Mulitmedia Library
Follow-up assessment of myocardial calcification secondary to fulminant myocarditis with computed tomography
A 16-year-old man underwent venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to hemodynamic collapse caused by viral fulminant myocarditis. Supplementary Figure 1 presents the time course of treatment. High-density areas wtihin the myocardium were initially detected by computed tomography (CT) 10 days after admission which was not observed on admission (Fig. 1A). The CT tissue attenuation value reached 106 Hounsfield Unit (HU) in these areas 40 days after admission (Fig. 1B), with changes in the left lateral wall being more evident than other areas.Multivessel coronary artery aneurysms as a complication of chronic active Epstein-Barr virus infection: An atypical and occasional complication
Coronary artery aneurysm (CAA) is defined as a coronary artery dilatation >1.5 times the diameter of the normal adjacent segments or the diameter of the patient's largest coronary vessel. It is an uncommon disease, present in 1–4% of coronary angiography findings.1IgG4-related disease: Coronary arteritis masquerading as coronary “masses”
A 64-year-old man with a history of psoriasis and latent tuberculosis presented to the emergency department with cough and dyspnea. Transthoracic echocardiogram (TTE) showed a large pericardial effusion with early echocardiographic signs of tamponade and a well circumscribed right atrioventricular groove mass extending into the pericardial space, moving with the cardiac cycle without independent mobility (Fig. 1). Pericardiocentesis drained 1 L of sanguinous fluid with a lymphocytic predominance and negative infectious and cytologic work-up.Budd-Chiari syndrome: A rare association of Scimitar syndrome
A 3-year-old asymptomatic girl was noted to have a heart murmur. Chest X-ray showed a curvilinear shadow along the right heart border (Fig. 1A) characteristic of the Scimitar sign. Echocardiography revealed a Scimitar vein (SV) draining the entire right lung to the inferior vena cava (IVC) which was stenosed at the junction with SV (Fig. 1B; arrow). CT angiography and hepatic venography revealed a 1.5 cm-long segment of stenosis in the IVC proximal to the insertion of the SV, resulting in outflow obstruction of short hepatic veins (HVs) with resultant intrahepatic veno-venous collaterals which coursed to the IVC above the level of stenosis (Fig. 2).Left ventricular assist device pseudo-thrombosis due to use of metal artifact reduction algorithm on cardiac CT
Projection-based metal artifact reduction (p-MAR) is a CT technique in which projection data corrupted by metallic artifact is replaced by ‘estimated’ corrected values. This technique has shown promise with its ability to improve image quality in patients with metallic hardware or implants. p-MAR is becoming increasingly popular, as it can be used after image acquisition and does not lead to increase in the radiation dose to the patient.1 While the advantage of p-MAR for metal artifact reduction is well established, it may induce artifact in high-attenuation cardiovascular structures with attenuation characteristics similar to metal.Multi-modality imaging and operative findings of a post-TAVR ventricular septal defect
Michael Morris: Consultant for Edwards Lifesciences. Educational training for Medtronic.Multiphase TAVR CT identifies unexpected sticky situation (Mechanical mitral valve leaflet dysfunction and bicuspid aortic valve)
60-year-old female with history of 33mm ATS mechanical mitral valve replacement 16 years ago for rheumatic mitral valve disease and permanent Atrial Fibrillation (AF) presented with one-year history of worsening exertional dyspnoea as well as symptom of pre-syncope. She was on warfarin for AF as well as mechanical mitral valve replacement (MVR) with therapeutic anticoagulation in the recent time. Her transthoracic echocardiogram was technically difficult as MVR leaflet motion and aortic valve morphology was not well visualised because of artefact from mechanical mitral valve (Panel 1 A: 4chamber still echo image showing reverberation artefact from mechanical mitral valve leaflets)) and aortic valve calcification.Coronary sinus to left atrium fistula on computed tomography angiography: Differentiation from unroofed coronary sinus with literature review
Atrial septal defectOcclusion of the left main coronary artery ostium by aortic valve cusp fusion in an adult
A 46-year-old female was admitted to hospital because of dyspnea and chest pain for 2 months with no apparent symptoms in the past years. She had no family history of sudden death or cardiac disorder. ECG showed a paroxysmal atrial fibrillation. Coronary CT was performed, revealing normal right coronary artery and pouch-like filling in the small left coronary aortic sinus that seemed to be covered by the thickened rudimentary left coronary cusp (Fig. A,B,C). Transcatheter coronary angiography showed occlusion of the left main coronary artery ostium and was supplied by a major collateral artery from right coronary artery (Fig.Utilization of coronary computed tomography angiogram in evaluation of left ventricular thrombus
