Volume 42 • Number 2

January 15, 2019

Pitfalls in Cardiac CT: Causes and Solutions

Deepali Saxena, DNB, Prabhakar Rajiah, MD, Rehan Quadri, MD, and
Sachin S. Saboo, MD

After participating in this educational activity, the diagnostic radiologist should be better able to differentiate the various
pitfalls encountered in cardiac CT, which can mimic cardiac lesions such as masses and thrombi, and to propose solutions
to avoid these pitfalls.

Category: Cardiac Imaging

Modality: CT
Key Words: Pitfalls in Cardiac CT; Imaging of Cardiac
Pitfalls
Cardiac CT is used increasingly in the evaluation of cardiac
abnormalities, particularly for coronary artery diseases.
Cardiac CT mainly provides morphological information, but it
also can generate some functional information. Cardiac CT can
be performed either with prospective electrocardiogram (ECG)
triggering or retrospective ECG gating. Several pitfalls can be
seen in cardiac CT, and these can be confused for abnormal
cardiac lesions. In this article, we provide solutions to avoid
their misdiagnosis.
Right Atrium
Crista Terminalis
On cardiac CT, the crista terminalis is a vertically oriented,
linear, low-attenuating, smooth muscle ridge in the lateral
wall of the right atrium, extending from the superior vena
Dr. Saxena is Associate Professor of Radiology, St. John’s Medical College
Hospital, Bangalore, India; Dr. Rajiah is Associate Professor of Radiology and
Associate Director, Cardiac CT and MRI, UT Southwestern Medical Center,
5323 Harry Hines Blvd, E6-122G, Mail Code 9316, Dallas, TX 75360, E-mail:
prabhakar.rajiah@utsouthwestern.edu; Dr. Quadri is Radiologist, and Dr. Saboo
is Assistant Professor of Radiology, UT Southwestern Medical Center, Dallas,
Texas.
The authors, faculty, and staff in a position to control the content of this CME
activity and their spouses/life partners (if any) have disclosed that they have no
relationships with, or financial interests in, any commercial organizations relevant
to this educational activity.
Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical
education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 2 AMA PRA Category 1
Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME
article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This continuing medical
education activity expires on January 14, 2021.
cava (SVC) to the inferior vena cava (IVC) (Figure 1). This
smooth muscle ridge is identified easily on CT especially
with use of triphasic contrast injection protocols, MRI, and
echocardiography. However, when prominent the crista ter-
minalis may mimic a neoplasm or a thrombus.1,2 The crista
terminalis can be distinguished from a cardiac lesion by use
of multiplanar reformatted (MPR) images, bicaval view, and
its low attenuation similar to fat.2
On cardiac CT, the crista terminalis is a
vertically oriented, linear, low-attenuating,
smooth muscle ridge in the lateral wall of the
right atrium.
Tenia Sagittalis
Tenia sagittalis is the most prominent pectinate muscle that
extends anterolaterally from the crista terminalis to the right
atrial appendage (Figure 2).3 This entity can mimic cardiac
neoplasm or thrombus on cardiac CT, but it can be distin-
guished based on its anatomic course on MPR images and
bicaval views.1
Eustachian and Thebesian Valves
The Eustachian valve is located at the junction of IVC
with the right atrium and prevents reflux of blood from the
right atrium into the IVC. The Thebesian valve is located
at the junction of the coronary sinus with the right atrium
and prevents reflux of blood from the right atrium into the
coronary sinus.4 On cardiac CT, these valves appear as thin,
curvilinear, hypoattenuating structures (Figure 3). These
1
 Figure 2. Tenia sagittalis. This axial, cardiac CT scan shows a
prominent pectinate muscle in the right atrium (arrow), consistent
with the tenia sagittalis.

Figure 1. Crista terminalis. Coronal plane from a preablation

cardiac CTA shows a vertically oriented, linear, low-attenuating,
smooth muscle ridge representing a prominent crista terminalis
(arrow) extending from the SVC to the IVC in the lateral wall of
the right atrium.
valves may be mistaken for cardiac tumor or thrombus.
However, thrombi are uncommon in these regions of high
venous flow.5 Assessment on four-chamber, short-axis, and
sagittal oblique views is helpful to delineate the anatomy
of these valves.
Chiari Network
Chiari network is a fenestrated remnant of the sinoatrial
valve in the right atrium. On cardiac CT, the Chiari network
appears as a thin, mobile, membranous structure extending
from the Eustachian or Thebesian valve to the crista termi-
nalis (Figure 4).3 The Chiari network can be mistaken for a
large Eustachian valve, or uncommonly for a cardiac mass.
However, its characteristic location on a four-chamber view
and asynchronous movement in retrospective ECG-gated
scan are helpful in distinguishing it from a cardiac mass.

