European Journal of Radiology 85 (2016) 435–451

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Review

Cardiac findings on non-gated chest computed tomography: A clinical

and pictorial review
Rene Epunza Kanza a,b,∗ , Christian Allard c , Michel Berube a
a
Department of Radiology, Chicoutimi Hospital, Saguenay, QC G7H5H6, Canada
b
Department of Radiology, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC J1H 5N4, Canada
c
Department of Pneumology, Chicoutimi Hospital, Saguenay, QC G7H5H6, Canada

a r t i c l e i n f o a b s t r a c t

Article history: The use of chest computed tomography (CT) as an imaging test for the evaluation of thoracic pathology
Received 26 August 2015 has significantly increased during the last four decades. Although cardiopulmonary diseases often overlap
Received in revised form in their clinical manifestation, radiologists tend to overlook the heart while interpreting routine chest
27 November 2015
CT. Recent advances in CT technology have led to significant reduction of heart motion artefacts and
Accepted 28 November 2015
now allow for the identification of several cardiac findings on chest CT even without electrocardiogram
(ECG) gating. These observations range from simple curiosity to both benign and malignant discoveries,
Keywords:
to life-threatening discoveries.
Cardiac findings
Computed tomography
We here present a clinical and radiologic review of common and less common cardiac findings dis-
Non-gated covered on non-gated chest CT in order to draw the attention of radiologists and referring physicians to
Chest these possibilities.
Overlooking © 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Recent advancements of CT technology have allowed for the

Non-gated chest computed tomography (CT) is one of the most
widely performed imaging tests for the initial assessment of pul-
monary disorders, with CT pulmonary angiography becoming the
first line of investigation for suspected pulmonary embolism. The
use of CT angiography to detect aortic dissection has also increased
and is still performed without electrocardiogram (ECG) gating in
several radiology departments. Cardiovascular and pulmonary dis-
eases often overlap in their clinical manifestation. Therefore, the
evaluation of both cardiac and pulmonary structures is very impor-
tant for the interpretation of routine chest CT, because occult
cardiac findings may alter the clinical course and the outcome for
patients with lung disease. On the other hand, putative pulmonary
disorders may be identified as cardiac disease, or the coexistence
of both cardiac and pulmonary diseases may be revealed. Nev-
ertheless, until recently, the heart was not the focus of interest
during the interpretation of routine non-cardiac chest CT, due to
poor image quality of the moving heart or due to the lack of back-
ground knowledge or interest in cardiovascular diseases among the
general radiologists community [1,2].
development of fast scanning CT machines that produce consid-
erably less cardiac motion artefacts due to their greater temporal
and spatial resolution [3–5]. ECG-gated techniques are usually
required to obtain this superior image quality free of motion arte-
facts, but the non-ECG-gated routine multiple detector CT (MDCT)
images obtained with the newer generation of CT scanners often
provide sufficient information to identify various incidental or non-
incidental cardiac abnormalities [6–8].
The purpose of the present pictorial review is:
1. To review the normal cardiac anatomy in non-gated chest CT and
to propose a stepwise approach to assess the heart for a system-
atic evaluation of the heart structures during the interpretation
of non-cardiac, non-gated chest CT; and
2. To describe common and less common cardiac abnormalities
encountered on routine (non-ECG gated) thoracic CT scans,
ranging from simple curiosity to benign, malignant, or even life-
threatening discoveries.

2. Normal cardiac anatomy on routine non-gated chest CT

∗ Corresponding author at: Department of Radiology, Chicoutimi Hospital affil-

iated with Sherbrooke University, 305 Rue Saint-Vallier, Saguenay, QC G7H 5H6,
Canada. Fax: +1 418 543 5104.
E-mail addresses: rn.kn.01@gmail.com, rene.kanza.epunza@usherbrooke.ca
(R.E. Kanza).
Radiologists and clinicians must first familiarize themselves
with the normal anatomy of the heart and pericardium (Fig. 1A–D)
as displayed on non-gated chest CT in order to avoid mistaking
them for abnormalities or diseases.

http://dx.doi.org/10.1016/j.ejrad.2015.11.042
0720-048X/© 2015 Elsevier Ireland Ltd. All rights reserved.
436 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451

Fig. 1. (A–D) Normal heart anatomy.

Axial non-gated contrast-enhanced chest CT obtained through the superior aspect (A and B), and the valvular/inferior levels (C and D) of the heart. RA—right atrium, LA—left
atrium, RV—right ventricle, LV—left ventricle. Note the mitral (short white arrow) and aortic (short white arrow) valve leaflets. IVS—interventricular septum, IAS—interatrial
septum. RAS—right aortic sinus of Valsalva, LAS—left aortic sinus of Valsalva, NCS—non-coronary sinus of Valsalva. LAA—left atrial appendage. RAA—right atrial appendage.
Note also pulmonary vein (PV) entering the LA (arrow). Normal pericardium seen as a single line (<2 mm thickness) surrounding the heart. PM—papillary muscles. CrT—crista
terminalis displayed as small filling defect in characteristic location within RA, should not be misinterpreted as thrombus. (MV—mitral valve, AV—aortic valve, TV—tricuspid
valve, normally more apical than MV). RCA—right coronary artery. LAD—left anterior descending.

