Section VIII Cardiac

Figure 1A
314. You are shown a frontal (Figure 1A) and a lateral (Figure 1B) radiograph of a 36-year-old woman complaining of shortness of breath and palpitations. Which one of the following is the MOST likely diagnosis? A. Aortic stenosis B. Mitral valve disease C. Atrial septal defect D. Primary pulmonary hypertension E. Total anomalous pulmonary venous return

Diagnostic In-Training Exam 2003

Section VIII Cardiac

Figure 1B

American College of Radiology

Section VIII Cardiac

Question #314 Findings: This standard chest radiograph of a 36-year-old female demonstrates the presence of moderate cardiomegaly. Further inspection reveals that there is left atrial and specifically left atrial appendage enlargement as evidence by a bulge along the left side of the heart just below the main pulmonary artery. There is increase in the subcarinal angle because of left atrial dilatation. In addition, there is pulmonary vascular redistribution indicating pulmonary venous hypertension. Rationales: A) Incorrect. Left atrial enlargement is not a feature of aortic stenosis. In addition, in aortic stenosis there is frequently post-stenotic dilatation of the ascending aorta and calcification in the area of the aortic valve, findings that are lacking in this particular case. B) Correct. Mitral valve disease is usually a sequela of rheumatic inflammation of the valve leaflets. The mitral valve is most commonly affected, and it takes several years for clinical manifestations to appear. Decreased flow thru the mitral orifice result in progressive pulmonary venous hypertension and variable enlargement of the left atrial chamber, particularly the appendage. Most cases present as a combination of stenosis and regurgitation, thus the generic term mitral valve disease should be used, particularly if there is left atrial enlargement which is more characteristic of insufficiency. C) Incorrect. A defect in the interatrial septum results in left to right shunting of blood and shunt vascularity consequently. Due to decompression of the left atrium into the right side, the left atrial chamber does not enlarge in atrial septal defect. D) Incorrect. Although the age and gender of this patient would suggest the diagnosis of primary pulmonary hypertension, the radiographic findings do not. Left atrial enlargement is not a characteristic feature of primary pulmonary hypertension. In primary pulmonary hypertension, the central pulmonary arteries are enlarged and there is tapering of the distal branches. The heart size remains normal except in later stages when dilatation of the right heart chambers develops as CO pulmonale ensues. E) Incorrect. Depending on the level of the total anomalous pulmonary venous return, the radiographic findings are going to vary. In type I (supra cardiac) the superior mediastinum is prominent because of enlargement of the brachiocephalic veins. This produces the so-called snowman configuration. If the venous return is directly into the coronary sinus or right atrium, there is enlargement of those chambers. The only type of anomalous pulmonary venous return that can produce pulmonary findings of venous hypertension similar to those of mitral valve disease is the infradiaphragmatic type. None of the types of total anomalous venous return cause left atrial enlargement for exclusion of that chamber constitutes the essence of those anomalies. Citations: Higgins CB: Essentials of cardiac radiology and imaging. Philadelphia, 1992, JB Lippincott Amplatz K: The roentgenographic diagnosis of mitral and aortic valvular disease. Am Heart J 64; 556-566. 1962

Diagnostic In-Training Exam 2003

Section VIII Cardiac

Figure 2A

Figure 2B
315. You are shown two CT images (Figures 2A and 2B) of a 42-year-old patient admitted to the hospital with complete heart block. Which one of the following is the MOST likely diagnosis? A. d-Transposition of the great arteries B. l-Transposition of the great arteries C. Truncus arteriosus D. Coarctation of the aorta E.
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Pseudocoarctation of the aorta

