-
DDx: contour abnormality in the upper mediastinum at the level of the aortic arch on chest film
- "3 Sign" = knob above aorta and aorta
- Reverse 3 is made on frontal view during barium esophagram because of mass effect on the esophagus
- Nonvascular
- -lymphadenopathy,
- -abscess,
- -mesenchymal tumor,
- -neurofibroma
- Vascular–aneurysm/ pseudoaneurysm,
- -coarctation of aorta (rib notching),
- -pseudocoarctation of aorta (no rib notching, not real stenosis; only a kink of the aorta)
-
Don't see any findings on chest radiograph???
- RIBS - notching (aortic coarctation) and posterior fractures (child abuse / NAT)
- TRACHEA - deviation, etc
-
DDx: Normal pulmonary blood flow on chest film with cardiac problems
Think "AORTIC / AV PROBLEMS"
- •Coarctation of Aorta
- •Pseudocoarctation of Aorta
- •Aortic valve disease
-
50-80% of people with coarctation / pseudocoarctation also have:
Bicuspid aortic valve
-
People with bicupsid aortic valve are at increased risk for ____?
Aortic dissection
-
Calcification on plain film of the a cardiac valve is diagnostic of:
Stenosis
-
DDx: Dilated Ascending Aorta
4 A's and a D
- Aortic valve disease (AS > AI) - (including Bicuspid aortopathy - 50-80% of people have coarctation)
- Atherosclerotic aneurysm
- Annuloaortic ectasia: Marfan’s
- Aortitis (syphilis, Takayasu’s)
- Dissection (rapid Δ)
-
DDx: Increased blood flow on chest film WITHOUT cyanosis
- PAPVR - LA NOT enlarged
- and
- Left to right shunts
- -Atrial septal defect - LA NOT enlarged
- –Ventricular septal defect - LA is enlarged
- –Patent ductus arteriosus - LA is enlarged
- –Atrioventricular septal defect (AVSD endocardial cushion defect)
-
3 Types of atrial septal defects
- Primum - seen in endocardial cushion defect, basically with AVSD, rare
- Secundum - most common, mid ASD
- Sinus venosus - high ASD near SVC entry; assoc with PAPVR
-
Pulmonary veins drain into SVC
Partial Anamolous Pulmonary Venous Return
-
RV, LA, LV enlargement, acyanosis, increased blood flow
VSD
-
Global chamber enlargement R>L, acyanotic with increased pulm flow
AVSD
-
Pure left sided cardiac enlargement with increased blood flow on chest film
Patent Ductus Areteriosis
-
DDx: Increased pulmonary blood flow with cyanosis
"5 T's"
Transposition - TAPVR w/o obstruction
- Truncus
- Tricuspid Atresia
- "Tingle" Single Left Ventricle - Hypoplastic Left Heart
-
"Egg on a String" chest film with cyanosis and increased blood flow, cyanosis
D-Loop Transposition of the Great Vessels
Superior mediastinum narrowed due to aorta anterior to PA and thymic involution
-
Snowman appearance of the mediastinum on chest film in a cyanotic kid with increased blood flow
TAPVR - Total Anomalous Pulmonary Venous Return
-
Pure right sided enlargement on a chest film with increased pulm. blood flow
- •If acyanotic:
- -ASD
- -PAPVR (look for abnormal vein)
- •If cyanotic:
- -TAPVR w/o obstruct (snowman)
- -D-loop TGA (egg-on-a-string)
-
Increased Blood flow with prominent right mediastinum "truncal arch" on chest film
Truncus arteriosis - aorta and PA arise off of same vessel
Always have VSD
-
Boot shaped heart with decreased blood flow
Tetralogy of Fallot
Upturned cardiac apex on chest film
- 1. VSD
- 2. Overriding aortic arch
- 3. Pulmonary stenosis
- 4. RVH
-
Congenital causes of decreased blood flow on chest film
- •Tetralogy of Fallot
- •Ebstein’s anomaly
- •Pulmonary atresia w/ intact ventricular septum and TR
-
Decreased blood flow with narrow upper mediastinum and cardiomegaly
Ebstein's Anomaly
-
Cyanotic newborn with decreased blood flow and massive cardiomegaly
Ebstein's (newborn to adult) versus Pulmonary Atresia w/ Intact Septum and Incompetent TV (newborn only)
-
Acquired causes of decreased blood flow with right heart enlargement on chest film
- •Tricuspid Insufficiency–with RV failure - (Think endocarditis because of IV drug abuse)
- •Carcinoid heart syndrome - TR and PS
-
Cyanotic newborn with diffuse edema
- •TAPVR with obstruction - normal size heart - confluence of pulmonary vessels drain into portal circulation (high resistance circuit)
- •Hypoplastic left heart - big right heart
-
Acyanotic newborn with edema on chest film
