google ads
Cardiac: Cardiac Ct: Beyond the Coronary Arteries Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Cardiac ❯ Cardiac CT: Beyond the Coronary Arteries

-- OR --

  • ASD: Atrial Septal Defect
    - Left to right shunt
    - Enlarged right atrium and right ventricle
    - Location
    --- Ostium primum defect (15-20%)
    --- Ostium secundum defect (75%)
    --- Sinus venosus defect (5-10%)
  • ASD: CT Findings
    - Direct visualization of ASD
    - Enlarged right atrium and right ventricle
    - Enlarged pulmonary arteries
    - Often PAPVR (right upper pulmonary vein into SVC)
  • ASD: Clinical Presentation
    - Usually asymptomatic early
    - Typically becomes symptomatic with increased age and by age 40, 90% of patients are symptomatic
    - Pulmonary arterial hypertension
    - Most common congenital cardiac anomalies
  • “Atrial septal aneurysm is a congenital malformation of the septum primum layer of the interatrial septum but differences between interatrial pressure forces have also been reported as a cause of its development. The widespread availability of transthoracic and transoesophageal echocardiography has identified atrial septum aneurysm with increasing frequency. The frequency of the anomaly in the general adult population is low (2.2%).”
    Atrial septal aneurysm and stroke
    Mohd Razaq, Ravi Kumar Parihar, and Ghanshyam Saini
    Ann Pediatr Cardiol. 2012 Jan-Jun; 5(1): 98–99.
  • "It has been speculated that ASA is a direct source of thrombus formation. This is supported by anecdotal findings demonstrating thrombotic material within the aneurysmal sac in the patients at autopsy or cardiac surgery. The mechanism of stroke in patients with ASA remains poorly understood. Cerebral embolism might result from paradoxical embolism of venous thrombi across a right to left shunt, passage of a thrombus created on the left atrial side of the aneurysm with atrial fibrillation.”
    Atrial septal aneurysm and stroke
    Mohd Razaq, Ravi Kumar Parihar, and Ghanshyam Saini
    Ann Pediatr Cardiol. 2012 Jan-Jun; 5(1): 98–99.
  • “Several authors have suggested that ASA (isolated or in combination with other defects) may cause arterial embolism. This suggestion is based on clinical studies demonstrating a statistical association between ASA and previous ischemic cerebral and/or peripheral embolic events. In fact, the incidence of clinical events compatible with cardiogenic embolism appears to be remarkably high in patients with ASA, ranging from 20% to 52%.”
    Atrial Septal Aneurysm in Adult Patients
    A Multicenter Study Using Transthoracic and Transesophageal Echocardiography
    Andreas Mügge et al. 
    Circulation. 1995;91:2785–2792
  • “The IMA arises from the first portion of the subclavian artery and immediately passes downwards close to the pleura within the upper intercostal space. Further distal, it proceeds anteriorly to the transversus thoracic muscle to end in the sixth intercostal space by dividing into the superior epigastric and musculophrenic artery.”
    Idiopathic internal mammary artery aneurysm
    Jens Heyn et al.
    J Surg Case Rep. 2014 Dec; 2014(12): rju125
  • “Aneurysms of the internal mammary artery (IMAA) are uncommon clinical entities and usually occur in patients after sternotomy, placement of a central venous catheter or pacemaker leads. Less common, these aneurysms are associated with vasculitis (e.g. Kawasaki disease), connective tissue disorders (e.g. Marfan syndrome), chest wall infections or atherosclerosis. However, changes in the structure of the vascular wall at the cellular level such as cystic medial necrosis or hyperplasia lead to loss of elasticity and formation of aneurysms.”
    Idiopathic internal mammary artery aneurysm
    Jens Heyn et al.
    J Surg Case Rep. 2014 Dec; 2014(12): rju125
  • “The internal mammary arteries (IMAs) are commonly used as the conduit to bypass major coronary artery stenosis, and have shown greater long-term patency rates and improved survival as compared to saphenous vein grafts (SVGs). The benefit of IMAs over SVGs on mortality has been consistently observed irrespective of age, gender, degree of luminal stenosis in the left main coronary artery or preoperative left ventricular function with the survival differences widening over time . The main differences are related to the development of atherosclerosis which has rarely been observed in the IMA graft while it develops at a fairly rapid rate in the SVG.”
