Lecture Heart CXR CT MRI Cardiomyopathy

Notes Scales and Music

The Cardiac Evaluation on the CXR – PA

First step – Is the heart enlarged?
  • Cardiothoracic ratio as a global method

Cardiothoracic Ratio

CARDIOMEGALY – THE CARDIOTHORACIC RATIO
The maximum transverse length of the heart is expressed as a percentage of the maximum length of the internal diameter of the chest. When this ratio – the cardiothoracic ratio (c t r) is greater than 50% cardiomegaly is present. The top image is normal and the bottom reflects cardiomegaly
Ashley Davidoff MD

Border Forming Parts of the Heart

FRONTAL CXR AND PARTS OF THE HEART

Two Basic Shapes of Cardiomegaly

    • Oval down and outer of LV
    • Triangular RV disease
  • Each of the Chambers
  • LA, LV, RA, V

CARDIOMEGALY – TWO BASIC TYPES -OVOID and TRIANGULAR
The ovoid form which suggests left ventricular dominance and triangular form which suggests right ventricular dominance.
Ashley Davidoff MD

LVE

Subtle Ovoid Form Suggestive on the PA and Confirmed on the Lateral – Using Both Views

ISCHEMIC CARDIOMYOPATHY S/P RCA OCCLUSION
62 year old female with acute chest pain atrial fibrillation, hypotension admitted to ICU. Clinical evaluation was considered to be non-ischemic cardiomyopathy with EF by echo of about 20%. She was hypotensive and, in the ICU, and CXR showed acute CHF with cardiomegaly. The TEE was more in keeping with segmental dyssynergy, Cardiac cath showed occluded RCA bot good collateralization from the LAD. MRI showed subendocardial LGE in the inferior and inferolateral portions of the LV consistent with a prior infarction and EF of 20%
Ashley Davidoff MD

 

Triangular Heart with RVE

With Mitral Stenosis

MITRAL STENOSIS
Triangular shaped heart with RVE LAE
Ashley Davidoff MD

With Pulmonary Hypertension

PULMONARY HYPERTENSION
Frontal x-ray with triangular shaped heart due to pulmonary hypertension with enlarged MPA and enlarged descending RPA .
Ashley Davidoff MD

The Enlarged Left Atrium

Widened Carinal Angle

Double Density

Straightened right Heart Border – prominent LA appendage

Triangular Heart

 

Right Atrial Enlargement

    • enlarged, globular heart
    • narrow pedicle
    • gross enlargement of the right atrial shadow, i.e. increased convexity in the lower half of the right cardiac border
      • right atrial convexity is more than 50% of the cardiovascular height
      • right atrial margin is more than 5.5 cm from the midline

RIGHT ATRIAL ENLARGEMENT ON FRONTAL X-RAY
The right atrium is the most difficult chamber to assess unless it is very large in which case it will present on the frontal CXR with a very large right paravertebral border. This is a 71 year old female person with rheumatic heart disease with pulmonary hypertension and tricuspid regurgitation hence resulting in a large right atrium (RAE)
Ashley Davidoff MD

If there is time you may want to run through the  collage of congenital heart disease cases

 

The Shapes of the Heart in Health and Disease

From top left ti right and across the rows they are:  The normal heart , the “football” of LV enlargement the “triangle” or “proud breast” of RV enlargement, “snowman” of total anomalous pulmonary venous return,  big PA mogul of pulmonary hypertension,  “egg on its side” of D transposition of the great vessels,   “boot shaped” heart seen in both pulmonary atresia and Tetralogy of Fallot, the long smooth combined Ao and PA mogul that has a differential diagnosis of L transposition, absence of the pericardium, and juxtaposition of the atrial appendages, the box shaped large heart of Ebstein’s anomaly, dextrocardia , and the water bottle” heart of a large pericardial effusion.