- •Noncardiogenic causes of edema–sepsis, transient tachypnea, lymphangiectasia, etc…
- •Systemic AV fistula: LV failure–vein of Galen, hepatic hemangioendothelioma
- •Left sided obstruction
- •In uterine myocarditis (TORCH infections)
- If > 6 weeks add,
- •Myocardial abnormalities
- •aberrant left coronary artery (ALCAPA)
- •glycogen storage disease
- •Large L →R shunt
-
Cardiogenic edema in older kids and adults
"LAMP"
- •LV failure: ischemic, nonischemic
- •(Atrial fibrillation / arrhythmias)
- •Mitral valve disease / obstruction
- •Pulmonary venous obstruction
-
Edema or redistribution of flow on chest radiograph with normal LV, but LAE, RVE
Mitral stenosis
(Most common cause rheumatic heart disease) - Look for Ca2+ near mitral valve
-
Causes of Mitral Insufficiency
- •Mitral valve prolapse
- •Rheumatic heart disease
- •Ruptured chordae (MI, trauma)
- •Dilated left ventricle
-
Increased size of LA appendage
Think mitral valve disease
-
Causes of centralized increased in pulmonary blood flow (pulmonary HTN)
- Chronic PE
- COPD, lung disease
- L →R shunt
- Primary PAH
- Chronic LVF
- Mitral stenosis
-
Lateralized blood flow on chest radiograph
- •Acquired:
- –Lobar collapse
- –Swyer-James
- –Stenosis of PA
- –(Unilateral lung transplant)
- •Congenital:
- –Hypoplastic PA - smaller left hemithorax, insult after lung began to form
- –Scimitar syndrome - smaller hemithorax usually with tubular structure (PV draining to IVC)
- –Pulmonary valve stenosis - unilateral hilar enlargement (big main and left PA)
-
DDx: right paratracheal opacity
- •Nonvascular
- –bronchogenic cyst
- –lymphadenopathy
- –mesenchymal tumor, etc
- •Vascular
- –aneurysm / pseudoaneurysm
- –aortic arch anomaly (right aortic arch, etc.)
-
Two types of right aortic arches
- 1. Mirror image (normal lateral view, 95% association with CHD)
- 2. Right aortic arch with abberant left subclavian (abnormal lateral view with some tracheal bowing, only 5% association with CHD)
-
Situs inversus totalis with bronchiectasis on chest radiograph
Kartagener's syndrome (also assoc with sinusitis)
-
Left aortic arch and cardiac apex with right stomach bubble
Situs ambiguous
- Worry about polysplenia / asplenia (won't see asplenia because they die due to encapsulated organism infection)
- Absent IVC with azygous continuation
-
DDx: Globular enlargement of the cardiac silhouette
- Myocardial:
- -Dilated / ischemic cardiomyopathy
- -Multivalvular dz--* rheumatic
- -Ebstein’s (Rt; decreased flow)
- Pericardial:
- -Pericardial effusion (water bottle on frontal view and fat stripe sign on lateral view)
-
Non-valvular cardiac calcifications: pericardial versus myocardial ?
- Myocardial - usually involve LV apex and set back from the sternum (? prior infarct)
- Pericardial - over RV, spares apex and abuts sternum (infection, uremia, XRT)
-
Distal clavicular resorption, pericardial calcifications, rugger jersey spine
Uremia
-
Chest radiograph - Heart shifted to left, but upper mediastinum not shifted
Congenital absence of the pericardium (heart not tethered to sternum, will droop posteriorly on supine CT)
-
Enhancement patterns on delayed post-gadolinium images of the heart on MR
- Myocardial infarction (Always involves subendocardium and then extends transmural)
- Myocarditis (no focal subendocardial involvement)
- - mid-myocardial = Myocarditis, Hypertrophic cardiomyopathy, Sarcoidosis
- - epidardial = Sarcoidosis, Myocarditis
- - circumferential diffuse subendocardial = Amyloid, sometimes post-transplant
-
LV Failure - Ischemic vs Non-ischemic
- Ischemic = revasc. will help if >50% of wall is viable
- -RV not involved
- -Focal wall thinning
- -MR enhancment = subendocardial, transmural
- Non-ischemic
- -RV involved
- -Uniform wall
- -No enhancement
-
LV aneurysm vs pseudoaneurysm
- Aneurysm
- -Prior MI
- -Occur at apex
- -Dyskinetic, wide neck, will calcify
- -Stasis of flow increases risk of thrombus need anticoagulation
- Psuedoaneurysm
- -Prior MI vs trauma
- -Occur inferior posterior wall
- -Narrow neck
- -Hole in heart contained only by thrombus, require surgery due to risk of rupture
-
Bi-atrial enlargement with normal sized ventricles
- Diastolic dysfunction
- Restrictive vs Constrictive
- •Clinically indistinguishable