    Why is the mammary artery so special and what protects it from atherosclerosis?
    Fumiyuki Otsuka, Kazuyuki Yahagi, Kenichi Sakakura, Renu Virmani
    Ann Cardiothorac Surg 2013;2(4):519-526
  • “The IMA is an elastic artery which arises from the subclavian artery. In adults the diameter of the IMA varies from 1.9 to 2.6 mm, with a wall thickness of 180 to 430 microns. The intima consists of endothelium with some neointima, which is seen in up to 50% of cases and rarely (13%) is there a substantial neointima which is greater than the medial thickness. The media consists of discreet lamellae of collagen and smooth muscle cells (SMCs) that are located between the elastic layers and are aligned circumferentially. The number of elastic layers varies from 7 to 11, depending upon the thickness of the wall of the IMA. The adventitia has been shown to possess very few vasa vasorum.”
    Why is the mammary artery so special and what protects it from atherosclerosis?
    Fumiyuki Otsuka, Kazuyuki Yahagi, Kenichi Sakakura, Renu Virmani
    Ann Cardiothorac Surg 2013;2(4):519-526
  • ASD: Atrial Septal Defect
    - Left to right shunt
    - Enlarged right atrium and right ventricle
    - Location
    --- Ostium primum defect (15-20%)
    --- Ostium secundum defect (75%)
    --- Sinus venosus defect (5-10%)
  • ASD: CT Findings
    - Direct visualization of ASD
    - Enlarged right atrium and right ventricle
    - Enlarged pulmonary arteries
    - Often PAPVR (right upper pulmonary vein into SVC)
  • ASD: Clinical Presentation
    - Usually asymptomatic early
    - Typically becomes symptomatic with increased age and by age 40, 90% of patients are symptomatic
    - Pulmonary arterial hypertension
    - Most common congenital cardiac anomalies
  • “Atrial septal aneurysm is a congenital malformation of the septum primum layer of the interatrial septum but differences between interatrial pressure forces have also been reported as a cause of its development. The widespread availability of transthoracic and transoesophageal echocardiography has identified atrial septum aneurysm with increasing frequency. The frequency of the anomaly in the general adult population is low (2.2%).”
    Atrial septal aneurysm and stroke
    Mohd Razaq, Ravi Kumar Parihar, and Ghanshyam Saini
    Ann Pediatr Cardiol. 2012 Jan-Jun; 5(1): 98–99.
  • "It has been speculated that ASA is a direct source of thrombus formation. This is supported by anecdotal findings demonstrating thrombotic material within the aneurysmal sac in the patients at autopsy or cardiac surgery. The mechanism of stroke in patients with ASA remains poorly understood. Cerebral embolism might result from paradoxical embolism of venous thrombi across a right to left shunt, passage of a thrombus created on the left atrial side of the aneurysm with atrial fibrillation.”
    Atrial septal aneurysm and stroke
    Mohd Razaq, Ravi Kumar Parihar, and Ghanshyam Saini
    Ann Pediatr Cardiol. 2012 Jan-Jun; 5(1): 98–99.
  • “Several authors have suggested that ASA (isolated or in combination with other defects) may cause arterial embolism. This suggestion is based on clinical studies demonstrating a statistical association between ASA and previous ischemic cerebral and/or peripheral embolic events. In fact, the incidence of clinical events compatible with cardiogenic embolism appears to be remarkably high in patients with ASA, ranging from 20% to 52%.”
    Atrial Septal Aneurysm in Adult Patients
    A Multicenter Study Using Transthoracic and Transesophageal Echocardiography
    Andreas Mügge et al. 
    Circulation. 1995;91:2785–2792
  • “The IMA arises from the first portion of the subclavian artery and immediately passes downwards close to the pleura within the upper intercostal space. Further distal, it proceeds anteriorly to the transversus thoracic muscle to end in the sixth intercostal space by dividing into the superior epigastric and musculophrenic artery.”
    Idiopathic internal mammary artery aneurysm