Mixing Artifact From SVC/IVC

The Eustachian valve is located at the junction Mixing of unenhanced blood from IVC with enhanced
of IVC with the right atrium and prevents reflux blood from SVC is commonly seen on CT (Figure 5), which
of blood from the right atrium into the IVC. creates a spurious filling defect in the right atrium. The dif-
ferential appearance of structures is exaggerated by a

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2
Figure 3. Eustachian valve. This axial, cardiac CT scan shows a
Eustachian valve (arrows) located at the junction of the IVC and
the right atrium. The Thebesian valve (black arrow) is seen at the
junction of coronary sinus (*) and the right atrium.
Valsalva maneuver, when incoming venous flow is increased
in both the SVC and the IVC. This artifact can be minimized
by performing the scan with shallow breaths or by using a
biphasic injection protocol (contrast medium followed by a
saline chaser). A delayed phase of CT may be acquired at
30 seconds because there is more homogeneous appearance
of the blood pool at this time, and a filling defect in this
phase is favored to be a cardiac neoplasm or thrombus than
a mixing artifact.6 The artifact also can be minimized by
using high-energy virtual monoenergetic images from a
dual-energy CT scanner.7
Figure 4. Chiari network. This axial scan from cardiac CTA shows
a fenestrated, membrane-like structure (arrow) adjacent to the
orifice of the IVC and coronary sinus with attachments to the
interatrial septum, consistent with Chiari network.
Figure 5. Mixing artifact from the SVC/IVC. This coronal scan
from a cardiac CTA study shows high-density enhanced blood
from the SVC (white arrow) mixing with the unenhanced
hypodense blood from the IVC, creating a spurious filling defect
in the right atrium (black arrow).
Left Atrium
Coumadin Ridge
Coumadin ridge (also known as warfarin ridge or left lateral
ridge) is a fold of visceral pericardium formed by coalition
of the left atrial appendage and the left superior pulmonary
vein. It contains the ligament of Marshall, nerve, and sinoatrial
node or atrial artery. It has a band-like appearance with a thin
proximal and bulbous distal part, the so-called “Q-tip” sign
(Figure 6). The Coumadin ridge can be misinterpreted as a
cardiac mass, but it can be resolved on MPR images.1
Coumadin ridge is a fold of visceral pericardium
at the junction of the left superior pulmonary
vein and left atrial appendage producing the
Q-tip sign.
Musculi Pectinati
Musculi pectinati are numerous variably oriented mus-
cular ridges that run in linear orientation in the left atrial
appendage (Figure 7). They are more numerous in the right
atrium than in the left atrium. Their parallel orientation,
especially on MPR images, distinguishes them from a car-
diac pseudomass or thrombus, which also are seen as filling
defects.1
Cor Triatriatum
Cor triatriatum is a persistent fibromuscular remnant of the
sinus venosus, either in the left (sinister) or right (dexter)
3
Figure 6. Coumadin ridge. This axial, cardiac CT scan shows a
band in the left atrium with a bulbous tip (arrow) at the junction
of the left superior pulmonary vein and left atrial appendage (A),
consistent with a coumadin ridge.
atrium. It is best visualized on axial CT as a curvilinear,
hypoattenuating band, dividing the left or right atrium into
two parts (Figure 8).3 The characteristic location of the cor
triatriatum on MPR images is useful in differentiating it from
a pedunculated thrombus.
Figure 7. Musculi pectinati. This axial scan from a cardiac CTA
for atrial fibrillation shows a pectinate muscle (arrow) in the left
atrial appendage, causing a filling defect.
4
Figure 8. Cor triatriatum. This axial, prospective cardiac CTA image
in a 64-year-old woman with chest pain and a history of metastatic
thyroid carcinoma shows a thin, linear septum (arrow) dividing the
left atrium into 2 parts and representing cor triatriatum sinister.
Slow Flow
Slow flow within the left atrial appendage leads to mixing
of low-attenuation blood with high-attenuation normal blood
pool, giving an appearance of thrombus on CT (Figure 9).
This is compounded by the fact that sluggish blood flow itself
predisposes to thrombus formation. Slow flow typically has
higher attenuation than a thrombus in the left atrial append-
age. The ratio of left atrial appendage attenuation in the
region of low density to that of the attenuation in the ascend-
