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Preface
Cardiac Imaging
Martin J. Lipton, MD
Lawrence M. Boxt, MD
Guest Editors
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.04.001
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Department of Radiology, Brigham and Womens Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
b
Department of Radiology, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003, USA
* Corresponding author.
E-mail address: mlipton@partners.org (M.J. Lipton).
these patients, instruction in the radiographic evaluation of the heart is limited or totally neglected in
many training programs. In particular, plain film
evaluation of the heart is trivialized, and radiology
residents are not instructed in their interpretation. A
dangerous gap exists between the use of imaging
studies and the ability of radiologists to perform and
interpret these examinations.
Plain film examination is still the most commonly
performed cardiac imaging test obtained in the United
States. The use of plain film examination has evolved
from being the only and most valuable imaging tool,
to its current use for detection of cardiac chamber
abnormalities and evaluating the instant state of
cardiac physiology [2]. Along with this evolution,
apparent institutional interest in cardiac plain film
examination has waned. Academic medical centers
fail to train radiology residents in the plain film
examination of the heart. By emphasizing new,
high-technology imaging modalities, notably MR
imaging and multidetector spiral CT, residents and
practicing radiologists are not availed of the sensitivity and reliability of the chest film for evaluating a
patients cardiac status. Reduced interest and awareness of radiologists limits the value of their interpretation, leading not only to underuse but also to
distrust of reported findings. This is sad and unfortunate, because plain film cardiac examination is
perhaps the most rapid, cost-effective, and safest
screening procedure for identifying and characterizing pulmonary and cardiac pathology. The chest
radiograph examination displays the heart in every
individual examined, and provides a daily exercise in
evaluating cardiovascular disease that is central for
understanding the morphologic and physiologic
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488
changes reflected in CT and MR imaging examinations [3]. The chest film is so closely tied to instruction in and understanding of disease mechanisms and
morphologic changes that result from these mechanisms, that the abandonment of training in plain film
diagnosis undermines the ability to maintain expertise
and control of CT and MR imaging of the heart. If
residents are not trained in plain film diagnosis of
heart disease, they will not have the tools to compete
for the use of cardiac CT and MR imaging. Nevertheless, so long as interpretation of the chest radiograph remains primarily the responsibility of the
radiologist, they are responsible for training radiologists competently to perform this service. To this end,
this article presents an approach to plain film examination of the heart. The approach is based on basic
principles of radiologic evaluation. It emphasizes the
relationship between the radiologic appearance of a
structure and the technique used to obtain that image,
and the relationship between the observation of a
structural abnormality and the anatomic relationships
that allow that observation to be made. This approach
is simple, organized in a logical manner, and when
applied rigorously results in not only accurate and
insightful differential diagnosis, but also a deep
understanding of cardiovascular disease processes,
which are essential for the best use of CT and
MR imaging examinations of the heart.
Radiologic technique
Before interpretation commences, the first step is
to evaluate the quality of the examination itself. Not
only should the observer be interested in the size and
shape of the radiologic contours, but also the radiologic technique used to obtain the image. Estimation
of the radiographic technique helps the observer to
assess the severity of pulmonary vascular changes. It
should be possible to visualize the thoracic spine
through the mediastinal shadow. Radiographic underexposure (light films) generally results in overestimation of the unsharpness of vessels leading to
overinterpretation of pulmonary vascular congestion.
Conversely, overpenetration (dark films) may produce better visualization of the mediastinal structures,
but prevents detailed observation of the pulmonary
parenchyma, leading to underestimation of congestion or the feeling that pulmonary blood flow is diminished. Equally important is an estimation of the
degree of inspiration, because this changes the appearance of the heart size and the pulmonary vessels.
shape
Lung fields and vascularity by zone
Search for calcifications
Patient position
Patient rotation changes the borders of the heart,
bringing some structures into profile, and others out.
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Radiographic projection
Conventional chest film examination of the heart
and lungs is performed using a six-foot posteroanterior beam. An upright patient faces the film screen
combination, and the radiographic exposure comes
from behind (the view is named by the course of the
beam, hence posteroanterior). Using this method,
the X-ray beam is nearly parallel (nondiverging).
The ventrally located heart is close to the film-screen,
and is not (minimally) magnified. Emergency room
or intensive care chest radiography is typically
performed from in front of the patient who leans
against the film cassette. In this anteroposterior
radiograph, the heart is away from the film-screen
combination, and the X-ray beam is not parallel and
diverges. These factors result in magnification of
the heart.
Chest radiographs obtained with the patient upright provide a reliable representation of the distribution of interstitial lung water and pulmonary blood
flow. The lower pulmonary lobes contain more parenchyma and receive more blood flow than the
upper lobes. The lower lobe pulmonary arteries and
veins should be greater in caliber than the upper lobe
branches. When supine, the lower lobe pulmonary
vessels lose their gravity dependence, and the upper
lobe pulmonary vessels become dependent. In the
supine chest radiograph, the upper lobe vessels appear greater in caliber than the lower lobe vessels,
giving the lungs the appearance of pulmonary redis-
Fig. 1. (A) Frontal chest radiograph, normal (expected) anatomy. (B) Diagram of border-forming structures, frontal view (From
Jefferson K, Rees S. Clinical cardiac radiology. 2nd edition. Butterworth; 1980; with permission.).
490
Skeletal abnormalities
Skeletal abnormalities are important observations
and often are only observed by a directed visual
search of the bony thorax, including the identification
of rib notching, sternal depression, vertebral body
erosion, premature sternal fusion, and scoliosis. Situs
abnormalities are of particular importance when
congenital heart disease is present or suspected and
may coexist.
Examples of abnormalities of specific segments
of the cardiac silhouette are used to describe how a
cardiac diagnosis is reached; these are listed in
Boxes 2 and 3. An organized and disciplined visual
search is the first fundamental requirement.
The second fundamental requirement for the radiologist is an understanding of the basic cardiac
radiographic anatomy. This knowledge is critical
and is currently poorly taught. It is essential for
developing a logical process of deduction, which
guides the search for a constellation of observations
necessary to deduce a differential diagnosis. The
normal border-forming structures in the mediastinum,
which determine the cardiovascular silhouette in the
Fig. 2. (A) Normal lateral chest radiograph. (B) Diagram of border-forming structures in the lateral projection (From Jefferson K,
Rees S. Clinical cardiac radiology. 2nd edition. Butterworth; 1980; with permission.).
position?
How does its size compare with the
Heart size
The size of the cardiac silhouette has importance,
because it may represent several underlying disease
processes [2]. It may be evaluated subjectively, or by
measuring the cardiothoracic ratio or by volume
measurement. Subjective assessment is the most
common method used by the experienced observer.
Technical factors mentioned previously should always be taken into consideration.
Aortic knob
It is surprising how often findings involving this
segment are overlooked. Box 4 states the issues very
simply. If the aortic knob cannot be identified,
congenital abnormalities should be considered, including a right-sided arch, coarctation of the aorta, or
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Fig. 4. (A) Right-sided aortic arch demonstrated on a frontal chest radiograph during a barium swallow. (B) Lateral radiograph
in the same patient shown in 4A. Note the smooth filling defect posteriorly on the barium near the level of the aortic arch caused
by an aberrant left subclavian artery. This finding indicates some form of vascular ring and probably no serious congenital
heart disease.
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Fig. 5. (A) Chest radiograph obtained in a young woman as part of a routine physical. Note that the aortic knob is abnormal
in size and appearance with a rim of calcification laterally. The remainder of the image is normal. (B) An aortogram in the
same patient as shown in 5A in a frontal projection demonstrating a calcified false aneurysm of the aorta, which was a sequel to
aortic arch transection 18 years earlier caused by trauma from an automobile accident.
Pulmonary artery
As noted previously, the normal aortic knob and
normal main pulmonary should be approximately
equal in size. This observation must be based primarily on examining that portion of the arc of each great
artery, which is visible on the frontal radiograph.
Fig. 6 demonstrates an asymptomatic young patient
in whom the only finding is an enlarged main
pulmonary artery segment. This is too large to be
simply physiologic as occurs frequently in young
women under 30 years. The important observations
lie in analyzing the right and left proximal pulmonary arteries, which in this patient are normal. This
key observation excludes the diagnosis of pulmonary
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Left atrium
The segment of the left atrial appendage should
not be convex outward from the heart. When it is
enlarged it usually indicates enlargement of the body
of the left atrium. Fig. 8A is an example of a localized
Fig. 8. (A) Chest radiograph showing an abnormal contour in the region of the left atrial appendage, which is usually associated
with an enlarged left atrium. (B) Lateral view of the same patient shown in 8A demonstrating a barium-filled esophagus, which
is displaced by the enlarged left atrial chamber.
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Fig. 10. (A) Triple valve replacement and generalized cardiomegaly. Braunwald-Cutter prostheses in the aortic (A), mitral (M),
and tricuspid (T) positions. All four chambers are enlarged with left atrial enlargement suggested by splaying of the carina
(arrows). (B) Lateral radiograph in the same patient. Aortic prosthesis lays anterosuperior to mitral. Enlargement of right-sided
chambers is indicated by filling in the anterior mediastinal window (From Coulden R, Lipton MJ. Radiological examination in
valvular heart disease. In: Al Zaibag M, Duran CMG, editors. Valvular heart disease. New York: Marcel Dekker; 1994. p. 162;
with permission.).
495
Summary
Fig. 11. The heart lies almost entirely within the left
hemithorax, yet the patient is not rotated. In the absence of a
reduced anteroposterior distance this appearance suggests
complete congenital absence of the left pericardium.
Sometimes, as in this patient, the aorta and main pulmonary
artery are more sharply defined than normally, because of
the presence of lung tissue lying between the great vessels.
References
[1] Jefferson K, Rees S. Clinical cardiac radiology. 2nd
edition. Butterworths; 1980.
[2] Lipton MJ. Plain film diagnosis of heart disease: cardiac
enlargement. Contemporary Diagnostic Radiology 1988;
11:1 6.
[3] Boxt LM, Reagon K, Katz J. Normal plain film examination of the heart and great arteries in the adult.
J Thorac Imaging 1994;9:208 18.
[4] Boxt L. Plain film examination of the normal heart.
Semin Roentgenol 1999;34:169 80.
[5] Coulden R, Lipton MJ. Radiological examination in valvular heart disease. In: Zaibag MA, Duran C, editors.
Valvular heart disease. New York: Marcel Dekker;
1994. p. 131 83.
Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard,
St. Louis, MO 63110, USA
b
Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
c
Kyushu University, Japan
d
Siemens Medical Solutions USA, Inc., 51 Valley Stream Parkway, Malvern, PA 19355, USA
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.03.004
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Fig. 1. Cardiac gating: the most commonly used configuration for ECG lead placement.
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Fig. 2. Transverse or transaxial images: (A) Dark-blood technique: single-slice breathhold turbo spin echo (TSE) T1 is often used
to assess cardiac morphology. (B) Bright-blood technique: breathhold cine gradient recalled echo (GRE) sequence is useful in
assessing cardiac function. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
Fig. 3. Coronal images. (A) Dark-blood technique: TSE T1. This plane nicely demonstrates the aortic valve (arrow). A plane set
through the mid aortic valve and left ventricular apex provides a five-chambered view. (B) Bright-blood technique: cine GRE.
This plane can be used to assess the jet of aortic stenosis or insufficiency. Ao, aorta; LV, left ventricle; RA, right atrium; RV,
right ventricle.
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Fig. 4. Bright-blood double-oblique images through pulmonary trunk (A) and aorta (B). Ao, aorta; LV, left ventricle; PT,
pulmonary trunk; RV, right ventricle.
lar apex, provide a horizontal long-axis or fourchamber view of the heart (Fig. 6). The horizontal
long-axis plane or four-chamber view displays the
relationship of the four cardiac chambers to each
other on a single image. Cine GRE images obtained
in this plane display mitral, tricuspid, and aortic valve
function and right and left ventricular contraction.
This image plane can also be obtained by oblique
transverse imaging through a short-axis scout.
Short-axis plane
The short-axis plane (Fig. 7) is obtained when
images are prescribed perpendicular to left ventricular
long axis seen on a two-chamber view. It shows the
true cross-sectional dimensions of cardiac chambers.
Initial images in this plane are performed through the
papillary muscles, with subsequent images performed
toward the heart apex and base. In this plane the left
ventricular myocardium is displayed as a doughnutshaped ring. Cine GRE images allow visualization
and quantification of systolic myocardial wall thick-
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Fig. 5. Two-chambered long-axis view. An image obtained parallel to the line shown on the transaxial image (A) provides the
vertical long-axis plane or two-chamber view (B). This image plane is ideal for assessing the mitral valve. LA, left atrium; LV,
left ventricle.
Fig. 6. Horizontal long-axis plane or four-chamber view (GRE, TrueFISP). An image obtained parallel to the line shown on the
vertical long-axis image (A) provides the horizontal long-axis or four-chamber view (B). In this image, both the mitral and
tricuspid valves can be assessed. LV, left ventricle; MV, mitral valve; RV, right ventricle; TV, tricuspid valve.
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Fig. 7. Short-axis plane. Bright-blood technique cine GRE. This image plane is favored in the assessment of left ventricular
function. Multiple contiguous short-axis images are obtained from the base of the heart to the apex (A) to provide images in the
short-axis orientation (B). Functional analysis software can then be used to calculate stroke volume, ejection fraction, and
myocardial mass. A horizontal four-chamber view can be prescribed from a short-axis image by drawing a line perpendicular to
the left ventricular septum. LV, left ventricle; RV, right ventricle.
Fig. 8. A line drawn through the left ventricular apex and aortic outflow as prescribed from a coronal image (A) provides a longaxis view sometimes known as the five-chamber view (B). This view demonstrates both aortic valve and mitral valve function
and displays portions of the right and left ventricles and atria and the aorta (five chambers). Ao, aorta; LA, left atrium; LV,
left ventricle; RA, right atrium; RV, right ventricle.
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perfusion. The following section discusses and illustrates each indication, MR imaging techniques including pulse sequences, and some clinical cases.
Adult congenital heart disease
With better cardiothoracic surgical techniques and
technologic advances many pediatric patients with
congenital heart disease survive into adulthood and
present with sequelae of their surgeries and disease.
These include patients with transposition of great
vessels and patients with tetralogy of Fallot. Cardiac
MR imaging can be used for postoperative follow-up
in these patients to assess for occluded shunts (Waterston, Glenn, and so forth); obstructed baffles; and
stenotic homografts. Cardiac MR imaging can also
be used for visualization of previously undetected
disease, such as patent ductus arteriosus, coarctation
of aorta, atrial septal defects, restrictive ventriculoseptal defect, and anomalous pulmonary veins. To
perform cardiac MR imaging for these conditions
one should identify the specific clinical question,
know the anatomy of the relevant pathology and
cardiac surgery, and be aware of the delayed complications typical of the performed surgery. Communication between the referring physician and the
physician performing the cardiac MR imaging examination is essential. In difficult cases one may want
to obtain consultation by teleradiology with a
trained cardiac MR imaging radiologist in an academic center.
General MR imaging protocol for congenital heart
disease
The first sequences obtained are usually blackblood sequences, such as HASTE (double IR
FSE-TSE), or TSE-FSE T1-weighted sequences.
Bright-blood sequences, such a sequential FLASH,
FASTCARD, trueFISP, or FIESTA, are essential
for demonstrating functional pathology and may be
necessary to visualize some intracardiac shunts. Cine
sequences (GRE) should be done, at the very least,
through the area of suspected pathology. Ideally,
depending on the disease, a congenital heart disease
protocol includes some transverse imaging (ie, the
black-blood scout) to assess the great vessels (ie, presence of a duplicated superior vena cava, sidedness of
the arch), and four-chambered long-axis black-blood
and cine sequences. Cine sequences should then be
performed through the aortic and pulmonic valve
planes and through any surgically created shunts
(Fontan, Waterston, Blalock-Taussig, and so forth) to
assess for patency and stenoses. Contrast-enhanced
MR angiography can be used to assess peripheral
pulmonary artery stenoses; bronchial collaterals (pulmonic atresia); or anomalous pulmonary veins.
Contrast-enhanced MR angiography
In the cardiac MR imaging assessment of adult
patients with congenital heart disease, contrast-enhanced MR angiography is useful for evaluation of
the aorta, pulmonary artery stenoses, collaterals, and
shunts (Fig. 9). Contrast-enhanced MR angiography
is a short breathhold three-dimensional GRE sequence with short TR and TE and flip angle. No cardiac gating is needed. It requires a test-bolus injection
or bolus tracking system, such as CareBolus (Siemens Medical Systems, Erlangen, Germany) or
SmartPrep (GE Medical Systems, Milwaukee, Wisconsin), to calculate the circulation time and obtain
images with maximum arterial enhancement. Injection rate is usually 2 mL/second of 0.2 mmol/Kg
Gd-DTPA. A commercially available MR imaging
compatible power injector is required. Images are
usually obtained in a coronal orientation, but can also
be obtained in an oblique-sagittal orientation to assess
the aortic arch. Both precontrast and postcontrast
images are acquired with the precontrast image
serving as a mask for image subtraction. After image
acquisition, postprocessed three-dimensional maximum intensity projection images can be created.
These maximum intensity projection images should
always be evaluated together with source images to
avoid misdiagnoses secondary to maximum intensity
projection induced artifacts.
Newer sequences that allow near real-time assessment of dynamic administration of a gadoliniumbased contrast bolus are now available. These sequences, although by necessity of lower resolution
than non real-time sequences, are helpful in the
assessment of shunts and fistulas [13].
Transposition of great arteries
In D-loop transposition (Fig. 10), the anatomic
relationship of great arteries is reversed. The aortic
valve arises anterior to the pulmonic valve. Aortic
valve and aorta arise from the right ventricle, which is
usually hypertrophied. The pulmonary valve and
pulmonary artery arise from the left ventricle. In
L-loop transposition, the aorta is left sided and arises
from the right ventricle, which may at times be
rudimentary. The pulmonary artery arises posteriorly
and to the right of the aorta from the left ventricle. If
the two ventricles are well-developed and there is no
interventricular communication this entity is referred
to as congenitally corrected transposition of the
great vessels. At times, however, there is a large
ventriculoseptal defect with a rudimentary right ven-
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Fig. 9. A 20-year-old female patient with hypertension, unresponsive to medication. Lateral (A) and coronal (B) views of
contrast-enhanced three-dimensional MR angiography clearly show coarctation of descending aorta (arrow) and extensive
collateral vessels.
