ABNORMAL MEDIASTINAL COUNTOUR

AORTA
-dilatation of the ascending aorta as a result of poststenotic dilatation is seen in approximately
80% of patients with aortic stenosis
-it can also be seen in patients older than 50 years when there is tortuosity of the entire aorta or
systemic hypertension
-Ascending aortic aneurysm (calcific with syphilis, not calcified with Marfan syndrome) is
another possibility
-a ductus bump adjacent to the aortic knob can be an indication of patent ductus arteriosus.

AZYGOUS VEIN DILATION

- >6 mm on upright PA radiograph or >1 cm on supine radiograph
-seen with intravascular volume expansion, elevated central venous pressure, right heart failure,
Valsalva maneuver, pregnancy, renal failure, vena cava obstruction, or azygos continuation of
the IVC
-dilatation of the SVC often accompanies volume expansion or elevated central venous pressure
but is more difficult to detect with certainty.

CARDIAC CALCIFICATION

CORONARY CALCIFICATION
-radiographs commonly demonstrate coronary artery calcification in a 3-cm triangle along the
upper left heart border, called the CAC (coronary artery calcification) triangle
-if chest pain and coronary calcification are present, there is a 94% chance the patient will show
occlusive coronary artery disease at angiography
-Fluoroscopic detection of coronary calcification actually has higher sensitivity and specificity in
screening asymptomatic individuals than does exercise-tolerance testing
-In symptomatic patients, the detection of coronary calcification approaches exercise-tolerance
testing in sensitivity and exceeds exercise-tolerance testing in specificity
-more than 82% of the patients with fluoroscopically demonstrated coronary artery calcification
and positive exercise-tolerance testing show significant coronary artery disease at angiography
-Calcifications have more significance when seen in patients under 60 years of age. Heavier and
more extensive calcification correlates with more severe coronary disease
-Detection of coronary calcification helps to differentiate patients with ischemic cardiomyopathy
from those with nonischemic cardiomyopathy.

VALVULAR CALCIFICATION
-seen in 85% of patients with acquired valvular disease but is rarely detected in patients under 20
years of age
-Aortic valve calcification is highly suggestive of valve disease
-Calcific aortic stenosis is most often degenerative or atherosclerotic in origin and is usually seen
in older men
-Extensive aortic annulus calcification is atherosclerotic in nature and has been associated with
conduction blocks.

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MITRAL VALVE CALCIFICATION
-highly suggestive of rheumatic valvular disease and is seen on the chest radiographs of
approximately 40% of patients with mitral stenosis
-it is even more common in patients with stenosis and regurgitation
-atherosclerotic calcification of the mitral annulus occurs in approximately 10% of the elderly
population
-it appears as circular, ovoid, C-shaped, or J-shaped calcification in the mitral annulus and can
lead to mitral valve incompetence

SINUS OF VALSALVA CALCIFICATION

-seen as a curvilinear density anterior and lateral to the ascending aorta

CALCIFIED LIGAMENTUM ARTERIOSUM

-seen as a linear calcification in the aortopulmonary window connecting the top of the left
pulmonary artery to the floor of the aortic arch

CALCIFIED LA
-thin curvilinear calcification in the wall of the LA is usually associated with mitral stenosis, left
atrial enlargement, atrial fibrillation, and left atrial thrombus.

Calcified pericardium is typically anterior and inferior in location. It can be single or double
layered and is associated with a high incidence of constrictive pericardial hemodynamics. Causes
include viral, hemorrhagic, and tuberculous pericarditis as well as postsurgical scarring.

CALCIFIED INFARCT
-Dystrophic calcification may occur in the myocardial wall from prior myocardial infarction.