07197 Images are  a combination of images from a personal collection and borrowed from the internet for educational purposes only. Some of the  sources are unknown and are used for educational  purposes alone 86774b02

TCV Links for extra info

Frontal CXR and Cardiomegaly 

The Cardiac Evaluation on the CXR -Lateral Exam

Normal and Abnormal

THE CV STRUCTURES  VISIBLE ON THE LATERAL EXAM –

A normal lateral examination of the chest X-ray is shown to exemplify the positioning of the cardiac chambers showing the right ventricular outflow tract (RVOT) anteriorly, the left atrium (LA) posteriorly and superiorly, the left ventricle (LV) posteriorly and inferiorly and the inferior vena cava (IVC) as a separate shadow posterior to the LV.
Ashley Davidoff MD

RULE OF 1/3 rds

  • Normal Anteriorly
    • RV takes up 1/3 of retrosternal space ((Sternomanubrial  jn to xiphi)
  • Inferiorly
    • LV takes up 1/3 of the hemidiaphragm
  • Posteriorly
    • LA 1/3, LV 2/3
The rule of thirds on the lateral examination states that;
the anterior border of the chest is divided into thirds; 1/3 for the RVOT and 2/3 for the retrosternal air space
the posterior border of the heart is divided into thirds; 1/3 for the LA and 2/3 for the LV.
the diaphragmatic border is divided into thirds; 1/3 for the LV and 2/3 for the rest of the diaphragm
Ashley Davidoff MD
15416C02Wlateral.8 rule of thirds
  • Abnormal
      • Anteriorly
        • RVE
          • RV > 1/3 of retrosternal space
      • Posteriorly
        • LAE
          • LA >1/3 of posterior heart border
          • Also elevates left main stem bronchus
Normal vs Abnormal – Left Ventricular Enlargement

Assessment of the Size of the left Ventricle (LV) on the Lateral CXR
Lateral examination of a chest x-ray (CXR) shows the normal in the upper row (a,b) and the abnormal and enlarged in the bottom row (c,d).
The objective evaluation is based on the relative positioning and size of the LV (white arrowhead) in relation to the IVC, (blue arrowhead), and the left hemidiaphragm (pink arrowhead)
Ashley Davidoff MD
15416C02Wlateral LV01L.8

RVE

NORMAL and RVE
The normal lateral CXR (a,b), shows anterior and superior border of the heart (anterior white arrowhead) occupying 1/3 of the border between the sternomanubrial junction and the diaphragm.
The posterior and inferior white arrowhead shows the posterior border of the heart occupied by the RV taking up 1/3 of the distance of the diaphragm.
Images c and d represent left ventricular enlargement showing that the LV occupies about half the length of the diaphragm, (red arrowhead) while the retrosternal distance is unchanged and normal (white arrowhead).
Ashley Davidoff MD

Normal vs Abnormal  – RVE and LAE

LATERAL EXAMINATION RVE AND LAE – MITRAL STENOSIS PULMONARY HYPERTENSION AND COR BOVINUM
71 year old Asian female with rheumatic heart disease dominated by calcific mitral stenosis mild MR, moderate tricuspid regurgitation 

Right Atrial Disease on the Lateral _ Only when it is very enlarged

 

Where is the Right Atrium?