American College of Radiology

Section VIII Cardiac

Question #315 Findings: This contrast-enhanced CT demonstrates the ascending aorta anterior and to the left of the pulmonary artery. Rationales: A) Incorrect. d-Transposition of the great arteries is a cyanotic condition in which the atrioventricular connections are concordant (right atrium connected to right ventricle and left atrium connected to the left ventricle), but there is ventriculoarterial discordance (right ventricle connected to aorta, left ventricle connected to the pulmonary artery). As a result, the ascending aorta arises anteriorly and to the right of the main pulmonary artery. B) Correct. In l-transposition of the great arteries there is atrioventricular discordance (right atrium connected to left ventricle, left atrium connected to the right ventricle) and ventriculoarterial discordance (right ventricle connected to aorta, left ventricle connected to the pulmonary artery). The hallmark of this congenital defect is the ascending aorta arising anteriorly and to the left of the pulmonary artery as this case illustrates. These patients also frequently present with heart block. C) Incorrect. Truncus arteriosus is a cyanotic heart condition characterized by lack of septation of the aortic root and main pulmonary artery thus resulting in a common arterial trunk arising from the heart. Invariably a ventricular septal defect allows mixing of blood from both ventricular chambers. Unless totally repaired in infancy, adult survival is extremely unusual. In truncus arteriosus, the great vessels are not transposed. D) Incorrect. In coarctation of the aorta there is a stenosis of the aorta (usually near the origin of the left subclavian artery) that produces variable obstruction to blood flow and if severe enough heart failure particularly in newborns. In adult patients, collateral vessels around the obstruction can lead to the formation of rib notching. This case demonstrates a normal diameter of the aorta with no collaterals. E) Incorrect. Pseudocoarctation of the aorta refers to a condition in which the aortic arch is elongated producing a characteristic S-shaped deformity of the aortic arch. The relationship of the aorta and the pulmonary artery is otherwise preserved. Citations: Reedy GP, Caputo GR: _Diagnosis Please. Case 15: Congenitally Corrected Transposition of the Great Arteries. Radiology 1999; 213:102

Diagnostic In-Training Exam 2003

Section VIII Cardiac

Figure 3A

Figure 3B
316. You are shown two images of a contrast-enhanced CT scan (Figures 3A and 3B) of a 62-year-old woman who developed hypotension several days after coronary by-pass graft surgery. Which one of the following is the MOST likely diagnosis? A. Cardiac volvulus B. Pericardial cyst C. Constrictive pericarditis D. Hemopericardium E.
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Post-pericardiotomy syndrome
American College of Radiology

Section VIII Cardiac

Question #316 Findings: Two contrast-enhanced CT images of the chest demonstrate the presence of high attenuation collection within the pericardial cavity producing mass-effect and displacement of the heart to the right. n addition, Figure 3B demonstrates a brightly enhancing structure on the inferior surface of the heart next to a metallic surgical clip near the distal portion of the posterior descending coronary artery. Rationales: A) Incorrect. Although the heart is displaced to the right inside the pericardiac sac, there is no volvulus effect thus excluding the diagnosis. B) Incorrect. Pericardial cysts are usually located in the right cardiophrenic angle and are usually filled with clear fluid. Although they can attain significant size, they do not displace the heart. C) Incorrect. Constrictive pericarditis can be excluded based on a normal thickness pericardium in this case. Pericardial constriction would in addition be very unusual to present clinically several days after surgery, as is the case with this patient. The fluid filled pericardial cavity and heart displacement of this case are atypical for constrictive pericarditis. D) Correct. The presence of high attenuation material in the pericardiac sac is characteristic of hemopericardium. Pericardial hemorrhage was a result of a pseudoaneurysm formation at the distal graft anastomosis to the posterior descending branch, which explains the finding on Figure B. Associated bilateral pleural effusions and heterogeneity of the liver are the result of associated congestive changes from cardiac tamponade physiology. E) Incorrect. In the post-pericardiotomy syndrome, clinical findings of chest pain and fever develops several days or weeks after cardiac or pericardial injury of all kinds including trauma, catheter perforation, or surgery. Treatment usually consists of aspirin or other non-steroidal anti-inflammatory drugs. Citations: D. Bryk, IG Kroop, J Budow; The effect of heart size cardiac tamponade and phase of the cardiac cycle in the distribution of pericardial fluid. Radiology 1996 93; 273-278 Spodick DH The Pericardium A Comprehensive Textbook. _Marcel Dekker, Inc. New York 1997.