Tetralogy of Fallot
The classic components of tetralogy of Fallot are a
large ventricular septal defect, right ventricular outflow tract obstruction, right ventricular hypertrophy,
and overriding aorta. Complete repair of tetralogy of
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Fig. 13. (A) Transaxial true FISP image shows an abnormal structure adjacent (arrow) to the aorta and superior pulmonary trunk.
(B) True FISP sagittal image obtained in plane through the long axis of the structure seen on image A provides greater
characterization and demonstrates that the structure is a patent ductus. Turbulent flow through the ductus produces a jet into the
pulmonary trunk (arrow).
Fig. 14. Anomalous right upper lobe pulmonary vein. Young woman with Turners syndrome who had an enlarged right atrium
seen on an echocardiogram. The etiology of the enlarged right atrium could not be determined. An oblique cine image
(A) showed a dilated superior vena cava with a small jet (arrow). Additional imaging in the plane of the jet (B) showed an
anomalous right upper lobe pulmonary vein (arrow).
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ated from superior vena cava duplication by following the vessel back to its origin.
Arrhythmogenic right ventricular dysplasia
One of the more frequent and important indications for cardiac MR imaging is the evaluation of patients with potential diagnosis of arrhythmogenic right
ventricular dysplasia. This condition is a primary disorder of the right ventricle with partial or total thinning and replacement of muscle by adipose or fibrous
tissue and enlargement of the right chambers of the
heart. Patients have ventricular arrhythmias and left
bundle branch block on ECG. The disease may lead
to sudden death. Right ventricular dysplasia is familial in 30% of cases. Inheritance pattern is possibly
autosomal-dominant with variable expression and
penetrance [14 16].
Right ventricular angiography and echocardiography cannot visualize pathologic structural changes
of right ventricular dysplasia in the myocardium.
Even with endomyocardial biopsy the diagnosis can
be difficult, because the disease rarely involves the
septum, which is the typical sampling site. Patients
are commonly referred for cardiac MR imaging
[17,18].
MR imaging findings in right ventricular dysplasia
MR imaging diagnosis is based on the identification of specific anatomic and functional abnormalities
of the right ventricle, which include the following
(Figs. 15 and 16): thinning of the right ventricular
Fig. 15. Biopsy-proved case of arrhythmogenic right ventricular dysplasia. (A) axial TSE T1-weighted image shows fatty
infiltration of the myocardium involving the pulmonary outflow tract (arrow). (B) Fat-saturated axial TSE T1-weighted image
shows signal dropout of this region (arrow), caused by fatty infiltration.
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Fig. 19. Right atrial myxoma. (A) Axial dark-blood HASTE shows a bilobed mass (arrow) straddling the tricuspid valve. Note
the relatively bright signal of the mass on this T2-weighted sequence. Images are acquired in diastole and do not demonstrate the
location of the mass throughout the cycle. (B) Axial bright-blood cine GRE image obtained in systole shows that the mass arises
from the right atrium with the point of tumor attachment at the intra-atrial septum (arrow).
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Fig. 20. (A) Sagittal breathhold single-slice TSE T1-weighted image in a young woman with Takayasus arteritis. Note the aortic
wall thickening (arrow). (B) Coronal breathhold cine GRE in the same patient shows a jet of aortic insufficiency (arrow) through
the aortic valve toward the left ventricle. The aortic insufficiency is caused by poor apposition of the aortic valve leaflets. Note
the dilatation of the sinuses at the aortic root.
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Summary
Because of the enormous economic and social
impact of cardiovascular disease in the United States
there is a need for improved noninvasive diagnosis.
Cardiac MR imaging is a versatile, comprehensive
technique for assessing cardiac morphology and
function. With an understanding of cardiac anatomy
and physiology and MR imaging physical principles,
cardiac MR imaging can be performed and can play
an important role in patient management.
References
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[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
Radiology Service, Veterans Affairs North Texas Healthcare System, 4500 South Lancaster Road, Dallas, TX 75126, USA
b
University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
* VA North Texas Healthcare System, Radiology Service (W-114), 4500 South Lancaster Road, Dallas, TX 75126.
E-mail address: andre.duerinckx@med.va.gov
patients with lung cancer invading the heart, pericardium, or large vessels; and postsurgical and posttraumatic findings. Also provided is a review of non
cardiac-related areas of plain film and cross-sectional
imaging correlation. Understanding this correlation
for thoracic imaging is one of the ideas and principles
outlined in the proposal for a curriculum in cardiothoracic radiology for medical students in the year
2000 by Kazerooni et al [17] and Collins et al [18]. It
is hoped that the reader gains a better understanding
and appreciation for the great value of cross-sectional
imaging and the power of the plain film in helping
detect and recognize thoracic pathology.
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Fig. 1. A 59-year-old man with question of dilated aorta. Correlation between frontal radiograph of the chest (A) and the frontal
view of a maximum intensity projection reconstruction of a three-dimensional contrast-enhanced MR angiogram of the thoracic
vessels (B). (C) An oblique sagittal (candy cane) view of the MR angiogram of the thoracic aorta is also shown. There is
excellent correlation between the appearance of the thoracic aorta and central pulmonary vessels on both the plain film and the
MR angiogram. The ascending aorta on MR image measured 3.1 cm, which is within normal limits.
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Fig. 2. A 62-year-old man with chest pain. Correlation between frontal radiograph of the chest (A) and the frontal view of a
maximum intensity projection reconstruction of a three-dimensional contrast-enhanced MR angiogram of the thoracic vessels
(B). (C) An oblique sagittal (candy cane) view of the MR angiogram of the thoracic aorta is also shown. When compared with the
aorta in Fig. 1, the increased tortuosity is well seen on the plain film. Incidental note is made of a bovine aortic arch. The
ascending aorta measured 3 cm, within normal limits.
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Fig. 3. A 77-year-old man with anemia and weight loss. (A, B) Frontal and lateral chest radiographs show mediastinal widening
with prominence of the aortic knob, and with a supra-aortic mass best seen on the lateral view. (C) Oblique sagittal (candy cane)
view from a MR angiogram shows a saccular aneurysm arising superiorly from the distal aortic arch, and corresponding to the
shadow seen on the lateral chest film.
teries, pulmonary hypertension, and pulmonary valvular stenosis. MR imaging can evaluate pulmonary
valve hemodynamics [56] and pulmonary anatomy
[45] and help make the diagnosis.
Dilatation of the left atrial appendage segment
The two normal structures that reside within this
area are the left atrial appendage (posteriorly) and the
right ventricular outflow tract (anteriorly). Bulging of
the left atrial appendix is the best single radiographic
sign of left atrial enlargement. This is a more reliable
sign than the more popular double contour within
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Fig. 4. A 53-year-old man with ascending aortic aneurysm and bicuspid aortic valve. (A) Chest radiograph suggests a dilated
ascending thoracic aorta. (B) MR angiogram, frontal view confirms the findings. (C) Black blood MR image, coronal image: the
proximal ascending aorta measured 5.5 cm in cross section. (D) Cine MR image in candy cane view shows the shape of the
ascending aorta and valve leaflets. (E) Cine MR image perpendicular to the aortic valve area shows the bicuspid leaflets.
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Fig. 4 (continued).
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Fig. 5. (A, B) Frontal and lateral chest radiographs suggest a focal contour anomaly along the left chamber border (frontal) and
bulging of the posterior contour (on lateral). (C, D) Follow-up MR image demonstrated a large left ventricular aneurysm. Both
black blood (C) and bright blood (D) four-chamber views clearly delineate the aneurysm. (E) A coronal black blood MR image
confirms the origin of the left chamber contour anomaly.
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used for HIV-positive patients with an echocardiographic suspicion of pericardial effusion. Differential
diagnosis by MR tomography is possible.
Adult congenital heart disease
The most important diagnostic features of conventional radiographs in the study of congenital heart
disease have been well described by Grainger [123]
and many others. These diagnostic features are the
pulmonary vasculature; the size of the heart; the
shape of the heart; the position, size, and shape of
the main pulmonary arteries; the position, size, and
shape of the ascending aorta and its arch; the presence
of associated features, (eg, skeletal changes); and
cardiac and visceral situs. Grainger [123] provided
an excellent summary of the importance of the shape
of the heart and how it may be very suggestive
of a specific congenital abnormality. These shapes
are usually described in picturesque and interesting
terms, such as egg-shaped (also called egg lying on
its side, or apple on a string, with a narrow vascular
pedicle) heart of uncorrected transposition of the
great vessels; the sitting-duck heart seen with persistent truncus arteriosus, an elevated rounded cardiac
apex, high right aortic (truncus) arch (in 30% 50%
of cases) and concave pulmonary bay; the bootshaped heart of tetralogy of Fallot, with an elevated
cardiac apex, right aortic arch (in 10% 30% of cases)
and narrow vascular pedicle; the figure-of-eight or
snowman or cottage loaf of bread heart of supracardiac total anomalous pulmonary venous drainage. Epsteins anomaly also presents with a typical
box-shaped square heart, with a prominent right
atrium and the atrialized portion of the right ventricle
(Fig. 6).
As pointed out in 1986 by Grainger [123], now
that corrective surgery is being increasingly practiced,
these picturesque descriptions are less frequently
applicable. Because of corrective surgery the cardiac
chambers and great vessels do not have time to develop the size and shape that produces the characteristic cardiac silhouette of the particular anomaly.
Also, these interesting descriptive shapes only occur
in the minority of examples of each abnormality. A
diagnosis must never be excluded because the shape
of the heart is not characteristic.
Some of the publications addressing this topic are
reviewed next. Baron in 1999 [124] described the
plain film diagnosis of common congenital cardiac
anomalies in the adult. Congenital cardiac lesions in
the adult have characteristic roentgen patterns that
should be recognized by the radiologist. In other
instances, abnormalities in the aorta or the position
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Fig. 6. A 55-year-old man with Ebsteins anomaly. (A, B) Frontal and lateral chest film show decreased pulmonary vascularity
with cardiomegaly. There is severe right atrial enlargement. (C, D) Coronal and axial bright blood MR images show very
enlarged right atrium, and the associated triscuspid regurgitation (black flow jet). This anomaly involves displacement of the
attachment of the tricuspid leaflet, with atrialization of the right ventricle. (Courtesy of Arthur Stilmann and Richard White,
Cleveland Clinic, Cleveland, OH.)
526
Fig. 7. A 55-year-old man suspected of having a massive pulmonary embolism. (A) Initial chest radiograph was unremarkable.
(B) Follow-up CT scan revealed a large intracardiac tumor extending in the right atrium and part of right ventricle. (Courtesy of
Francisco Garcia-Morales, VA North Texas Healthcare Center, Dallas, TX.)
527
Fig. 8. A 59-year-old man with metastatic lung cancer (non small cell carcinoma, stage T4) presents with bilateral lower
extremity edema and right upper extremity edema and skin rash. (A) Chest radiograph shows the right upper lung lobe mass.
(B) CT scan shows cross section of mass. The SVC is displaced anteriorly. (C) Three-dimensional contrast-enhanced MR
angiogram shows the arterial and venous structures, and demonstrates mild compression but patency of the SVC. (D) A
noncontrast time-of-flight MR venogram shows only the venous structures, and confirms the same findings.
528
Fig. 9. A 51-year-old with metastatic renal cell carcinoma (pulmonary mets). (A) Chest radiograph shows multiple nodular
masses. (B, C) Transaxial MR images confirm the multiple lung masses, and suggest that some may be invading the pericardium.
(D) Close up of an MR image showing one mass adjacent to the left posterior pericardium. (E, F) Cine MR images shown at
two points in the cardiac cycle demonstrate how the mass seen in Fig. 9D does not invade the pericardium. Myocardial
tagging during a MR image study (not shown here) can further improve the visualization of possible pericardial involvement
and adhesions.
overall image quality of ECG-triggered MR angiography was better than that of conventional MR
angiography (kappa 0.41). The authors concluded
that ECG-triggered MR angiography improves the
image quality and the detection of hilar and mediastinal invasion of bronchogenic carcinoma.
Edmondstone [156] in 1998 reported on flitting
radiographic shadows as an unusual presentation of
cancer in the lungs. The author states that tumor
involvement of pulmonary blood vessels occurs frequently in advanced lung cancer and occasionally
may cause pulmonary infarction. This author also
reports a case of diffuse obstruction of pulmonary
arteries by cancer in which no primary tumor was
found, and which presented as flitting radiographic
opacities because of pulmonary infarction.
Takahashi et al [157] in 2000 also evaluated the
ability of breath-hold gadolinium-enhanced threedimensional MR angiography to assess the invasion
of the pulmonary vein and the left atrium by lung cancer in 20 consecutive patients with lung cancer. They
concluded that breath-hold gadolinium-enhanced
three-dimensional MR angiography is suitable for assessing invasion of the pulmonary vein and the left
atrium by lung cancer.
Neither MR imaging nor CT, however, is always
perfect in predicting tumor resectability. Because of
discrepancies in predicting resectability by imaging
techniques (CT and MR imaging) compared with
actual intraoperative findings Loscertales et al [158]
in 2002 reported on how they perform systematic
exploratory videothoracoscopy as the first step in the
surgical evaluation of patients with lung cancer. The
authors [158] claim that resectability of centrally
located primary tumors with intrapericardial extension (clinical T4) can only be established by direct
examination of the pericardial sac contents. In these
instances, they added videopericardioscopy to their
presurgical evaluation protocol. Their study suggests
that exploratory videothoracoscopy is superior to imaging techniques (CT or MR imaging) in detecting
tumor extension into the pericardium. In addition,
short of an exploratory thoracotomy, videopericardioscopy seems to be the most definitive study to establish resectability of centrally located tumors with
pericardial invasion. Unnecessary exploratory thoracotomies can be avoided.
529
530
regression analysis showed a combination of obscuration or convexity of the aorticopulmonary window and a displaced left paraspinal interface to be
the most useful predictor of hemorrhage (P < .05).
Rank correlation analysis indicated obscuration or
convexity of the aorticopulmonary window; a displaced left paraspinal interface; enlarged aortic knob
width; enlarged thoracic aorta size; an enlarged,
obscured, or irregular aortic margin; and left pleural
or extrapleural space fluid were potential individual
predictors of hemorrhage (P < .05). Observer sensitivities for recognizing hemorrhage were 30% to
59% and specificities were 83% to 91%. Sensitivities
for distinguishing an abnormal (N = 70) from a
normal (N = 20) mediastinum were 79% to 90%
and specificities were 65% to 90%. Fultz et al [35]
concluded that obscuration or convexity of the aorticopulmonary window and a displaced left paraspinal
interface on radiographs may indicate mediastinal
hemorrhage. Further imaging is required to establish
a definitive diagnosis.
Plewa et al [169] in 1997 studied cervical prevertebral soft tissue measurements and chest radiographic findings in acute traumatic aortic injury.
Mediastinal widening, aortopulmonic window opacification, and blurring of the aortic knob were the most
sensitive chest radiography findings in acute traumatic aortic injury, although each of these lacked
useful specificity and accuracy. Cervical soft tissue
swelling is not a useful marker for acute traumatic
aortic injury.
Kram et al [32] in 1989 performed a 10-year
retrospective analysis of 82 patients with suspected
thoracic aortic rupture caused by blunt chest trauma
to define which symptoms and signs were helpful in
making an early diagnosis. Chest roentgenographic
signs seen with significantly greater frequency in the
12 patients with thoracic aortic rupture than in
70 patients without such rupture included a widened
paratracheal stripe (seven patients); deviation of the
nasogastric tube or central venous pressure line
(five patients); blurring of the aortic knob (nine
patients); abnormal paraspinous stripe (six patients);
and rightward tracheal deviation (five patients).
Mediastinal widening of greater than 8 cm occurred
in 11 of the 12 patients with thoracic aortic rupture
(sensitivity, 92%); its specificity, however, was only
10% (11 true-positive and 63 false-positive results).
531
Fig. 10. A 55-year-old man with prior thoracic aortic aneurysm repair. (A, B) Frontal and lateral chest radiographs suggest a
tortuous aorta, with prominence of the aortic knob. (C, D) Oblique sagittal (candy cane) views of the aorta during a threedimensional contrast enhanced MR angiogram demonstrate the complex postsurgical appearance of the thoracic aorta, with
partial dissection, aneurismal dilatation, and thrombus formation in the residual false lumen. (E) Transaxial cine MR image
demonstrates dissection in the ascending aorta.
532
Fig. 11. A 33-year-old man with Marfan syndrome identified at age 27 when he was found to have an aortic dissection. He
underwent surgery at age 29 involving aortic valve replacement and repair of ascending aortic aneurysm. Patient presented with
new chest pain. (A) Chest radiograph does not show any significant aortic anomaly; the cardiac silhouette is at upper limits of
normal, with a prominent arch but no widening of the mediastinum. (B, C) Two views from an MR angiogram (B, frontal, and C,
candy-cane) show the graft repair of the ascending aorta, but no aneurysm or dissection. (D) CT scan shows aneurysmal
dilatation of the ascending aorta (diameter 7 cm), starting at the aortic root and extending to the proximal arch (not shown), with
contrast accumulation in the perigraft area, suggesting a postsurgical leak. (E, F) MR image cross-sectional imaging also shows
uptake of contrast in the peri-graft area. The appearance of the perigraft area after surgical repair of ascending thoracic aorta can
be quite variable.
533
Fig. 11 (continued).
anomalies, such as bronchopulmonary sequestration [128], are more likely to manifest with cyanosis
and to be associated with congenital cardiac anomalies, especially atrial septal defects. Thrombosis,
tumor invasion, and inflammatory conditions often
also cause acquired systemic and pulmonary venous
anomalies (Fig. 12). MR imaging provides excellent
delineation of the abnormal vessels and associated
lesions. Both cross-sectional imaging and functional
imaging using flow measurement or MR angiography can be very useful in delineating these abnormalities. Plain film findings sometimes give a clue
as to a particular type of abnormality, such as in
the case of certain types of anomalous pulmonary
venous connections.
Pulmonary vein ablation offers the potential to
cure patients with atrial fibrillation. Cross-sectional
imaging is routinely used to investigate the incidence
of pulmonary vein stenosis after radiofrequency
catheter ablation of refractory atrial fibrillation
[177 182]. Arentz et al [178] reported on this in
2003 and concluded that at 2-year follow-up, the risk
of significant pulmonary vein stenosis or occlusion
after radiofrequency catheter ablation of refractory
atrial fibrillation with conventional mapping and
ablation technology was 28%. Distal ablations inside
smaller pulmonary veins should be avoided because
of the higher risk of stenosis than ablation at the
ostium. Dill et al [180] in 2003 investigated the
incidence and time course of pulmonary vein stenosis
after radiofrequency catheter ablation within a period
of 3 months. Contrast-enhanced MR angiography
was used to visualize pulmonary veins and was
compared with radiographic angiography. Dill et al
[180] conclude that the occurrence and progression
of pulmonary vein stenosis is a potential significant
534
Fig. 12. A 56-year-old with left upper extremity swelling. (A) Chest radiograph shows cardiomegaly with pulmonary congestion
and bilateral effusions. No left apical mass is noted. (B, C) Frontal views of contrast-enhanced MR venograms show the upper
thoracic and neck veins. The angiogram was performed twice, first with contrast injection in the right arm (B) and then in the left
arm (C). The MR venogram obtained with the left-sided contrast injection demonstrates severe narrowing of a long segment of
the left inominate vein (C) because of prior instrumentation.
