FIGURE 18-1. Atrial septal defect. A: Posteroanterior (PA) chest radiograph shows marked enlargement of the central and all segments of the pulmonary arteries. The cardiac silhouette is enlarged. B: Lateral view shows filling in of the retrosternal clear space, secondary to right ventricular enlargement, and pulmonary artery enlargement.
FIGURE 18-2. Atrial septal defect. A: PA chest radiograph of a 17-year-old boy with a heart murmur since birth shows enlargement of the cardiac silhouette, enlarged central and peripheral pulmonary arteries ("shunt vascularity"), a normal- to small-sized aorta, and "absent" superior vena cava shadow. B: Lateral view shows enlargement of the right ventricle, as evidenced by increased opacification posterior to the sternum.
FIGURE 18-3. Atrial septal defect with Eisenmenger physiology. PA (A) and lateral (B) chest radiographs of a 52-year-old woman with a large, long-standing ASD that has resulted in a reversal of shunting of blood and pulmonary arterial hypertension. There is aneurysmal enlargement and calcification of the central pulmonary arteries, enlargement of the right heart, and "absence" of the superior vena cava shadow. C: CT shows large main (M), right (R), and lower (L) lobe pulmonary arteries. Long-standing left-to-right shunting of blood has resulted in pulmonary artery aneurysms, which contain low-attenuation thrombus (arrowheads), and calcification (arrows). D: CT at a level inferior to (C) shows enlarged lower lobe pulmonary arteries containing thrombus (T) and calcification (C), enlarged right atrium (RA), and enlarged right ventricle (RV), causing leftward bowing and hypertrophy of the interventricular septum (arrows). The pulmonary artery lumina are outlined by high-attenuation contrast material (L).
FIGURE 18-4. Atrial septal defect occluder. A: PA chest radiograph of a 50-year-old woman with a history of transient ischemic attacks shows an Amplatzer Septal Occluder device (AGA Medical Corporation, Golden Valley, MN) (arrow) in the location of the foramen of ovale. B: Lateral view confirms appropriate placement of the device (arrow).
FIGURE 18-5. Right aortic arch. A: PA chest radiograph shows a right-sided aortic arch and descending aorta. The trachea is not deviated to the right, as is usually seen with a left aortic arch. B: Lateral view shows a posterior impression on the tracheal air column, secondary to compression from the aberrant left subclavian artery crossing from right to left.
FIGURE 18-6. Right aortic arch with aberrant left subclavian artery. A: Scout view from a CT of a 29-year-old man with dysphagia shows deviation of the trachea to the left (arrowheads) and a right-sided descending thoracic aorta (arrows). B: CT shows the right-sided aortic arch (A) and an aberrant left subclavian artery (SCA) arising from the posterior arch and coursing posterior to the trachea (T) and esophagus (E). Note the compression of the esophagus from the aberrant vessel, causing the patient's dysphagia. There is also a persistent left superior vena cava (arrow), in addition to a right superior vena cava (arrowhead). C: CT at a level inferior to (B) shows the persistent left superior vena cava (arrow) coursing in a left paramediastinal location before draining into the coronary sinus more inferiorly. The descending aorta is midline at this level.
FIGURE 18-7. Pseudocoarctation of the aorta. A: PA chest radiograph of a 50-year-old woman shows a left paratracheal "mass" (arrows). Sternotomy wires are present from previous coronary artery bypass graft surgery. B: CT shows the left subclavian artery (S), right (R) and left (L) brachiocephalic veins, and the high-riding, "buckled" aortic arch (A). C: Sagittal reconstruction shows the buckled aortic arch (arrows) and focal kinking of the aorta at the isthmus (arrowhead). This reconstruction shows how an axial view at the level of the aortic arch (dashed line) will show "two" rounded, contrast-enhanced structures adjacent to each other.
TABLE 18-1 RADIOGRAPHIC APPEARANCES OF CARDIAC VALVULAR DISEASE
FIGURE 18-8. Rheumatic mitral stenosis. PA (A) and lateral (B) chest radiographs of a 40-year-old woman show enlargement of the right ventricle (note increased opacity posterior to the sternum on the lateral view) and left atrium (note the convexity of the left heart border inferior to the left pulmonary artery shadow; arrows). The central pulmonary arteries are enlarged from pulmonary arterial hypertension, and there is pulmonary vascular redistribution. Unlike the aortic valve, the mitral valve may be severely stenotic and, as in this case, have no radiographically visible calcification.
FIGURE 18-9. Mitral stenosis. A: PA chest radiograph of a 43-year-old woman with atrial fibrillation and a history of rheumatic fever as a child shows abnormal convexity to the upper left heart border, indicating an enlarged left atrial appendage (arrow). B: Lateral view shows posterior displacement of the pulmonary venous confluence (arrows).