In the majority of patients, the heart is ventromedially posi- resolution of the newer generation of CT machines. Radiologists
tioned in the chest, with a left and anterior orientation of the apex. and clinicians should be familiarized with CT findings of the peri-
Therefore, in general, on an axial chest CT, the right chambers cardium for early diagnosis, which may in fact provide the sole
(atrium and ventricle) form the right lateral and anterior borders explanation for the patient’s symptoms.
of the heart, whereas the left chambers (atrium and ventricle) form
the posterior and left lateral borders. The improved spatial reso-
3.1. Pericardial effusion
lution of the new generation of CT scanners often allows easier
detection of the normal pericardium, which should be less than
Pericardial effusion (Fig. 2A–C) is one of the most common
2 mm in thickness (Fig. 1D) [9]. Whenever contrast medium is
pericardial pathologies seen on non-gated CT. Common causes
used, structures like the coronary arteries, valves, papillary mus-
of pericardial effusion are heart failure, infection, renal failure
cles, interatrial and interventricular septa, as well as other heart
(uraemia), connectivitis disease, injuries such as trauma, radia-
structures that were not clearly identifiable on unenhanced CT
tion therapy, or myocardial infarction (Dressler syndrome) [9,10].
become visible and incidental findings may be easier to depict.
CT attenuation values (Hounsfield unit, HU), thickness, and the
In fact, a quick but systematic evaluation of the heart
enhancement may help to characterize the pericardial effusion and
including the pericardium is a part of our clinical experi-
to distinguish a simple from a more worrisome condition as fol-
ence with non-gated chest CT interpretation. We evaluate the
lows:
heart from the outside to the inside (pericardium → coronary
arteries → myocardium → chambers → valves), or vice versa if nec-
essary. These stepwise evaluations of the pericardium, the coronary 3.1.1. Simple pericardial effusion/transudate
artery (calcium, take off, course, termination), the myocardium Pure or near water density HU of <20, without or with regular
(assessment of thickness, perfusion defect, abnormal density, sep- slight enhancement, is likely a simple effusion (Fig. 2A).
tal position), the heart chambers (check for size and contour, look
for filling defect and the valves) allow us to detect several significant
3.1.2. Purulent/exudative pericardial effusion
findings at the time of routine chest CT interpretation.
An effusion with a higher CT density of 20–35 to 40 HU is likely
In some cases, it may be useful to obtain reformatted images in
to be exudative or purulent effusion. It often shows enhancement
the coronal, sagittal, or oblique plane.
and irregular thickening (Fig. 2B).

3. Pericardial abnormalities
Although CT is not the first modality to assess pericardial
abnormalities in a clinical setting (except for the identification of
pericardial calcifications), virtually all pericardial diseases are read-
ily identifiable on CT even without ECG gating given the improved
3.1.3. Hematoma/Haemorrhagic pericardial effusion
A denser pericardial effusion with CT attenuation values of
40–50 to 80 HU (Fig. 2C) likely represents a hematoma or haemor-
rhagic pericardial effusion. It is often seen following thoracic aortic
dissection, trauma, or malignancy.
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451
Fig. 2. (A–C) Pericardial effusions.
Axial chest CT of 3 different patients showing respectively simple effusion (A), exudative effusion in the setting of pericarditis (B), and haemorrhagic pericardial effusion (C).
Note near water density in (A) (black arrow), irregular thick and enhanced pericardium in (B) (white arrows), and hyperdense fluid in (C) (black star).
3.2. Pericarditis
Pericarditis refers to an inflammation of the pericardium in
response to a host of conditions. It may or may not be associated
with effusion. Common CT sign of pericarditis include effusion,
thickening >2 mm, and enhancement of the pericardial layers
(Fig. 2B). It may rarely show gas density suggestive of infective
causes, while the presence of calcifications often indicates chronic-
ity.
3.3. Calcifications/constrictive pericarditis
The detection of pericardial calcification on non-gated chest
CT is quite common, and CT is the best modality to demonstrate
these calcifications (Fig. 3). It often indicates previous inflamma-
tory or infective changes. In our clinical experience, pericardial
calcification is nowadays often seen in patients with a history
of asbestosis or radiation therapy, and more rarely tuberculosis.
Constrictive pericarditis is caused by the fibrosis and/or calcifi-
cation of the pericardium that inhibits the diastolic filling of the
heart. Although calcification is often associated with constrictive
pericarditis (20–40%), calcification by itself is not a diagnosis or
pathognomonic sign of constrictive pericarditis. Nonetheless, the
demonstration of a calcified or thick pericardium on a CT scan
in the appropriate clinical setting usually supports a diagnosis of
constrictive pericarditis. Other imaging findings associated with
constrictive pericarditis are dilatation of the inferior vena cava
(IVC), deformed or tubular shaped ventricles, angulation of the
interventricular septum, pericardial/pleural effusion, and ascites
[11]. All these findings may be readily identifiable on non-gated
chest CT.
3.4. Cardiac tamponade
Cardiac tamponade is a life-threatening condition in which clas-
sically tension pericardial effusion (either simple, or exudative, or
post-trauma hematoma) compresses the heart chambers to the
point of compromising the systemic venous return to the right
heart. Cardiac echography is often the first imaging modality in
the diagnosis of tamponade, and CT is only used when ultrasound
is not conclusive or an MRI is not readily available. CT findings of
tamponade include compression or deformity of the heart cham-
bers, shift of the septum, enlargement of IVC, and reflux of contrast
media from the right atrium to the IVC (Fig. 4) [12]. Non-gated chest
CT could be the first method to (incidentally) reveal these findings.
Recognition and early report of these CT findings by the radiologist
may warrant early intervention and eventually save the patient’s
life.
437
4. Coronary artery abnormalities
4.1. Coronary artery calcification/atherosclerosis
Coronary artery disease is one of the leading causes of mor-
bidity and mortality throughout the world. CT scanning, including
non-gated chest CT, presents an extremely sensitive method for
the detection of coronary artery calcification (Fig. 5A) [13]. It is
almost an exclusive sign or evidence of atherosclerosis, except for
the potential medial calcification in patients with renal failure.
Although coronary calcification is a common coronary abnormal-
ity seen on chest CT, one cannot infer the presence of significant
stenosis from the presence of calcium alone. Nevertheless, it is
still an important observation to report, because it is well docu-
mented that coronary calcification identifies an individual at risk
for acute cardiac events [8,14]. No clear guideline exists at present
for the necessity to report coronary calcium detected on a chest
CT, or to warrant further investigation with ECG-gated MDCT or
conventional invasive coronary angiography.
In our clinical experience, we tend to report these calcifications
matched with the age and sex of the patient. Further investigation
with non-invasive ECG-gated MDCT using the recently introduced
fractional flow reserve by computed tomography (FFR-CT) or
reverse gradient attenuation (RGA) technology may be suggested
in selected patients, such as young patients or female patients with
significant calcification, in order to detect haemodynamic stenosis.
4.2. Anomalous origin and course, aneurysm, and fistula
Although these observations are rarer, a wide degree of normal
variations with variable clinical significance or further acquired
changes may be detectable or suspected on non-gated chest CT.
These include congenital anomalies such as an anomalous origin
and course, which can be either benign (Fig. 6) or malignant. Any
malignant course (especially interarterial from RCA) should be noti-
fied and confirmed using ECG-gated MDCT or MRI, because it is a
potential cause of sudden death with an estimated risk of 25–40%
in patients with exercise activity [15].
Certain benign congenital abnormalities or variations may war-
rant surgical awareness. For instance, the responsible cardiologist
and surgeon should be notified of a possible single coronary artery
(Fig. 6), which must be confirmed prior to proceeding with any
unrelated surgery or procedure.
Furthermore, coronary fistulas and aneurysms (Fig. 7) can also
be detected during non-gated chest CT interpretation. Coronary fis-
tula is defined as an abnormal connection between the coronary
artery and cardiac or vascular chambers without normal transition
through the capillary bed of myocardium. It is usually a congenital
438 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451