RIGHT ATRIUM (RA) on the LATERAL
In the normal patient the RA is not border forming and is not visible. It lies to the right and slightly inferior and anterior to the left atrium, posterior and superior to the right ventricle, and to the right and superior to the left ventricle
Ashley Davidoff MD
  • Axial Imaging Explaining why the RA cannot be see on the Lateral –
    • since it is neither anterior nor posterior border forming
NORMAL CARDIAC ANATOMY ON A GATED CT SCAN
Axial images through the RA show the right atrial appendage in the top row and the body of the RA in the bottom row, neither of which would be visible on the lateral exam.
Ashley Davidoff MD
  • When the RA enlarges-
    • it moves laterally and anteriorly see CT below so that it can now be an anterior border forming structure
DOMINANT RIGHT ATRIAL ENLARGEMENT CT SCAN – RETROSTERNAL AIRSPACE OCCUPIED MOSTLY BY THE RA
83-year-old male with significantly enlarged right atrium, as well as a mildly enlarged left atrium with evidence of CAD, atrial fibrillation and hypertension.
On CT scan the right atrium and appendage (blue overlay (b,d,f) are positioned against the anterior chest wall and sternum (red arrowheads). On the superior most images (b,d) the RV is not present and only takes up a retro-sternal position alongside the right atrium on the most inferior image (f)
Ashley Davidoff MD
RAE on the Lateral
DOMINANT RIGHT ATRIAL ENLARGEMENT. LATERAL EXAMINATION
83-year-old male with significantly enlarged right atrium, as well as a mildly enlarged left atrium with evidence of CAD, atrial fibrillation and hypertension.
On the lateral CXR, the right atrium the blue line overlay indicates the position of the RV against the anterior chest wall. In addition, the right atrial appendage is so large (see CT below) that it lies against the sternum. The RA therefore occupies the entire retrosternal air space and results in decrease of the retrosternal airspace. This is the rare instance when the RA shares with, but dominates the anterior retrosternal position with the RV.
Ashley Davidoff MD
DOMINANT RIGHT ATRIAL ENLARGEMENT
83 year old male with significantly enlarged right atrium, as well as a mildly enlarged left atrium with evidence of CAD, atrial fibrillation and hypertension.
On CT scan the right atrium is positioned against the anterior chest wall. In addition, the right atrial appendage is so large that it lies against the sternum as well resulting in a decrease in the retrosternal air space. On the lateral, the cardiac shadow takes up more than 1/2 of the diaphragm. In this uncommon instance this finding is caused by the enlarged right atrium rather than LVE
Ashley Davidoff MD

 

Next

Davidoff  with Notes Scales and Music of the Axial Imaging of the Heart

NOTES SCALES AND MUSIC – AXIAL IMAGING OF THE HEART

 Notes

As we scan from superior to inferior

  • NOTES OF THE HEART ON CT
    As we start from top to bottom we scan through the PA, aorta, then LA RA, RV and LV
    Ashley Davidoff MD

Scales

Going superior to inferior and clockwise

1st stop Aorta LA 

      • FIRST STOP
        Max AP dimension of the LA in the region of the aorta. At this point the LA looks rectangular
        Ashley Davidoff MD 

2nd Stop
4 chamber

NORMAL VOLUME EVALUATION OF THE ATRIA AND VENTRICULAR CAVITIES ON A GATED CT SCAN
Axial images through the 4 chambers at the level of the A-V valves during diastole (mitral valve open) enables an approximate volume evaluation of the chambers. The atria are approximately the same volumes, and are about 1/3 the volume of the ventricles. The right ventricle (RV) is about 2/3 the volume of the left ventricle (LV)
Ashley Davidoff MD
3rd Stop MPA and Bifurcation
3rd STOP
MPA – Aorta
Ashley Davidoff MD

What to do at each stop

Stop 1

NORMAL LINEAR DIMENSION OF THE LA ON A GATED CT SCAN
Stop 2

 

HOW THE SCALES PROCEED
Clockwise Rotation
NORMAL LINEAR DIMENSION OF THE RIGHT ATRIUM ON A GATED CT SCAN
Axial images through the body of the right atrium (RA) at the level of the tricuspid valve shows a linear dimension of 4.2cms (normal up to about 5cms)
Ashley Davidoff MD
NORMAL LINEAR DIMENSION OF THE RIGHT VENTRICULAR CAVITY ON A GATED CT SCAN
NORMAL LINEAR DIMENSION OF THE LEFT VENTRICULAR CAVITY ON A GATED CT SCAN
NORMAL THICKNESS OF THE LV SEPTUM AND FREE WALL ON A GATED CT SCAN
Get a Sense of Relative Volumes
NORMAL VOLUME EVALUATION OF THE ATRIA AND VENTRICULAR CAVITIES ON A GATED CT SCAN
3rd Stop PA and Aorta
NORMAL LINEAR DIMENSION OF THE MPA AND AORTA ON A GATED CT SCAN
Practice Practice Practice
  • Music
    • LAE
    • RAE
    • RVE
      • RV dilated
      • RVH
    • LVE
      • Dilated LV
      • LVH