Summary
Multiplanar imaging using MR imaging or CT
offers significant added information when trying to
clarify abnormalities seen on a plain film of the chest.
Knowledge of the plain film appearance of the
normal heart is an essential starting point. The choice
between MR imaging or CT or MR angiography or
CT angiography as the most appropriate follow-up
study is in a state of flux, because technology is
changing rapidly and the use of new scanners and
postprocessing techniques is proliferating. The actual
selection of one cross-sectional modality over the
other seems to be dictated more by availability of
scanners and personal choice, besides generic concerns about radiation dose [194] and the use of
iodinated contrast media. It is hoped that this article
535
Acknowledgments
The author thanks Murray G. Baron, MD, from
Emory University Hospital in Atlanta, GA, for
providing his opinions and insight in the evaluation
of plain film findings. Portions of this manuscript are
based on his 2001 review in the International Journal
of Cardiovascular Imaging [3]. The author also
thanks his colleagues for suggesting or providing
some of the cases illustrated here: Francisco GarciaMorales, MD, from the VA North Texas Healthcare
System, Dallas, Texas; Arthur Stillman, MD, PhD,
and Richard White, MD, from the Cleveland Clinic,
Cleveland, Ohio.
References
[1] Higgins CB. Essentials of cardiac radiology and imaging. Philadelphia: JB Lippincott; 1992.
[2] Miller SW. Cardiac radiology: the requisites. St Louis:
Mosby; 1996.
[3] Baron MG. Correlation of plain films and MR of the
heart. Int J Cardiovasc Imaging 2001;17:453 6.
[4] Weigel S, Tombach B, et al. Thoracic aortic stent
graft: comparison of contrast-enhanced MR angiography and CT angiography in the follow-up: initial
results. Eur Radiol 2003;13:1628 34.
[5] Pereles FS, McCarthy RM, et al. Thoracic aortic dissection and aneurysm: evaluation with nonenhanced
true FISP MR angiography in less than 4 minutes.
Radiology 2002;223:270 4.
[6] Kreitner KF, Kunz RP, et al. Contrast-enhanced threedimensional MR angiography of the thoracic aorta:
experiences after 118 examinations with a standard
dose contrast administration and different injection
protocols. Eur Radiol 2001;11:1355 63.
[7] Silverman JM, Raissi S, et al. Phase-contrast cine MR
angiography detection of thoracic aortic dissection.
Int J Cardiovasc Imaging 2000;16:461 70.
[8] Krinsky GA, Reuss PM, et al. Thoracic aorta: comparison of single-dose breath-hold and double-dose
non-breath-hold gadolinium-enhanced three-dimensional MR angiography. AJR Am J Roentgenol
1999;73:145 50.
[9] Rubin GD. CT angiography of the thoracic aorta.
Semin Roentgenol 2003;38:115 34.
[10] Lawler LP, Fishman EK. Multi-detector row CT of
thoracic disease with emphasis on 3D volume rendering and CT angiography. Radiographics 2001;21:
1257 73.
[11] Batra P, Bigoni B, et al. Pitfalls in the diagnosis of
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* Corresponding author.
E-mail address: ellakaz@umich.edu (E.A. Kazerooni).
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.03.006
544
Table 1
Apparatus seen on postcardiac surgery chest radiographs
Location
Apparatus
Airway
Endotracheal tube
Tracheostomy tube
Central venous pressure catheter
Pulmonary artery catheter
Intra-aortic balloon pump
Extracorporeal life support cannulas
Temporary epicardial pacing leads
Left atrial catheter
Assist devices
Chest tubes
Drains
Drainage tubes
Feeding tubes
Venous
Arterial
Cardiac
Pleural
Mediastinum
Esophagus
tubes that may be seen on chest radiographs in postcardiac surgery patients. Although some are commonplace, such as endotracheal tubes and central venous
catheters (Fig. 1), others, such as IABPs and ventricular assist devices, are less commonly encountered.
Airway
Endotracheal tubes provide respiratory support
and airway protection in the immediate postoperative
period. The normal position of an endotracheal tube
is with the tip 2 to 6 cm above the carina. Complications of endotracheal tube placement are as follows:
Vocal cord injury
Right main bronchus intubation (Fig. 2)
Contralateral lung collapse
Ipsilateral pneumothorax
Esophageal intubation
Airway rupture
Delayed airway stenosis
In the past, extubation usually was deferred until
the day after cardiac surgery. Today, patients frequently are weaned from the ventilator and extubated
soon after leaving the operating room [6]. Most
low- and moderate-risk patients undergoing cardiac
surgery with cardiopulmonary bypass using opioid
analgesia are extubated within 7 to 11 hours after
operation. This has been shown to reduce the length
of stay in the ICU with no increase in postoperative
complications [7]. Prolonged ventilatory support in
the postoperative period may necessitate a tracheostomy. Complications of tracheostomy tubes include
positioning in soft tissues outside the airway, airway
stenosis, and trachea-innominate artery fistula.
Vascular
Venous
Fig. 1. Typical apparatus seen on post cardiac surgery
radiographs. Note the normal position of the endotracheal
tube (ET), Swan-Ganz catheter (SG), mediastinal drains
(M), and esophageal tube entering the stomach (T).
Central venous catheters are essential for monitoring, modifying fluid and pressure balances, and
administering therapeutic substances, such as drugs
545
546
Fig. 4. Pulmonary artery pseudoaneurysm in a 71-year-old man with hemoptysis after Swan-Ganz catheter placement.
(A) Radiograph showing catheter in right pulmonary artery (arrow). The patient subsequently moved in bed and had an episode
of hemoptysis. The catheter was found wedged and subsequently pulled back. (B) Radiograph 2 hours later demonstrates new
opacification of the right upper lobe caused by hemorrhage; the Swan-Ganz catheter is in the pulmonary outflow tract (arrow).
(C) Pulmonary angiogram demonstrates a pseudoaneurysm of the anterior branch of the right upper lobe pulmonary artery.
(D) Radiograph 48 hours after embolization demonstrates resolving pulmonary hemorrhage and embolization coils.
However, it yields only a modest increase in cardiac output. Failure of the IABP to improve hemodynamic performance of the failing heart may prompt
use of an alternative form of mechanical circulatory
support, such as a centrifugal pump, extracorporeal
life support, pneumatic pulsatile pumps, or an implantable LVAD.
Centrifugal pumps are the second most commonly
used cardiac-assist devices. Centrifugal pumps impart
momentum to fluid by means of blades, impellers, or
concentric cones, yielding continuous nonpulsatile
flow. The left ventricular support system consists of
a cannula that siphons blood from the heart, usually
from the left atrium; a pump that drives the blood
back into the arterial circulation under pressure; and a
return cannula connected to the aorta or femoral
artery [20]. When both ventricles require support, a
separate cannula siphons the blood from the right
atrium and passes it to a second pump. The blood is
then returned under pressure to the pulmonary artery.
Extracorporeal membrane oxygenators for extracorporeal life support provide combined heart and lung
support, with similar hospital survival rates to centrifugal mechanical support in the setting of postcardiotomy cardiogenic shock. They can be used to
sustain patients until a long-term form of LVAD can
be placed [21]. Venovenous extracorporeal life sup-
547
548
549
550
portable radiography may create an illusionary opacity in the left retrocardiac region that can be misinterpreted as atelectasis or consolidation behind the
heart [31].
Pneumonia
Nosocomial pneumonia has an incidence of approximately 4% in patients undergoing coronary
bypass graft surgery [32]. Radiographic confirmation is sometimes difficult because of the frequent
coexistence of atelectasis and edema. Clinical correlation and comparing changes on sequential radiographs are helpful.
Pulmonary embolism
Pulmonary embolism occurs infrequently after
cardiac surgery, with an incidence 0.56%. It carries
a high mortality of 34% [33]. Risk factors include
preoperative bed rest, recent cardiac catheterization,
and postoperative congestive heart failure. The relatively low incidence of pulmonary embolism after
cardiac surgery has been attributed to intraoperative
heparinization and postoperative anticoagulation or
antiplatelet therapy. In addition, cardiopulmonary bypass causes changes in blood elements that may retard
clotting. These changes include consumption of coagulation factors, activation of the fibrinolytic cascade, and thrombocytopenia and platelet dysfunction.
The cardiomediastinal silhouette
The cardiomediastinal silhouette is an important
postoperative guide to the general well-being of the
patient. A change in its size or shape may indicate
mediastinal hemorrhage or cardiac tamponade. After
surgery the mediastinum appears slightly wider than
on the preoperative radiograph, in part because of the
anteroposterior supine technique used for portable
radiography. In addition, some mediastinal bleeding
normally occurs. The mediastinal width may be
reduced if the patient is on positive end-expiratory
pressure, and may increase slightly following extubation if the lung volumes decrease. Katzberg et al
[30] related the postoperative mediastinal width to the
severity of bleeding by comparing the width of the
mediastinum on preoperative posteroanterior radiographs with postoperative anteroposterior radiographs. Stable patients without clinical evidence of
bleeding widen their mediastinum by an average
of 35%. Patients with moderate bleeding of 30 to
280 mL who did not require reoperation had an
average 47% increase in width, and patients requiring
551
Delayed complications
Sternal dehiscence, osteomyelitis, and mediastinitis
Sternal dehiscence, osteomyelitis, and mediastinitis are interrelated but uncommon serious postoperative complications. They are associated with a high
mortality and morbidity [38]. The diagnosis of sternal
dehiscence may be evident on physical examination.
The two major radiographic signs of dehiscence are
the mid-sternal stripe sign [41] and sternal wire
displacement [42]. The latter is highly specific
(Fig. 10). A recent study on the frequency of sternal
wire abnormalities in patients with sternal dehiscence concluded that sternal wire abnormalities, most
notably displacement, are present in most patients
with sternal dehiscence and that radiographic abnormalities precede the clinical diagnosis in most cases
Fig. 10. Sternal dehiscence with sternal wire displacement on the frontal chest radiograph. (A) Midline vertically aligned
sternotomy wires after cardiac surgery. (B) Later, there is malalignment of the upper two sternal wires (arrows).
552
Pericardial complications
553
Fig. 15. Multidetector coronary CT angiogram reconstruction demonstrates a patent right internal mammary artery
coronary bypass graft with adjacent surgical clips.
Fig. 14. (A,B) CT of constrictive pericarditis secondary to prior cardiac surgery in a 61-year-old man who developed right heart
failure 3 months after replacement of the aortic root and ascending aorta for type A dissection. Axial contrast-enhanced CT
images demonstrate pericardial thickening (arrowheads) and a small amount of pericardial fluid (F). Note the dissection in the
descending aorta and small bilateral pleural effusions.
554
graft patency after coronary artery bypass. Retrospective electrocardiographic-gated multidetector spiral
CT permits the noninvasive assessment of bypass
graft patency and stenosis with high diagnostic accuracy (Fig. 15). This method is still limited, however,
by a significant number of bypass grafts that are
unevaluable for the presence or absence of significant
stenosis [53]. With improvements in surgical techniques and medical care, an increasing number of
patients are now candidates for reoperative cardiac
surgery. Defining the anatomy of pre-existing grafts
is critical in the reoperative cardiac surgery patient,
because injury to these vital structures is associated
with significant postoperative morbidity and mortality. Internal mammary grafts are at particular risk;
however, accurate evaluation of saphenous vein
grafts is equally important. The anatomic relationship
of the grafts to the sternum must be assessed accurately to prevent injury during sternal reentry. The use
Fig. 16. Saphenous vein graft pseudoaneurysm in a 69-year-old man at the proximal anastomosis of a graft to the right coronary
artery. (A) Posteroanterior and (B) lateral chest radiographs demonstrate an anterior mediastinal mass (*). Note the ring-shaped
proximal graft markers. (C) Contrast-enhanced CT demonstrates an anterior mediastinal mass with central contrast enhancement
(arrow) that is contiguous with the coronary graft ostium extending from the ascending aorta. Note the mural thrombus (T).
555
556
and strips used to reinforce sutures appear as highattenuation material bordering the wall of the aorta or
the graft (Fig. 18), and should not be confused with
extravascular contrast material from a leaking graft
(Fig. 19). Kinking of the graft or puckering of the
anastomosis may create the appearance of a transverse low-attenuation band traversing the aorta on
axial images, mimicking dissection. Multiplanar CT
reconstructions are useful to avoid making this mistake. The button technique, where a small portion of
the native aorta around the coronary artery ostium is
implanted onto the graft, may create the appearance
of an outpouching from the graft on CT or MR
imaging. Failure to recognize the relationship of the
outpouching to the coronary artery may result in the
misdiagnosis of a pseudoaneurysm. Circumferential
low-attenuation or soft tissue material surrounding or
adjacent to the graft on CT may be seen for months to
years following surgery and should not be mistaken
for leak or infection. Other mimics of pathology
include the collapsed native aorta adjacent to a graft
(Fig. 20), and reinforcement of the graft with bovine
pericardium (Fig. 21). Endovascular stent management of thoracic aortic aneurysms and dissections
(Fig. 22) may be used in patients with multiple
comorbidities as an alternative to graft placement,
to reduce the incidence of negative surgical outcomes
in these high-risk patients.
Fig. 20. Collapsed native aorta (arrow) medial to a descending aortic graft.
557
Fig. 22. (A, B) Multiplanar CT reformatted images of an aortic stent graft in a 69-year-old woman placed for a type B dissection.
Displayed on soft tissue and bone window settings. Note the thrombosed false lumen (arrows).
Fig. 23. Mitral (M) and tricuspid (T) valvuloplasty rings demonstrated on posteroanterior (A) and lateral (B) radiographs.
558
Fig. 24. (A, B) Posteroanterior and lateral views of a ball-in-cage type of aortic mechanical prosthesis (arrow).
postoperative appearance typically includes an enlarged cardiac silhouette usually caused by a discrepancy between the size of the transplanted heart and
the native pericardium [62]. The size of the cardiac
silhouette decreases over time. A double right atrial
contour caused by overlap of the donor and recipient
right atria may be seen on postoperative chest radiographs. At CT, the normal postoperative appearance
of the heart and great vessels may include a high
redundant main pulmonary artery, a space between
the recipient superior vena cava and donor ascending
aorta, and a caliber change from the recipient to
donor ascending aorta [63].
Heterotropic cardiac transplantation is reserved
for patients with high pulmonary resistance who
receive a small donor organ, or who have acute or
Fig. 25. Medtronic-Hall (Medtronic, Minneapolis, MN) tilting disc mechanical aortic valve (arrow) demonstrated on posteroanterior (A) and lateral (B) radiographs.
potentially reversible myocardial dysfunction. In heterotropic transplantation the donor heart is placed in
the right thoracic cavity and connected to the recipients heart in such a manner that the native right
ventricle provides most of the right-sided cardiac
output and the donor left ventricle provides the bulk
of the left-sided cardiac output. An enlarged cardiac
559
Fig. 27. (A, B) Mosaic mitral bioprosthesis (Medtronic, Minneapolis, MN). The mosaic bioprosthesis is a stented new-generation
porcine heart valve for implantation in the aortic and mitral positions. Note the ringlike markers at the prosthesis (arrowheads).
560
Fig. 29. (A) Posteroanterior and (B) lateral radiographs of a Bioprosthetic porcine mitral valve (arrows) (Baxter Health Care,
Irvine, CA).
561
Fig. 30. (A) Posteroanterior and (B) lateral radiographs of a Carpentier-Edwards aortic valve bioprosthesis (arrows) (Baxter
Health Care, Irvine, CA).
Systemic to pulmonary arterial shunts are performed for palliation of right-to-left shunts in cyanotic congenital heart disease. These include the
subclavian artery to pulmonary artery shunt (Blalock-Taussig); the ascending aorta to right pulmonary
artery shunt (Waterston-Cooley); descending aorta to
left pulmonary artery (Fig. 33); and the superior vena
cava to right pulmonary artery anastomosis. Creation
of these shunts is accompanied by an increase in
pulmonary vascularity (right side in the WaterstonCooley shunt and bilateral in the Blalock-Taussig
shunt), and enlargement of the cardiac silhouette on
chest radiographs [68]. Unilateral rib notching on the
same side of the anastomosis is a recognized feature
of the Blalock-Taussig operation. More recent procedures for anastomosis of the subclavian artery to the
pulmonary artery use a Gortex graft without interruption of the subclavian artery. In this situation rib
notching should not occur [69].
Tetralogy of Fallot is the most common form of
complex congenital heart disease. Complete correction often requires widening of the outflow tract of the
right ventricle with a patch graft. Aneurysmal dilatation of this patch is not an uncommon complication,
producing a bulge on the left heart border just below
the hilum [70]. It is important to assess residual
anatomic problems, such as a residual ventricular
septal defect, the extent of pulmonary stenosis,
amount of pulmonary regurgitation, and biventricular
function in the follow-up of these patients.
Coarctation of the aorta may be treated surgically
with resection and anastomosis, patch grafts or a tube
graft, and using catheter-based techniques [71]. With
562
Fig. 32. Mechanical mitral valve dysfunction. (A) Frontal radiograph demonstrates massive cardiac enlargement. The left atrium
is enlarged secondary to prosthetic mitral valve dysfunction. (B) CT demonstrates a massive left atrium (LA) containing
thrombus (T).
Summary
The normal postoperative appearances following
cardiac surgery and the imaging of the common
complications have been described. Awareness of
local surgical preferences and postoperative protocols
along with a teamwork approach with referring clinicians is emphasized.
References
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[2] Leong CS, Cascade PN, Kazerooni EA, Bolling SF,
Deeb GM. Bedside chest radiography as part of a
postcardiac surgery critical care pathway: a means of
decreasing utilization without adverse clinical impact.
Crit Care Med 2000;28:383 8.
[3] OBrien W, Karski JM, Cheng D, Carroll-Munro J,
Peniston C, Sandler A. Routine chest roentgenography on admission to intensive care unit after heart operations: is it of any value? J Thorac Cardiovasc Surg
1997;113:130 3.