    Jens Heyn et al.
    J Surg Case Rep. 2014 Dec; 2014(12): rju125
  • “Aneurysms of the internal mammary artery (IMAA) are uncommon clinical entities and usually occur in patients after sternotomy, placement of a central venous catheter or pacemaker leads. Less common, these aneurysms are associated with vasculitis (e.g. Kawasaki disease), connective tissue disorders (e.g. Marfan syndrome), chest wall infections or atherosclerosis. However, changes in the structure of the vascular wall at the cellular level such as cystic medial necrosis or hyperplasia lead to loss of elasticity and formation of aneurysms.”
    Idiopathic internal mammary artery aneurysm
    Jens Heyn et al.
    J Surg Case Rep. 2014 Dec; 2014(12): rju125
  • “The internal mammary arteries (IMAs) are commonly used as the conduit to bypass major coronary artery stenosis, and have shown greater long-term patency rates and improved survival as compared to saphenous vein grafts (SVGs). The benefit of IMAs over SVGs on mortality has been consistently observed irrespective of age, gender, degree of luminal stenosis in the left main coronary artery or preoperative left ventricular function with the survival differences widening over time . The main differences are related to the development of atherosclerosis which has rarely been observed in the IMA graft while it develops at a fairly rapid rate in the SVG.”
    Why is the mammary artery so special and what protects it from atherosclerosis?
    Fumiyuki Otsuka, Kazuyuki Yahagi, Kenichi Sakakura, Renu Virmani
    Ann Cardiothorac Surg 2013;2(4):519-526
  • “The IMA is an elastic artery which arises from the subclavian artery. In adults the diameter of the IMA varies from 1.9 to 2.6 mm, with a wall thickness of 180 to 430 microns. The intima consists of endothelium with some neointima, which is seen in up to 50% of cases and rarely (13%) is there a substantial neointima which is greater than the medial thickness. The media consists of discreet lamellae of collagen and smooth muscle cells (SMCs) that are located between the elastic layers and are aligned circumferentially. The number of elastic layers varies from 7 to 11, depending upon the thickness of the wall of the IMA. The adventitia has been shown to possess very few vasa vasorum.”
    Why is the mammary artery so special and what protects it from atherosclerosis?
    Fumiyuki Otsuka, Kazuyuki Yahagi, Kenichi Sakakura, Renu Virmani
    Ann Cardiothorac Surg 2013;2(4):519-526
  • “Coronary angiography is the current gold standard in providing anatomical information regarding the extent and severity of coronary artery disease. Access site practice has changed in a number of European and Asian countries from mainly being transfemoral (TFA) to transradial (TRA) in view of less access site related bleeding complications, mortality and shorter hospital stay associated with TRA. For instance, in the United Kingdom use of radial access has increased from 14% to 80% between 2005 and 2014 in patients undergoing percutaneous coronary intervention (PCI) and it is estimated that this practice change has saved an estimated 450 lives nationally.”
    Hand dysfunction after transradial artery catheterization for coronary procedures
    Muhammad Ayyaz Ul Haq et al.
    World J Cardiol. 2017 Jul 26; 9(7): 609–619.
  • “Nevertheless, despite of its clear advantages over TFA, TRA is not without limitations and is associated with longer operator learning curve, increased radiation exposure in individual operators at the start of their learning curves and higher case radial proportion to translate the better results of randomized trials into clinical practice. Moreover, vascular complications such as RAO and radial artery spasm are not uncommon and very recently concerns have been raised that patients undergoing TRA PCI may encounter hand dysfunction.”
    Hand dysfunction after transradial artery catheterization for coronary procedures
    Muhammad Ayyaz Ul Haq et al.
    World J Cardiol. 2017 Jul 26; 9(7): 609–619.