Left Ventricular (LV) thrombus may occur due to global or regional LV dysfunction, especially after acute anterior myocardial infarction (MI). LV thrombus has a critical clinical significance as it may lead to thromboembolic complications. Imaging strategies utilized in detecting LV thrombus include Echocardiogram (Echo) and Cardiac Magnetic Resonance Imaging (CMR). We present the following case to illustrate the role of Coronary Computed Tomography Angiogram (CCTA) in the evaluation of LV thrombus and its clinical significance in demonstrating fine surface details of the thrombus compared to Echo and CMR.An unusual left anterior descending artery myocardial bridging
A 43 year-old man was admitted for transient (10 min) acute chest pain that was highly suggestive of angina and appeared after an unusual intense effort. He has no personal history and none of the traditional cardiovascular risk factors. Baseline electrocardiogram showed no repolarization abnormality. High-sensitivity cardiac troponin was undetectable (<4 ng/mL). Transthoracic echocardiography showed mild wall motion abnormalities (apical and septo-apical hypokinesia) and left ventricle ejection fraction was subnormal.Anomalous left coronary artery from right pulmonary artery (ALCARPA) with dual left anterior descending arteries- a hitherto unreported combination of coronary anomalies diagnosed on dual source CT
An 8 month old infant was admitted to the hospital with worsening food intolerance and tachypnea. ECG showed deep Q waves in V4-V6. Echocardiography revealed an abnormally dilated left ventricle (5.5cm) with ejection fraction of 20%. In addition, the left coronary sinus was not seen to give arise to any coronary artery and the origin of left main coronary artery (LCA) could not be delineated. CT Angiography (CTA), being a non invasive method of choice to diagnose anomalous coronary anatomy, was done on a 384-slice dual source scanner (Siemens SOMATOM Force).Truncus arteriosus communis associated with interrupted aortic arch – Type B and right aberrant subclavian artery: A rare entity
An eutrophic one-day-old-girl was examined by regional pediatric cardiologist due to mild hypoxemia and systolic murmur. As transthoracic echocardiography (TTE) detected a nonspecific form of truncus arteriosus communis (TAC), the admission to cardiac intensive care unit without Prostaglandin E1 infusion was recommended. Except for elevated renal function parameters, the patient presented with diminished pulses and prolonged capillary refill time in all four extremities on admission. On one hand, TTE confirmed TAC with a nonstenotic truncal valve, isolated origins of pulmonary artery branches and turbulent flow at its distal part streaming to descending aorta, but could not clearly depict the aortic arch and its branches on the other hand.Highly atypical double barrel outlet to aorta in double inlet left ventricle, double outlet right ventricle
A full-term female was born to a mother whose pregnancy was complicated by prenatal diagnosis of complex congenital heart disease. A postnatal echocardiogram showed double inlet left ventricle, hypoplastic anteriorly placed outflow chamber {right ventricle (RV)} and possible double outlet right ventricle. Retrospective ECG-gated computed tomography angiography (CTA) with dose modulation was obtained to delineate complex intracardiac anatomy (Siemens dual source “Drive” scanner; temporal resolution 75 ms, 80 Kv, 48 mAs, Dose length product 19 mGycm).Anomalous origin of the left circumflex artery from the right coronary sinus with retro-aortic course: A potential malign variant
A 46-year-old man with an unremarkable past medical history and no cardiovascular risk factors was referred to perform cardiac magnetic resonance (CMR) for recent suspected myocarditis. CMR showed normal left ventricular volumes and systolic function, hypokinesis at the level of basal to mid inferolateral wall, and transmural late gadolinium enhancement with ischemic pattern was evident in the left circumflex artery territory at the basal and mid inferolateral wall (Fig. 1). To rule out the presence of obstructive coronary artery disease (CAD), an ECG-gated coronary computed tomography angiogram (CCTA) was performed, showing an anomalous origin of the circumflex coronary artery from the right coronary sinus with a retro-aortic course (Fig.Subtle sings of contained cardiac rupture following myocardial infarction
A 59-year-old man was admitted with a 2-h history of stabbing chest pain and dizziness. On arrival he was in shock with an arterial blood pressure of 70/30 mmHg and he had electrocardiographic changes suggestive of lateral ST elevation myocardial infarction (STEMI). Emergency invasive coronary angiography showed stenoses of left anterior descending (75–94%), circumflex (50–74%) and right (50–74%) coronary arteries along with a complete occlusion of a small obtuse marginal branch. None of these were treated with primary intervention.A rare coronary anomaly -- type 4 dual left anterior descending artery accompanying anomalous origin of the left coronary artery from the right coronary sinus