[4] Silverstein DS, Livingston DH, Elcavage J, Kovar L,
Kelly KM. The utility of routine daily chest radiography
in the surgical intensive care unit. Journal of TraumaInjury Infection & Critical Care 1993;35:643 6.
[5] ACR. American College of Radiology Appropriateness Criteria: thoracic. Routine daily portable X-ray.
Reston, VA: American College of Radiology; 1999.
563
564
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
[51]
[52]
[53]
[54]
[55]
Imaging techniques
The entire aorta from the arch to iliac bifurcation
can be imaged in seconds with current multidetector
* Corresponding author.
E-mail address: statli@partners.org (S. Tatli).
CT angiography
Development of CT angiography
Spiral CT technique acquires data continuously as
the patient travels through the scanner gantry [1].
Since its introduction in the early 1990s, spiral CT
technology has improved substantially so that CTA
has become the modality of choice for most centers in
the evaluation of acute and chronic thoracic aortic
disease. The introduction of four-detector scanners in
1998 with a faster gantry rotation time (0.5 seconds)
improved scanning efficiency by nearly eightfold in
comparison with a single-detector scanner. Since
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.03.005
566
contrast agent usage. In addition, no clear enhancement peak may be encountered depending on the
patients body habitus.
In the authors institution and many others, empirical timing for imaging of the thoracic aorta with a
delay time of 25 seconds after the administration of
125 mL of nonionic contrast agent is used, resulting
in excellent arterial enhancement in most patients.
The delay time should be increased slightly (5
10 seconds) in older patients, and also in those with
decreased cardiac output or known aortic aneurysm.
A second scan at 60 seconds may be useful to detect
late-enhancing vascular structures.
Electrocardiographic gating
Although less frequent with multidetector CT
scanning, the motion caused by transmitted cardiac
pulsation to the major arteries creates problems.
These pulsation artifacts are particularly pronounced
in the proximal ascending aorta and may frequently
mimic an intimal flap resulting in a false-positive
diagnosis of aortic dissection. This problem can be
avoided by ECG gating, which is available in new CT
scanners and is being used routinely for imaging the
thoracic aorta. ECG gating can be applied prospectively or retrospectively [8].
In prospective ECG triggering, the acquisition of
the axial images of the aorta is performed during a
selected period of the R-R interval, for example
60%. The operator can select this delay time manually. In retrospective gating, axial images are obtained
with simultaneous recording of the patients ECG
signal. After completion of the scanning, only the
data acquired during a predefined phase of the cardiac
cycle (generally the diastolic phase) are used for
image reconstruction.
Study protocol
Oral contrast agent is not given before CTA and
all image acquisitions are obtained with breath-holding. An initial nonenhanced scan of the whole thoracic aorta is obtained (collimation: 1.5 mm; slice
thickness: 5 mm; reconstruction interval: 5 mm). This
nonenhanced scan is important for proper planning of
the contrast-enhanced scan and also useful in the
evaluation of certain entities, such as intramural
hematoma, and endoleak after endoluminal stent
placement. The thinnest available collimation is not
necessary for this nonenhanced acquisition and 5 mm
reconstructions are usually sufficient. ECG-gated
contrast-enhanced scanning is then performed from
567
568
MR angiography
MR angiography techniques
MR angiography of the thoracic aorta usually
requires a combination of several available MR
imaging methods, each of which has certain advantages and contributes to the diagnostic versatility of
the technique. CE-MRA is the most widely used
MRA method because it is rapid and robust. CEMRA provides projection images of the aorta similar
to conventional invasive angiography. Black-blood
MR imaging permits assessment of the vessel wall by
saturating the signal from the lumen. Phase-contrast
imaging provides functional information about the
flow. Gradient-echo cine images can demonstrate
aortic regurgitation in the presence of disease of the
ascending aorta. Time-of-flight MRA offers limited
clinical value and today is not being used in routine
clinical imaging of the thoracic aorta. The field continues to develop and many new exciting MRA
methods, such as temporally resolved CE-MRA,
and parallel imaging techniques (eg, sensitivity encoding and simultaneous acquisition of spatial harmonics) promise further improvement in acquisition
time and resolution. The following paragraphs describe the most commonly used MRA techniques.
Phase-contrast imaging
Phase-contrast imaging is a unique MR imaging
technique that measures blood flow and can be used
in many clinical applications to evaluate physiologic
properties of blood flow. In phase-contrast imaging,
the phase shift difference between the moving spins
in the blood and that of the surrounding stationary
tissue is compared by using a bipolar gradient,
allowing detection of blood flow velocity. Two scans
are acquired (flow-sensitive scan and a flow-compensated reference scan), which are automatically
subtracted from each other. The resulting data are
processed into two sets of images: magnitude (anatomic) and phase-contrast (velocity) (Fig. 2). In
phase-contrast images, the gray value of each pixel
represents velocity information of that pixel. Higher
569
Fig. 1. A 55-year-old man with type B aortic dissection. T1-weighted axial image (A) with black-blood technique shows
excellent suppression of the luminal blood signal and demonstration of intimal flap (arrow) in the descending aorta. Contrastenhanced MRA of the aorta with sagittal oblique source (B), subtracted (C), MIP (D), and axial reformation (E) images show a
dissecting intimal flap (arrows). The subtracted image (C) was obtained by subtracting the unenhanced mask image from the
contrast-enhanced source image (B) and demonstrates better suppression of the background signal. MIP image (D) allows overall
evaluation of the dissecting intimal flap (arrows), which extends from the aortic arch to the abdominal aorta.
570
Fig. 2. Phase-contrast imaging of the aorta. Magnitude (A) and phase (B) axial images display the ascending (AA) and
descending (DA) aorta at the level of pulmonary artery (arrow). Flow encoding was set from the superior to the inferior direction
and images were obtained with ECG gating. On the phase image (B), the ascending aorta appears black and the descending aorta
white because of the opposite direction of the flow in these arteries. The volume and velocity of the flow can be calculated with
available software.
571
Clinical applications
Atherosclerotic disease of the aorta
Atherosclerosis is the commonest disease afflicting the arterial system. It may present as an acute or
chronic syndrome [24]. The atherosclerotic process
begins in childhood as fatty streaks in the intima of
arteries and usually develops for many decades
before cardiovascular complications occur [25]. The
progression of atherosclerosis is accelerated in the
presence of risk factors, such as aging, hypertension,
hypercholesterolemia, and smoking [26]. Atherosclerosis causes intimal thickening with the accumulation
of lipid-laden foam cells and proliferation of smooth
Table 1
Acquisition parameters of contrast-enhanced MR angiography of the thoracic aorta
FOV
Matrix
Bandwidth
Flip angle
NEX
K-space
Contrast
amount/rate
Saline
amount/rate
Delay
Acquisition
time
30 cm
256 256
31.125 kHz
35 40
0.5
Centric
40 mL/2.5 mL
20 mL/2.5 mL
25 s
21 s
572
573
Fig. 4. A 73-year-old woman with atherosclerotic aneurysm. Axial T1-weighted image with black-blood technique (A) and
sagittal oblique reformation of contrast-enhanced MRA (B) show the aneurysm involves the distal ascending (AA) and proximal
descending (DA) thoracic aorta.
sis, or occlusion are other clinically significant complications of aneurysms. Multiplanar reformations are
sometimes useful to measure the true diameter of the
tortuous aorta. CE-MRA is a luminogram and should
not be used for diameter measurement. The current
examination and also all available previous studies
should always be reviewed and compared. The comparison should include the earliest studies not to miss
a slowly expanding aneurysm; serial measurements
should be made at the same location of the aneurysm.
In patients with ascending aortic aneurysm, MR cine
imaging of the left ventricular outflow tract or phasecontrast imaging of the aortic valve can be added to
the routine imaging protocol for evaluating any associated aortic valve regurgitation (Fig. 7).
Aortic dissection
Aortic dissection occurs when blood dissects into
the media of the aortic wall through an intimal tear,
producing an intimal flap by separation of the false
lumen from the true lumen [40]. It generally is
secondary to chronic hypertension [41]. In young
patients with aortic dissection, an underlying process,
such as connective tissue disorders (Marfan or EhlersDanlos syndromes), should be investigated [42,43].
The proximal ascending aorta and the descending
aorta just distal to the left subclavian artery are two
common sites for initiation of the dissection. Sudden
onset of severe chest or back pain is a characteristic
presenting symptom [44,45]. Aortic dissection involving the ascending (Stanford type A) is a surgical
emergency with high mortality and may be complicated by contained rupture into the pericardium
causing pericardial tamponade, involvement of coronary arteries causing acute myocardial ischemia, and
extension to the arch arteries compromising brain
perfusion (Fig. 8) [41,44]. Additionally, aortic valve
disruption may lead to aortic regurgitation leading to
congestive heart failure. Dissections arising distal to
the left subclavian artery (Stanford type B) are
usually treated medically with surgical intervention
restricted for patients with signs of aortic expansion
and persistent clinical symptoms (see Fig. 1). Paraplegia caused by spinal cord ischemia is a frequent
complication and observed in up to 30% after surgery
of type B dissections [44]. The detection of side
574
Fig. 6. A 32-year-old man with Marfan syndrome. Axial (A) and sagittal oblique reconstruction (B) images of CTA show a
marked dilation of the aortic root (arrows) at the level of the sinus of Valsalva resulting in a pear-shaped aortic root, which is
typical for this syndrome.
Fig. 7. A 35-year-old man with Marfan syndrome. Sagittal oblique image (A) from diastolic phase of steady-state free precession
cine acquisition nicely displays dilated aortic root (black arrows) with regurgitant flow caused by aortic valve insufficiency
(white arrows). Phase-contrast images from the level of aortic valve obtained during systole (B) and diastole (C). Systolic flow
from the left ventricle to aorta is black (arrow in B); however, the regurgitant flow from the aorta to ventricle (arrow in C) is
white because flow encoding was set in a superior-to-inferior direction.
575
Fig. 8. A 60-year-old man with a history of hypertension and family history of aortic dissection presented with a sharp epigastric
pain radiating to chest. CTA showed type A dissection. Axial image at the level of sinus of Valsalva (A) shows intimal flap (black
arrows) and tear site (black arrowhead). Note a large hemopericardium (white arrows). The intimal flap was involving the ostia
of right coronary artery (not shown here). Dissection of the descending aorta is also seen (white arrowhead). Axial image at the
level of the right pulmonary artery (B) clearly shows intimal flap separating the false lumen (arrows) from the true lumen
(arrowheads). Note low density of the false lumen because of delayed flow. (C) Axial image at more cranial level reveals
involvement of major arch arteries (arrows). Coronal image from three-dimensional reformation (D) nicely displays the extent of
the dissection (arrows).
576
Intramural hematoma is an atypical form of dissection without flow in the false lumen or a discrete
intraluminal flap and constitutes 10% to 20% of acute
aortic syndromes [44,49,50]. Once considered an
entity diagnosed only at necropsy, with the introduction of high-resolution cross-sectional imaging in
clinical use, the in vivo diagnosis is now feasible.
Arterial hypertension is the most frequent predisposing factor as in aortic dissection [50]. The pathogenesis of intramural hematoma still remains unclear.
Spontaneous rupture of the aortic vasa vasorum or
penetrating atheromatous ulcer was proposed as the
initiating event [51]. Intramural hematoma most frequently involves the ascending aorta or proximal
segment of the descending aorta as in those with
classic dissection. The acute complications of aortic
dissection, such as aortic insufficiency, rupture into
pericardium, and branch vessel involvement, may
also occur with intramural hematoma. It may regress
over the time with resorption of the hematoma or
progress to develop serious complications [52,53].
It is generally considered to be a precursor of overt
Fig. 10. A 49-year-old man with a history of hypertension presented with acute chest pain. Precontrast (A) and postcontrast
(B) axial CTA images revealed intramural hematoma. Note a high-density crescent-shaped wall thickening in the descending
thoracic aorta (arrows), which is better appreciated on precontrast image.
577
media of the aortic wall [58]. A penetrating atherosclerotic ulcer is typically located in the descending
thoracic aorta and can be associated with a variable amount of hematoma within the aortic wall
[49,59 61]. It generally affects elderly individuals
with hypertension and extensive aortic atherosclerosis [60], presenting with chest or back pain. Penetrating atherosclerotic ulcer can result in localized
tear through the adventitia forming pseudoaneurysm,
which can be quite large (Fig. 12). Many penetrating
atherosclerotic ulcers are diagnosed in asymptomatic
patients who undergo imaging for other reasons and
remain unchanged over time. It can be complicated,
however, by saccular or fusiform aortic aneurysms,
classic dissection, or aortic rupture [60,62]. Intramural
hematoma may also result in a focal outpouching
resembling penetrating atherosclerotic ulcer (Fig. 13)
[49]. There is discrepancy in the prognosis of penetrating atherosclerotic ulcer on outcome studies. Tittle
et al [63] reports that rupture occurred during the
initial admission in 38% of cases, whereas others
indicated more benign course in most of the patients
[60,62,63].
In imaging, penetrating atherosclerotic ulcer is
seen as an outpouching extending beyond the contour
of the aortic lumen and CT and MR imaging can
demonstrate associated intramural hematoma in acute
578
Fig. 13. Unenhanced axial CT image (A) shows intramural hematoma (arrows) in the descending aorta. On follow-up CTA, a
focal outpouching (arrows) developed at this region, resembling penetrating atherosclerotic ulcer as seen on axial (B) and sagittal
oblique MIP (C) images.
stage. The diagnosis can be difficult when the presentation overlaps with atypical focal aortic dissection. In
fact, several other different entities (eg, focal aneurysm with irregular atherosclerotic thrombus, or
contained aortic rupture) may also produce ulcerlike
lesions in the aorta resembling penetrating atherosclerotic ulcer [62]. As in classic dissection, these lesions
are managed surgically if located in the ascending
aorta, whereas more distal penetrating atherosclerotic
ulcer without clinical signs of instability is managed
medically and followed by sequential imaging [64].
Unstable descending aorta-penetrating atherosclerotic
ulcer is considered for more aggressive treatment,
such as stent-graft placement. Endovascular stent graft
579
Fig. 14. A 41-year-old woman with Takayasus arteritis. Contrast-enhanced axial image with black-blood technique (A) from
the level of the aortic arch obtained with ECG gating, breath-holding, and fat saturation. Note enhancing thickening of the aortic
wall (arrows). Coronal MIP image from contrast-enhanced MRA (B) shows involvement of the aortic arch branches. Total
occlusion of left subclavian artery (white arrow), severe stenosis of the origin of the left common carotid (black arrow), and long
segment stenosis of the right common carotid artery (white arrowheads) are evident. Note also aberrant origin of left vertebral
artery from the arch (black arrowhead).
580
Fig. 17. CTA of a patient with suspicion of aortic coarctation on plain chest radiographs. Sagittal oblique MIP (A,B) and threedimensional reconstruction with volume rendering technique (C) demonstrates that there is aortic tortuosity (arrow) rather than a
true coarctation (pseudocoarctation). The patient did not have any clinical or other evidence of a coarctation.
Fig. 18. Axial CTA image through the upper chest showing a right-sided arch (arrows) with an aberrant left
subclavian artery arising from the diverticulum of Kommeral (arrowheads), which is coursing to left side posterior to
the trachea.
581
commonly involves thoracotomy with graft interposition. Dacron (polyester) graft is the most commonly
used synthetic graft. The diseased native aorta can be
either completely replaced by the graft (interposition
technique) or wrapped around the inserted graft
(inclusion technique). In the postoperative period,
follow-up by CT or MR imaging is routinely recommended to identify graft stability and possible
complications, such as graft dehiscence or pseudoaneurysm. In addition, the coexisting disease of
the descending aorta, which commonly remains unrepaired unless symptomatic, requires surveillance in
terms of progress of the disease. The anastomosis site
can be identified by abrupt change in aortic caliber or
an abrupt transition between nonatherosclerotic (graft)
and atherosclerotic (native) aortic wall (Fig. 19).
High-attenuation rings (felt strips) can help to distinguish the proximal anastomosis site. These rings are
used to reinforce the proximal anastomosis. Lowattenuation or soft tissue density material surrounding
or adjacent to the aortic graft can be seen months or
years after the surgery. These materials possibly
represent an old hematoma that has evolved into
fibrous tissue and should not be mistaken for leakage
or infection. The use of an interposition graft requires
the coronary arteries to be anastomosed to the graft
with a button of native aortic root. These buttons can
582
Fig. 20. This patient was status post endovascular stent (arrows) replacement because of aneurysm. Axial (A) and sagittal
MIP reformation (B) of CTA show marked contrast leakage into the aneurysmal sac caused by malpositioning of the
stent (arrowheads).
Fig. 21. CTA of a 22-year-old man who sustained injury from a motorcycle accident. Axial (A) and sagittal reformatted
(B) images elegantly display traumatic rupture of the descending aorta (black arrows). Note mediastinal hematoma (white arrow)
and bilateral pleural effusions (arrowheads).
Summary
CT angiography and MR angiography are valuable tools in the evaluation of acute and chronic disorders of the thoracic aorta. These noninvasive
modalities provide crucial information about the
vessel wall and surrounding mediastinal structures
in addition to aortic lumen and should be used as a
first-line diagnostic method, reserving conventional
angiography for therapeutic intervention. CT is fast,
robust, widely available, and cost-effective. MR
imaging uses no ionizing radiation or nephrotoxic
iodine and allows a comprehensive evaluation of the
aorta including functional flow measurements and
evaluation of aortic valve.
Understanding of principles of the techniques is
important to obtain consistently diagnostic images.
Proper demonstration of the obtained images by
means of postprocessing techniques is equally important to communicate properly with referring physicians. Knowing the natural history of aortic diseases
and imaging features can lead to an accurate diagnosis and proper management of patients with aortic disease.
References
[1] Kalender WA, Seissler W, Klotz E, Vock P. Spiral
volumetric CT with single-breath-hold technique,
continuous transport, and continuous scanner rotation.
Radiology 1990;176:181 3.
[2] Hidajat N, Maurer J, Schroder RJ, Wolf M, Vogl T,
Felix R. Radiation exposure in spiral computed tomography: dose distribution and dose reduction. Invest
Radiol 1999;34:51 7.
[3] Hartnell GG. Imaging of aortic aneurysms and dissection: CT and MRI. J Thorac Imaging 2001;16:35 46.
[4] Fleischmann D, Rubin GD, Bankier AA, Hittmair K.
Improved uniformity of aortic enhancement with customized contrast medium injection protocols at CT
angiography. Radiology 2000;214:363 71.