FIGURE 18-10. Mitral insufficiency. A: PA chest radiograph of an 84-year-old woman shows an enlarged cardiac silhouette and right upper lobe pulmonary opacity representing edema. B: CT shows an enlarged left atrium (LA) and bilateral pleural effusions. C: CT at a level inferior to (B) shows calcification of the mitral valve (arrow) and enlargement of the left ventricle (LV). D: CT with lung windowing shows ground-glass opacity limited to the right upper lobe. Right upper lobe edema in patients with mitral insufficiency is thought to be caused by the regurgitant jet of blood flow through the mitral valve to the right superior pulmonary vein.
FIGURE 18-11. Mitral annulus calcification. PA (A) and lateral (B) chest radiographs of an 87-year old woman show a C-shaped calcification in the expected location of the mitral annulus (arrows) and a dual-lead pacemaker. C: CT shows dense calcification of the mitral annulus (arrow).
FIGURE 18-12. Pulmonic stenosis. A: Anteroposterior chest radiograph of a 52-year-old man shows an abnormal opacity in the expected location of the main and left pulmonary arteries (arrow). B: CT shows marked enlargement of the main pulmonary artery (PA). C: CT at a level inferior to (B) shows marked enlargement of the left pulmonary artery (LPA) and a normal-size right pulmonary artery.
FIGURE 18-13. Multivalvular disease. PA (A) and lateral (B) chest radiographs of a 66-year-old woman with a history of rheumatic fever show mitral (solid arrows) and tricuspid (dashed arrows) valve prostheses.
FIGURE 18-14. Arrhythmogenic right ventricular dysplasia. MRI shows delayed hyperenhancement of the right ventricular free wall (arrows). (Image courtesy of David Bluemke, MD, PhD, Johns Hopkins Medical Institutions, Baltimore, MD.)
FIGURE 18-15. Lipomatous hypertrophy of the interatrial septum. CT of a 72-year-old woman shows fatty infiltration of the interatrial septum (F), which spares the fossa ovalis (arrow).
FIGURE 18-16. Left atrial myxoma. CT of a 63-year-old man shows a low-attenuation mass (arrow) in the anterior left atrium (LA), along the interatrial septum. Note the right atrium (RA), aortic outflow track (Ao), right ventricle (RV), and left ventricle (LV).
FIGURE 18-17. Pericardial metastases. A: PA chest radiograph of a 76-year-old woman with breast cancer shows an enlarged cardiac silhouette and numerous pleural-based masses. The left hemidiaphragm is elevated, and there is blunting of the left costophrenic angle. B: CT shows pericardial and left pleural effusions, as well as a soft tissue mass infiltrating the anterior pericardium (arrow). C: Coronal reformatted CT shows left pleural-based masses (arrows) and pericardial effusion (P). The more inferior mass involves the pericardium.
FIGURE 18-18. Carcinoma invading the heart. CT shows a large right lung mass compressing the superior vena cava (arrow) and left atrium (LA). The right superior and inferior pulmonary veins are obliterated.
FIGURE 18-19. Cardiac anatomy. A: Electrocardiography-gated multidetector CT shows a normal left main coronary artery (arrow) arising from the left coronary cusp. B: The left anterior descending coronary artery (arrow) arises from the left main coronary artery and courses anteriorly in the interventricular groove. C: Occasionally, as in this case, the left main coronary artery terminates in a trifurcation, giving rise to an intermediate coronary artery (ramus intermedius; solid arrow), left anterior descending coronary artery (coursing anteriorly), and left circumflex coronary artery (dashed arrow). D: The right coronary artery arises from the right coronary cusp (solid arrow). Note the left anterior descending coronary artery (dashed arrow) and circumflex coronary artery (curved arrow). E: The circumflex coronary artery gives rise to marginal branches (arrow). Note the left (L), right (R), and noncoronary (N) cusps. F: Papillary muscles (solid black arrow) are connected to the mitral valve leaflets via the chordae tendineae (dashed black arrows). Note the right coronary artery (curved white arrow). G: Anterior papillary muscles are seen in the left ventricle (arrow). H: The coronary sinus (arrow) drains into the right atrium (RA). I: The posterior descending coronary artery (arrow) arises from the right coronary artery in 85% of individuals and courses in the posterior interventricular sulcus.
FIGURE 18-20. Coronary artery stent. A: Lateral chest radiograph of a 46-year-old man shows a right coronary artery stent (arrows). B: CT shows calcification in the left main and left anterior descending arteries (arrow).
