Case 47 Clinical Presentation

Transcription

1 93 Case 47 C Clinical Presentation 45-year-old man presents with chest pain and new onset of a murmur. Echocardiography shows severe aortic insufficiency.

2 94 RadCases Cardiac Imaging Imaging Findings C () sagittal oblique view of the aortic valve and ascending aorta shows a linear low-attenuation structure ( white arrow ), which is the noncoronary cusp of the valve, at the level of the aortic valve, extending into the left ventricular (LV) outflow tract. The posterior leaflet of the mitral valve ( black arrow ) and origin of the right coronary artery (R) are shown. () coronal oblique view of the aortic valve and ascending aorta is rotated 90 degrees from (). The linear low attenuation structure (open black arrow) in the LVOT is the noncoronary cusp of the aortic valve. (C) n axial oblique, en face view of the aortic valve shows a curvilinear density of the noncoronary cusp of the aortic valve (white arrows ), which has been avulsed from the wall of the sinus of Valsalva (black arrows ). Differential Diagnosis vulsion of a cusp of the aortic valve : Dissection of the thoracic aorta may begin with or secondarily involve the aortic valve. When dissection is limited to the aortic valve, the valve is incompetent, resulting in a murmur. Vegetation of the aortic valve: Vegetation of cardiac valves is most commonly seen in patients with infective endocarditis and congenital deformities of a valve. Neoplasm of the aortic valve: Papillary fibroelastomas of the aortic valve are benign neoplasms that arise from cardiac valves. When on the arterial side of the aortic valve, they can obstruct the valve, becoming a source of emboli or causing insufficiency. Essential Facts Trauma is the most common cause of avulsion of a cusp of the aortic valve. Valval insufficiency rapidly or progressively leads to congestive heart failure or death unless surgically corrected. Valvuloplasty and valve replacement are surgical options. vulsion of the noncoronary cusp of the aortic valve has been reported in patients with pseudoxanthoma elasticum, an inherited connective tissue disease. Other Imaging Findings The tear of the intimal surface of the aorta may be the site of dissection. Examine the ascending aorta and origins of the coronary arteries for extension of dissection. The avulsed leaflet is mobile; in this case, the leaflet prolapses into the LV outflow tract during diastole. Severe aortic insufficiency is also present. Pearls & Pitfalls Vegetation and tumors of the aortic valve are more likely to be masslike, not linear, as is this avulsed leaflet. non electrocardiography (ECG)-gated computed tomography (CT) scan will fail to show the findings because of motion of the aortic valve. In patients with acute chest pain, consider magnetic resonance imaging or ECG-gated multidetector CT.

3 127 Case 64 Clinical Presentation 73-year-old man presents with a history of hypertension, heart failure, and diabetes, as well as chronic atrial fibrillation.