[5] Lipton MJ, Higgins CB. Computed tomography: the
technique and its use for the evaluation of cardiocirculatory anatomy and function. Cardiol Clin 1983;1:
457 71.
[6] van Hoe L, Marchal G, Baert AL, Gryspeerdt S, Mertens L. Determination of scan delay time in spiral
CT-angiography: utility of a test bolus injection.
J Comput Assist Tomogr 1995;19:216 20.
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584
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[61]
[62]
[63]
[64]
[65]
[66]
[67]
[68]
[69]
[70]
[71]
585
Division of General Diagnostic Radiology, Interdisciplinary Cardiac Imaging Centre, Medical University of Graz,
Auenbruggerplatz 9, Graz 8036, Austria
b
Department of Radiology, Brigham and Womens Hospital, Harvard Medical School, 75 Francis Street,
Boston, MA 02115,USA
* Corresponding author.
E-mail address: rainer.rienmuellerl@meduni-graz.at
(R. Rienmuller).
Anatomy
The pericardium consists of two layers: an outer
fibrous layer (the fibrous pericardium) and an inner
visceral layer (the epicardium) creating an inner sac,
the pericardial cavity [1]. The wall thickness of the
inner layer varies between 0.05 and 1 mm [2], being
thicker above (eg, right ventricular myocardium) and
thinner along the thicker myocardial wall of the left
ventricle [3]. The inner surface of the outer layer is
lined by a layer of mesothelial cells producing serous
fluid. Under physiologic conditions the pericardial
sac contains 20 to 25 mL of serous fluid, which may
vary considerably in different individuals [4].
Functional anatomy
Histologically, the outer layer consists of just two
and the inner layer of three superimposed network-like
connective tissue structures giving the outer layer
more elasticity and distensibility; this is in contrast to
the inner layer, which appears less distensible and
stiffer [3]. That way, with an increasing pericardial
effusion, which is accompanied by increasing intrapericardial pressure, the outer layer stretches and
expands outward to prevent tamponade until it reaches
maximal distensibility. Next, the rising intrapericardial
pressure is directed to the inner layer (with lower
distensibility) impeding the normal diastolic filling
of the right ventricle and later also of the left, leading
to increased filling pressures, decreased cardiac out-
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.03.003
588
Topographic anatomy
The pericardial sac encloses the heart, the proximal part of the ascending aorta, the pulmonary trunk,
and short segments of the left pulmonary veins. The
pars diaphragmatica of the pericardial sac is anchored
to the central tendon of the diaphragm. The sternocostal components of the pericardial sac are anchored
by the pericardio phrenic ligament to the diaphragm.
Superiorly lies the sternopericardial ligament.
The posterior and both lateral areas of the pericardium are connected to the aorta, tracheal bifurcation, and the right and left mediastinal pleura by
connective tissue. The retrosternal space is filled by
various amounts of fatty tissue (plica adiposa), which
may also be found in the recessus costomediastinalis.
Upward (cranially) approximately 1 to 1.5 cm below
the origin of the brachycephalic trunk the pericardial
sac is reflected onto itself creating the superior
junction line around the ascending aorta and the
pulmonary trunk until it reaches the ligamenta arteriosum [2].
The second pericardial junction line runs nearly
vertically from the superior to the inferior caval veins
enclosing in part both vessels. Because of the variety
in number and location of the pulmonary veins entering the left atrium the course of this junction line is
variable. A part of the left atrium is covered, but only
by the outer pericardial layer creating with the left
arterial wall the so-called mesocardium [2].
The transversal sinus of the pericardium localized
between ascending aorta and pulmonary trunk and
between the superior caval vein and left atrium shows
a variable course and may, dependent on the amount
of pericardial fluid, show a number of recesses, just
Pericardial function
It seems appropriate to distinguish between anatomic and mechanical function of the pericardium.
The anatomic functions consist of the following:
Fixing of cardiac position in the thoracic cavity
[1,6]
Isolation of adjacent thoracic structures to re-
589
Fig. 2. Electron-beam tomography image of normal pericardial line (arrow) seen in front of the right atrium, right
ventricle, and anterior to the left ventricular apex. Note how
it is separated from the heart by periepicardial fat and connective tissue. (From Groll R, Schaffer GJ, Rienmuller R.
Pericardial sinuses and recesses: findings at electrocardiographically triggered electron-beam CT. Radiology 1999;
212:69 73; with permission.)
590
Table 1
Imaging methods: heart, anatomy, function
Pericardium
Epicardium
Myocardium
Valves
Cavity
Coronary wall
Coronary lumen
RV function
LV function
Myocardial perfusion
Coronary flow
Intracavitary flow
CT
EBT
MR imaging
++
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+++
+++
++
(+ + +)
(+ + +)
+++
+++
++
(+ + +)
+++
++
+
+
+
+
+
++
+
+
++
+
Pericardial pathology
Pericarditis
Any pericardial stimulus of a certain threshold
may cause a classic inflammatory reaction [10], the
extent and distribution of which may be seen on CT
or MR imaging as a thickened pericardial line ( 1
2 mm). As long as this pericardial line appears
smooth from both sides of the pericardial sac, this
finding may be regarded as acute; if it appears
irregularly thickened it is regarded as a chronic
inflammatory or postinflammatory process (Fig. 3)
[13]. This inflammatory reaction is usually accompanied by a different amount of exudation into the
pericardial cavity [10]. The exudate may be serous,
fibrinous, purulent, hemorrhagic, or mixed and a
careful analysis of measured CT values or MR
591
Pericardial effusion
Any increase of pericardial fluid, in dependence
on the distensibility characteristics of the individual
patients pericardium, increases the intrapericardial
pressure. Generally, slow increase of pericardial fluid
up to 3 L is well tolerated [17]. The rapid development with a sudden increase of pericardial fluid,
however, may cause sudden tamponade without prodromal symptoms (Fig. 5). This means that it is not
the volume of pericardial fluid but rather the intrapericardial pressure that is the most important factor
in determining the risk of tamponade. This intra-
Fig. 5. (A) Drawing of midventricular-level slice of pericardial effusion illustrating the subepicardial fat and connective tissue and normal configuration of both ventricles
and both atria. (B) Drawing of midventricular-level slice of
pericardial effusion with no visualization of the subepicardial fat and connective tissue, with tubelike configuration of
both ventricles because of elevated intrapericardial pressure, causing compression of both ventricles and enlargement of both atrial auricles, which are seen near the cardial
apex, because of the presence of morphologic (signs) determinants of pericardial tamponade. (From Rienmueller R,
Seiderer M, Doliva R, Kemkes B, Lissner J. Pericardial and
congestive heart failure: diagnostic with CT- and MR-imaging. Ann Radiol 1986;29:95 100; with permission.)
592
[18 20]
Decrease of end-diastolic volume [18,21]
Increase of end-diastolic pressures in all cardiac
chambers [10,22,23]
Constrictive pericarditis
Definition
The term constrictive pericarditis [26,27] is applied to a disorder in which inflammatory or noninflammatory pericardial processes have caused
scarring or calcification of one or both pericardial
layers, which leads to constriction [1] and frequently
to compression of the underlying cardiac chambers.
As a sequel of these pathologic pericardial changes,
the normal physiologic compliance of one or both
pericardial layers is lost resulting mechanically in
impaired (restrictive) filling of the cardiac chambers
during diastole.
Pericardial tamponade
If the intrapericardial pressure is elevated above
a value of 20 mm Hg, no effective filling of the
ventricles is possible resulting in pericardial tamponade [24]. In CT and MR imaging with pericardial
effusion the loss of definition of the subepicardial
space (connective and fatty tissue) with compression
of the ventricles and deformation of the atria (with the
atrial auricles being seen to the level of the cardiac)
suggests the presence of pericardial tamponade
(Fig. 5) [25]. The swinging motion of the heart may
[19,27]
Decrease of ventricular volumes [27,36]
593
594
Fig. 6. Electron-beam tomography slices at the level of the superior (A) and inferior (B) caval veins, above (C) and through the
midventricular level (D) of the heart, showing enlargement of both caval veins (coronary sinus), of the atria, and normal
configuration of both ventricles with calcified pericardium from the pars diaphragmatica (B) pericardii around the heart (C,D) until
the superior junction line, confirming global type of calcified pericardial constriction. Only at the left ventricular apex is the
pericardium not calcified. (Calcified pericardium anterior to the apex of the left ventricle may be seen without pericardial
constriction). The intramyocardial calcification arising near the calcified pericardium dorsal of the left ventricle (D) is suggestive of
previous perimyocarditis. The posterolateral wall of the left ventricle and the interventricular septum (systolic image) have a normal
wall thickness, which excludes myocardial atrophy. At pericardiectomy caution is necessary during pericardial decortication to
prevent myocardial damage. Intramyocardial calcification may be difficult to see and overlooked if only MR imaging is used.
595
596
Fig. 9. (A) Drawing of midventricular-level slice of the leftsided form of pericardial constriction. The thickened
periepicardium is separated by subepicardial fat from the
compressed left ventricle. The interventricular septum often
is bent to the left. (B) Drawing of midventricular-level slice
of the right-sided form of pericardial constriction. The
thickened periepicardium is separated by subepicardial fat
from the compressed right ventricle. The interventricular
septum often is bent to the right. (From Rienmuller R,
Gurgan M, Erdmann E, Kemkes BM, Kreutzer E, Weinhold
CH. CT and MR evaluation of pericardial constriction: a
new diagnostic and therapeutic concept. J Thorac Imaging
1993;8:108 21; with permission.)
Right ventricle
Interventricular
septum < 1 cm
Periepicardium not
separated from
ventricular wall
Irregular wall thickening
597
Fig. 10. (A) Drawing of midventricular-level slice in leftsided myocardial atrophy with thinning of the posterolateral wall and the interventricular septum. (B) Drawing of
midventricular-level slice of the right myocardial fibrosis
showing irregular thickening of the right ventricular wall and
focal nonseparable thickened periepicardium. (From Rienmuller R, Gurgan M, Erdmann E, Kemkes BM, Kreutzer E,
Weinhold CH. CT and MR evaluation of pericardial constriction: a new diagnostic and therapeutic concept. J Thorac
Imaging 1993;8:108 21; with permission.)
598
Fig. 11. Perioperative mortality (percentage) in patients with pericardial constriction from retrospective (1980 1984) and
prospective (1985 1991) CT and MR imaging studies. In a retrospective study 6 of 20 patients expired with the previously
described determinants of myocardial atrophy and fibrosis, respectively (mortality rate could be decreased from 30% 16.5%). In
the prospective study 5 of 30 patients expired, 3 because of the presence of myocardial atrophy-fibrosis (mortality 10%) and
2 (without myocardial atrophy-fibrosis) because of surgical complications (mortality 6.6%). (From Rienmuller R, Gurgan M,
Erdmann E, Kemkes BM, Kreutzer E, Weinhold CH. CT and MR evaluation of pericardial constriction: a new diagnostic and
therapeutic concept. J Thorac Imaging 1993;8:108 21; with permission.)
disease?
Summary
In patients with restrictive or constrictive cardiac
hemodynamics, in whom there is elevation of diastolic pressure in all four cardiac chambers, CT or MR
imaging can determine the presence or absence of the
morphologic determinants of pericardial constriction
to identify and characterize patients with pericardial
constriction. Diagnostic thoracotomy to distinguish
between pericardial constriction and restrictive cardiomyopathy is now considered obsolete [43].
Myocardial atrophy and fibrosis may be detected
preoperatively by CT or MR imaging. In these
patients pericardiectomy is contraindicated and cardiac transplantation should be considered as an alternative surgical treatment [43].
Presurgical planning is critical to determine the
form and extent of pericardial constriction because
this dictates the optimal thoracotomy approach. The
extent of disease and the area of periepicardial
fenestration, and the optimal sequence for performing
the periepicardial decortication (first along the left
ventricle, then in the left atrioventricular groove,
anterior to the pulmonary trunk, anterior to the right
599
Fig. 12. MR imaging slices (A) coronal, (B) through the midventricular level in the short axis view in a gradient echo white blood
pool image, (C) at midventricular level in long axis view, and (D) spin echo (black blood pool image) technique. The superior
caval vein (A) and the right atrium (A,C) are enlarged and the right ventricle is compressed (B D) by pericardial mass of
inhomogeneous signal intensity (B D). This pericardial mass is surrounded by calcified outer and inner layer of the pericardium
(difficult to see without CT). The subepicardial fat and connective tissue in high (white) signal intensity (D) between the inner
pericardial layer and the normal thickness of the ventricular myocardium exclude right myocardial fibrosis and atrophy.
ventricle, and finally in the area of the right atrioventricular groove in patients with global pericardial
constriction), can all be guided by imaging [43].
The continuous improvement of coronary artery
imaging using advance CT and MR imaging technology will in the near future replace coronary angiography in this disease entity. Cine CT and cine
MR imaging techniques will depict coronary artery
anomalies and interventricular septal motion [65],
and measure blood flow for the early recognition
of restrictive flows in subacute or masked pericardial constriction.
Intravenous contrast-enhanced CT or MR imaging
will in the future be increasingly applied for the differential diagnosis of acute (nonfibrotic) and chronic
(fibrotic) pericarditis and will play an important role
in triaging patients for either conservative therapy
or surgical pericardiectomy [43]. In addition, these
Acknowledgments
The authors are grateful to Mrs. Gollowitsch for
her secretarial assistance and Dr. U. Reiter for graphical preparation.
References
[1] Shabetai R. The pericardium. New York: Grune &
Stratton; 1981.
[2] Bargman W, Doerr W. Das herz des menschen. Stuttgart: Georg Thieme Verlag; 1963.
600
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]
[50]
[51]
[52]
[53]
[54]
601
The Heart Institute of Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003, USA
b
Department of Medicine, Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201, USA
c
Department of Radiology, Beth Israel Medical Center, First Avenue at 16th Street, New York, NY 10003, USA
d
Department of Radiology, Albert Einstein College of Medicine of Yeshiva University, 1300 Morris Park Avenue,
Bronx, NY 10461, USA
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.03.010
604
conventional CT became the gold standard for detection of coronary arterial and myocardial, pericardial,
valvular, and intracavitary calcium. The development
of electron-beam CT and the subsequent development
of spiral and now multidetector spiral CT have
decreased image acquisition time to a point where
very small arterial calcium deposits may be detected
and reliably quantitated. Calcium is transparent on a
MR imaging examination, appearing as a signal void
within some other tissue. It is of limited value for
calcium evaluation.
Vascular calcification
Great vessel calcification
Discrete, rimlike calcification of the aorta (Fig. 1)
and aortic arch is usually a sign of degenerative
intimal change, most often resulting from atherosclerosis [2]. The distance between visualized calcification and the outer aortic contour is an estimation of
aortic wall thickness; its measurement may be helpful
in evaluating acute and chronic changes. If care is
taken to consider the effects of supine versus upright
examination, and the effects of tangential visualization of the heart and aorta in oblique or anteroposterior versus posteroanterior examination, then the
distance between intimal calcification and the outer
wall of the aorta should be no greater than 10 mm
[3]. Aortic arch calcification appears curvilinear,
605
Fig. 2. A 78-year-old woman with acute onset of back pain. (A) Anteroposterior radiograph shows dilatation of the aortic arch
and a curvilinear calcification medial to the lateral border of the arch (arrows). (B) Anteroposterior radiograph obtained 4 years
earlier. The intimal calcification (arrows) is closer to the outer border of the arch.
606
Fig. 4. A 40-year-old woman with primary pulmonary hypertension. (A) Posteroanterior (PA) radiograph demonstrates dilatation
of the main and hilar pulmonary arteries and right heart. (B) Enlargement of the right hilum reveals curvilinear segmental
pulmonary arterial calcification (arrows).
Myocardial calcification
Myocardial calcification is usually classified as
either dystrophic or metastatic [29]. Dystrophic calcification is more common; not associated with elevation of serum calcium or phosphorus levels [30];
607
Fig. 6. Asymptomatic 60-year-old man. (A) PA radiograph shows some increased curvature of the left ventricular contour and
mild pulmonary vascular redistribution. A curvilinear calcification is faintly seen (arrows) medial to the mid-left heart border.
(B) Magnified, enhanced view of the mid-left heart border. The large arrow shows the left bronchus crossing the left heart border.
The faintly viewed calcifications are parallel in nature, tram track calcification. (C) Lateral view shows the curvilinear
calcification (arrows) superimposed on the mass of the heart. (D) Magnified, processed view from the lateral examination. The
calcification (arrows) is now seen to be tram track in appearance.
608
609
Fig. 11. Chest examination in a 67-year-old man with a history of previous myocardial infarction. (A) PA radiograph shows
calcification (arrowhead) of a normal size aortic arch. The contour of the left ventricle is rounded and extends toward the left
chest wall. Immediately subjacent to and following the contour is a series of vague calcific densities (arrows). (B) In lateral view,
the fine curvilinear calcification (arrows) appears sharper than in the PA. It follows the bulging interventricular septum.
The calcium is deposited in the left atrial endocardium, more often found posteriorly and superiorly.
Left atrial calcification is usually thin walled and
follows the curvature of the chamber (Fig. 14) [41].
Calcification may also be found within a mural
thrombus in the left atrial appendage. Right atrial
calcification is extremely rare, occurring usually in
the setting of tricuspid rheumatic valvulitis [42]. CT
reveals a laminated structure with calcification and
distinct margins, without invasion of the right atrial
wall [42].
Pericardial calcification
Pericardial calcification results from exposure to
infection, trauma, or hemorrhage, or therapeutic radiation. The most common causes of pericardial
calcification in the past (tuberculosis, histoplasmosis,
and purulent pericarditis) are hardly seen today in the
antibiotic era. Nevertheless, these diseases are still
endemic in other parts of the world, and in an era of
global air travel they may present locally. Traumatic
pericardial disease, including surgical pericardotomy
for intracardiac or coronary artery bypass graft surgery, results in residual blood left within the pericardial space, the nidus for future calcification. Patients
who have undergone previous mantel radiation treat-
610
Fig. 13. A 34-year-old man with shortness of breath. (A) Overpenetrated display of a PA radiograph demonstrates dense, irregular
calcification projecting over the dilated left ventricle. (B) On lateral examination the dense calcification is projected over the
ventricular mass. Notice the posterior displacement of the left ventricular wall (arrows) indicating dilatation. (C) Oblique axial
double inversion recovery MR acquisition. Although the left ventricle (LV) is hypertrophied, there are numerous irregular signal
voids throughout the myocardium (arrows) representing the endocardial and myocardial calcifications.
cation is only about 1 to 2 mm in thickness, but longstanding disease may be associated with 1- to 2-cm
thick lesions. Pericardial calcification is most commonly found within the atrioventricular grooves (dependent portions of the pericardial space) and in
the lower and diaphragmatic portions of the pericardium. Pericardial calcification is usually found on
both the right and left sides of the heart. Although
it may present as a local plaque, it more commonly
is seen as an extensive process. Differentiation between myocardial and pericardial calcification is
based on the distribution and character of the calcification. Pericardial calcification tends to be diffuse,
globally involving the pericardial space, and surrounding the heart (Fig. 16). Myocardial calcification
localizes to the left side of the heart; the myocardium
resides to the left. Differentiating a solitary pericardial from myocardial calcification based on the peripheral distribution of the pericardium may be
difficult on CT examination, and nearly impossible
on a plain film. Pericardial calcification tends to be
clunky and ugly in character (Fig. 17), whereas
611
[43,44]. Calcification is an important sign of pericardial constriction, but is not pathognomonic. Pericardial calcification may be present in the absence of any
physiologic insult to the heart.