ing aorta ratio of more than 0.75 is a reasonable predictor
that the focus of low attenuation is due to slow flow and has
a high negative predictive value of thrombus.2 Delayed
enhancement CT imaging at 30 to 60 seconds has been
proven useful in discriminating the two entities. In prone
imaging, the slow flow disappears, whereas thrombus per-
sists. Iodine map in dual-energy CT shows no significant
iodine in a thrombus.1
Interatrial Septum
Lipomatous Hypertrophy of Interatrial Septum
Fat deposition in the interatrial septum assumes a dumbbell
shape due to sparing of the fossa ovalis and is seen more
frequently in obese patients. Criteria for lipomatous hyper-
trophy of the interatrial septum are nonenhancing interatrial
septum with fat attenuation less than −50 HU and thickness
more than 20 mm (Figure 10). At thickness more than 30
mm, a greater association of supraventricular tachycardia is
reported. Care should be taken not to misinterpret the lipo-
matous hypertrophy of the interatrial septum as a neoplastic
lipomatous cardiac mass. On fluorodeoxyglucose-positron
emission tomography scans, lipomatous hypertrophy of the
interatrial septum appears “hot” due to the presence of hyper-
metabolic brown fat.2
Figure 9. Slow flow. This axial image from a retrospective cardiac
CTA preradiofrequency ablation shows a hypoattenuating region
in the left atrial appendage (arrow). This had an attenuation of
120 HU, which is indicative of slow flow.
Lipomatous hypertrophy of the interatrial
septum is fat deposition in the interatrial
septum with a dumbbell shape due to sparing
of the fossa ovale.
Thin Fossa Ovalis and Patent Foramen Ovale
During fetal development, the septum primum and the sep-
tum secundum fuse to form the fossa ovalis. Persistent phys-
iologic thinning of the fossa ovalis can be mistaken for an
atrial septal defect. Usually, the foramen ovale is covered,
but with inadequate fusion of the septum primum and the
septum secundum, a patent foramen ovale results (Figure 11).
With a thin fossa ovalis, a jet of contrast medium is not
demonstrated across the interatrial septum. With a patent
foramen ovale, a flap-like appearance of the interatrial septum
is seen, along with an inferiorly directed jet of contrast
medium across the interatrial septum. In doubtful cases,
echocardiography with bubble study may be needed.1
Right Ventricle
Fat in the Right Ventricle Wall
Incidental fat deposition in the right ventricular wall
(Figure 12) has been noted in 17% of asymptomatic patients,
mostly in the elderly.1 This fat deposition can mimic
arrhythmogenic right ventricular dysplasia or old myocardial
infarction. However, the characteristic location of fat in the
superior wall of basal and mid right ventricle and the right
ventricular outflow tract can aid in distinguishing incidental
fat in the right ventricular wall from arrhythmogenic right
Figure 10. Lipomatous hypertrophy of the interatrial septum. This
axial CT scan shows lipomatous hypertrophy of the interatrial
septum (arrows), which has a dumbbell configuration, with the
gap in between representing the fossa ovalis.
ventricular dysplasia and old myocardial infarction.1 Moreover,
fat deposition is no longer a major criterion for arrhythmo-
genic right ventricular dysplasia in the new classification.1
Right Ventricle Moderator Band
The right ventricular moderator band represents the most
prominent right ventricular trabeculation that extends from
the base of the anterior papillary muscle to the interventricu-
lar septum and contains the right bundle branch (Figure 13).4
An enlarged or hypertrophied right ventricular moderator
band simulates a cardiac mass or thrombus, or a double-
chambered right ventricle. Characteristic features of a right
ventricular moderator band include its typical attachment
sites especially on MPR images1 and enhancement similar
to the myocardium.3
Characteristic features of a right ventricular
moderator band include its typical attachment
(base of the anterior papillary muscle to the
interventricular septum) and enhancement
similar to the myocardium.
Membranous Septal Aneurysms
A thin, membranous ventricular septum is identified rou-
tinely just beneath the aortic valve and can be mistaken for a
ventricular septal defect. A ventricular (Figure 14) or atrial
septal aneurysm is defined by bowing of the thin membranous
septum by more than 10 to 15 mm to either side. A membranous
5