  • “In conclusion, hand dysfunction is an exceedingly rare complication post TRA. There is significant heterogeneity in the methodology and reporting of the studies investigating hand function after TRA. Patients may develop non-specific sensory symptoms or muscle weakness but majority of these symptoms resolve over time. Future studies should be focused around assessing such complications using robust methodology and more importantly reporting on the clinical relevance of hand function. Given the reductions in mortality, MACE and major bleeding complications associated with use of TRA in high risk groups undergoing PCI, TRA should remain the default access site for PCI in such high risk groups of patients at risk of bleeding complications, in line with international guidelines and consensus statements.”
    Hand dysfunction after transradial artery catheterization for coronary procedures
    Muhammad Ayyaz Ul Haq et al.
    World J Cardiol. 2017 Jul 26; 9(7): 609–619.
  • “ The risk of Radiation Induced Heart Disease (RIHD) is dependent upon the volume and region of heart that falls within the radiation field, the total RT dose, additional insults such as cardiotoxic chemotherapy or traditional cardiovascular risk factors, and time since exposure.”
    Radiation-Induced Heart Disease: An Under-Recognized Entity?
    Davis M, Witteles RM
    Curr Treat Options Cardio Med (2014) 16:317-331
  •  “Radiation Induced Heart Disease (RIHD) may manifest as pericardial disease, myocardial disease, valvular disease, conduction abnormalities, coronary artery disease, or cardiovascular death. Recent evidence suggests that RIHD may be more common than was previously believed.”
    Radiation-Induced Heart Disease: An Under-Recognized Entity?
    Davis M, Witteles RM
    Curr Treat Options Cardio Med (2014) 16:317-331
  • Atrial septal aneurysm
    - Bulging of the fossa ovalis 10-15 mm beyond the tissue of interatrial septum into left or right atrium
    - Associated with PFO in the majority of cases
    - If filled with unopacified blood, can mimic an intracardiac mass
  • Membranous septal aneurysms
    - Bulging of the membranous portion of the interventricular septum below the aortic annulus into the right ventricle
    - Usually 10-15 mm in size
    - Associated with VSD in 20% of cases
    - In children, plays role in spontaneous VSD closure
    - Rarely can fill with clot or become infected
    - Must be distinguished from sinus of valsalva aneurysm (above annulus)
  • Caseous mitral annular
    calcification
    - Homogenous, high attenuation, lobulated mass centered on mitral annulus
    - Composed of calcium, cholesterol, cells
    - Benign but can distort valve by mass effect, erode and result in embolization
    - Do not mistake for coronary artery aneurysm
  • Lipomatous hypertrophy of
    interatrial septum
    - Fat density, spares fossa ovalis (dumbell shape)
    - May be referred from echo for a mass
    - Can be hot on PET (brown fat)
    - Benign, but may cause obstruction of IVC in rare cases
  • “In patients scheduled to undergo noncoronary cardiovascular surgery, coronary CT angiograms are of diagnostic image quality in 81% of cases.”
    Ruling Out Coronary Artery Disease with Noninvasive Coronary Multidetector CT Angiography before Noncoronary Cardiovascular Surgery
    Catalan P et al.
    Radiology 2011; 258:426-434
  • “ The presence of severe coronary artery calcification is the only independent predictor of nondiagnostic coronary CT angiography: an Agaston score of about 600 shows the best predictive accuracy for performing diagnostic coronary CT angiography.”
    Ruling Out Coronary Artery Disease with Noninvasive Coronary Multidetector CT Angiography before Noncoronary Cardiovascular Surgery
    Catalan P et al.
    Radiology 2011; 258:426-434
  • “ In nonselected patients scheduled to undergo noncoronary cardiovascular surgery, preoperative coronary CT angiography was diagnostic in 81% of cases. Preoperative ICA could be safely avoided in patients without significant CAD by using coronary CT angiography. The Agaston score, but not the presence of atrial fibrillation, was an independent predictor of nondiagnostic coronary VT angiography.”
    Ruling Out Coronary Artery Disease with Noninvasive Coronary Multidetector CT Angiography before Noncoronary Cardiovascular Surgery
    Catalan P et al.
    Radiology 2011; 258:426-434