Valvular calcification
Valvular calcification usually indicates the presence of valvular sclerosis or hemodynamically significant stenosis [45]. It is commonly associated with
rheumatic fever, congenital malformation, old endocarditis, and atherosclerosis. Mitral valvular calcification is overwhelmingly associated with preceding
rheumatic fever. Mitral valve calcification can take
two forms. Mitral annular calcification is rarely seen
before the sixth decade and is considerably more
common in women (Fig. 18). Annular calcification
appears as dense ringlike clumps, varying from 2 to
4 cm in diameter. The ring takes a particular orientation, defining the posterior atrioventricular ring.
Annular calcification is commonly associated with
normal mitral valve function (Fig. 19). When present,
however, the valvular dysfunction is more often
mitral insufficiency than stenosis. Mitral annular
calcification is common in end-stage renal disease
and may develop and progress over a short period of
time. Mobile components associated with mitral annulus calcification detected by echocardiography may
directly cause cerebrovascular accidents [46]. Mitral
Fig. 15. A 96-year-old woman who feels a little tired. (A) PA radiograph shows the long, irregular peripheral calcification
(arrows) along the right heart border, extending to beneath the heart. (B) In lateral examination, the calcification (arrows) follows
the anterior aspect of the heart.
612
Fig. 16. Planar reconstructions obtained from a 70-year-old woman with shortness of breath. (A) Coronal reconstruction obtained
immediately posterior to the sternum (long arrow). The calcified parietal (arrow 1) and visceral (arrow 2) pericardial layers are
separated by serous fluid. Note the right pleural effusion (eff), and immediately inferior to the right diaphragm, ascites (asc).
(B) Coronal reconstruction 3 cm behind Fig. 16A. The calcified parietal pericardium extends up to the ascending aorta (Ao) on
the right, and over the top of the main pulmonary artery (PA) on the left.
613
Intracavitary calcification
The aortic valve resides in nearly the geographic
center of the heart. It is often projected over the spine,
limiting the value of posteroanterior radiography for
its detection (Fig. 21). In lateral view, aortic valve calcification is thick, and often found within the middle
Tumor calcification
The most common tumor of the heart, the left
atrial myxoma, calcifies in about 10% of cases
Fig. 20. Frames of a cineangiogram in cranialized left anterior oblique projection obtained from the same patient in Fig. 8.
(A) End diastolic frame shows separation of the thickened, calcified anterior (A) and posterior (P) mitral leaflets. (B) The two
leaflets coapt during ventricular systole. Note the limited excursion of the leaflets, reflecting the limited mitral orificial area in
mitral stenosis.
614
Fig. 21. A 54-year-old man with degenerative calcific aortic stenosis. (A) PA radiograph shows increased curvature of the lower
left heart border, and dilatation of the ascending aorta (arrows). The aortic arch (Ao) is not dilated. (B) Lateral view shows the
dense, thick calcification in the center of the heart (short arrows). The retrosternal clear space is filled from behind (arrows
a,b,c) by the dilated ascending aorta. Also note the clear inferior retrocardiac space just above the gastric air bubble (Bu). The left
ventricle is hypertrophied, but not dilated.
615
Fig. 24. A 70-year-old woman with intermittent shortness of breath. (A) PA radiograph shows flattening of the left atrial
appendage segment of the left heart border (arrow), indicating left atrial enlargement. (B) In lateral view, the irregularly calcified,
3-cm left atrial myxoma is seen (arrows) abutting the posterior atrioventricular ring, and mitral orifice.
tumors are more common than primary cardiac malignancies, but these tumors do not calcify sufficiently for plain film diagnosis.
Summary
Cardiac calcification may be a reflection of degenerative processes associated with aging, and not a
reflection of a pathologic process that affects cardiac
function. This is probably true in cases of mitral
annular and isolated aortic annular calcification. Pericardial calcification indicates a previous insult; in the
proper clinical circumstances, pericardial calcification
indicates pericardial constriction, a clinically important condition to exclude. Calcification of the coronary arteries reflects the presence and progression of
atherosclerosis. Use of very fast CT allows quantitation of coronary calcium, a method of screening
patients at risk for coronary heart disease. Aortic
leaflet calcification is associated with a valvular
gradient. Myocardial calcification reflects the presence of a scar or ventricular aneurysm.
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[16] Margolis JR, Chen JTT, Kong Y, et al. The diagnostic
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[17] Schultz KW, Thorsen MK, Gurney JW, et al. Comparison of fluoroscopy, angiography and CT in coronary
arterial calcification. Appl Radiol 1989;6:38 43.
[18] Stanford W, Rooholamini M, Rumberger J, et al. Evaluation of coronary bypass graft patency by ultrafast
computed tomography. J Thorac Imaging 1988;3:
52 5.
[19] Moore EH, Greenberg RW, Merrick SH, et al. Coronary artery calcifications: significance of incidental
detection on CT scans. Radiology 1989;172:711 6.
[20] Budoff MJ, Georgiou D, Brody A, et al. Ultrafast computed tomography for the detection of coronary artery
disease: a multicenter study. Circulation 1996;93:
898 904.
[21] Agatston AS, Janowitz WR, Hildner FJ, et al. Quantification of coronary calcium using ultrafast computed
tomography. J Am Coll Cardiol 1990;15:827 32.
[22] Blumgart D, Schmermund A, Goerge G, et al. Comparison of electron beam computed tomography with
intracoronary ultrasound and coronary angiography for
detection of coronary atherosclerosis. J Am Coll Cardiol 1997;30:57 64.
[23] Rumberger JA, Simons DB, Fitzpatrick LA, et al.
Coronary artery calcium areas by electron beam computed tomography and coronary atherosclerotic plaque
area: a histologic correlative study. Circulation 1995;
92:2157 62.
[24] Schmermund A, Denktas AE, Rumberger JA, et al.
Independent and incremental value of coronary artery
calcium for predicting the extent of angiographic coronary artery disease: comparison with cardiac risk factors and radionuclide perfusion imaging. J Am Coll
Cardiol 1999;34:777 86.
[25] Arad Y, Spadaro LA, Goodman K, et al. Predictive
value of electron beam CT of the coronary arteries:
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[26] Detrano RC, Wong ND, Tang W, et al. Prognostic
significance of cardiac cinefluoroscopy for coronary
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J Am Coll Cardiol 1994;24:354 8.
[27] Sangiorgi G, Srivatsa SS, Rumberger JA, et al. Arterial
calcification and not lumen stenosis is highly correlated with atherosclerotic plaque burden in humans;
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620
Table 1
Frequency of side effects seen with pharmacologic stress in the authors institution over a 4-year period
No symptoms %
Minor or moderate %
Early termination %
Medical intervention %
Adenosine (850)
Dobutamine (261)
Dipyridamole (86)
5.5
85.5
7.9
0.5
9.2 (24)
64 (167)
23.8 (62)
4.5 (12)
22 (19)
48 (41)
NA
30 (26)
(47)
(727)
(67)
(4)
Numbers in brackets refer to the number of patients in each group. Dipyridamole was abandoned after the first 2 years because of
a high level of side effects.
adenosine stress in 0.5% of cases and during dobutamine stress in 5% (Table 1) [2]. In none of these did
intervention amount to more than plasma expansion
using a colloid infusion or use of a nitrate spray. A
duty doctor must be available in the case of an
adverse reaction or prolonged symptoms, but does
not need to be physically present. This simplifies
bookings when supervising junior medical staff are in
short supply, improving efficiency for the department
and the duty doctor [3]. When using vasodilating
stressors, such as adenosine or dipyridamole, there is
no need to stop rate-limiting antianginal medication.
b-Blockers are only stopped for dobutamine stress
tests (24 hours before examination).
One- or two-day protocol?
Thallium 201 (201Tl) imaging is by its very nature
a 1-day protocol. As a potassium analogue, it is taken
up rapidly by myocytes with a high first-pass extraction fraction (85%). Initial myocardial uptake is
directly proportional to flow up to approximately
2.5 times resting blood flow. Because 201Tl is not
bound to myocytes, redistribution starts immediately.
Rapid redistribution means stress imaging must be
performed as soon after injection as possible, before
significant redistribution occurs. Rest images are
acquired later, usually at 2 to 4 hours. This ties the
patient stressing process closely to the gamma
camera room, increasing camera time and potentially
reducing patient throughput. When one adds the
disadvantages of long half-life, high patient radiation
dose (18 mSv), and a gamma emission energy that
is relatively poor for imaging, it is clear why 201Tl
is used less and less. Sixty percent of departments
in the United Kingdom now use technetium
99m (99mTc) based agents.
By contrast, 99mTc is better suited to perfusion imaging. 99mTc has a relatively short half-life
(6 hours); has a gamma emission energy of 140 KeV,
which is ideally suited to the physics of the gamma
camera; better radiation dosimetry (allowing a higher
621
expected from the literature. Nuclear perfusion reports need to be systematic and should include the
following main points:
1. Type of stress and if completed
2. Physiologic response to stress
3. Patient parameters if likely to be a cause of
attenuation artifact
4. Location, severity, and reversibility of reductions in tracer uptake
5. Additional findings (eg, transient ventricular
dilatation)
It is important to mention the method of stress
used and whether the patient experienced symptoms
or had ECG changes during or after stress. Given
the potential for antagonism of heart rate rise by
b-blockers and adenosine by caffeine, it is essential
to include details of change in pulse and blood
pressure. Any patient who experiences little or no
physiologic change may have had inadequate stress,
so the report should be qualified accordingly (risk
of a false-negative result). One must be particularly
cautious when a patient with a high pretest probability of CAD has no symptoms, no change in
physiologic parameters, and a normal scan. In this
case it may be necessary to repeat the examination
with exercise or dobutamine stress as appropriate.
Patient height, weight, and body habitus should be
considered because these have a bearing on attenuation artifact.
Tomographic images are best reviewed in standard cardiac planes (Fig. 2). Some authors prefer a
monochromatic gray scale, whereas others have argued that a continuous color scale provides better
interobserver agreement [7]. More important is consistency of approach. Reporters should become familiar with one display system and adhere to that
system. The location, severity, and reversibility of all
perfusion abnormalities should be described.
Location is best dealt with using a standard
segmental model and the 17-segment model, recently
adopted by consensus among a number of imaging
bodies, is ideal (Fig. 3) [8]. Description of location
and its relationship to the segmental model is helped
by using bulls-eye plots of rest and stress data
(Fig. 4). Tracer uptake in the stress portion of the
examination should be described in semiquantitative
terms (ie, normal, mildly reduced, moderately reduced, or severely reduced). When scaling the display
to show the most intense region of myocardial uptake
as 100%, it must be remembered that normal variations in perfusion can reduce tracer uptake by 30%.
Even greater reductions can be seen in regions of
622
Fig. 2. (A) Standard cardiac tomographic planes derived from SPECT data showing short axis in rows from apex to base with
stress images above matched to rest images below. Horizontal and vertical long axis slices are also matched stress with rest.
(B) Short axis rings of left ventricular activity can be nested one inside the other with basal ring at the periphery and apex at
the centre to give a bulls-eye plot. Bulls-eye plots showing rest (C) and stress (D) from a sestamibi SPECT data set in
a normal patient.
normal myocardial perfusion when attenuation artifact is present. The reversibility of defects compared
with rest images needs to be described semiquantitatively (ie, fully reversible, partly reversible, or irreversible) (Fig. 5). In some instances, a pattern of
reverse distribution may occur with areas of normal
uptake during stress showing patchy decrease in
tracer activity at rest. Although it has been suggested
that this appearance may be caused by partial thick-
623
Fig. 4. Bulls-eye plots showing rest (A) and stress (B) sestamibi SPECT in a patient with large, moderately severe, but almost
fully reversible defect in the mid and distal anterior wall and apex.
624
Fig. 5. Bulls-eye plots showing rest (A) and stress (B) sestamibi SPECT in a patient with large, moderately severe, fixed defect in
the mid and distal anterior wall and apex.
625
Fig. 6. Bulls-eye plots showing rest (A) and stress (B) sestamibi SPECT in a patient with a mild fixed defect in the mid and distal
anterior wall. This is a typical site for breast attenuation artifact and showed normal wall motion on ECG-gated SPECT. (C) Left
coronary angiogram confirms normal left anterior descending.
were reviewed [16]. Improved accuracy and diagnostic confidence has had a major impact on the position
of nuclear perfusion imaging in the diagnostic
chain. In patients with a low or intermediate probability of CAD, ECG-gated SPECT now becomes a
cost-effective gatekeeper for coronary angiography.
Quantitative variables derived from ECG-gated
images have also been shown to contain powerful
and additional prognostic information. Sharir et al
[17] have shown that poststress ejection fraction is a
risk factor in predicting cardiac death and that this is
independent of the extent of the perfusion defect. In
626
Fig. 7. Bulls-eye plots showing rest (A) and stress (B) sestamibi SPECT in a patient with a large severe reversible defect in the
mid and distal anterior apex and anterior septum wall. This defect is associated with transient ischemic dilatation of the left
ventricle as shown in all three planes at rest (C) and (D) stress (1 hour after stress injection). Figs. 7C and D are ECG-gated
SPECT images in systole. Arrows show focal area of hypokinesia with stress.
627
628
an individual patient, recovery of one or two segments often makes little difference to either symptoms or prognosis. An increase in ejection fraction
predicts improved survival but to achieve this a significant volume of hibernating tissue needs to be
revascularized [48].
The combination of scar and hibernation in the
same poorly contracting segment of myocardium is a
629
Fig. 9. Bulls-eye plots comparing rest (A) and stress (B) sestamibi SPECT and FDG PET (C) in a patient with an established
infarct and hibernating myocardium. SPECT shows a very extensive severe fixed anteroapical defect with a moderately severe
fixed inferior defect. FDG PET shows the inferior defect to be active metabolically and likely to represent hibernating
myocardium. The inferior wall recovered function following revascularization.
630
631
Summary
Nuclear medicine continues to evolve quickly
with new techniques, such as ECG-gating and attenuation correction helping to improve specificity and
reporter confidence. These improvements in accuracy have been matched by renewed interest in the
use of nuclear perfusion imaging as a gatekeeper
for coronary angiography. The scene is set for a
significant increase in demand for nuclear imaging.
Radiologists and imaging cardiologists must be prepared to meet the challenge. New methods of working are needed to increase efficiency and more
systematic reporting is essential if published standards of accuracy are to be met in nonspecialist
centers. The latter is particularly important if nuclear
perfusion imaging is to deliver the improvements in
patient selection for coronary angiography and revascularization that are anticipated.
References
[1] Coyne E, Belvedere D, Vande Streer P. Thallium-201
scintigraphy after intravenous infusion of adenosine
compared with exercise thallium testing in the diagnosis of coronary artery disease. J Am Coll Cardiol 1991;
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[2] White C, Stone DL, Coulden RA. Does pharmacological stress in myocardial perfusion imaging need medical supervision? Nucl Med Commun 2000;21:395.
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[61] Groutars RG, Versijlbergen JF, Muller AJ, et al. Prognostic value and quality of life in patients with normal
rest thallium-201/stress technetium-99m tetrofosmin
dual isotope myocardial SPECT. J Nucl Cardiol
2000;7:333 41.
[62] Berman D, Hachamovitch R, Kiat H, et al. Incremental
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tomography. J Am Coll Cardiol 1995;26:639 47.
Coronary artery disease (CAD) remains the leading cause of death in western nations. The standard of
reference for diagnosis of CAD is coronary catheter
angiography. In the year 1999 more than 1.83 million
cardiac catheter examinations were performed in the
United States [1]. The greatest advantage of catheter
angiography is its high spatial resolution and the
option of directly performing interventions, such as
balloon dilatation or coronary stenting. Only one third
of all coronary catheter examinations in the United
States were performed in conjunction with an interventional procedure (percutaneous transluminal coronary angioplasty [PTCA]), however, whereas the rest
were performed for mere diagnostic purposes (ie, for
verifying the presence and degree of CAD only) [1].
Accordingly, a reliable, noninvasive tool for imaging
of the coronary arteries and for early diagnosis of
CAD is highly desirable.
Imaging of the heart has always been technically
challenging, because of the hearts continuous
motion. CT imaging of the heart moved into the
diagnostic realm by the introduction of electron-beam
CT [2] and multidetector-row CT (MDCT) [3,4] and
the development of ECG-synchronized scanning and
reconstruction techniques [5]. These modalities allow
for faster volume coverage and higher spatial and
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doi:10.1016/j.rcl.2004.03.011
636
were introduced [3,4,10] that provide an up to eightfold performance compared with 1-second rotation
single-slice CT systems. The performance of current
16-slice CT systems with 420-millisecond rotation
now represents a nearly 40-fold improvement as
compared with the acquisition speed of single-slice
CT [8]. The combination of fast rotation time and
multidetector-row acquisition became of particular
importance for cardiac applications.
To reduce motion artifacts caused by cardiac
pulsation, it is necessary either to scan or reconstruct
raw data at a time point with the least cardiac motion
(ie, in the diastole of the heart cycle). For successful
electrocardiogram (ECG) synchronization, prospective ECG triggering and retrospective ECG gating are
the two strategies that are used most commonly.