Figure 11. Patent foramen ovale. This axial plane from retrospec-
tive cardiac CTA for chest pain shows a flap at the interatrial
septum and a jet of contrast medium (arrow) extending from the
left to the right atrium.
septal aneurysm may be observed in cardiac congenital cases,
postoperative cases, or after increased atrial or ventricular
pressures.8 In addition to careful observation on reformatted
CT images, lack of contrast jet across the septum and dynamic
retrospective CT angiography (CTA) are useful in diagnosing
a membranous septal aneurysm.1 In difficult cases, echocar-
diography or MRI is useful in characterization.
Left Ventricle
Papillary Muscles
Prominent papillary muscles may simulate a cardiac mass
or thrombus.1 These muscles are interpreted easily based on
Figure 12. Fat in the right ventricular wall. Short-axis reconstruc-
tion of cardiac CT shows prominent low density within the right
ventricle wall (arrows) that matches the density of the epicardial
fat with normal thickness of the right ventricular wall. The findings
are most consistent with incidental right ventricular wall fat.
6
Figure 13. Right ventricular moderator band. This axial, contrast-
enhanced CT scan shows a prominent moderator band in the
right ventricle (arrow), which extends from the base of the ante-
rior papillary muscle to the interventricular septum.
their anterolateral and posteromedial left ventricular
attachment sites and MPR images (Figure 15).
Pericardium
Pericardial Recess
Pericardial reflections are raised into recesses and sinuses
and can contain physiologic amount of fluid, which can be
interpreted as enlarged lymph nodes (Figure 16). Fluid in the
anterior portion of superior aortic recess may be mistaken
for an aortic dissection. Knowledge of location of the various
named pericardial sinuses, their continuity with the pericar-
dial reflections, and fluid attenuation is helpful to make the
diagnosis.5
Figure 14. Membranous septal aneurysm. This axial, contrast
CT scan shows a focal bulging of the membranous septum
(arrow), consistent with an aneurysm at the site of membranous
ventricular septum.