4 128 RadCases Cardiac Imaging Imaging Findings () In this axial maximum intensity projection image, the coronary anatomy is well seen, with only mild atherosclerotic disease in the left main and left anterior descending arteries. The left atrial appendage (L: outlined with dotted white line ) does not fill completely with contrast, as it is partially filled with thrombus ( black arrow ). () In a coronal oblique image, the course of the left main ( white arrow ) and left circumflex ( double white arrow ) arteries and their relationship to the L ( dotted white line ) are seen. This relationship is important when a procedure to occlude the L is considered. Extrinsic compression of the coronary is theoretically possible if an L occlusion device expands the L. Differential Diagnosis L thrombus : Soft-tissue-attenuation material in the distal L does not extend into the left atrial chamber. The tissue is well marginated. L neoplasm: The sharply defined tissue in the L is attached to a motionless (akinetic) wall; both are characteristic of chronic thrombus rather than neoplasm. Left atrial thrombus: The filling defect is clearly contained within the atrial appendage; it does not extend through the narrow mouth of the L into the atrial chamber. Essential Facts The L, shaped like a windsock, has a narrow orifice. The L abuts the left pulmonary artery and overlies the bifurcation of the left main coronary artery. During atrial systole and during other periods when left atrial pressure is high, the L functions as a decompression chamber. Obliteration or amputation of the L may help to reduce the risk for thromboembolism, but it may result in undesirable physiologic sequelae such as reduced atrial compliance and a reduced capacity for atrial natriuretic factor secretion in response to pressure and volume overload. Other Imaging Findings n echoic mass within the L on echo is helpful in the diagnosis but is frequently not detected with conventional two-dimensional transthoracic echocardiography (TTE). Transesophageal echocardiography is more sensitive than TTE in the detection of thrombus. Sensitivity of CT for detection of L thrombus can be increased by repeated contrast injection or delayed imaging. Pearls & Pitfalls lways look for L thrombus in patients with a history of atrial fibrillation. L thrombus can also be found in patients with a history of mitral valve disease or rheumatic valve disease. Specifically mention the presence or absence of L thrombus in reports of CT or magnetic resonance examinations performed to define pulmonary vein anatomy before ablation procedures. Cardiac thrombus develops on a motionless segment of the wall. mass on a moving wall is a muscle bundle or neoplasm and is not thrombus. Stasis of blood in the L can appear similar to thrombus. Chronic L thrombus is likely to be a smoothly marginated rather than an irregular filling defect. Embolic disease from a cardiac source is more likely to be the presenting sign of an atrial mass (myxoma) rather than L thrombus.

5 171 Case 86 C D Clinical Presentation 6-day-old boy presents with cyanotic congenital heart disease.

6 172 RadCases Cardiac Imaging Imaging Findings C D () posteroanterior view of an aortogram shows opacification of the ascending aorta () and a patent ductus arteriosus (PD) (white arrow) and left pulmonary artery (black arrow). () left posterior oblique view of the heart in a reconstructed computed tomography (CT) image shows the PD ( white arrow ) and ascending aorta (o). (C) n anteroposterior view of the heart from the CT image also shows the ascending aorta (o), PD ( white arrow ), and left pulmonary artery (black arrow ). (D) n angled superior view of the heart with altered window and level settings reveals the overriding position of the ascending aorta (o) (PD, white arrow), which receives outflow from the right (RV) and left (LV) ventricles. Differential Diagnosis Pulmonary artery atresia, tetralogy of Fallot : The main and right pulmonary arteries are absent. The left pulmonary artery arises from the PD, which fills from the aorta. PD: lthough the ductus arteriosus is patent, the other abnormalities indicate more serious congenital heart disease. The pulmonary circulation is ductus-dependent. Vascular ring: vascular ring occurs when vascular structures surround the trachea and the esophagus. lthough this patient has a right-sided aortic arch and PD, a vascular ring is not complete because there is discontinuity of the left and main pulmonary arteries. Essential Facts Four cardiac malformations are found in patients with tetralogy of Fallot: Pulmonary valve atresia; main, branch, or peripheral pulmonary artery atresia and/or stenoses Hypertrophy of the right ventricular myocardium due to increased work by the ventricle pumping blood through the pulmonary valve and arteries ventricular septal defect (VSD), typically with malalignment of the atrial and ventricular septa, allowing decompression of the right ventricle Malalignment of the VSD allowing the aortic valve to override the defect, so that blood from both ventricles is ejected into the ascending aorta The aortic arch is right-sided in 25% of patients with tetralogy of Fallot. Tetralogy of Fallot is the most common type of cyanotic congenital heart disease (5 7% of cases). Infants are most often cyanotic because of decreased pulmonary blood flow. Other Imaging Findings lthough not seen in this patient, the cardiac apex may be displaced upward by hypertrophy of the right ventricle. This finding is the boot-shaped cardiac silhouette seen on chest radiographs. Chest radiographs and CT also show decreased pulmonary vascularity. Pearls & Pitfalls If the distance between the right ventricular outflow tract (RVOT) and confluent pulmonary arteries is minimal, it may be possible to surgically repair the RVOT to physiologic status. The origin of the pulmonary arteries may be from the right ventricle, aorta, or ductus arteriosus in patients with tetralogy of Fallot.