Thus

  • First Image
    • top left image
      • sizes to remember (approximate +/- 1cms) Mantra 4,5,4,5
    • top right image –
      • at the level of the mitral valve the atria are about the same size and about 1/3 the size of their respective ventricles
    • bottom left
      • at this level the overall volume of the RV is about 2/3 the size of the LV
    • bottom right
      • In diastole (if you can appreciate open mitral valve) thickness is up to 1.2 cms – 1.4 is upper limits normal
  • Next series of images – as you start from the top of the heart on the axial image and follow the order so you can remember mantra (4,5,4,5 – of the approx sizes of the structures)
    • Where to measure LA –
      • Look for the aorta – and then look up and down till you find max dimension
    • Where to measure RA
      • See where the approx position of TV  and the from posterior wall to the TV
    • Where to measure RV and LV cavity dimensions
      • – at at the level of the A-V valves or mid septum by the moderator band
    • LV wall thickness
      • Same level
    • Overall Volume Assessment
      • At the same level  Rule of thirds for volume
    • MPA and Ao
      • At bifurcation of MPA
    • Systole and diastole to look assess EF
      • On gated images – compare peak systole to diastole using eyeball and mitral or tricuspid valve  and use rule of thirds

Summary

NOTES SCALES AND MUSIC
At the level of the mitral valve which is also about mid septum, the chambers are relatively all best visualised. This is a place where approximate size can be evaluated

LA +/- 4cms (post wall to MV)

NORMAL LINEAR DIMENSION OF THE LA ON A GATED CT SCAN
The aorta is a reference structure and is usually about the same size or smaller. In this instance it is 3.5cms.

RA +/- 5cms (post wall to TV)

NORMAL LINEAR DIMENSION OF THE RIGHT ATRIUM ON A GATED CT SCAN
(normal up to about 5cms)

RV +/- 4cms (transverse) not >6

NORMAL LINEAR DIMENSION OF THE RIGHT VENTRICULAR CAVITY ON A GATED CT SCAN
(normal up to about 4-5cms)

LV +/-  5cms (transverse) not >6

NORMAL LINEAR DIMENSION OF THE LEFT VENTRICULAR CAVITY ON A GATED CT SCAN
 (normal up to about 5-5.5cms)

LV Thickness in Mid Septal Region

Buzz 

1.2 

NORMAL THICKNESS OF THE LV SEPTUM AND FREE WALL ON A GATED CT SCAN
Axial images through the left ventricle (LV) in mid septal region at the level of the opened mitral valve (early diastole) shows a septal thickness of 8.8mms and free wall thickness of 9mms (normal up to about 12mms)
Ashley Davidoff MD

Volume Assessment of the Cavities (Rule of Thirds)

Buzz

RA = LA = 1/3 ventricles

RV = 2/3 LV

 

NORMAL VOLUME EVALUATION OF THE ATRIA AND VENTRICULAR CAVITIES ON A GATED CT SCAN
Axial images through the 4 chambers at the level of the A-V valves during diastole (mitral valve open) enables an approximate volume evaluation of the chambers. The atria are approximately the same volumes, and are about 1/3 the volume of the ventricles. The right ventricle (RV) is about 2/3 the volume of the left ventricle (LV)
Ashley Davidoff MD

PA/Ao

Buzz

3/3.5

NORMAL LINEAR DIMENSION OF THE MPA AND AORTA ON A GATED CT SCAN
Axial images through the main pulmonary artery (MPA) and proximal ascending aorta (Ao) shows a MPA measurement of 2.5cms (normal up to 3cms) and referenced to the aorta usually about the same size or
Ashley Davidoff MD