Diagnostic In-Training Exam 2003

Section VIII Cardiac

Figure 4A
317. You are shown three contrast-enhanced images of a chest CT of a patient with atypical chest pain (Figures 4A, 4B and 4C). Which one of the following is the MOST likely diagnosis? A. Lipomatous hypertrophy of the interatrial septum B. Atrial lipoma C. Atrial myxoma D. Bland thrombus in the right atrium E. Atrial liposarcoma

American College of Radiology

Section VIII Cardiac

Figure 4B

Figure 4C
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Section VIII Cardiac

Question #317 Findings: Contrast-enhanced CT images through the heart demonstrate the presence of diffuse thickening of the interatrial septum with thinning at the level of the fossa ovalis as seen on Figure 4C. The septal thickening is characterized by very low attenuation tissue characteristic of fat. Rationales: A. Correct. Lipomatous hypertrophy of the interatrial septum is characterized by deposition of non-encapsulated fat in the interatrial septum, sparing the fossa ovalis, a characteristic feature. It can be associated with arrhythmias. B. Incorrect. Atrial lipoma can occur in any portion of the atria including the atrial septum. However, they do not spare the fossa ovalis as this case illustrates. Lipomas consist of encapsulated mature adipose cells, can grow to significant size, and are considered distinct from lipomatous hypertrophy of the interatrial septum. C. Incorrect. Atrial myxomas are soft tissue benign tumors of the heart that can be found in any chamber, but are most commonly seen in the left atrium, attached to the interatrial septum. The fatty nature of this case excludes the diagnosis of myxoma. D. Incorrect. The fatty appearance of the atrial infiltration excludes the diagnosis of bland thrombus of the right atrium. E. Incorrect. Liposarcoma of the heart is extremely rare, and as liposarcomas at other sites is characterized by strands of soft tissue within the fatty tumoral mass. Again, the pure fatty nature of the tumor and sparing of the fossa ovalis excludes liposarcoma as a diagnosis. Citations: Araoz PA, Mulvagh SL, Tazelaar HD, Julsrud PR, Bree JF; CT and MR imaging of Benign Primary Cardiac Neoplasms with Echocardiographic Correlation. Radiographics 2000 20:1303-1319

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American College of Radiology

Section VIII Cardiac

Figure 5A

318. You are shown coronal CINE images in diastole (Figure 5A) and systole (Figure 5B) of a patient with chest pain. Which one of the following is the MOST likely diagnosis? A. Type A aortic dissection B. Syphilitic aortitis C. Aortic stenosis D. Aortic regurgitation E. Atherosclerotic aortic aneurysm

Diagnostic In-Training Exam 2003

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Section VIII Cardiac

Figure 5B

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American College of Radiology

Section VIII Cardiac

Question #318 Findings: Cardiac cine images in diastole and systole demonstrate the presence of a focal area of dark jetting arising from the aortic valve during systole (Figure 5B). No other areas of signal abnormalities are seen. Rationales: A. Incorrect. Other than the systolic signal abnormality arising from the aortic valve during ventricular systole, the aorta has normal appearance without intimal flaps that are the hallmark of aortic dissection. B. Incorrect. Syphilitic aortitis is a rare delayed sequela of tertiary syphilis frequently occurring 15-30 years after the primary infection. Most cases involve the aortic root or arch and calcifications are common. The aortic leaflets are usually spared, and aneurysms are common. C. Correct. Aortic stenosis is usually a consequence of degeneration of a bicuspid aortic valve, a condition seen in about 2% of the population. The presence of turbulent jetting across the aortic valve during ventricular systole makes this the most plausible diagnosis. D. Incorrect. Lack of signal below the aortic valve during diastole (Figure 5A) implies a competent aortic valve thus excluding regurgitation as an alternative. E. Incorrect. The aorta does not show any aneurysm formation in this case thus excluding the diagnosis. In addition, atherosclerosis does not typically involve the aortic valve. Citations: Dominique Didier, Osman Ratib, Ren Lerch, and Beat Friedli. Detection and Quantification of Valvular Heart Disease with Dynamic Cardiac MR Imaging. RadioGraphics 2000 20: 1279-1299. VB Ho and MR Prince. Thoracic MR aortography: imaging techniques and strategies. RadioGraphics 1998 18: 287-309. SA Rebergen, RA Niezen, WA Helbing, EE van der Wall, and A de Roos. Cine gradient-echo MR imaging and MR velocity mapping in the evaluation of congenital heart disease. RadioGraphics 1996 16: 467-481

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