CALCIFIED VENTRICULAR ANEURYSM

-thin curvilinear calcification anterolaterally near the apex is most often seen with true
aneurysms
-posterior curvilinear calcification is usually seen in pseudoaneurysms

CALCIFIED THROMBUS
-seen as clumpy calcification in the LA or, less commonly, in the LV

CALCIFIED PULMONARY ARTERIES

-thin, eggshell-like calcification in the walls of the pulmonary arteries is virtually diagnostic of
long-standing pulmonary arterial hypertension

TUMORS
-rounded or stippled calcifications are seen occasionally in atrial myxomas and rarely in other
cardiac neoplasms

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MYOCARDIAL INFARCTION
-after acute infarction, the chest radiograph will initially show a normal heart size in 90% of
cases
-cardiomegaly and congestive failure will eventually develop in 60% to 70% of cases, more fre-
quently with anterior wall infarction, multivessel disease, or left ventricular aneurysm. -
increasing stages of pulmonary venous hypertension, particularly alveolar edema, are associated
with worsened prognosis.
-Complications:
RV INFARCTION- 33%
-occurs in approximately 33% of inferior wall infarctions
-symptoms are caused by the reduction in right ventricular ejection fraction, which returns to
normal within 10 days in approximately 50% of cases
-diagnosis may be established using technetium pyrophosphate (PYP) radionuclide scans
(right precordial electrocardiographic leads can also assist in making the diagnosis)
-complications: cardiogenic shock, elevated right atrial pressure, and decreased pulmonary artery
pressure

VENTRICULAR ANEURYSM- 12%

- develops in approximately 12% of survivors from myocardial infarction
- also be caused by Chagas disease or trauma and are rarely congenital (usually seen in young
black males)
-aneurysms present with congestive failure, arrhythmias, and systemic emboli
-True aneurysms are broad-mouthed, localized outpouchings that do not contract during systole
-they are typically anterior or apical and result from LAD disease
-chest radiograph shows a localized bulge along the left cardiac border and may show rimlike
calcification in the wall
-Fluoroscopy detects up to 50% of cases
-Radionuclide ventriculography or myocardial perfusion scan detects 96%
-Echocardiography, contrast-enhanced CT, and MR are also accurate at detecting true
aneurysms.

DRESSLER SYNDROME - 4%
-also known as the postmyocardial infarction syndrome
-similar to the postpericardiotomy syndrome complicating cardiac surgery
-onset is typically 1 week to 3 months postinjury (peak at 2 to 3 weeks), but relapses occur up to
2 years later
-presentation includes fever, chest pain, pericarditis, pericardial effusion, and pleuritis, with
pleural effusion usually more prominent on the left
-responds well to anti-inflammatory medication

MYOCARDIAL RUPTURE - 3.3% of infarcts

- may occur 3 to 14 days after infarction
-mortality rate approaches 100% and accounts for 13% of myocardial infarction deaths
-chest radiograph shows acute cardiac enlargement secondary to leakage of blood into the
pericardium

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-rupture of the interventricular septum (1%) typically occurs between days 4 and 21, usually as a
complication of anterior myocardial infarction and LAD disease
-mortality is 24% within 24 hours and 90% within 1 year
-Swan-Ganz catheter measurements show an acute increase in saturation in the RV, although the
wedge pressures may be normal
-chest radiographs show acute pulmonary vascular engorgement and right-sided cardiac
enlargement because of left-to-right shunt. Pulmonary edema is not a typical feature. –
-Echocardiography readily demonstrates the septal defect.

PAPILLARY MUSCLE RUPTURE -1%

- is suggested by abrupt onset of mitral regurgitation, with acute pulmonary edema on the
radiograph
-typically, the LV is only minimally enlarged, whereas the LA enlarges quickly
-Inferior infarcts are associated with posteromedial papillary rupture
-Anterior infarcts less commonly affect the anterolateral papillary muscle
-Mortality is 70% within 24 hours and 90% within 1 year
-Echocardiography confirms the diagnosis.