FIGURE 18-21. Anomalous origin of coronary artery. CT shows the right main coronary artery arising from the right coronary cusp (solid arrow). The left main coronary artery also arises from the right coronary cusp and courses posterior to the aorta (dashed arrows). This is considered a benign anomalous course. (Case courtesy of Cris A. Meyer, MD, and Rhonda Strunk, RT, R(CT), University of Cincinnati 3D Post Processing Lab, University of Cincinnati Medical Center, Cincinnati, OH.)
FIGURE 18-22. Anomalous origin of coronary artery. CT shows the right main coronary artery arising from the right coronary cusp (solid arrow). The left main coronary artery also arises from the right coronary cusp. The left anterior descending coronary artery courses anterior to the pulmonary artery, a benign course (dashed arrow). The circumflex coronary artery (angled arrow) courses posteriorly, between the aorta and pulmonary artery (PA). This anomaly can result in angina pectoris or myocardial infarction. (Case courtesy of Cris A. Meyer, MD, and Rhonda Strunk, RT, R(CT), University of Cincinnati 3D Post Processing Lab, University of Cincinnati Medical Center, Cincinnati, OH.)
FIGURE 18-23. Coronary artery calcification. A: CT of a 66-year-old man shows dense calcification in the left anterior descending coronary artery (arrow). B: CT at a level inferior to (B) shows dense calcification of the circumflex coronary artery (dashed arrow) and a stent in the right coronary artery (solid arrow).
FIGURE 18-24. Poststernotomy infection. A: CT of a 47-year-old woman who underwent coronary artery bypass grafting shows fluid in the presternal and retrosternal areas and an air–fluid level in the presternal area (arrow). B: CT at a level inferior to (A) shows abnormal air and fluid in the retrosternal area (arrow).
FIGURE 18-25. Poststernotomy infection. A: CT performed 13 days after coronary artery bypass grafting shows air in the presternal area (solid arrow) and fluid in the retrosternal area (dashed arrow). B: CT at a level inferior to (A) shows a focal fluid collection with an enhancing rim (arrow) encasing the right coronary artery.
FIGURE 18-26. Coronary artery bypass graft aneurysm. A: PA chest radiograph of a 70-year-old woman with a history of coronary artery bypass grafting shows an abnormal left mediastinal contour (arrow). B: CT shows a round mass with peripheral calcification (arrows) at a graft site. C: MRI shows the graft aneurysm (arrows) adjacent to the main pulmonary artery (P). Note the ascending aorta (A), superior vena cava (SVC), and descending aorta (D).
FIGURE 18-27. Left ventricular aneurysm. A: Lateral CT scout image of a 78-year-old man with ischemic cardiomyopathy and previous anteroseptal and apical septal myocardial infarction shows a curvilinear area of calcification overlying the heart (arrow). B: CT shows a focal outpouching of the left ventricular apex with a densely calcified rim (arrow). Note the relatively wide aneurysmal neck, which is typical of true aneurysms and distinguishes this from a pseudoaneurysm.
FIGURE 18-28. Right paratracheal pericardial recess. A: CT shows a mass of fluid attenuation in the right paratracheal area (arrow). This fluid collection should not be mistaken for paratracheal lymphadenopathy. B: CT at a level inferior to (A) shows pericardial recess fluid (R) posterior to the ascending aorta.
FIGURE 18-29. Right pulmonary vein pericardial recess. CT shows a focal fluid collection (arrow) adjacent to the right inferior pulmonary vein. This should not be mistaken for lymphadenopathy or other masses.
FIGURE 18-30. Acute infectious pericarditis. A: PA chest radiograph of a 26-year-old man with a neck abscess shows an enlarged cardiac silhouette. B: CT shows high-density pericardial fluid and thickening and enhancement of the pericardium (arrows). C: CT at a level inferior to (B) shows a focal pericardial fluid collection (solid arrow) compressing the superior vena cava (dashed arrow) and left atrium. The patient had clinical symptoms of pericardial tamponade.
TABLE 18-2 COMMON CAUSES OF PERICARDIAL EFFUSION
FIGURE 18-31. Constrictive pericarditis. PA (A) and lateral (B) chest radiographs show curvilinear calcification conforming to the anatomy of the pericardial sac (arrows).
FIGURE 18-32. Uremic pericarditis. A: PA chest radiograph of a 33-year-old woman with acute chest pain and a history of human immunodeficiency virus infection–related nephropathy shows a "water bottle"–shaped heart. B: After drainage of exudative pericardial fluid, the chest radiograph shows air outlining the pericardial sac (arrows). C: CT shows pneumopericardium (solid arrow), including air in the pericardial recess (dashed arrow).
FIGURE 18-33. Purulent pericarditis. A: PA chest radiograph of a 61-year-old man with acute chest pain shows pneumopericardium (arrows). The air in the pericardial sac does not extend above the aortic arch. B: CT shows air confined to the pericardial sac (P). One hundred forty milliliters of gas and pus were drained via pericardiocentesis.