CARDIAC RADIOLOGY

• "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)

• RIBS - notching (aortic coarctation) and posterior fractures (child abuse / NAT)
• TRACHEA - deviation, etc

Think "AORTIC / AV PROBLEMS"

• •Coarctation of Aorta
• •Pseudocoarctation of Aorta
• •Aortic valve disease

Bicuspid aortic valve

Aortic dissection

Stenosis

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)

• 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)

• 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

Partial Anamolous Pulmonary Venous Return

VSD

AVSD

Patent Ductus Areteriosis

"5 T's"

• Transposition
• TAPVR w/o obstruction
• Truncus
• Tricuspid Atresia
• "Tingle" Single Left Ventricle - Hypoplastic Left Heart

D-Loop Transposition of the Great Vessels

Superior mediastinum narrowed due to aorta anterior to PA and thymic involution

TAPVR - Total Anomalous Pulmonary Venous Return

• •If acyanotic:
• -ASD
• -PAPVR (look for abnormal vein)
• •If cyanotic:
• -TAPVR w/o obstruct (snowman)
• -D-loop TGA (egg-on-a-string)

Truncus arteriosis - aorta and PA arise off of same vessel

Always have VSD

Tetralogy of Fallot

Upturned cardiac apex on chest film

• 1. VSD
• 2. Overriding aortic arch
• 3. Pulmonary stenosis
• 4. RVH

• •Tetralogy of Fallot
• •Ebstein’s anomaly
• •Pulmonary atresia w/ intact ventricular septum and TR

Ebstein's Anomaly

Ebstein's (newborn to adult) versus Pulmonary Atresia w/ Intact Septum and Incompetent TV (newborn only)

• •Tricuspid Insufficiency–with RV failure - (Think endocarditis because of IV drug abuse)
• •Carcinoid heart syndrome - TR and PS

• •TAPVR with obstruction - normal size heart - confluence of pulmonary vessels drain into portal circulation (high resistance circuit)
• •Hypoplastic left heart - big right heart

• •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

"LAMP"

• •LV failure: ischemic, nonischemic
• •(Atrial fibrillation / arrhythmias)
• •Mitral valve disease / obstruction
• •Pulmonary venous obstruction

Mitral stenosis

(Most common cause rheumatic heart disease) - Look for Ca2+ near mitral valve

• •Mitral valve prolapse
• •Rheumatic heart disease
• •Ruptured chordae (MI, trauma)
• •Dilated left ventricle

Think mitral valve disease

• Chronic PE
• COPD, lung disease
• L →R shunt
• Primary PAH
• Chronic LVF
• Mitral stenosis

• •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)

• •Nonvascular
• –bronchogenic cyst
• –lymphadenopathy
• –mesenchymal tumor, etc
• •Vascular
• –aneurysm / pseudoaneurysm
• –aortic arch anomaly (right aortic arch, etc.)

• 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)

Kartagener's syndrome (also assoc with sinusitis)

Situs ambiguous

• Worry about polysplenia / asplenia (won't see asplenia because they die due to encapsulated organism infection)
• Absent IVC with azygous continuation

• 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)

• Myocardial - usually involve LV apex and set back from the sternum (? prior infarct)
• Pericardial - over RV, spares apex and abuts sternum (infection, uremia, XRT)

Uremia

Congenital absence of the pericardium (heart not tethered to sternum, will droop posteriorly on supine CT)

• 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

• 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

• 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

• Diastolic dysfunction
• Restrictive vs Constrictive
• •Clinically indistinguishable
• •Both: non-compliant ventricles
• •Restrictive: progressive, fatal (amyloid)
• •Constrictive: cured surgically (calicifcation - usually cured by stripping)

BOTH: Bi-atrial enlargement with normal sized ventricles

• Distinguished on MR =
• Restrictive: LVH with abnormal enhancment (i.e. Amyloid)
• Constrictive: Normal thickness and enhancment

• •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

>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

• 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.

(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

• •Aneurysm - >1.5 x normal (West - atherosclerosis, East - Kawasaki's)
• •Pseudoaneurysm
• •Fistula - to lower resistance to CS, chamber, MPA
• •Dissection - mild ↑size

• Myocardial bridging
• - normal vessels should always be surrounded by fat
• - should do stress test to assess for ischemia

• 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

• Lung,
• Breast,
• Lymphoma,
• Melanoma

> 3mm of fluid

• -Infection (TB)
• -Malignancy (Met vs Mesothelioma) - can be nodular

Left SVC most likely

Wire shift

• Pericardial cyst
• Prominent fat pad
• Lymphadenopathy
• Solitary fibrous tumor
• Loculated effusion
• Morgagni hernia

Ebstein's Anomaly

Pulmonic Valve Stenosis

• -left hilar mass (?↑main PA)
• -massive left PE (should be peripherally oligemic)
• -valvular pulmonic stenosis
• -small R hilum, redirect flow

• -lobar collapse
• -hypoplastic R PA
• -scimitar syndrome

• Cor triatriatum
• vs
• Thrombus

Pulmonary emboli with right heart strain

Right heart strain changes management and lytics are used

• 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