Fig. 3. (A–C) Pericardial calcification/constrictive pericarditis.

Evolving constrictive pericarditis. Axial chest of the same patient (63-year-old male) showing pericardial calcification (white arrow) with slight pericardial thickening (A).
Two years later, the patient became symptomatic with dyspnoea and apparition of mild circumferential pericardial effusion (black arrow) (B) and mild to moderate bilateral
pleural effusion (white arrow). He developed constrictive pericarditis symptoms and underwent partial pericardectomy (white arrow) (C).

Fig. 4. (A–D) Cardiac tamponade.

Axial non-gated chest CT of two different patients with tamponade physiology. (A and B), a case of acute pericardtitis. Note the heart contour deformity (triangular shape), the
tubular shape of the left ventricle (white arrows), the pleural effusion, and the reflux of contrast medium into the IVC (black arrow). (C and D), a case of acute circumferential
pericardial effusion developed following coronary graft bypass surgery with tamponade signs that required surgical intervention. Note the tubular shape of the LV and the
bullet shape (white arrows) of the heart.

malformation but sometimes can develop as an iatrogenic fistula
after trauma or biopsy. Coronary artery aneurysm is defined as a
segment of the coronary artery that has a diameter that exceeds
the diameter of normal adjacent coronary segment by 1.5 times
and involves less than 50% of the total length of the vessel. It can
be congenital or caused by atherosclerosis, infection, or Kawasaki
disease. It is reported that coronary aneurysm occurred in 15–25%
of patients with untreated Kawasaki disease [16].
5. Myocardium/heart chamber abnormalities
Myocardial disease as well as chamber abnormalities may be
detected on routine non-gated chest CT, and sometimes the first is
associated with latter.
Common myocardial abnormalities observed in these cases may
be perfusion defects, calcification, fat density, or changes in thick-
ness.
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451 439

Fig. 5. (A–C) Coronary calcification.

Axial non-gated chest CT images of a patient without known cardiac history who was admitted for left pleural effusion de novo investigation and showed incidental
extensive calcifications (white short arrow) in the left coronary artery tree (A), posterolateral LV wall subendocardial hypodensity due to fatty metaplasia associated with
thin myocardium (white arrow) consistent with remote myocardial infarction (B). (C) Two-chambers view reformatted image was also obtained. The patient was diagnosed
with ischemic cardiomyopathy.

5.1. Old myocardial infarction 5.2. Severe myocardial ischemia/acute myocardial infarction

Evidence of remote myocardial infarction is quite commonly
detected on non-gated chest CT in patients with past history of
acute coronary syndrome. Rarely this is also observed in patients
without any known medical history of heart disease. CT findings in
these cases include an area of hypodensity or perfusion defects in a
given coronary artery territory. This area may show fat density due
to metaplasia (Fig. 5B–C) or calcifications (Fig. 8). The myocardium
often appears thinner, and the left ventricular may appear balloon-
ing in keeping with the aneurysm. Old myocardial infarction may
be associated with dysrhythmia and thrombus formation (Fig. 8).
Although it is difficult and rare to depict on non-gated CT, acute
myocardial infarction can be diagnosed as myocardial hypodensity
or a perfusion defect (Fig. 9) in a given coronary artery territory
in the appropriate clinical scenario. One of the major pitfalls to
consider here is a beam-hardening artefact, which can mimic a per-
fusion defect. The imaging finding will usually be matched with
an ECG and with laboratory results showing significant troponin
elevation.
Although some studies demonstrated the usefulness of routine
chest CT for the detection of a myocardial perfusion defect [7],

Fig. 6. (A–D) Single coronary artery.

(A–C) Axial non-gated chest CT angiography images showing a single coronary artery arising from the right coronary sinus (black arrow) with aberrant course of the left
coronary artery anterior to the pulmonary artery trunk (white arrow). (D) Invasive coronary angiography (CAG) image showing a single coronary artery arising from the right
coronary sinus, concordant with the non-ECG-gated CTA findings.
440 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451

Fig. 7. (A and B) Coronary aneurysm.