     

  • "A small focus of discrete myocardial thinning along the apical/diaphragmatic surface of the left ventricle is a normal anatomic feature. The thinning is sometimes such that no wall can be seen there over a span of up to several millimeters."

    Left Ventricular Apical Thinning as Normal Anatomy
    Johnson KM et al.
    J Comput Assist Tomogr 2009;33: 334-337

     

  • "Myocardial density was visually classified as normal or hypodense and was verified by a ratio of infarct HU/normal HU of <.75 within a constant rgion of interest. Hypodense areas were classified as either subendocardial (,50% of the myocardial thickness) or transmural (>50% of the myocardial thickness)."

    Multislice coronary computed tomographic angiography in emergency department presentations of unsuspected acute myocardial infarction
    J Cardiovasc Comput Tomogr (2009) 3, 272-278
    Hecht HS, Bhatti T

     

  • "Areas of hypoenhancement represent territories of depressed blood flow, but they are nonspecific in their etiologies. Decreased perfusion may be secondary to a critical coronary artery stenosis or occlusion, microvascular obstruction , or myocardial scar."

    Evaluation of myocardial viability by multidetector CT
    Mendoza DD, Weigold WG
    J Cardiovasc Comput Tomogr (2009) 3, Supplement 1, S2-S12

  • "In addition to detailing coronary anatomy, cardiac chamber sizes, LV EF, and wall motion abnormalities, MDCT permits reliable myocardial viability assessment. Thus, MDCT, is a powerful, comprehensive noninvasive method for the evaluation of the heart."

    Evaluation of myocardial viability by multidetector CT
    Mendoza DD, Weigold WG
    J Cardiovasc Comput Tomogr (2009) 3, Supplement 1, S2-S12

     

  • "Of the atrial diverticula, 88% were superior and anterior, 9% were right lateral superior, and 3% were inferior. Of accessory appendages, 34% were inferior posterior, 32% were left inferior and 18% were superior anterior,14% were inferior posterior and 2% were right inferior posterior."

    Cardiac CT Assessment of Left Atrial Accessory Appendages and Diverticula
    Abbara S et al
    AJR 2009; 193:807-812

  • "Left atrial diverticula and accessory appendages are commonly found on cardiac gated CT."

    Cardiac CT Assessment of Left Atrial Accessory Appendages and Diverticula
    Abbara S et al
    AJR 2009; 193:807-812

  • "In conclusion, high resolution cardiac CT represents a unique tool to assess subtle anatomic cardiac variants. Our data show that left atrial accessory appendages and diverticula can be found in more than one fifth of subjects undergoing cardiac CTA and are more common in men."

    Cardiac CT Assessment of Left Atrial Accessory Appendages and Diverticula
    Abbara S et al
    AJR 2009; 193:807-812

  • Atrial Septal Defect: Facts
    - Most common congenital cardiac defect to present in adulthood
    - ASD provides left to right shunt
    - Three subtypes with ostium secundum most common (80-90% of ASDs)
  • Left Atrial Appendage Thrombi Protocol
    - Scan 1: trigger the injection 6 seconds after 100 HU is reached in ascending aorta
    - Scan 2: this scan is 30 seconds after first scan is completed
    - Injection protocol was 60-90 cc of Iopamidol-370 injected at 5 cc/sec
  • "Two phase cardiac CT angiography can be used to differentiate thrombus from circulatory stasis, which may cause a pseudo-filling defect on early phase CT images."