Volumes in Systole and Diastole

NORMAL MRI IN SYSTOLE AND DIASTOLE
19 year old male with syncope with normal MRI.
Images a and b show peak systole with volumes of the LV and RV about 1/3 the volume of their respective ventricles when in diastole. This leaves 2/3 of volume has been ejected implying that the ejection fraction is 66%
Ashley Davidoff MD

 

Summary
NOTES SCALES AND MUSIC
At the level of the mitral valve which is also about mid septum, the chambers are relatively all best visualised. This is a place where approximate size can be evaluated
Ashley Davidoff MD

LV Mass and LV Mass Index

Left ventricular mass and left ventricular mass indexed to body surface area estimated by LV cavity dimension and wall thickness at end-diastole.

Method
  • Evaluation on short axis parallel to the true LV short axis
  • LV mass is measured at a single time point within the cardiac cycle (the standard is end-diastole)
  • single breath-hold removes respiratory artifact.
  • About 10 slices will cover the ventricle,
  • Simpson’s method (“stack of disks”)
  • calculated from the
    • product of the myocardial volume
      • difference between the epicardial and endocardial LV volumes by a semi-three dimensional data set
    • specific gravity of heart muscle (1.05 g/ml).
LV MASS EVALUATION
Diagrammatic representation of the LV with typical CMR short axis images obtained.
Myerson,S et al Assessment of Left Ventricular Mass by Cardiovascular Magnetic Resonance
Hypertension Vol. 39, No. 3 2002

 

BSA Calculator 

Normal Values have such a wide range depending on sex age and race – Echo and MR measurement are fairly consistent

Females about 60 g/m2
Males about 70 g/m2

 

 

 

References and Links

LV mass was significantly higher in males compared to females (mean ± SD of 53 ± 9 g/m2 vs 42 ± 7 g/m2). Petersen et al JCMR

Normal values of LV mass indexed to body surface area were found to be 70  (+/- 6-9 g/m2 in men and 61 (+/- 6 -8 g/m2 in women. Mizukoshi, showed echo and MR good correlation

Normal values of LV mass indexed to body surface area were found to be 60  (+/- 9 g/m2 in men and 49  (+/- 7 g/m2 in women). Fuchs EHJ CV Imaging

Reference Ranges & Partition Values for LV Mass Indexed To BSA (g/m2)
Female Male
Reference Range 43-95 49-115
Mildly Abnormal 96-108 116-131
Moderately Abnormal 109-121 132-148
Severely Abnormal ≥122 ≥149
Chuang, et al Manning CMR Reference Values for Left Ventricular Volumes, Mass and Ejection Fraction Using Computer-Aided Analysis: The Framingham Heart Study  JMRI

 

Aurigemma G1, Davidoff A, Silver K, Boehmer J.

Mizukoshi, Left ventricular mass quantitation using single-phase cardiac magnetic resonance imaging.  1992 Jul 15;70(2):259-62.

Mizukoshi, MD,  et al CLINICAL INVESTIGATIONS
LEFT VENTRICULAR MASS AND FUNCTION
Normal Values of Left Ventricular Mass Index Assessed
by Transthoracic Three-Dimensional
Echocardiography

 

 

Our Patient

65 year old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s

JACCOUD’S ARTHROPATHY
65 year old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s  Xray shows non erosive arthropathy with ulnar deviation of 2nd through 5th MCP joints
SLE
Heart
  • Pancarditis
    •  pericardium, pericarditis 25% most common
    • myocardium, myocarditis is rare and caused by vasculitis
    • endocardium – Libman-Sacks 10%  mitral and tricuspid valve
  • myocardial infarction 9X increase
  • Cardiac complications in  about 50% and major cause of death