Axial non-gated single detector chest CT (A) of a 15-year-old girl with Kawasaki disease shows aneurysmal dilatation of the left coronary artery (black star). A corresponding
ECG-gated MDCT (B) obtained 4 years later demonstrates a partially thrombosed aneurysm.

Fig. 8. (A and B) Old myocardial infarction.

Non-gated axial CECT of the thorax shows incidental mural thrombus (black arrow) within a left ventricular apical slight aneurysm due to previous myocardial infarction.
Note the thin hypodense myocardial wall with dystrophic calcification (white arrow).

there are currently no clear guidelines regarding the protocol to in doubt, based on our clinical experience it is helpful to call or con-
be followed when a myocardial perfusion defect is suspected upon sult with the referring physician when these findings are detected
routine work up for chest pain using CT in clinical practice. When on the CT scan.

Fig. 9. Acute myocardial infarction.

Non-gated axial and coronal CT angiography in a patient with severe chest pain showing extensive Stanford A aortic dissection extending to the aortic valve, showing
inferoseptal transmural hypodensity suggestive of acute myocardial infarction. ECG on admission (not shown here) shows signs of inferoseptal AMI.
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451
Fig. 10. Hypertrophic cardiomyopathy (HCM).
Axial pulmonary CTA images show evidence of apical myocardial thickening with the sparing of the basal myocardium resulting in the classic spade-like configuration of the
left ventricle (arrow). The patient was confirmed to have the apical variant of hypertrophic cardiomyopathy with a small apical LV pseudoaneurysm.
5.3. Aneurysm and pseudoaneurysm of the myocardium
Myocardial aneurysms and pseudoaneurysms may develop
as complications of myocardial infarction, or sometimes follow-
ing certain surgical procedures or trauma. True left ventricular
aneurysm (Fig. 8), which is defined as a myocardial area of thin-
ning and bulging on non-gated chest CT, is quite common in old
myocardial infarction. Pseudoaneurysms are rare but hold a higher
risk of rupture, because there is a discontinuity of the myocardial
wall that is contained by the pericardium. It is reported to occur
between 5 and 10 days post infarction [17]. Both true aneurysms
and pseudoaneurysms may be associated with thrombus. Pseudoa-
neurysms often show a narrower neck on the CT compared with
a true aneurysm. Although it is critical to differentiate between
true and false aneurysms due the difference in the management
required for both, with the latter usually requiring prompt sur-
gical repair, this differentiation may sometimes prove difficult or
impossible even using ECG-gated cardiac CT or MRI.
5.4. Thick myocardium and hypertrophic cardiomyopathy (HCM)
Although precise quantitative myocardial thickening is difficult
to identify on non-gated chest CT, a qualitative visual assessment
is often possible. A thick myocardium may be seen in response to
some pathological conditions such as hypertension, valvular dis-
eases, infiltrating diseases like amyloidosis, sarcoidosis, or Fabry
disease, or physiological conditions as seen in athlete’s heart. HCM
is defined as idiopathic myocardial hypertrophy (Fig. 10) without
a primary cause. It is a genetic disease affecting the sarcomere and
the associated myofilaments.
Further evaluation by ultrasound, ECG-gated cardiac CT, or MRI
may be required.
5.5. Heart chamber dilatation/dilated cardiomyopathy (DCM)
Dilatation of the heart chambers is usually observed in heart
failure or in response to certain valvulopathies. Sometimes it may
be due to ischemic cardiomyopathy in which there is a dilatation
with thinning myocardium due to an old infarction.
DCM refers to a wide spectrum of dilated cardiomyopa-
thy, including idiopathic, toxic, infectious, familial, metabolic,
post-infiltrative, and connective tissue diseases, chemotherapy,
peripartum, myocarditis, and endocrinopathies, but excluding
ischemic, hypertensive, and valvular heart disease.
Heart chamber dilatation including DCM can be readily detected
on non-gated chest CT. Further investigation by echocardiography,
441
ECG-gated cardiac CT, and MRI may be required to allow for a better
characterization.
5.6. Pulmonary artery hypertension and right heart strain
Although a CT scan, by itself, does not offer a diagnosis for
right heart strain, it may sometimes strongly suggest this condi-
tion. Important CT features observed in this case include dilatation
of the right heart chambers compared to the left ones, flattening or
bowing of the interventricular septum, reflux of the intravenous
contrast medium into the inferior vena cava and hepatic veins,
and dilatation of the pulmonary artery trunk (Fig. 11). Pulmonary
artery trunk measuring more than 30 mm in diameter and, more
importantly, the pulmonary artery to aorta ratio of >1 are sug-
gestive of pulmonary hypertension in appropriate clinical settings
[18,19]. The radiologist should pay attention to these features and
propose cardiac ultrasound or MRI, which represent the most suit-
able modalities for functional evaluation. ECG-gated CT may also
be proposed for selected patients.
5.7. Dense myocardium
A gradient of density between the interventricular septum and
the blood in the adjacent heart chamber may be obvious on an
unenhanced CT as a sign for anaemia (Fig. 12). Although this feature
often reflects low haemoglobin levels, some patients with normal
haemoglobin levels but with glycogen and iron storage disease may
also show these findings.
6. Valvular diseases
Valvular heart disease is common and symptoms may be similar
to those of lung diseases that drive the use of the chest CT.
Although valvular heart disease assessment typically requires
cine imaging by ultrasound, ECG-gated MRI, or CT through the valve
of interest, non-gated chest CT may reveal some important direct
morphologic changes (calcification, thickening) or indirect phys-
iologic changes (chamber dilatation). Indeed, calcifications of the
heart valves can provide important information regarding under-
lying valvular heart disease, and unenhanced CT even without
ECG-gating is the best modality to demonstrate valvular heart cal-
cification.
6.1. Aortic valve calcification/disease
Aortic stenosis is a narrowing of the aortic outflow tract that
causes flow obstruction. The symptoms, including dyspnoea, chest
442 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451

Fig. 11. Pulmonary artery hypertension/strain.