- •Both: non-compliant ventricles
- •Restrictive: progressive, fatal (amyloid)
- •Constrictive: cured surgically (calicifcation - usually cured by stripping)
-
Restrictive vs Constrictive diastolic dysfunction
BOTH: Bi-atrial enlargement with normal sized ventricles
- Distinguished on MR =
- Restrictive: LVH with abnormal enhancment (i.e. Amyloid)
- Constrictive: Normal thickness and enhancment
-
Causes of sudden cardiac death
- •Familial hypercholesterolemia
- •Aortic dissection
- •Anomalous coronary course
- •Cardiac sarcoid - arrhythmia, defib placed
- •Arrhythmogenic RV dysplasia - fibrofatty replacement best eval on MR, wall thinning and dyskinesis, RV enlargement, genetic, defib placed
- •Hypertrophic cardiomyopathy - no cause, genetic, arrhythmia - defib placed, LVOT obstr. from bulky septum - can have surgery to debulk
-
Wall thickness to call hypertrophic cardiomyopathy
>1.2-1.5cm
- Septal location - in western world - must evaluate for LVOT obstruction - may see jet below aortic valve on MR, SAM (systolic anterior motion of the mitral valve leaflet)
- Apical location - in Asia
-
What is a "malignant" coronary artery anomaly?
- When the coronary artery anomaly tracks between the aorta and PA, it can become compressed during states of high output leading to sudden death.
- Treated surgically.
Retroaortic and prepulmonic forms are benign anomalies and are incidental.
-
Cutoffs when evaluating coronary CTA for stenosis
(Always evaluate MIPs and cross sections of vessels)
- < 50 % not hemodynamically significant - medical managment with statin to prevent rupture, etc
- 50-75% go to stress test
- >75% stenosis or occlusion with expansion (MI) go to cath
-
DDx: coronary artery enlargement
- •Aneurysm - >1.5 x normal (West - atherosclerosis, East - Kawasaki's)
- •Pseudoaneurysm
- •Fistula - to lower resistance to CS, chamber, MPA
- •Dissection - mild ↑size
-
Narrowed vessel diving into myocardium on CTA
- Myocardial bridging
- - normal vessels should always be surrounded by fat
- - should do stress test to assess for ischemia
-
Cardiac mass differential
- Benign:
- -thrombus - no enhancement, MC mass, atrial-usually from afib, ventricular - usually from aneurysm
- -myxoma - MC benign neoplasm, left atrium, penduculated, stalk arises from IAS and can go through MV, variable enhance
- -lipomatous hypertrophy IAS - signal follows fat on MR, doesn't involve fossa ovale like myxoma does, occ caval obst arryth
- Malignant:
- -mets - sessile, enhances, MC than primary malig
- -primary sarcoma - usually in right atrium
-
Hematogenous mets to heart
- Lung,
- Breast,
- Lymphoma,
- Melanoma
-
Measurement to call pericardial effusion
> 3mm of fluid
-
Differential for enhancing pericardial effusion
- -Infection (TB)
- -Malignancy (Met vs Mesothelioma) - can be nodular
-
If pacer lead or line seen left of the aorta
Left SVC most likely
-
Best indicator for sternal dehiscence
Wire shift
-
DDx: Right cardiophrenic angle mass
- Pericardial cyst
- Prominent fat pad
- Lymphadenopathy
- Solitary fibrous tumor
- Loculated effusion
- Morgagni hernia
-
MR shows
Tethered tricuspid valve
Right cardiomegaly with hypokinetic RV
Ebstein's Anomaly
-
Big main and left PA
RVH
Lateralized blood flow pattern
Pulmonic Valve Stenosis
-
DDx: Left hilar enlargement:
- -left hilar mass (?↑main PA)
- -massive left PE (should be peripherally oligemic)
- -valvular pulmonic stenosis
- -small R hilum, redirect flow
-
DDx: Small right hilum w / shift to R
- -lobar collapse
- -hypoplastic R PA
- -scimitar syndrome
-
DDx: Linear filling defect in left atrium with no turbulent flow around linear defect
- Cor triatriatum
- vs
- Thrombus
-
Multiple pulmonary emboli
Right heart enlargement
Straightening / convexity towards left of IV septum
Pulmonary emboli with right heart strain
Right heart strain changes management and lytics are used
-
Left cardiac apex and aortic arch, right stomach bubble
- Situs ambiguous
- Polysplenia (die young if asplenic)
- Interruption of IVC with azygous continuation
-
2 chamber view of the heart
-
3 Chamber view of the heart
-
4 Chamber view of the heart
-
Short axis view of the heart
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