SLE and the Heart TCV

Scleroderma
  • Heart
    • Pulmonary hypertension secondary to lung and renal disease
      • right sided disease – increase RV and RA
    • Pancarditis
      • pericardial disease
      • myocardial disease, – myocardial fibrosis
      • conduction system abnormalities, arrhythmias,
      • Endocardium and valvular disease – infrequent
  • Scleroderma,  Pulmonary Hypertension RVF Cor Pulmonale Pericardial effusion
    40 year old female with known interstitial lung disease (a and b) shows enlarged right atrium and right ventricle and small pericardial effusion (c and overlaid in maroon in d) and enlarged esophagus (overlay in pink in d) and an edematous gallbladder wall from chronic right heart failure.
Hands

Soft Tissue Calcification Ulnar Deviation

SCLERODERMA
Radiographs of both hands show abnormal alignment of the metacarpophalangeal joints, most marked on the left, in keeping with subluxation. The bone density appears normal. There is joint space loss and evidence of erosive arthropathy particularly evident at the metacarpophalangeal joinft of the right 3rd and 4th MCP’s. Dense soft tissue calcifications are seen in the fingertips and along the ulnar aspect of the right wrist/distal forearm.
Case courtesy of Dr Jan Frank Gerstenmaier,
Radiopaedia.org, rID: 23125

Acroosteolysis

SCLERODERMA
Acroosteolysis in a female patient with scleroderma
Case courtesy of Dr Minh Xuan Truong,
Radiopaedia

 

TCV –Scleroderma and the Heart

Rheumatoid Arthritis
Heart
  • Increased incidence of
    • congestive heart failure and
    • ischemic heart disease associated with an
    • increased mortality
  • Pancarditis
Hands

Erosive Osteoarthritis dominant in the MCPs and Carpals

RHEUMATOID ARTHRITIS
Showing degenerative and erosive changes dominantly at the MCP joints, intercarpal joints, ulnar carpal and radiocarpal joints and to lesser extent the PIP joints. There is ulnar deviation more prominent on the right hand
Ashley Davidoff MD

Rheumatoid Arthritis and Heart Disease TCV
RA and the Hand TCV

For more extensive info in see TCV on Hands and Heart 

? Cardiomegaly ? CHF

CARDIOMEGALY – LVE RVE
Chest Xray of a 65 year old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s presented with 2 weeks of dyspnea and elevated troponins suggestive of a STEMI.

 

Places to review

Cardiothoracic ratio
Shape of the Heart (ovoid or triangle)
Carinal angle for LA enlargement
Equalisation cephalisation, interstitial edema

 

CARDIOMEGALY – LVE RVE
Chest X-ray of a 65-year-old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s presented with 2 weeks of dyspnea and elevated troponins suggestive of a STEMI. CXR on the frontal view shows a CT ratio that is probably normal, equivocal carinal angle and no evidence of CHF. Lateral exam suggests RVE with RV : sternal ration being >30% and LV: diaphragm ratio being >33%
Ashley Davidoff MD

 

Answer

Probable LVE and RVE

Unusual PA not enlarged and LA not enlarged

Mitral Annular Calcification
  • Degenerative process associated with
    • aging,
    • cardiovascular risk factors.
  • Degeneration from increased mitral valve stress
    • Aortic Stenosis
    • Hypertension
    • Hypertrophic Cardiomyopathy
  • Also seen in
    • chronic kidney disease, (Ca PO4 disorder)
    • following radiation therapy. 
  • Associated with
    • arrhythmias and heart blocks
    • MS and MR are rare
Our Case

Mitral Annulus and Aortic Annulus Calcification

MITRAL ANNULAR AND AORTIC ANNULAR CALCIFICATION
Other Examples
MAC and  IHD
MAC and IHD – FAT AND CALCIUM IN THE HEART
56 year old male with history of coronary artery disease. Axial CT through the heart shows apical curvilinear fat (yellow arrowheads, ( a and b) associated with apical myocardial dystrophic calcification (green arrowheads c and d) both indicating prior apical MI. In addition there mitral annular calcification (red arrowhead, b) and multifocal fatty deposits in the RV (white arrowheads, a and b) usually depicting age related degenerative changes.  The calcification in the annulus is premature and unusual for this 56 year old male patient. Note the small bilateral pleural effusion The association of atherosclerosis and MAC are well known.  Premature MAC should therefore be a warning for premature heart disease.
Ashley Davidoff MD
Examples of Uncommon Complications
Heart Block, MR and MS

SEVERE MITRAL ANNULAR CALCIFICATION
Axial CT through the mitral annulus shows severe mitral annular calcification extending into the ventricular cavity and the ventricular septum.