Axial non-gated pulmonary CTA in a patient with PAH demonstrates marked enlargement of the pulmonary artery trunk (>30 mm). Note also the enlarged right heart
chambers, shift of the interventricular septum, and reflux of the contrast medium into the IVC.

help to characterize chronic aortic stenosis, or sometime may be the

first imaging modality to demonstrate evidence of aortic stenosis
by showing valvular calcification (Fig. 13). Other CT findings of aor-
tic stenosis include left ventricular hypertrophy and dilatation of
the ascending aorta.

6.2. Mitral valve calcification/disease

Mitral valve leaflet calcification (Fig. 14A) is characteristic of

Fig. 12. Hyperdense myocardium.
Axial non-gated unenhanced chest CT in a patient with leukaemia and anaemia
demonstrates a dense myocardium (black star). The myocardium shows higher
attenuation than the ventricular chamber.
rheumatic mitral valve stenosis [21]. It may be associated with pri-
mary calcification of the left atrial wall, which is almost always due
to rheumatic disease [22]. CT is very sensitive to demonstrate these
calcifications.
MV leaflet calcification should be differentiated from mitral
annular calcification (MAC) (Fig. 14C) that is normally located in
the posterior and outer ring of the valve and is due to degenera-
tive processes and usually associated with normal valve function.
It is nonetheless important to report MAC depicted incidentally,
because it represents a documented marker of coronary artery dis-
ease [23] and may be associated with an increased risk of stroke
[24].

6.3. Pulmonary and tricuspid valve abnormalities

pain, and syncope, are often similar to those of common lung dis-
eases. Although aortic valve calcification is not pathognomonic
of stenosis, almost all patients with aortic stenosis show various
degrees of valvular calcification, which is known to be positively
correlated with the degree of stenosis [20]. Non-gated chest CT may
Tricuspid and pulmonary valve leaflets may be difficult to assess
on cardiac ultrasound due to a poor acoustic window. Cardiac MRI
is the best modality to assess these valves. Nevertheless, thoracic CT
even without ECG-gating may prove useful in selected cases, as it

Fig. 13. Aortic valve calcification.

Axial non-gated chest CT shows extensive calcifications (arrow) of the aortic valve. The patient has been diagnosed with severe aortic stenosis.
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451 443

Fig. 14. (A–D) Mitral valve and annulus calcifications.

Axial non-gated chest in two different patients. Patient 1 (A and B) demonstrates heavy mitral valve calcifications (white arrow) that differ from mitral annulus calcifications
(black arrow) demonstrated in patient 2 (C and D).

Fig. 15. Pulmonary stenosis.

Axial non-gated pulmonary CTA in a patient with dyspnoea to rule out embolism shows thick pulmonary valve (black arrow) with enlargement of the pulmonary trunk
(>30 mm and greater than the aorta) and focal thickening of the RV wall (white arrow) suggestive of pulmonary stenosis. No embolism was found.

can show calcifications, leaflets, or right ventricular wall thickening
(Fig. 15).
7. Congenital heart diseases
Certain congenital heart diseases such as small atrial septal
defect (ASD) or patent ductus arteriosum (PDA) may be silent
and may not be discovered until the teenage years or adulthood.
They may be incidentally detected during non-gated thoracic CT
performed for a non-cardiac-related purpose. In our clinical expe-
rience, when a chest CT is performed to investigate symptoms such
as an unexplained dyspnoea or abnormal vascular shadow detected
during routine chest X-ray for instance,we systematically look for
those small congenital heart findings.
It is currently estimated that there are more adults than chil-
dren living with congenital heart disease in the United States [25].
This is likely due to advances in medicine that increase the life
expectancy in this population. Among all congenital heart diseases,
ASD accounts for about one-third of cases in adults [26]. There
are 3 main types of ASD: ostium primum defect (15–20%), ostium
444 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451

Fig. 16. Atrial septal defect.

Axial non-gated chest CTA demonstrates inferior sinus venous type of atrial septal defect (arrows). Note also cardiomegaly with enlarged right heart chambers.

Fig. 17. (A–D) Partial anomalous pulmonary vein return (PAPVR).

Axial non-gated CECT of the chest in a patient with lymphoma shows incidental PAPVR. There is an aberrant vessel receiving the drainage of left upper lobe and coursing
lateral to the aorta before finally entering into the left brachiocephalic vein (arrows).