    Left Atrial Appendage Thrombi in Stroke Patients: Detection with Two-Phase Cardiac CT Angiography versus Transesophageal Echocardiography
    Hur J et al.
    Radiology 2009; 251:683-690

  • " Compared with transesophageal echocardiography (TEE), two phase cardiac CT angiography, with a sensitivvity of 100% and a specificty of 98%, is useful for detecting left atrial appendage thrombus."

    Left Atrial Appendage Thrombi in Stroke Patients: Detection with Two-Phase Cardiac CT Angiography versus Transesophageal Echocardiography
    Hur J et al.
    Radiology 2009; 251:683-690

  • "Two phase 64-section cardiac CT angiography is a noninvasive sensitive modality for detecting left atrial appendage thrombi and differentiating thrombus from circulatory stasis in stroke patients."

    Left Atrial Appendage Thrombi in Stroke Patients: Detection with Two-Phase Cardiac CT Angiography versus Transesophageal Echocardiography
    Hur J et al.
    Radiology 2009; 251:683-690

  • Cardiac Lymphoma: Facts

    "Patients with chronic thromboembolic pulmonary hypertension may be asymptomatic for several years before their presentation with symptoms such as recurrent acute or progressive exertional dyspnea, chronic nonproductive cough, atypical chest pain, tachycardia, syncope, and cor pulmonale."

    CT Diagnosis of Chronic Pulmonary Thromboembolism
    Castaner E et al.
    RadioGraphics 2009; 29:31-53

  • Cardiac Lymphoma: Facts
    - Usually related to extensive systemic involvement
    - Primary cardiac lymphoma is rare
    - Primary cardiac lymphoma more common in immunosuppresed patients and favors the right side of the heart
  • Cardiac Angiosarcoma: Facts
    - Most common primary malignant tumor of the heart
    - Arises most commonly in the right atrial free wall
    - Most other primary cardiac tumors arise from the left atrium
  • Cardiac Myxomas: Facts
    - Most common benign primary tumor of the heart
    - Arises from left atrium near interatrial septum
    - Most difficult dx in many cases is an cardiac thrombus
  • Atrial Myxoma vs Thrombus: Key Differential Dx Parameters
    - CT attenuation of mass
    - Size of mass
    - Left vs right atrium
    - Origin of mass
    - Lesion shape
    - Lesion mobility
    - Occurrence of prolapse
  • "Atrial myxoma and thrombi can be differentiated by their distinguishing features of size, origin, shape, mobility and prolapse. CT is accurate in determining the origin of myxomas but may fail in some cases."

    Atrial Myxomas and Thrombi: Comparison of Imaging Features on CT
    Scheffel H et al.
    AJR 2009; 192:639-645

  • Patent Ductus Arteriosus (PDA): Facts

    - Isolated Patent Ductus Arteriosus accounts for up to 10-12% of all congenital heart anomalies
    - Most incidentally discovered PDAs in adult are asymptomatic
    - Diagnosis on CT is based on defining a vessel connecting the main pulmonary artery and the aorta that is patent
  • Patent Ductus Arteriosus (PDA): CT Findings

    - Calcification at the site of the PDA is common
    - Communication best seen on MPR and 3D images
    - Flow may be from aorta to pulmonary artery or pulmonary artery to aorta
  • "MDCT represents a novel method of noninvasively assessing patent ductus arteriosus in adults that provides detailed anatomic information."

    Morphologic Assessment of Patent Ductus Arteriosus in Adults using Retrospectively ECG-Gated Multidetector CT
    Morgan-Hughes GJ et al.
    AJR 2003; 181:749-754

Privacy Policy

Copyright © 2024 The Johns Hopkins University, The Johns Hopkins Hospital, and The Johns Hopkins Health System Corporation. All rights reserved.