PSEUDOANEURYSM
-contained myocardial ruptures consisting of a localized hematoma surrounded by adherent
pericardium
-causes include infarction and trauma
-patients are at high risk for delayed rupture
-posterolateral or retrocardiac in location and have smaller mouths than true aneurysms
-MR is the most accurate at detecting pseudoaneurysms, but they can also be seen with
echocardiography.

CARDIOGENIC SHOCK
- implies that systolic pressure is less than 90 mm Hg and is typically associated with acute
pulmonary edema and worsened prognosis

AV BLOCK
-common, especially after inferior wall infarcts resulting from either ischemia or injury to the
atrioventricular nodal branch of the right coronary artery or increased vagal tone
-complete heart block occurs with larger infarcts and has a worse prognosis

INFARCT IMAGING (p 634Brant)

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CARDIAC MASSES
- include thrombi, primary benign tumors, primary malignant tumors, and metastatic tumors
-Lipomatous hypertrophy, moderator bands, and papillary muscles may simulate cardiac masses.
-do not deform the outer contours of the heart, chest radiography is typically not useful, except
for the occasional calcific mass
-Nuclear scintigraphy, CT, and cardiac angiography identify intracardiac masses. –
-Echocardiography is usually the initial mode of evaluation, and MR may be helpful when there
is uncertainty

THROMBI
-are the most frequent cause of an intracardiac mass and are most common in the LA and LV,
where they present a risk of systemic emboli
-Intra-atrial thrombi are usually associated with atrial fibrillation, often secondary to rheumatic
heart disease
-Thrombosis commonly occurs along the posterior wall of the LA
-Clots within the left atrial appendage are difficult to detect on transthoracic echocardiography
but are readily identified with transesophageal echo and MR
-Left ventricular thrombi are usually secondary to recent infarction or ventricular aneurysm
-differentiation of tumor versus clot is best done with MR using gradient-echo techniques
-clots typically have low signal, whereas tumors have intermediate signal
-clots will not enhance, whereas neoplasms will typically appear as enhancing masses on CT or
MR
-Cine-mode gradient-echo MR is useful for determining the morphology of a lesion
-Intracardiac lipomas or lipomatous hypertrophy have characteristic bright signal on T1WIs and
remain relatively bright on T2WIs
-Fat-saturation sequences help to make the specific diagnosis of lipoma, which is the second
most common benign tumor
-MDCT can also characterize lipomas and lipomatous hypertrophy

BENIGN TUMOR
-Hydatid cysts - typically show a bulge along the left heart border, with associated curvilinear
calcification, and are at risk for rupture into the pericardium or myocardium
-Atrial myxoma makes up 50% of primary cardiac tumors and is the most common primary
benign tumor
-it occurs most frequently in patients in the 30- to 60-year age range and is often accompanied
by fever, anemia, weight loss, embolic symptoms (27%), or syncope
-most (75% to 80%) myxomas are in the LA and may mimic rheumatic valvular disease
clinically
-cardiomegaly, left atrial enlargement, pulmonary venous hypertension, and ossific
pulmonary nodules may be seen
-enlargement of the left atrial appendage is uncommon
-Echocardiography, CT, and MR show the atrial filling defect, which may prolapse into the
LV during diastole
-may be pedunculated and are usually lobulated
-On M-mode echo, the E-F slope is typically decreased, with numerous echoes seen behind
the mitral valve

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-Other benign tumors:
Lipoma
Rhabdomyoma -found in 50% to 85% of tuberous sclerosis patients
Fibromas -12% of which may calcify
Teratoma- rare

MALIGNANT TUMOR
1 malignant tumor -Angiosarcoma is the most common primary malignant cardiac tumor,
followed by rhabdosarcoma, liposarcoma, and other sarcomas.
2 malignant tumor -Metastatic cardiac tumors are 10 to 20 times more common than primary
cardiac tumors
-Breast, lung, melanoma, and lymphoma are the most common neoplasms to metastasize to
the heart
-MR is excellent for detecting direct extension, intracardiac metastases, and pericardial
involvement

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