Figure 15. Papillary muscle. This short-axis reconstruction of
cardiac CT shows anterolateral and posteromedial papillary mus-
cles (arrows).
Figure 16. Pericardial recess. This axial CT scan at the level of
aortic arch in a patient with a history of metastatic breast cancer
shows mildly hyperattenuating fluid (arrow) in the retro-aortic
superior pericardial recess, mimicking right upper paratracheal
lymphadenopathy. Note left breast cancer mass (M) and left axil-
lary nodal metastasis (N).
Cardiac Valves
Caseous Mitral Annular Calcification
Liquefactive necrosis of the mitral annulus results in peri-
annular calcification with a central lower attenuation.
Heterogeneity often is noted due to differing stages of evolu-
tion and admixture of fat, necrosis, and calcification.
Differentiation from cardiac mass or thrombus on CT is based
on its location in the posterior mitral annulus and character-
istic central lower attenuation (350–500 HU) with surround-
ing higher attenuation calcification (>500 HU).9,10
Caseous mitral annular calcification represents
liquefactive necrosis of the mitral annulus with
periannular calcification and central lower
attenuation.
Conclusion
This CME article emphasizes that diagnostic radiologists
should be familiar with the several pitfalls of cardiac CT to
avoid misdiagnosis.
References
1. Terpenning S, White CS. Imaging pitfalls, normal anatomy, and anatomical
variants that can simulate disease on cardiac imaging as demonstrated on
multidetector computed tomography. Acta Radiol Short Rep. 2015;4(1). doi:
10.1177/2047981614562443.
2. Kassop D, Donovan MS, Cheezum MK, et al. Cardiac masses on cardiac
CT: a review. Curr Cardiovasc Imaging Rep. 2014;7(8):9281.
3. Baxi AJ, Tavakoli S, Vargas D, et al. Bands, chords, tendons, and membranes
in the heart: an imaging overview. Curr Probl Diagn Radiol. 2016;45(6):380-
391.
4. O’Brien JP, Srichai MB, Hecht EM, et al. Anatomy of the heart at multidetector
CT: what the radiologist needs to know. Radiographics. 2007;27(6):1569-1582.
5. Broderick LS, Brooks GN, Kuhlman JE. Anatomic pitfalls of the heart and
pericardium. Radiographics. 2005;25(2):441-453.
6. Chaturvedi A, Oppenheimer D, Rajiah P, et al. Contrast opacification on
thoracic CT angiography: challenges and solutions. Insights Imaging.
2017;8(1):127-140.
7. Kalisz K, Buethe J, Saboo SS, et al. Artifacts at cardiac CT: physics and
solutions. Radiographics. 2016;36(7):2064-2083.
8. Dodd JD, Aquino SL, Holmvang G, et al. Cardiac septal aneurysm mimick-
ing pseudomass: appearance on ECG-gated cardiac MRI and MDCT. Am J
Roentgenol. 2007;188(6):W550-W553.
9. Mallat N, Limeme M, Zaghouani H, et al. Caseous calcification of the mitral
annulus on MDCT: a rare intracardiac mass. Acta Radiol Short Rep.
2013;2(7). doi: 10.1177/2047981613502177.
10. Rinuncini M, Zuin M, Scaranello F, et al. Differentiation of cardiac thrombus
from cardiac tumor combining cardiac MRI and 18F-FDG-PET/CT imaging.
Int J Cardiol.212:94-96.
7
 CME QUIZ: VOLUME 42, NUMBER 2
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1. The location of the Eustachian valve in the heart is 5. Which one of the following is a characteristic feature of a
A. junction of the tenia sagittalis with the right atrial append- membranous septal aneurysm on cardiac CT?
age A. Presence of right-to-left contrast jet
B. junction of the IVC with the right atrium B. Nonmobility of the septum
C. mid ascending aorta C. Bowing of septum more than 10 to 15 mm on either side
D. junction of the coronary sinus with the right atrium D. Indentation of the ascending aorta
E. junction of the SVC with the right atrium E. Dilation of the sepal branch of coronary artery
2. Which one of the following CT cardiac imaging techniques 6. Which one of the following imaging features distinguishes an
can be used to distinguish an SVC/IVC mixing artifact from a enlarged right ventricular moderator band from a double-
cardiac neoplasm or thrombus in the right atrium? chambered right ventricle on enhanced MDCT?
A. Polyenergetic images of dual-energy CT A. Extension from the base of the posterior papillary muscle
B. Shallow breath scan to the interventricular septum
C. First-pass perfusion CTA B. Enhancement similar to the myocardium
D. Scanning during Valsalva maneuver C. Round shape
E. Single-phase contrast injection D. Extension to the tricuspid valve plane
E. Presence of a ventricular sepal defect
3. Which one of the following pathologic entities can potentially
mimic right ventricular wall fat on cardiac multidetector CT 7. Which one of the following is a classic feature of lipomatous
(MDCT)? hypertrophy of the interatrial septum in cardiac CT?
A. Lipomatous hypertrophy of the interatrial septum A. Sparing of the fossa ovalis
B. Acute myocardial infarction B. Fat attenuation of −30 HU
C. Loeffler’s endomyocardial fibrosis C. Thickness of 10 mm
D. Arrhythmogenic right ventricular dysplasia D. Infiltration of the right atrium
E. Hypertrophic cardiomyopathy E. Narrowing of the left ventricular outflow tract
4. Figure 17 is a sagittal, short-axis reconstruction from a cardiac 8. Which one of the following cardiac structures produces the
CT scan. The most likely diagnosis is “Q-tip sign” in cardiac imaging?
A. enhanced mitral valve A. Interatrial septum
B. calcified papillary muscle B. Crista terminalis
C. fat in mitral annulus C. Eustachian valve
D. vegetations attached to mitral valve D. Coumadin ridge
E. caseous mitral annular calcification E. Tenia sagittalis
9. The location of the crista terminalis in the heart is
A. right atrium
B. right ventricle
C. left atrium
D. left ventricle
E. ascending aorta
10. The location of the tenia sagittalis in the heart is
A. right atrium
B. right ventricle
C. left atrium
D. left ventricle
E. pulmonary artery

Figure 17.
8