secundum defect (75%), and sinus venosus defect (5–10%) (Fig. 16).
All these diagnoses may be readily visible on non-gated enhanced
chest CT; however, some findings should be evaluated with caution
especially in the case of the secundum ostium type that is located in
the fossa ovalis area where the septum may be too thin to delineate
the findings with sufficient confidence.
Partial anomalous pulmonary vein return (PAPVR) (Fig. 17) is a
congenital anomaly in which the pulmonary veins drain into the
systemic vein rather than the left atrium. Scimitar vein is a curved
anomalous venous trunk located in right medial costophrenic sul-
cus and draining into the inferior vena cava. Drainage of right-sided
PAPVR into the superior vena cava is often associated with sinus
venosus atrial septal defect. All these findings may be readily
detected on non-gated chest CT.
Other complex or rare congenital heart diseases including tetral-
ogy of Fallot, transposition of the great artery, Ebstein anomaly
(Fig. 18), or vascular abnormalities can also be readily identified on
non-gated chest CT. Further investigation using ultrasound, MRI, or
ECG-gated MDCT imaging may be necessary in selected cases.
8. Cardiac/pericardial tumours and tumour-like lesions
Cardiac masses are rare entities that can be broadly classified as
neoplastic or non-neoplastic. Neoplastic masses are classically sub-
divided into metastatic, primary malignant, and primary benign
tumours. Cardiac masses are traditionally most often discovered
as incidental findings in patients evaluated by echocardiography
for other indications. The advancement of medicine throughout
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451
Fig. 18. (A and B) Ebstein anomaly.
Axial non-gated pulmonary CTA (A) performed to rule out pulmonary embolism in a patient without a known history of cardiac disease shows severe cardiomegaly and
dilated right heart chambers with apical displacement of the tricuspid valve (arrows) with “atrialisation” of the right ventricle suggestive of Ebstein anomaly. A corresponding
four-chamber view echocardiography image (B) confirms CT findings consistent with Ebstein anomaly. TV: tricuspid valve; MV: mitral valve.
Fig. 19. Cardiac metastasis.
Axial non-gated CECT of a patient with operated metastatic lung cancer shows a
mediastinal mass extending through the pericardium and invading the right ven-
tricular outflow tract (arrow).
the last three decades has facilitated the detection of cardiac mass
using cross-sectional imaging modalities such as cardiac MRI and
thoracic CT even without ECG gating. CT for instance provides an
unrestricted imaging window and better soft tissue contrast res-
olution than echocardiography, while the latter remains the most
available and readily performed imaging modality.
Given the large number of patients actually undergoing chest CT
for various indications, detection of cardiac masses may increase in
the future if the radiologists and clinicians are well informed about
the potential that non-gated chest CT offers.
8.1. Neoplastic tumours
8.1.1. Metastases
The majority of cardiac and pericardial tumours are metastases
(Fig. 19). They occur 100–1000 times more often than primary
cardiac tumours [27]. They may reach the heart via lymphatic or
haematogenous spread, direct extension, or transvenous spread.
445
The most common site of metastatic disease is the pericardium, fol-
lowed by the epicardial fat, the myocardium, and finally the heart
cavity. Rarely the metastasis extends to the valve as in carcinoid
cancer that usually spreads to the pulmonary valve. The cardiac
tumours are often associated with pericardial effusion and the
multiplicity of heart masses is suggestive metastatic disease, with
metastases generally appearing late in the course of the primary
disease. Although rare in the absence of disseminated malignancy,
an isolated cardiac involvement is also possible.
8.1.2. Primary malignant tumours
Primary malignant cardiac tumours are rare. Angiosarcoma is
the most common primary malignant tumour in adults, and rhab-
domyosarcoma in children [28]. Other tumours include lymphoma,
osteosarcoma, fibrosarcoma, leiomyosarcoma, liposarcoma, myofi-
broblastic tumours, and pericardial malignant tumours such as
mesothelioma and synovial sarcoma. Although they can be read-
ily detectable on non-gated chest CT, they often present with
non-specific imaging findings. They usually appear as invasive
or infiltrative mass involving the cardiac wall and/or chambers
without any known primary malignancy. These tumours are also
associated with poor prognosis with a median survival time of 6–12
months.
8.1.3. Primary benign tumours
8.1.3.1. Myxoma. Myxoma is the most common primary cardiac
neoplasm [28]. Although it can occur in any cardiac chamber, this
typically intracavitary mass lesion is usually located in the left
atrium (75%, with 25% seen in the right atrium) and is attached
to the atrial septum. It appears on contrast-enhanced CT as a
low attenuation sometimes containing calcifications (about 50% of
right atrial myxomas calcify) (Fig. 20). It may show heterogeneous
enhancement. Other benign primary tumours include fibroblas-
tomas, lipomas, and fibromas.
8.2. Tumour-like lesions (=non neoplastic)
8.2.1. Thrombus
Intracavitary thrombus is the most common cardiac mass lesion
of all categories included. It typically appears on contrast-enhanced
CT as a low attenuation mass usually without enhancement (Fig. 8).
Its detection in the left chambers and differentiation from other
tumours is very important because of its potential to embolize.
Most of these thrombi are located in the left ventricle in the
446 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451

Fig. 20. (A and B) Cardiac myxoma.

Axial non-gated CECT (A) demonstrates incidentally a left atrial hypodense mass (arrow) with central calcifications. The mass was attached to the interatrial septum and was
identified as a myxoma after surgery. (B) shows the corresponding echocardiography image.

Fig. 21. Atrial thrombus.

Non-gated pulmonary CTA in a patient with dyspnoea and atrial fibrillation to rule out pulmonary embolism shows a large hypodense mass (white arrows) within the
enlarged right atrium and appendage associated with pericardial and pleural effusion (black arrow). The mass was at first diagnosis a possible malignancy. Cardiac MRI (not
shown here) performed in another institution identified this atrial mass as a large thrombus, and the patient clinically improved with heparin therapy.