Prospective ECG triggering has long been used in
conjunction with electron beam CT and more recently
with single-slice spiral CT [11 13]. A prospective
trigger signal is derived from the patients ECG and
the scan is started at a defined time point, usually
during diastole. MDCT allows simultaneous acquisition of several slices within one heartbeat. The shorter
scan times facilitate routine clinical application. This
technique is also the most dose-efficient way of ECG
synchronization [7]. Usually, however, a rather thick
collimation (3 mm with electron beam CT, 2.5 mm
with four-slice CT) is used for prospectively triggered
Fig. 1. Graph shows reconstruction with retrospectively electrocardiogram (ECG)-gated four-slice multidetector-row CT
(MDCT) scanning. The same basic principle also applies to newer generations of 8-slice and 16-slice CT scanners. Oversampled
scan data and the ECG of the patient are simultaneously recorded. Based on input from both data sources retrospective ECG
gating creates image stacks reconstructed at the same phase of the heart cycle. Usually diastole is chosen to suppress cardiac
motion. In this manner the entire volume of the heart (z) is covered within one breathhold (Adapted from Ohnesorge B, Flohr T,
Becker C, et al. Cardiac imaging by means of electrocardiographically gated multisection spiral CT: initial experience.
Radiology 2000;217:564 71; with permission.).
637
Data visualization
Visualization of high-resolution MDCT data sets
consisting of several hundred individual axial images
is a daunting task. Still, some findings, such as
atherosclerotic lesions within the vessel wall, are best
evaluated based on individual axial sections. For better
visualization of the coronary artery tree in its entirety,
the following strategies are most commonly used.
Maximum intensity projection
For visualization of the coronary artery tree at
contrast-enhanced MDCT coronary angiography,
maximum intensity projections (MIPs) [18] are a
robust and easy to perform secondary visualization
tool for data viewing in daily clinical practice. Using
MIPs or other two-dimensional or three-dimensional
visualization methods (see later discussion) for diagnosis not only displays coronary artery MDCT data in
a more intuitive format but also condenses diagnostic
information into few relevant sections or views if
appropriate strategies are chosen. For routine visualization of large-volume MDCT coronary angiography datasets, the authors routinely perform three
dedicated MIP reconstructions to create views of
the left (Fig. 2A) and right (Fig. 2B) coronary arteries
and of the entire coronary arterial tree from a craniooblique perspective (spiderview) (Fig. 2C).
Multiplanar reformats
Another simple tool for secondary visualization of
high-resolution MDCT coronary angiography data is
use of multiplanar reformats. Because of the near
isotropic nature (equal voxel dimensions in x, y, and
z axis) of high-resolution MDCT acquisitions, image
data can be rearranged in arbitrary imaging planes
with comparable image quality as in the original axial
section. An additional option is creating curved
multiplanar reconstructions, which is especially useful to follow the course of coronary arteries (Fig. 3).
Three-dimensional visualization
Especially for nonradiologists it often is difficult
to mentally convert two-dimensional axial images
into three-dimensional anatomic information. Threedimensional postprocessing is a means to intuitively
638
Fig. 2. Maximum intensity projections (MIPs) are routinely used for the display of the coronary artery tree at MDCT coronary
angiography and are a robust and easy to perform secondary visualization tool for data viewing in daily clinical practice. For
routine visualization of large-volume MDCT coronary angiography datasets the authors routinely perform three MIP reconstructions. Views are created of the left (A, note spotty calcifications of the left anterior descending coronary artery) and right
(B) coronary arteries and of the entire coronary arterial tree from a cranio-oblique perspective (C, note calcification of the left
anterior descending coronary artery [arrow]).
639
Clinical applications
Calcium scoring: clinical rationale
Because arterial calcification almost always represents atherosclerosis, detection of coronary artery
calcium by means of CT is a sensitive, noninvasive
tool for determining the presence of coronary atherosclerosis [19]. The absence of coronary calcification
at CT has a high negative predictive value for ruling
out the presence of atherosclerosis and of stenotic
CAD (eg, in a population of patients with atypical
chest pain) [20 22]. Attempts have been made to use
the presence and degree of coronary calcification for
determining the extent and location of stenotic disease [23 25] and for defining patients at risk of hard
cardiac events (ie, unstable angina, myocardial infarction, need for revascularization, coronary death)
[24,26]. Early excitement has been tempered, however, by the results of meta-analyses pooling prognostic data on the positive predictive value of an
elevated calcium score. According to these analyses
there is only a very moderately increased risk for hard
Advanced software tools are actively being developed that facilitate viewing and analysis of large
volume data sets. Dedicated software algorithms
allow for automated segmentation and extraction of
the coronary artery tree from contrast-enhanced CT
studies of the heart. Intuitive visualization of the entire
course of a coronary artery can be achieved by displaying a curved multiplanar reformat along an automatically generated centerline of the vessel (Fig. 5).
It needs to be determined whether such tools are able
to increase the accuracy for lesion detection and
stenosis quantification.
Similarly, efforts are being directed at image
coregistration from different image modalities, such
as MR imaging and CT. Cardiac MR imaging is used
successfully for analysis of myocardial function and
perfusion and allows assessing myocardial viability
by differentiating myocardial scars from areas of
hypoperfusion or hibernation. Combining structural
CT information on coronary artery lesions with
functional MR imaging information on the state of
myocardial motion, perfusion, and viability enables
gauging the functional significance of atherosclerotic
lesions for choice of adequate therapeutic regimens.
MR imaging advantages for functional assessment
display and convey information on the often complicated anatomy of tortuous coronary arteries. The most
commonly used technology for three-dimensional
visualization of the coronary arterial tree is volume
rendering (Fig. 4).
640
Fig. 5. Dedicated software platform for automated segmentation and extraction of the coronary artery tree from contrastenhanced CT studies of the heart (right upper image panel of user platform). Intuitive visualization of the entire course of the left
anterior descending coronary artery is achieved by displaying a curved multiplanar reformat along an automatically generated
centerline of the vessel (lower image panel of user platform).
641
Fig. 6. Prototype software platform enabling spatial image coregistration of MR imaging (right upper image panel of user interface)
and CT (left upper image panel of user interface) data. Combining structural CT information on coronary artery lesions with
functional MR imaging information on the state of myocardial motion, perfusion, and viability enables comprehensive assessment
of cardiac morphology and function.
to sensitively detect changes in the total atherosclerotic disease burden in patients with and without
specific therapy. As compared with prospectively
ECG-triggered technique, MDCT acquisition with
retrospective ECG gating is associated with higher effective radiation exposure of the patient (ie, 2 mSv in
men and 2.5 mSv in women [40]). Frequently, healthy,
asymptomatic individuals undergo coronary calcium
scoring in the context of primary prevention. Especially in this population it is imperative to keep radiation dose to a minimum. This can be achieved by
adapting scan protocols accordingly [41], or by using
sophisticated technical developments, such as ECGbased tube current modulation [40], which can
decrease effective radiation exposure of the patient
by as much as 50% [40].
The most commonly used algorithm for quantification of coronary artery calcium is the traditional semi-
642
Fig. 7. Commercial semiautomated coronary calcium scoring software platform. Three-dimensional based selection and viewing
tools are used to identify calcified lesions and to attribute them to different vascular territories (left main, left anterior descending,
circumflex, right coronary artery). The most common algorithms for quantification of coronary artery calcium are the traditional
Agatston score, volume scores, and total calcium mass.
643
Fig. 8. MDCT evaluation of myocardial function. A retrospectively ECG gated data set is reconstructed during end-diastole
(upper left image panel of user interface) and end-systole (upper right image panel of user interface). Shown are multiplanar
reformats along the short axis of the heart. A dedicated software algorithm is used to quantify myocardial thickening during
systole within different sections of the myocardium on a color-coded map (lower left image panel of user interface).
644
Fig. 9. Catheter angiography (A) and volume rendered reconstruction of a contrast enhanced 16-slice CT coronary angiography
(B) in a patient with a super-dominant right coronary artery (RCA). The RCA gives rise to two major branches, which cross over
to the left anterior surface of the heart, connecting the RCA with the left anterior descending territory.
645
Fig. 12. Prototype software based on the clinical tool in Fig. 5. An automated centerline is created along the vessel lumen. The
lumenal profile is automatically analyzed and a stenosis caused by a partially calcified atheromatous lesion is detected by
the algorithm.
646
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[1] AHA. 2002 heart and stroke statistical update. Dallas
(TX): American Heart Association; 2001.
[2] Lipton MJ, Higgins CB, Boyd DP. Computed tomography of the heart: evaluation of anatomy and function.
J Am Coll Cardiol 1985;5:55S 69S.
[3] McCollough CH, Zink FE. Performance evaluation of
a multi-slice CT system. Med Phys 1999;26:2223 30.
[4] Klingenbeck-Regn K, Schaller S, Flohr T, et al. Subsecond multi-slice computed tomography: basics and
applications. Eur J Radiol 1999;31:110 24.
[5] Ohnesorge B, Flohr T, Becker C, et al. Cardiac imaging
by means of electrocardiographically gated multisection
spiral CT: initial experience. Radiology 2000;217:
564 71.
[6] Becker CR, Ohnesorge BM, Schoepf UJ, Reiser MF.
Current development of cardiac imaging with multidetector-row CT. Eur J Radiol 2000;36:97 103.
[7] Schoepf UJ, Becker CR, Obuchowski NA, et al. Multislice computed tomography as a screening tool for colon
cancer, lung cancer and coronary artery disease. Eur
Radiol 2001;11:1975 85.
[8] Flohr T, Bruder H, Stierstorfer K, et al. New technical
developments in multislice CT, part 2: sub-millimeter
16- slice scanning and increased gantry rotation speed
for cardiac imaging. Rofo Fortschr Geb Rontgenstr
Neuen Bildgeb Verfahr 2002;174:1022 7.
[9] Kopp AF, Kuttner A, Heuschmid M, et al. Multidetector-row CT cardiac imaging with 4 and 16 slices for
coronary CTA and imaging of atherosclerotic plaques.
Eur Radiol 2002;12(suppl 2):S17 24.
[10] Hu H, He HD, Foley WD, Fox SH. Four multidetectorrow helical CT: image quality and volume coverage
speed. Radiology 2000;215:55 62.
647
[11] Schoepf UJ, Becker CR, Bruening RD, et al. Electrocardiographically gated thin-section CT of the lung.
Radiology 1999;212:649 54.
[12] Becker CR, Jakobs TF, Aydemir S, et al. Helical and
single-slice conventional CT versus electron beam CT
for the quantification of coronary artery calcification.
AJR Am J Roentgenol 1999;174:543 7.
[13] Becker CR, Knez A, Jakobs TF, et al. Detection and
quantification of coronary artery calcification with electron-beam and conventional CT. Eur Radiol 1999;9:
620 4.
[14] Hong C, Becker CR, Schoepf UJ, et al. Coronary artery calcium: absolute quantification in nonenhanced
and contrast-enhanced multi-detector row CT studies.
Radiology 2002;223:474 80.
[15] Fleischmann D, Rubin GD, Bankier AA, Hittmair K.
Improved uniformity of aortic enhancement with customized contrast medium injection protocols at CT
angiography. Radiology 2000;214:363 71.
[16] Bae KT, Tran HQ, Heiken JP. Multiphasic injection
method for uniform prolonged vascular enhancement
at CT angiography: pharmacokinetic analysis and
experimental porcine model. Radiology 2000;216:
872 80.
[17] Hittmair K, Fleischmann D. Accuracy of predicting and
controlling time-dependent aortic enhancement from a
test bolus injection. J Comput Assist Tomogr 2001;25:
287 94.
[18] Napel S, Marks MP, Rubin GD, et al. CT angiography
with spiral CT and maximum intensity projection.
Radiology 1992;185:607 10.
[19] Wexler L, Brundage B, Crouse J, et al. Coronary artery
calcification: pathophysiology, epidemiology, imaging
methods, and clinical implications. A statement for
health professionals from the American Heart Association. Writing Group. Circulation 1996;94:1175 92.
[20] Shemesh J, Tenenbaum A, Fisman EZ, et al. Absence
of coronary calcification on double-helical CT scans:
predictor of angiographically normal coronary arteries
in elderly women? Radiology 1996;199:665 8.
[21] Laudon DA, Vukov LF, Breen JF, et al. Use of electron-beam computed tomography in the evaluation of
chest pain patients in the emergency department. Ann
Emerg Med 1999;33:15 21.
[22] Georgiou D, Budoff MJ, Kaufer E, et al. Screening
patients with chest pain in the emergency department
using electron beam tomography: a follow-up study.
J Am Coll Cardiol 2001;38:105 10.
[23] Agatston AS, Janowitz WR, Hildner FJ, et al. Quantification of coronary artery calcium using ultrafast
computed tomography. J Am Coll Cardiol 1990;15:
827 32.
[24] Detrano R, Hsiai T, Wang S, et al. Prognostic value of
coronary calcification and angiographic stenoses in patients undergoing coronary angiography [see comments]. J Am Coll Cardiol 1996;27:285 90.
[25] Schmermund A, Bailey KR, Rumberger JA, et al. An
algorithm for noninvasive identification of angiographic
three-vessel and/or left main coronary artery disease in
648
[26]
[27]
[28]
[29]
[30]
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[32]
[33]
[34]
[35]
[36]
[37]
[38]
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649
Advanced Cardiovascular Imaging, 62 East 88th Street, Lower Level, New York, NY 10128, USA
b
Cardiovascular Research Foundation, 55 East 59th Street, New York, 10022, NY, USA
c
Radiology Associates Imaging, Halifax Medical Center, 303 North Clyde Morris Boulevard,
Daytona Beach, FL 32114-2002, USA
d
Department of Radiology, Lenox Hill Hospital, 100 East 77th Street, New York, NY 10021, USA
Functional evaluation
Cardiac size and function provide important prognostic information in ischemic heart disease and a
variety of acute and chronic cardiac diseases [1 3].
In clinical practice, ventricular volumes and global
function are usually subjectively assessed using two-
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.03.007
652
Fig. 1. Large, unrestricted field-of-view. Oblique coronal view prescribed parallel to the aorta (along the white line as shown
in the inset). This view is in an imaging plane not attainable by echocardiography. The heart, with a jet of aortic insufficiency,
is clearly visualized as are abdominal viscera and both lung fields. In this case, there is a lung mass in the right lower lobe
fast spoiled gradient echo [15,16]. Because of reliance on flow-related enhancement for contrast, these
older sequences are more susceptible to signal loss
caused by in-plane saturation and turbulent flow
[13,16,17]. Both segmented fast spoiled gradient
echo and SSFP techniques provide qualitative assessment of myocardial motion with adequate (eg, < 80
millisecond) temporal resolution. SSFP images may
also be acquired in real time to provide reproducible,
accurate evaluation of ventricular function and mass,
without the need for normal sinus rhythm, breathholding, or cardiac gating [18].
Left ventricular function can be assessed qualitatively and quantitatively. Qualitative assessment
involves a subjective evaluation of function both
globally and regionally. Abnormal segments are characterized as hypokinetic (less than 40% systolic
thickening); akinetic (less than 10% systolic thickening); dyskinetic (paradoxical systolic motion with
thinning); or aneurysmal.
Several MR imaging methods are available quantitatively to assess myocardial motion. Normal LV
myocardium demonstrates systolic wall thickening
and radial shortening, with measures of regional
653
Fig. 2. Standard segmental nomenclature. Series of short axis diagrams indicating how the left ventricle can be divided into
17 segments. The heart is divided into three sections of equal longitudinal length: base, mid-ventricle, and apex. The base and
midventricle are each divided into six equal segments, the apex into four. The tip of the apex is designated as segment 17. This
17-segment model is generally accepted by many professional cardiac imaging societies.
myocardial function including systolic wall thickening, wall motion, and myocardial strain. Tagging
methods apply a parallel grid, two-dimensional array,
or radial pattern of radiofrequency saturation bands
to the myocardium before excitation and readout
Table 1
Sample size: MRI versus transthoracic echocardiography
Standard deviation percent
Ejection fraction
End-systolic
volume
End-diastolic
volume
Myocardial mass
CMR
normal
CMR
abnormal
Echocardiography
2.4
4.7
2.5
6.5
6.6
15.8
3.5
7.4
23.8
6.4
6.4
36.4
654
Fig. 3. CMR steady-state free precession images. (A) Four-chamber, (B) three-chamber, (C) short-axis views, and (D) oblique
coronal. All show excellent contrast between the blood pool and myocardium.
Fig. 4. Autoregulation, a schematic. (A) Rest: arteriolar segments distal to a stenotic parent vessel dilate by autoregulatory mechanisms to maintaining distal flow. The normal
arteriolar segment retains contractile reserve and has the
capacity to dilate in response to increased oxygen demand or
pharmacologic vasodilation. (B) Stress: the normal vessel
dilates allowing increased coronary flow. Without perfusion
reserve the vessel distal to a stenotic lesion remains the same
size resulting in relatively delayed and diminished coronary
flow into that territory.
sion reserve [49]. At rest, the process of autoregulation may result in equal perfusion of myocardial
segments supplied by a stenotic coronary artery and
segments supplied by a normal coronary artery. In
these regions of myocardium distal to a stenotic lesion
there is diminished capacity to increase blood flow in
the face of increased oxygen demand or generalized
coronary arteriolar dilation and consequent loss of
myocardial perfusion reserve. A segment distal to a
stenosis may then become hypoperfused relative to
the normal segment during periods of increased coronary blood flow [50,51]. This is the basis for stress
perfusion testing. Stress may be induced by increasing
demand by exercise or pharmacologically using inotropes, such as dobutamine. Pharmacologic vasodilators, such as adenosine or dipyridamole, increase
resting coronary flow four to eight times in regions
of normal perfusion [52,53]. These vasodilators do not
induce ischemia by increasing myocardial oxygen
demand and are probably safer in an outpatient
setting. Also, particularly adenosine has a rapid onset and cessation of action allowing for quick and
safe testing.
Vasodilator stress perfusion
Regional myocardial blood flow may be assessed
by dynamic MR imaging during the first pass of an
extracellular gadolinium chelate contrast agent. It is
important to obtain complete coverage of the heart
with high temporal resolution adequately to track the
passage of contrast through the myocardium. Compared with nuclear perfusion studies, CMR has the
advantage of being able to evaluate perfusion across
the transmural extent of the myocardium, allowing
differentiation of the subepicardium and subendocar-
655
Fig. 5. Delayed and diminished perfusion. Ischemic myocardial segments exhibit delayed and diminished enhancement following bolus contrast administration relative to
normally perfused myocardial segments.
656
Fig. 6. Perfusion defect. Selected short axis views obtained during pharmacologic stress (top row) and during resting conditions
(bottom row). The apex of the heart is to the viewers left with successive images to the right more toward the base. These images
illustrate perfusion defects as evidenced by diminished enhancement in the subendocardial zone of the lateral wall and extending
into the anterior wall and inferior wall toward the base of the heart.
