateral wall hypertrophy (1%) DDX: septal tumor (enhances with Gd) |
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Congestive heart failure
Case findings: Cardiomegaly Interstitial edema Increased central markings |
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TAPVR, infracardiac
Case findings: Normal size heart Congestive heart failure |
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Aortic coarctation
Congenital stenosis of proximal descending aorta at the isthmus Associated Aortic bicuspid valve (50%) VSD, aortic stenosis, MV abnormalities, PDA Velocity-encoded cine images are taken at a level below the coarctation and at the level of the diaphragm Used to measure blood flow during a cardiac cycle to determine the presence and degree of collateral flow around the coarctation Collateral flow would indicate hemodynamic significance DDX: Pseudocoarcation: normal gradient pressure across area of narrowing Takayasu’s arteritis: lower thoracic and abdominal aortic stenosis |
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Aortic coarctation
Congenital stenosis of proximal descending aorta at the isthmus Associated Aortic bicuspid valve (50%) VSD, aortic stenosis, MV abnormalities, PDA Velocity-encoded cine images are taken at a level below the coarctation and at the level of the diaphragm Used to measure blood flow during a cardiac cycle to determine the presence and degree of collateral flow around the coarctation Collateral flow would indicate hemodynamic significance DDX: Pseudocoarcation: normal gradient pressure across area of narrowing Takayasu’s arteritis: lower thoracic and abdominal aortic stenosis |
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Pulmonary sling
Case findings: Esophogram: posterior indentation on trachea and anterior indentation on esophagus left pulmonary artery passes between trachea and esophagus MR: origin of left pulmonary artery from the right pulmonary artery Pulmonary artery sling may compress the right main stem bronchus or bronchus intermedius Left pulmonary artery is smaller with less flow Associated with: Complete cartilage rings which may cause a long segment tracheal stenosis Tracheal bronchus Left aortic arch, normal branching Left aortic arch, aberrant RSA Right aortic arch Right aortic arch with aberrant LSA (MC) Kommerell diverticulum and left-sided ligamentum arteriosum form a vascular ring Mirror-image right aortic arch (2nd MC) Associated with CHD (95%): MC tetralogy of Fallot or truncus arteriosus Right aortic arch with isolated LSA (rare) Esophogram: posterior indentation on esophagus from the aberrant LSA at the level of the aortic arch Right aortic arch, aberrant LSA Right aortic arch, mirror image branching Double aortic arch True vascular ring MC right arch is dominant (80%) Dominant arch is MC posteriorly located arch and cranial Left arch MC located anteriorly and right arch posteriorly Descending aorta is MC left-sided Cardiac surgical procedures Glenn: SVC to right pulmonary artery Rastelli: truncus arteriosus, pulmonary (artery) atresia Right ventricle to pulmonary artery Fontan: pulmonary atresia Right atrium to pulmonary artery Blalock-Taussig shunt: tetralogy of Fallot subclavian artery to pulmonary artery TGV Jatene: arterial switch Mustard/Senning: atrial baffle Tricuspid atresia Fontan and Glenn procedures to bypass the RV |
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Scimitar syndrome
Components of scimitar syndrome: PAPVR (infracardiac) from the right lung to the IVC Hypoplasia of right lung with dextroposition of heart; Hypoplasia of right pulmonary artery Systemic arterial supply of the right lower lobe from the abdominal aorta Not all components need to be present |
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Aortic insufficiency
Case findings: Flow jet emanating from the aortic root into the left ventricle represents aortic regurgitation No flow jet into aortic root to suggest aortic stenosis |
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Transposition of great vessels (TGV)
Case findings: MR: aorta is anterior right of pulmonary artery Complete TGV: Cardiac chambers are in normal position Connection between left and right heart (VSD, ASD) necessary for life Congenitally corrected transposition Cardiac chambers are also switched (compatible with life) Aorta is located on the left and arises from RV RV lies posterior and to the left of the LV Anatomic right ventricle Triangular configuration Muscular band around the outflow tract Coarse trabecular pattern of the apical septum Moderator band at its apex Arteriovenous valve and semilunar valve separated by muscle Jatene (arterial switch): pulmonary artery straddles aorta on axial images Mustard/Senning: atrial baffle Jatene (arterial switch) for TGV |
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Tricuspid atresia
Case findings: Solid bar of fat and muscle between dilated RA and hypoplastic RV Large secundum-type ASD RV outflow tract stenosis, infundibular stenosis (not shown) Tricuspid valve and inflow portion of RV are absent Hypoplastic RV consists of conus portion, which appears as an outpouching of LV Associated with ventricular septal defect, pulmonary stenosis, and pulmonary atresia Classified by associated cardiac anomalies: Normally related great arteries (70%) TGV (25%) Corrected TGV (5%) Treated with Fontan and Glenn procedures to bypass the RV |
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PAPVR
Case findings: MIP: drainage of the right upper lobe pulmonary vein into SVC Types: Supracardiac: draining into SVC, brachiocephalic vein, or azygous vein Cardiac: draining into RA or coronary sinus Infracardiac: draining into IVC Called scimitar syndrome Associated with hypogenetic right lung MC is right upper pulmonary vein draining into SVC Associated with sinus venosus ASD PAPVR (supracardiac) Left upper lobe pulmonary vein (arrow) into a left vertical vein, which drains into the left brachiocephalic vein |
