612 Section Five: Cardiac Radiology
FIGURE 22.39. Left Atrial ThrombusCT. Contrast-enhanced
FIGURE 22.37. Thrombus in the Left VentricleMR. Late contrast-
enhanced image in a two-chamber orientation using an inversion-re-
covery gradient-echo sequence 10 minutes following gadolinium infu-
sion at 0.2 mM/kg. Note the subendocardial hyperenhancement in the
basal inferior wall (arrows) and focal transmural hyperenhancement
at the apex (curved arrow). The arrowhead identifies a thrombus at
the apex that fails to take up contrast.
CARDIAC MASSES
Cardiac masses include thrombi, primary benign tumors, pri-
mary malignant tumors, and metastatic tumors. Lipomatous
hypertrophy, moderator bands, and papillary muscles may simu-
late cardiac masses. Because most cardiac masses do not deform
the outer contours of the heart, chest radiography is typically
not useful, except for the occasional calcific mass. Nuclear scin-
tigraphy, CT, and cardiac angiography identify intracardiac
masses. Echocardiography is usually the initial mode of evalua-
tion, and MR may be helpful when there is uncertainty.
Thrombi are the most frequent cause of an intracardiac
mass and are most common in the LA and LV, where they pres-
ent a risk of systemic emboli (Fig. 22.37). Intra-atrial thrombi
FIGURE 22.38. Left Atrial ThrombusEchocardiography.
Transesophageal echo shows echogenic thrombus (arrow) in the left
atrium (LA). The mitral valve (arrowhead) and the left ventricle (LV)
are shown.
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MDCT demonstrates large thrombus (arrow) in the appendage of the
left atrium (LA).
are usually associated with atrial fibrillation, often secondary
to rheumatic heart disease. Atrial thrombi commonly occur
along the posterior wall of the LA. Clots within the left atrial
appendage are difficult to detect on transthoracic echocar-
diography but are readily identified with transesophageal echo
(Fig. 22.38), CT (Fig. 22.39), and MR. Left ventricular
thrombi are usually secondary to recent infarction or ven-
tricular aneurysm (Fig. 22.40). The differentiation of tumor
versus clot is best done with MR using gradient-echo tech-
niques. Clots typically have low signal, whereas tumors
have intermediate signal. Clots will not enhance, whereas
neoplasms will typically appear as enhancing masses on CT
or MR.
Benign Tumors. Atrial myxoma makes up 50% of primary
cardiac tumors and is the most common primary benign tumor
(Figs. 22.41, 22.42). It occurs most frequently in patients in
the 30- to 60-year age range and is often accompanied by
fever, anemia, weight loss, embolic symptoms (27%), or syn-
cope. Myxomas frequently calcify; most (75% to 80%) occur
in the LA and they can mimic rheumatic valvular disease clini-
cally. Cine-mode gradient-echo MR is useful for determining
the morphology of the lesion. Intracardiac lipomas or lipoma-
tous hypertrophy are readily identified on MDCT. MR is also
FIGURE 22.40. Left Ventricular ThrombusCT. Axial contrast-
enhanced CT through the left ventricle (LV) demonstrates calcification
in an apical, left ventricular aneurysm (arrow). Note the nonenhanc-
ing low-density thrombus within the aneurysm.
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FIGURE 22.41. Left Atrial MyxomaMR. Two-chamber, long-axis
gradient-echo cine image shows a left atrial myxoma (arrow). The
myxoma has very low signal on this gradient-echo image.
useful and will demonstrate characteristic bright signal on
T1WI and remain relatively bright on T2WI. Fat saturation
sequences help to make the specific diagnosis of lipoma, which
is the second most common benign cardiac tumor.
Cardiomegaly, left atrial enlargement, pulmonary venous
hypertension, and ossific pulmonary nodules may be seen.
Echocardiogram, MR, and CT show the atrial filling defect
which may prolapse into the ventricle during diastole
(Fig. 22.42). Atrial myxomas may be pedunculated and are
usually lobulated. On M-mode echo, the EF slope is typi-
cally decreased with numerous echoes seen behind the mitral
valve.
Other benign tumors include fibromas (12% of which
may calcify), lipomas, rhabdomyomas, and the rare teratoma.
Rhabdomyomas (Fig. 22.43) are found in 50% to 85% of
tuberous sclerosis patients. Hydatid cysts typically show a
bulge along the left heart border, with associated curvilinear
calcification, and are at risk for rupture into the pericardium
or myocardium.
FIGURE 22.42. Right Atrial MyxomaCT. Contrast-enhanced
MDCT demonstrates a large right atrial myxoma (M), which was
noted to prolapse through the tricuspid valve.
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Chapter 22: Cardiac Imaging in Acquired Diseases 613
FIGURE 22.43. Left Ventricular RhabdomyomaMR. Coronal
spin-echo image through the aorta (Ao) and left ventricle (LV) demon-
strates a high-signal polypoid mass near the outflow tract of the LV
(arrow). This young patient had tuberous sclerosis, and a presumptive
diagnosis of ventricular rhabdomyoma was made. Note the delinea-
tion of the right atrium (RA) and right ventricle (RV).
Malignant Tumors. Metastatic tumors are the most com-
mon malignant cardiac tumor and are 10 to 20 times more fre-
quent than primary cardiac tumors. Breast, lung, melanoma,
and lymphoma are the most common neoplasms to metasta-
size to the heart. MR is excellent for detecting intracardiac
tumors (Fig. 22.44) and for evaluating direct tumor extension
or pericardial involvement. Angiosarcoma is the most com-
mon primary malignant cardiac tumor, followed by rhabdo-
sarcoma, liposarcoma, and other sarcomas.
PERICARDIAL DISEASE
Pericardial effusion is the most common abnormality of the
pericardium. The normal pericardial stripe is 2 to 3 mm on
chest radiograph and CT and less than 4 mm on MR. Plain
films show thickening of the pericardial stripe or differential
FIGURE 22.44. Metastasis to the Heart. Single frame from an axial
steady-state free precession cine series in a patient with metastatic
nonsmall cell lung carcinoma with tumor (arrow) visualized filling
the RV apex.
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