657
Stress function
The blood oxygen level dependent imaging technique exploits the paramagnetic properties of deoxyhemoglobin as an intrinsic contrast agent and does
not require exogenous contrast agents. In myocardial
segments supplied by a stenotic coronary artery, there
is maximal oxygen extraction from the capillary
bed as compared with normal myocardial segments
where there is submaximal oxygen extraction. The
fraction of paramagnetic deoxyhemoglobin in vessels
downstream of a stenosis is higher than in normal
658
tissue and can in principle be detected using a T2*weighted imaging sequence [82]. This blood oxygen
level dependent imaging technique is well established in animal [83,84] and human [85 88] cardiac
imaging. Wacker et al [89] measured the T2* at rest
and following dipyridamole stress. They showed
significant reductions of T2* in regions associated
with a stenotic epicardial artery (P < .01) with further
T2* reduction after vasodilator stress (P < .001). This
technique shows promise as a noninvasive measure
of myocardial perfusion without the requirement of
exogenous contrast.
Myocardial viability
Following ischemia, myocardium may be infarcted
or reversibly injured [90 92]. Reversible myocardial
dysfunction may be acute or chronic. Stunned
myocardium occurs following an acute ischemic
episode with early reperfusion. The muscle is dysfunctional but viable. Segmental dysfunction may
remain for up to 3 to 6 months after the ischemic
insult. Hibernating myocardium is viable but dysfunctional because of chronic ischemia [91]. Hibernating segments are likely to improve in function
following revascularization [93].
Hibernating, stunned, and infarcted myocardium
may all appear as regional wall motion abnormalities
of any degree. The ability to distinguish hibernating
or stunned myocardium from infarcted myocardium
is important as it may guide therapeutic intervention
and subsequent prognosis, as revascularization of
viable segments may improve regional and global
LV function [94 98] and subsequent long-term survival [2,99 103].
There are two methods used to assess myocardial
viability: contrast-enhanced MR imaging to recognize MDE and the identification of myocardial contractile reserve.
Delayed hyperenhancement
The second method of assessing myocardial viability is contrast-enhanced CMR and the evaluation
of MDE. Current MR imaging techniques for detecting myocardial viability rely on the extracellular
distribution of gadolinium chelates within the myocardium. Gadolinium distributes in the extracellular
space according to an open two-compartment pharmacokinetic model. In regions of increased extracellular space (eg, infarction), higher concentrations of
gadolinium accumulate with concomitant slower
clearance and higher signal on T1-weighted se-
quence. After acute myocardial insult, the extracellular volume in the infarcted region is increased about
fourfold [104,105]. With time, the extracellular volume begins to decrease but remains about double in
size compared with preinfarction because of chronic
inflammation and fibrosis [106]. In 2001 Simonetti et
al [107] showed an average of 485% increase in
signal intensity between infarcted and normal myocardium using a heavily T1-weighted inversion recovery sequence set to null normal myocardium. At
some delayed time following gadolinium administration (10 to 30 minutes), high spatial resolution images
are acquired during suspended respiration. Regions
with increased extracellular space (eg, infarction)
appear white, in contrast to the adjacent normal black
(nulled) myocardium. This pulse sequence, known as
MDE or delayed contrast-enhanced MR imaging,
has become the standard imaging sequence for the
assessment of myocardial infarction. This delayed
enhancement occurs in acute and chronic infarction,
which precludes the assessment of infarct age by this
technique. In some acute infarcts, however, microvascular obstruction may occur. In these cases the
core of the infarct remains dark, distinguishing it
from chronic infarction. Any entity that causes myocardial scar and subsequent increased extracellular
volume also shows similar contrast (eg, sarcoid myocarditis [108 114], acute myocarditis [115,116], and
hypertrophic cardiomyopathy [117 120]). Future
improvements include three-dimensional MDE
sequences, which offer increased signal-to-noise ratio
(SNR) and allow for the acquisition of the entire LV
length in a single breathhold.
The high spatial resolution of the MDE sequence
allows exquisite definition of the extent of injured
myocardium (Fig. 7). Numerous studies have demonstrated the excellent correlation between size, shape,
and volume of the hyperenhancement zone as compared with histopathology [58,121 126]. Gerber et al
[127] concluded that absence of delayed hyperenhancement had a sensitivity of 82% and an accuracy
of 74% in predicting recovery of myocardial function. It has also been shown that, for acute infarction,
the transmural extent of infarction as demonstrated by
MDE predicts long-term improvement in contractile
function [126,128,129]. Kim et al [130] showed a
striking relationship between the transmural extent of
hyperenhancement using MDE and the likelihood of
improvement of contractile function after revascularization. Globally, an increasing extent of delayed
hyperenhancement correlated with decreased improvement in the mean wall-motion score (P < .001)
and ejection fraction after revascularization (P <
.001). Regional functional improvement was also
659
Fig. 7. Microvascular obstruction MDE and anomalous coronary artery. (A) Short axis and (B) two-chamber MDE images of a
patient with a recent infarct (arrows). There is a transmural infarct involving the anterior wall in the mid-ventricle. The central
dark region of the infarct represents an area where extracellular contrast cannot diffuse and is characteristic of microvascular
obstruction. (C, D) Images from the same patient show an anomalous coronary artery (arrows) with malignant course between
the aorta and the pulmonary artery. Cardiac catheterization showed a long anomalous left main with occlusion of the first
diagonal branch of his left anterior descending coronary artery.
predicted by the transmural extent of delayed hyperenhancement in each segment ( P < .001). This is
independent of time since the ischemic insult, the
presence of wall motion abnormalities, or the history
of revascularization [128].
Importantly, MDE can define the presence, location, and transmural extent non Q wave myocardial
infarction [131]. Diagnosis of myocardial infarction
can be missed clinically if not recognized during the
relatively short period of cardiac enzyme elevation.
These small, usually subendocardial, infarcts are often
not associated with regional wall motion abnormalities and may not be diagnosed with conventional tests
of functional assessment. This is important because
non Q wave infarction is a sensitive marker for future
ischemic events [132]. Non Q wave infarcts have a
higher incidence [133], and have a mortality rate that
is equal to [134,135] or greater than [136] Q wave
infarction. The MDE technique allows detection of
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Fig. 9. MDE thrombus. (A) Three-chamber and (B) short axis apical MDE images show a large transmural apical infarction with
thrombus adherent to the endocardial apical surface. The MDE technique is the most sensitive CMR technique for detecting
intracardiac thrombus.
662
Technical factors
A variety of techniques have been used for coronary MR angiography including two- and threedimensional segmented k-space gradient echo [174],
multishot echo planar imaging (EPI) [175], and spiral
k-space acquisitions. Most current efforts use threedimensional techniques, which offer the advantage
of higher SNR and spatial resolution and greater potential for postprocessing using volume rendering,
maximum intensity projection, or curved planar reformation [176,177]. The goal of all of these techniques is to make the artery lumen brighter and
simultaneously suppress the surrounding fat.
Spiral k-space acquisition is attractive because of
its efficient use or gradient power, allowing for
reduced scan times [178]. Furthermore, the spiral
k-space acquisition offers greater sampling density
at the center of k-space and is relatively insensitive to
motion-induced phase errors because first gradient
moments are inherently zero [179]. Cartesian k-space
acquisitions with asymmetric sampling also reduce
scan time and are less sensitive to off-resonance
phase errors [180]. These innovative sequences will
likely further improve acquisition time, SNR, and
CNR [176,181]. Projection reconstruction techniques
may also be used for coronary MR angiography
663
Fig. 10. Coronary arteries. Three-dimensional steady-state free-precession sequence obtained during a single breath-hold
demonstrates the proximal extent of the right coronary artery, the left main coronary artery, and the circumflex coronary artery.
664
Summary
Over the past two decades there has been significant progress in the field of MR imaging and its
application to the investigation of ischemic heart
disease. The concept of a single, rapid, noninvasive
examination that evaluates perfusion, morphology,
global and regional ventricular function, viability,
and coronary anatomy has been realized. Many
studies have now convincingly demonstrated the
superiority of MR imaging over other modalities for
a wide spectrum of cardiovascular disease. The
convenience of a single noninvasive test without the
limitations inherent in competing modalities ensures
CMR will become a routine diagnostic tool for
evaluating ischemic heart disease. It is expected that
MR imaging will assume a greater role in the evaluation of cardiovascular disease as the technology
becomes more clinically available, and referring
physicians and patients become more aware of and
comfortable with the modality.
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[2] White HD, Norris RM, Brown MA, Brandt PW,
Whitlock RM, Wild CJ. Left ventricular end-systolic
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Ragosta M. Improved outcome after coronary bypass
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survival of patients with coronary artery disease and
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997 1004.
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673
a
Department of Radiology, Emory University Hospital, 1364 Clifton Road Northeast, Atlanta, GA 30322, USA
Division of Cardiology, Department of Internal Medicine, Emory University Hospital, 1364 Clifton Road Northeast,
Atlanta, GA 30322, USA
Until recently, the population of adults with congenital heart disease has been small, with little impact
on the overall practice of radiology. The number of
patients remained stable over the years because the
birth rate of children with cardiac anomalies varies
little and, in the absence of effective means for
treatment, so does the annual death rate. This has
changed radically in the last five or so decades
because of advances in open heart surgery, anesthesiology, and cardiac imaging techniques. Most conditions that used to be almost automatically fatal in
the first years of life can now be corrected or successfully palliated so that, at present, in this country
about 85% of all infants with congenital heart disease
survive into adult life [1]. Using statistics from the
mid-1980s forward, it has been estimated that in the
year 2000 there were about 787,000 patients with
congenital heart disease of all degrees of severity in
the United States, treated and untreated, but excluding the numerous cases of isolated bicuspid aortic
valve [2]. This number increases by about 5% each
year and almost certainly exceeds 1 million as of
2004 and continues to enlarge.
Although correction of a lesion may re-establish a
relatively normal pattern of blood flow, more than
half of adult survivors are at significant risk for
developing complications either from their operative
procedures or from lingering effects of the original
lesion. Many of these complications can be managed
effectively or corrected if detected promptly. Patients
with congenital heart disease, regardless of their stage
of treatment, should be followed with periodic examinations. Because most of these examinations and
* Corresponding author.
E-mail address: mbaron@emory.edu (M.G. Baron).
those related to episodes of intercurrent disease include radiograph studies, it is likely that most radiologists at one time or another are involved with the
care of congenital cardiac patients.
0033-8389/04/$ see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.03.008
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Fig. 3. Transcatheter occlusion of atrial septal defect in a 42-year-old woman with a Cardioseal device (arrows). (A) Frontal view.
(B) Lateral view.
Fig. 4. PLAATO (arrows) device delivered by catheter into the left atrial appendage to prevent dissemination of possible future
thrombi. Patient has atrial fibrillation. (A) Frontal projection. (B) Lateral projection.
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Fig. 7. The aortic knob. (A) Normal aortic knob. The aortic knob is formed by the most distal portion of the aortic arch, as the
vessel curves downward to become the descending aorta. Its upper margin (arrow) is normally clearly silhouetted against the
adjacent air-containing lung. (B) In coarctation, the aortic knob is obscured by the left subclavian artery and the expected incisura
between the aortic knob and mediastinum is not visible.
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Fig. 9. Coarctation of the aorta. Aneurysm at site of repair. (A) Frontal view. The aneurysm (arrow) does not obliterate the
smoothened border of the mediastinum because it is situated posteriorly on the descending aorta. (B) Lateral view.
Tetralogy of Fallot
At an early stage in development, before the heart
divides into four separate chambers, the two ventricles have a single, common outflow tract, the
conus, which leads to a common outflow vessel,
the truncus arteriosus. As the embryo grows, the
conus is divided by a midline septum, which joins
the interventricular septum so that the right ventricle
communicates with the more anterior conal channel
and the left ventricle with the posterior one. At about
the same time, a septum forms in the midline of the
truncus and joins the conus septum. The right ventricular conus channel communicates with the anterior
truncal channel, which develops into the main pulmonary artery, and the left ventricular conus channel
becomes continuous with the posterior truncal compartment, the future systemic aorta [17].
If the conus septum develops anterior to the
midline of the conus the outflow tract of the right
ventricle is narrowed, appearing in the mature heart
as infundibular stenosis, often with stenosis or hypoplasia of the pulmonary valve. In the most severe
case, the pulmonic valve is atretic. Because the
conus septum is in the wrong position, its lower
end is misaligned with the interventricular septum
and the two do not meet, leaving a large ventricular
septal defect through which the two ventricles intercommunicate freely. The aortic root is usually enlarged, extending anteriorly to override the septal
defect so that it receives blood from both ventricles.
As a result of the right-to-left shunt, unoxygenated
blood is directly recirculated to the body and the
patient is cyanotic.
Almost all tetrads are detected early in life. Of the
few who slip into adulthood untouched, most have
minimal forms of the anomaly and slight, if any,
cyanosis (pink tetrads). These patients usually have
normal-appearing chest films, except for the common
association of a mirror image right aortic arch, a
finding common to all forms of tetralogy.
Before the advent of effective cardiopulmonary
bypass, the surgical approach to tetralogy was limited
to creation of a palliative, extracardiac, left-to-right
shunt, designed to bring more of the poorly saturated
systemic blood to the pulmonary circulation and so
improve overall oxygenation. The common anastomoses were (1) the Blalock-Taussig shunt, in which a
subclavian artery was transected and its proximal
portion connected end-to-side to a pulmonary artery;
(2) the Waterston shunt, a side-to-side anastomosis
between the ascending aorta and the right pulmonary
artery; and (3) the Potts shunt, a side-to-side connection between the descending aorta and the left main
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Fig. 12. Tetralogy with hypoplastic right ventricular outflow tract and pulmonic valvular stenosis. (A) Selective right
ventriculogram: systole. The entire infundibulum (In) is narrowed, as are the pulmonic valve annulus and main pulmonary artery.
Bowing of the pulmonic valve away from the ventricle indicates pulmonic valve stenosis (arrowheads). A transannular patch
was used when this patient was repaired. The left pulmonary artery (LPA) shows poststenotic dilatation and follows an abnormal
posterolateral course rather than going directly posterior as in the normal. The ascending aorta (Ao) is faintly opacified because
of the right-to-left shunt through the ventricular septal defect (not seen in this section). (B) Coronal section, spin echo image of
another patient, postcorrection of tetralogy with a transannular patch. The infundibulum (In) is wide open and the patch bulges
outward along the left side of the heart. RA, right atrium; RV, right ventricle.
684
Fig. 13. Status postrepair of tetralogy of Fallot. (A) An infundibular patch (arrow) bulges from the left border of the cardiac
silhouette in the same region as does a dilated left atrial appendage. This patient has a right aortic arch (A), however, which
should suggest the possibility of a tetralogy. (B) This patient required a transannular patch and the bulge is considerably more
extensive than in the previous case. The patch (arrow) extends almost to the roof of the main pulmonary artery, distinguishing
it from the more limited bulge of a dilated left atrial appendage. Ao, aortic knob.
Fig. 14. Tetralogy of Fallot. Because of the degree of hypoplasia of the pulmonary artery, a valved conduit extending from the
right ventricle to the pulmonary artery was inserted at age 6 and replaced once thereafter, about 22 years ago. (A) Frontal view.
The valve ring is too high for an aortic valve and is somewhat more medial than usual for a pulmonic valve. (B) Lateral view.
The valve lies far anterior in the heart as does a normal pulmonic valve.
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involve considerable suturing near the venous orifices, although problems frequently do not appear
until years after the surgery. Obstruction of pulmonary venous inflow is usually caused by development
of a stenotic ring within the left atrium, which affects
all pulmonary veins and results in the typical radiographic picture of congestive failure with pulmonary
venous distention and pulmonary edema. If only the
orifices of the right pulmonary veins, or less commonly the left veins, are compromised, the congestive
changes are limited to the involved lung.
Transposition of the great arteries, either untreated
or following an atrial switch, is usually obvious on
contrast-enhanced CT studies of the chest, even
without cardiac gating. If the aorta is positioned in
front of the pulmonary artery and the ventricles are in
normal position, the picture is diagnostic. This must
be distinguished from conditions in which the aorta is
so dilated that it extends further anteriorly than the
main pulmonary artery, as in some cases of tetralogy
of Fallot. In such instances, the aorta is mostly
alongside, and its posterior wall may still be behind,
the pulmonary artery. This is not a transposition.
With a well-functioning atrial switch procedure,
the abnormal circulatory pathway through the heart
and lungs may not be obvious on nongated scans
because both sides of the heart are usually opacified
when the images are obtained. When the superior
vena caval orifice is stenotic, however, the appearance is often specific. Because the obstruction occurs
at the cavoatrial junction, the higher pressure in the
proximal cava causes it to empty into the azygos
vein and reverse its flow (Fig. 17). Although some
flow into the azygos is not uncommon with normal
scans because of the pressure of injection or the
patient performing a Valsalvas maneuver, the retrograde flow is transitory, the azygos is of normal
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Fig. 17. Transposition of the great arteries post Mustard operation with superior caval stenosis. (A) Axial section just below the
azygous-caval junction. The azygous vein (Az) is densely opacified because of retrograde flow from the cava (S). A, ascending
aorta in the position usually occupied by the pulmonary artery; P, pulmonary artery, posterior to the aorta; D, descending aorta.
(B) Section at level of bronchial bifurcation. The aortic valve (AV) lies anterior and slightly to the left of the main pulmonary
artery (P). Note the size of the azygous vein (Az), which is almost as large as the descending aorta (D). L, left pulmonary artery;
R, right pulmonary artery; S, superior vena cava. (C) Section at level of pulmonary veins. The right inferior pulmonary vein (RL)
and the left inferior vein (LL) enter the right atrium (RA) and are directed by the baffle through the mitral valve into the left
ventricle (LV). (D) Level of the ventricles. The inferior vena caval flow (IVC) flows through the mitral valve into the left
ventricle (LV).
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Fig. 18. Anomalous origin of the right coronary artery from the left coronary sinus, 0.6-mm thick multislice CT sections. (A) The
right coronary artery is seen originating from the left coronary cusp, almost adjacent to the left coronary artery (not seen on this
section). It courses anteriorly between the right ventricular outflow tract (P) and the aorta (Ao). (B) A section, 1.2 mm more
caudad, shows the right coronary artery (arrow) turning downward into the atrial ventricular sulcus.
Summary
Because of the addition of the ever-increasing
number of adults with corrected congenital heart
disease, in addition to the relatively stable number
of patients reaching maturity without operation, it is
likely that many radiologists will be involved with
their care. Not uncommonly, no pertinent clinical
information is provided at the time, especially when
the patient is seen at an emergency room because of
intercurrent disease. The radiologist interpreting the
[17]
[18]
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