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Polysplenia syndrome
Case findings: XR: Ambiguous position of the liver Dextroposition of the heart MR: Situs ambiguous with the liver on both the right and left side At least two small spleens Stomach is on the right Persistent left SVC drains into the pulmonary venous atrium Not shown: Interruption of the IVC with azygous continuation Aorta and pulmonary artery arise from a common single ventricle Bilateral pulmonary arteries are seen passing over bilateral bronchi consistent with bilateral left-sidedness Bilateral left-sidedness with bilateral hyparterial bronchi Situs ambiguous, multiple small spleens Cardiac manifestations: Interruption of the IVC with azygous continuation (70%) Persistent left SVC (50%) Partial or total anomalous pulmonary venous connection (50%) Atrial septal defect (80%) Ventricular septal defect (70%) Single ventricle (5%) Malposition of the great arteries (30%) |
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Pericardial hematoma
Case findings: Mass in the left atrioventricular groove, compressing the LA and LV Acute angle of pericardial interface with the mass, indicating an intrapericardial location Signal is intermediate T1, without enhancement Not shown: Dark foci internally and dark rim on GRE images (central and peripheral calcifications) Low T2 DDX pericardial mass: MC pericardial hematoma Pseudoaneurysm Pericardial cyst Low T1, homogeneous high T2, no enhancement Neoplasm |
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Lymphoma
Case findings: Mediastinal mass that encases the distal trachea and bilateral mainstem bronchi Mass invades the roof of the left atrium Enhances homogeneously DDX: Thrombus Thrombus is darker on GRE sequences than muscle Tumor on GRE cine images is similar to, or higher than, the myocardium Tumor enhances with gadolinium, whereas clot does not Angiosarcoma MC primary cardiac tumor (MC in RA) Unlikely to be centered around the carina Fibrosing mediastinitis: should not invade the heart Metastasis: MC small cell carcinoma of the lung Lymphoma (different patient) |
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Atrial lipoma
Case findings: Homogeneously high T2 mass in LA Mass intrinsically bright on T1 (not shown), and does not enhance after gadolinium SI of mass homogeneously reduced with FS MC benign primary tumor of the heart MC in RA (this case was a LA lipoma) |
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Angiosarcoma
Case findings: Focally enlarged and lobulated interventricular septum mass Mass demonstrates enhancement DDX of thickened interventricular septum: Asymmetric hypertrophic cardiomyopathy MC malignant primary intracardiac tumor Other primary malignant tumors: Rhabdomyosarcoma Leiomyosarcoma Liposarcoma Lymphoma |
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Pericardial cyst
Case findings: Cystic mass conforming to the contour of the heart and the main pulmonary artery Low T1, high T2, no enhancement Benign developmental lesion formed when part of the embryonic percardium is pinched off MC found in the right anterior cardiophrenic angle behind the right atrium DDX of benign mediastinal cyst: Bronchogenic cyst Thymic cyst Pericardial cyst: cyst conforms to the contour of other mediastinal structures |
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Constrictive pericarditis
Case findings: Pericardium is thickened over the RA and TV Pericardium is clearly identified between two layers of fat (pericardial fat and epicardial/subpericardial fat) Etiology: Cardiac surgery, radiation therapy Tuberculosis, post-viral pericarditis Collagen vascular disease Infiltration of the pericardium by neoplasm Clinically difficult to differentiate between constrictive pericarditis and restrictive cardiomyopathy Patients with constrictive pericarditis may benefit from pericardiodectomy whereas those with restrictive cardiomyopathy would not Restrictive cardiomyopathy Pericardium is of normal thickness (< 2 mm) Constrictive pericarditis Pericardium is > 4 mm thick DDX thickened pericardium (use clinical history to help diagnose) Constrictive pericarditis After cardiac surgery Uremic pericarditis Pericardial effusion |
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Tuberculous pericarditis
Uncommon cause of pericarditis Features: Thickening of the pericardium and/or pericardial effusion Enhancement of the pericardium seen in tuberculous pericarditis and may be due to granulation tissue in the pericardium |
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Ventricular aneurysm
Case findings: Pericardial effusion with high T1 (serosanguinous) Left ventricular true aneurysm True ventricular aneurysm Large segment of nonviable myocardium Focal wall thinning and is deformed during diastole and dilates during systole MC located in the anterolateral and apical aspect of LV, wide ostium False ventricular aneurysm Cavity that communicates with ventricular lumen, but not formed by myocardium Results from a contained rupture of LV after myocardial infarction MC in posterior and diaphragmatic aspect of LV, narrow ostium False ventricular aneurysm |
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Arrhythmogenic right ventricular dysplasia (ARVD)
Case findings: High T1 in myocardium of RV anterior free wall, corresponding to fatty infiltration NB: signal from the posterior portion of the heart was suppressed with a posterior saturation band to reduce artifact Right ventricular dysplasia Results from replacement RV myocardium with fat or LC fibrous tissue Results in right ventricular arrhythmias, which may be provoked by exercise and complicated by syncope or sudden cardiovascular collapse MC men at a young or middle age DDX: Right ventricular outflow tract tachycardia (no evident structural abnormality) |