MAC and Caseous Necrosis

MAC and CASEOUS NECROSIS
69 year old female with MAC who presents with an echo finding of a mass on the mitral valve thought to represent a myxoma. CT confirmed a low-density mass measuring in the soft tissue range associated with mitral annular calcification. 

MAC and CASEOUS NECROSIS T1 BRIGHT
. MRI showed a mass in the region of the posterior leaflet of the MV with T2 hyperintensity suggesting aqueous component and T1 hyperintensity suggesting increased protein content. There was no enhancement of the lesion. Peripheral T1 and T2 low intensity reflects calcification. A diagnosis of caseous necrosis of MAC is most likely
MAC and CASEOUS NECROSIS T2 BRIGHT
MRI showed a mass in the region of the posterior leaflet of the MV with T2 hyperintensity suggesting aqueous component (upper image) and focal T1 low intensity nodule on the posterior leaflet reflects the MAC  There was no enhancement of the lesion.  A diagnosis of caseous necrosis of MAC is most likely
MAC Dextrocardia and Bacterial Endocarditis

DEXTROCARDIA, MAC and BACTERIAL ENDOCARDITIS

Links and References

MAC – Medscape

Abramovitz Y et al Mitral Annulus Calcification. J Am Coll Cardiol 2015;66:1934-1941. (excellent review)

Allison M, et al Mitral and Aortic Annular Calcification Are Highly Associated With Systemic Calcified Atherosclerosis  Circulation Vol. 113, No. 6

Rodriguez C et al Association of Annular Calcification and Aortic Valve Sclerosis With Brain Findings on Magnetic Resonance Imaging in Community Dwelling Older Adults

The Cardiovascular Health Study

Volume 57, Issue 21, May 2011G

  • The points I want to try and get across
  • How to diagnose constrictive pericarditis  on CT
    • Questions and Answers
        • What are the signs of constrictive pericarditis on CT
          •  pericardial thickening
            • diffuse or localized(2mm – 3mm equivocal)
          • signs of impaired diastolic filling of the right ventricle
          • ie signs of  right heart failure including
            • dilatation of the
              • RA
              • IVC and hepatic veins
              • Coronary Sinus
              • Azygos vein
              • Hepatomegaly
          • What is the role of the CXR and LA in Dx
            •  increase in left atrial because it cannot fill therefore
            • increase in pulmonary venous pressure
            • Usually normal size LA
              • However since LA hmay be only partly covered by pericardium, it may in fact enlar

 

  • In our patient there is
    • no pericardial thickening
    • minor pericardial calcification
CORONARY CALCIFICATION AND PERICARDIAL CALCIFICATION
CORONARY CALCIFICATION AND PERICARDIAL CALCIFICATION
  • There are
      • focal adhesions near the LAD
PERICARDIAL ADHESION
Are There Signs of Constriction?

Consider

Pericardium Thickness
Size of the Right Atrium
? CONSTRICTION  – NORMAL SIZED ATRIAL CHAMBERS
The axial image through the region of the AV valves shows normal sized atria. Constriction would be unlikely in the face of a normal sized right atrium.  Note the flattened surface of the right atrium
Ashley Davidoff MD
? Size of the Coronary Sinus
? CONSTRICTION  – NORMAL SIZED CORONARY SINUS
The axial image through the region of the  normal sized coronary sinus. Constriction would be unlikely in the face of a normal sized coronary sinus. Note the flattened surface of the right atrium.
Ashley Davidoff MD
? Size of the Azygos Vein and IVC
QUESTION CONSTRICTION
The axial image is through the region of the normal azygos vein (above) and the normal sized IVC (below). Constrictive pericarditis would be unlikely in the face of a normal sized azygos vein and IVC.