setting of post infarction’ myocardial aneurysms (Fig. 8). Some-
times they can be located in the left or right atrium wall or in
some slow flow regions like atrial appendages, where they are
often observed in the setting of atrial fibrillation (Fig. 21). Chronic
thrombi may rarely show peripheral enhancement (due to fibrous
pseudocapsule) and/or may contain calcification and may be diffi-
cult to differentiate from myxoma, even using ECG-gated MDCT or
MRI. Nevertheless, characteristic changes during the cardiac cycle
or prolapse of the myxoma through the atrio-ventricular valve may
help to differentiate myxoma from the thrombus.
8.2.2. Lipomatous hypertrophy of the inter-atrial septum (LHIS)
LHIS is an excess of normal brown fat in the interatrial septum
that is characteristically sparing the fossa ovalis in contrast to the
interatrial lipoma. On the CT scan it shows fat density, and an MRI
with fat saturation may confirm the presence of the fat component.
It is known that LHIS may characteristically mimic malignancy
even in a PET scan [29]. Nonetheless, the typical dumbbell-
shaped appearance (Fig. 22) may help to differentiate LHIS from
malignancy in these complicated cases and allow for a confident
diagnosis of lipomatous hypertrophy.
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451
Fig. 22. Lipomatous hypertrophy of the interatrial septum.
Non-gated CECT of the thorax depicts excessive amount of fat in the interatrial septum sparing the fossa ovalis and showing a characteristic dumbbell-shape appearance
(arrows) consistent with lipomatous hypertrophy of the interatrial septum.
Fig. 23. Valvular vegetations.
Axial non-gated CECT in a patient with infective endocarditis showing a rounded
hypodense aortic valve mass (arrow) consistent with a vegetation.
8.2.3. Valvular vegetations
Valvular vegetations refer to the irregularly shaped or round
masses (Fig. 23) adherent to the endocardium or valves in the set-
ting of infective endocarditis. It appears on contrast CT as small
hypodense lesions measuring up to 1 cm. The valvular vegetations
normally involve a valvular free edge. Tricuspid valve is the most
common location of vegetation in patients who abuse intravenous
drugs. Although it can be detected on non-gated CT, vegetations
are best visualized on echocardiography, cardiac MRI, or ECG-gated
cardiac CT.
8.2.4. Pericardial cyst
Pericardial cysts are defined as benign fluid-containing con-
genital lesions that arise from the pericardium but do not
communicate with the pericardial space. On CT, they usually appear
as uniloculated water attenuation with well-circumscribed struc-
tures (Fig. 24) typically located in the right anterior cardiophrenic
angle. Although usually asymptomatic, in some rare instances,
patients may complain of chest pain or persistent cough.
8.2.5. Normal physiological findings mimicking cardiac mass
8.2.5.1. Crista terminalis. Crista terminalis is a vertically oriented
smooth muscular ridge within the right atrium (Figs. 1A and 25 ).
It may sometimes be prominent, and care should be taken not to
mistake it for a thrombus or a tumour.
447
Fig. 24. Pericardial cyst.
Axial non-gated pulmonary CTA of a 68-year-old male patient showing incidental
water density round mass (arrows) in the right paracardiac region abutting the right
heart border suggestive of a pericardial cyst.
8.2.5.2. Pseudofilling defect/mixing artefact. Pseudofilling defects or
mixing artefacts refer to an area of inhomogeneous hypodensity
(Fig. 25) seen in the right atrium or in some area of slow flow such
as atrial appendage due to mixing of contrast- and non-contrast-
enhanced blood. It should not be mistaken as a thrombus or a mass.
In doubt delayed enhanced CT may be obtained which will reveal
a more homogenous blood.
9. Post-operative cardiac findings
Patients with a history of heart surgery are increasing due to the
recent advances in medicine. Gross signs of prior cardiac surgery are
often obvious on non-gated chest CT given the presence of metallic
density or other artificial densities of synthetic material used to
make valves or bypass grafts. The presence of sternostomy wires
is often indicative of possible open-heart surgery in the past. Signs
of post-operative complications may sometimes be readily visible
on non-gated chest CT. With increasing knowledge of normal heart
anatomy and basic information on common cardiovascular devices
or/and surgery procedures, radiologists should be able to analyse
common post-operative findings on non-gated chest CT and depict
complications as early as possible during routine chest CT.
448 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451
Fig. 25. Pseudofilling defect/mixing artefact.
Axial non-gated CECT in an asymptomatic patient demonstrates an inhomogenous hypodense area (white arrows) in the right atrium due to mixing of contrast enhanced
blood and unenhanced blood consistent with pseudofilling defect or “mixing artefact”.
9.1. Cardiac pacemakers and implantable cardioverter
defibrillators
Permanent pacemakers and implantable cardioverter defibril-
lators are actually increasingly being employed for monitoring
and treatment of patients suffering from various cardiac arrhyth-
mias, which makes them actually a common incidental finding on
non-gated chest CT. Pacemakers are normally employed to reg-
ulate the cardiac rate, whereas ICD are indicated for monitoring
and therapy of patients who are at risk for sudden death from
ventricular fibrillation or tachycardia. Radiologists often overlook
these devices, maybe because they are not familiarized with the
radioanatomy, which is difficult to assess on non-gated CT because
of beam-hardening artefacts that can worsen when a chest CT is
performed with contrast medium, and complicate a correct assess-
ment of the tip position. In our clinical experience, this assessment
may be improved by using the bone window, and sometimes coro-
nal reconstructions may be necessary. Pacemakers and ICD are
composed of pulse generators (often inserted into the left subclav-
icular subcutaneous fat) and lead wires, and the key to distinguish
between pacemakers and ICD is the presence of two shock coils
in the ICD (Fig. 26A–F). There are many types depending on the
location and number of leads including single and dual chambers
(in the right atrium and ventricle) and biventricular types (leads
placed in the right atrium, right ventricle, and left ventricle via the
coronary sinus). Biventricular pacemakers are often used for car-
diac resynchronization therapy usually in the case of severe heart
left failure with left-sided intraventricular conduction delay. ICD
and pacemakers may also be used in combination. Chest X-ray is the
most commonly used imaging modality to visualize these devices.
Although relatively rare, those electronic devices may be associated
with some complications that are difficult to assess on plain chest
radiographs, but may become readily visible on chest CT even with-
out ECG gating. Sometimes they may be suspected on non-gated CT,
and may triggered ECG-gated cardiac CT for better characterization.
These complications include pneumothorax, haemothorax,
mediastinal or pericardial hematoma or due vein or myocardial
perforation, leads malposition or fracture, subcutaneous infection
and emphysema, or vein thrombosis [30].
9.2. Prosthetic heart valves
Patients with artificial valves are increasing. Theses valves may
be inserted using open surgery or transaortic valve implantation
(TAVI) techniques. There are two types of artificial valves: mechan-
ical (metallic) and bioprosthetic (tissue). The mechanical valves
have a longer lifespan compared to the bioprosthetic valves but
require anticoagulation. Although assessment is difficult due to
beam-hardening artefacts, the recognition of these valves and the
differentiation between mechanical and bioprosthetic valves is
often possible on non-gated chest CT. Two of the most commonly
used prosthetic valves are St. Jude Medical and the Carpentier-
Edwards valves (Fig. 27A–B). The St. Jude valve is a mechanical valve
with 2-half-moon shaped leaflets whereas the Carpentier-Edward
valve is made from bovine pericardial tissue. They have a distinct
appearance on the CT scan. St. Jude is a bileaflet valve closing and
opening according to the heart cycle, while the Carpentier-Edward
valve is recognised by its three metallic structs oriented in the shape
of a triangle in a cross-section view and its U shape in profile view
(Fig. 27A–B). There is actually an increasing use of expandable post
TAVI bioprosthetic valves such as the Edwards-SAPIEN prosthetic
valve (Fig. 27C).
Annuloplasty rings are often readily recognised on non-gated
chest CT by their characteristic location and lack of leaflets. They
may sometimes be difficult to distinguish from annular calcifica-
tions.
9.3. Pseudoaneurysm and abscess following valve replacement
Despite advances in prosthetic valve design and techniques,
complications after valve replacement remain a leading cause of
morbidity and mortality. Transthoracic or transesophagal echocar-
diography and fluoroscopy are usually used to detect valve
dysfunction, but these methods may not allow for the identification
of some specific underlying causes such as infective endocarditis
with pseudoaneurysm or abscess formation which could be nicely
assessed using ECG-gated cardiac CT. Nevertheless, these findings
may also be readily visible on non-gated chest CT performed for a
non-cardiac purpose (Fig. 28). The early recognition of these condi-
tions is important, as they may be associated with poor prognosis
if there is delay in diagnosis and treatment [31].
9.4. Coronary artery bypass graft
Although more detailed interpretation are usually required for-
mal ECG-gated cardiac CT, common coronary artery grafts are
often readily identified on non-gated chest CT (Fig. 29). Radiologist
should be aware of and become familiar with commonly used coro-
nary bypass types and techniques. The most common configuration
includes the use of the left internal mammary artery and saphenous
vein grafts (SVG) (Fig. 29) to bypass stenotic and atherosclerotic
portions of the native coronary vessels. SVG usually takes off from
the anterior aspect of the aorta to the distal aspect of LAD or obtuse
marginal.
Intramammary artery, especially on the left side, is increasingly
used for bypass grafting due to its several advantages over the
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451 449