Invasive coronary angiographyNon-ECG gated CT in a case of takotsubo cardiomyopathy
We report a 60-year-old woman with a past history of thoracic aortic aneurysm (TAA) surgery and abdominal aortic aneurysm (AAA) who was admitted to our hospital complaining of chest pain. On admission, emergency non-electrocardiogram (ECG) gated contrast enhanced computed tomography (CT) was performed to rule out aortic dissection. CT revealed no remarkable changes in TAA or AAA (not shown here). However, apical ballooning, thinning of the apical wall and thickening of the basal wall were observed, together with normal apical wall enhancement (Fig.“Cantrell’s pentalogy”- Angiographic CT evaluation
A 36 year old pregnant was send to us from a pacific coast hospital. By c-section a full term male newborn was delivered, with a total cardiac exposure through an anterior thoracic wall defect (Fig. 1). At the time of delivery no cyanosis was identified. A non-gated 128- slice tomography angiography (CTA) showed: Ectopia corids, levocardia with levoapex, concordant atrioventricular and ventriculoatrial connections, side-by-side aorta and pulmonary artery (PA). Hypoplastic aortic root and ascending aorta.Simple cough presentation of a rare variant of a meandering left pulmonary vein
A 17-year-old female presenting to respiratory clinic with 4 months history of mild cough. Her physical examination is unremarkable. A chest radiograph showed a left-sided peri-hilar high-density tubular structure, thought to be a vascular malformation (Fig. 1). A computed tomography pulmonary angiogram (CTPA) revealed an unusual venous drainage of the left lung. The tubular structure was a meandering unilateral single pulmonary vein draining the left upper-lobe (Fig. 2a) then tortuously descending to cross the oblique fissure and join the left lower-lobe pulmonary vein before directly merging into the left side of the left atrium (Fig.More than an atrial septal defect
A 49 year-old man was referred to our cardiology clinic because of an atrial septal defect (ASD) with left-to-right shunt and severe right chambers dilation detected on a transthoracic echocardiogram. The patient was asymptomatic and physical examination was unremarkable. A transoesophageal echocardiogram showed signs of an anomalous pulmonary venous drainage (APVD), so an angio-computed tomography was performed which confirmed the severe right chambers dilation (Fig. 1) and showed an ASD at the postero-superior portion of the interatrial septum compatible with a sinus venosus defect (Fig.Vanished into thin air - Morgagni hernia producing echo artifact and diagnosed by cardiac CT
An 82-year-old woman presented with aphasia and right sided weakness and was diagnosed with an acute stroke. She was unable to undergo an MRI due to a cochlear implant but received thrombolytics for suspected large vessel occlusion. A carotid CT angiogram did not show significant stenosis. She underwent a transthoracic echocardiogram (TTE) to rule out a potential cardiac etiology. TTE windows were challenging [Panel A, Parasternal long axis view (PLAX). Panel B, Short axis view (SAX), Movie 1]. Subcostal views were only marginally better.Tetralogy of fallot with pulmonary atresia and aorto-pulmonary window: Or is it truncus arteriosus?
A four month old female child presented with past history of multiple episodes of respiratory tract infection. On examination, she was febrile, tachypneic and cyanosed. Chest radiograph showed normal cardiac size with pulmonary plethora and mediastinal shift to the right. She was maintaining low oxygen saturation even with oxygen support. Echocardiography was suggestive of truncus arteriosus including the typical associated ventricular septal defect. Cardiac CT was performed, revealing a perimembranous ventricular septal defect (black asterisk in Fig.Never too late for amplatzer endocarditis: Key role of cardiac CT imaging
Twenty-year-old New Zealand Maori man with previous percutaneous closure of right coronary artery to right ventricular fistula with an 8mm Amplatzer septal occluder at the age of eight presented with fevers, generalized body aches and diarrhea. He was hypotensive on admission requiring vasopressor support. Six blood cultures grew methicillin-sensitive Staphylococcus aureus. Transthoracic echocardiogram (TTE) revealed new moderate right ventricular dilation and dysfunction, and tricuspid regurgitation but no evidence of endocarditis.Azygous tumor thrombus extending into the heart
Cardiac tumors are very rare. However, metastatic tumors to the heart are approximately 30 times more common than primary cardiac tumors.1 Typically, patients with right atrial (RA) tumors present with symptoms of right heart failure from extension of the mass into the right ventricle resulting in tricuspid obstruction and insufficiency.2