Fig. 26. (A–F) Pacemaker and ICD.

Axial and coronal chest CT images with corresponding chest X-ray images in two different patients. Patient 1 has a dual-chamber pacemaker (A–C), patient 2 has a single
lead ICD (D–F). Note that the ICD is easily recognizable on plain X-ray by its thick shock coil (black arrow) and its big generator box (white arrow).

Fig. 27. (A–C) Prosthetic heart valves.

Axial non-gated chest CT images (bone and soft tissue windows) in 3 different patients with prosthetic aortic valves and their corresponding lateral chest X-ray. Patient 1
with mechanical aortic valve with the popular bileaftlet St-Jude Medical type (A). Patient 2 with the bioprosthetic Carpentier-Edwards which is recognised by its 3 metallic
structs or its U shape in the lateral view (B). Patient 3 with the expandable post TAVI stented Edwards-SAPIEN bioprosthetic valve (C). Recognition of the presence of these
prosthetic valves is important in order to depict possible complications.
450 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451

Fig. 28. Pseudoaneurysm following valve replacement surgery.

Axial non-gated chest CECT in a patient with dyspnoea and chest pain following mitral valve replacement surgery demonstrates an abnormal collection of blood pool density
material (black arrows) posterior to the left coronary sinus and anterior to prosthetic mitral valve consistent with the pseudoaneurysm of the mitral-aortic intervalvular
fibrosa. This patient was diagnosed with infective endocarditis.

Fig. 29. Coronary artery bypass graft.

Non-gated CECT demonstrates evidence of coronary bypass graft taking off from the anterior aspect of the ascending aorta (arrows) bypassing arteriosclerotic native left
descending artery and left circumflex artery. Recognition of this may help to depict early or late complications and triggered ECG-gated cardiac CT.

SVG, including decreased post-operative mortality and long-term
patency rates above 90% at 10 years [32]. Native atheroscle-
rotic coronary arteries are usually visible due to calcified plaques
(Fig. 29). The presence of continuous visible contrast within the
graft indicates patency but does not guarantee absence of stenosis.
Some early or late bypass graft complications may be detected on
chest CT and include rupture or leaks, pseudo or true aneurysm,
and atherosclerosis. ECG-gated CT and conventional angiography
remain the modalities of choice for further characterization.
structures during interpretation of the routine thoracic CT is impor-
tant and will help to compile a comprehensive report.
Radiologist should familiarize themselves with normal cardiac
anatomy as well as common and uncommon cardiac and pericar-
dial abnormalities seen during routine non-gated chest CT. Some
of these observations may be directly related to the patient’s
symptoms, and reporting them could critically change the clini-
cal decision and management, and trigger further investigation by
echocardiography, ECG-gated cardiac CT, or MRI.

10. Conclusion
Conflict of interest
Several pertinent cardiac findings are readily available on non-
cardiac chest CT. The systematic review of the heart and pericardial The authors declare that they have no competing interests.
 R.E. Kanza et al. / European Journal of Radiology 85 (2016) 435–451 451

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