Thus constrictive pericarditis is not present

ABR

Links and References

Napolitano  G et al Imaging Features of Constrictive Pericarditis: Beyond Pericardial Thickening  Canadian Association of Radiologists Journal  Volume 60, Issue 1, February 2009, (good review)

Senapati A et al,  Disparity in spatial distribution of pericardial calcifications in constrictive pericarditis Openheart BMJmj. Volume 5, Issue 2

Khalid, N et al Pericardial Calcification StatPearls

  • First our patient
    • subtle linear fat accumulation in the septum in this patient with CAD
  • Second
    • show examples of fat in the heart

There are a lot of cases – Do not feel the need to complete in 3 minutes

FAT IN THE SEPTUM
Clinical summary of a 65 year old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s presented with 2 weeks of dyspnea and elevated troponins suggestive of a STEMI. Cardiac cath showed 2 vessel disease and she was referred for CABG. At surgery there were adhesions and the surgeon was unable to identify the coronaries as a result of the fibrosis. She was closed without surgery. She subsequently had a diagnostic MRI and endomyocardial biopsy which showed chloroquine related cardiomyopathy
Ashley Davidoff MD
Normal and Normal Variants

Epicardial and Pericardial Fat

THE PERICARDIUM , EPICARDIAL FAT AND PERICARDIAL FAT                                     CT scan through the 4 chambers shows a normal  pericardium (white line) surrounded by an inner lining of epicardial fat (yellow in contact with the red myocardium ) and an outer layer of pericardial fat)  .  Note that the coronary arteries (white dots run in the epicardial fat.                                                                        Ashley Davidoff MD heart anatomy P 08

 

 

Large Amount of Epicardial and Pericardial Fat associated with

    • increased cardiovascular risk, especially for coronary artery disease.  – Metabolic Syndrome
PERICARDIAL FAT
An axial T1 weighted MRI shows a large amount of fat (yellow overlay) around the heart. The epicardial fat is the inner layer and is intimately related to the heart and the pericardial fat is the outer layer. The normal pericardium is seen as a black line between the two layers of fat. Although the pericardium looks like a single layer, it actually consists of two structures – the epicardial serous component and the pericaricardial fibrous component. In pericardial effusion the two layers are separated.
The amount of fat is more than expected and this amount is often associated with Syndrome X.
Courtesy of Ashley Davidoff M.D. 32141.8 code normal heart epicardial fat pericardium anatomy cardiac imaging radiology MRI

 

Epicardial Fat with Mild Pressure Effect on the RV

EPICARDIAL FAT
CT scan through the RV and LV shows epicardial fatty accumulation in the subendocardium of the right ventricle. The normal pericardium, (white arrowhead) and normal epicardial fat (yellow arrowhead) are shown in the lower images.
Ashley Davidoff MD
130641L
Degenerative and Age Related Changes in the RV
AGE RELATED FAT INFILTRATION
Axial, non contrast CT scan of a 100 year old female showing physiological accumulations of fat in the right ventricle (RV) and likely in the papillary muscles of the left ventricle (LV)
Ashley Davidoff MD
In the RV Wall
CT scan through the RV shows fatty infiltration in the right ventricle. The normal pericardium, (white arrow) normal epicardial fat (orange) arrowhead) and fat infiltrating the RV (yellow arrow) are shown in (b)
Ashley Davidoff MD
130639L
Atrial Septal Lipoma and Large Amount of Pericardial Fat Patient on Steroids
ATRIAL LIPOMA
Axial CT scan through the heart is from a 71year old female who is on steroid therapy. A large amount of fat is noted in the epicardium (yellow arrowhead) and also in the interatrial septum resulting in an atrial lipoma.
In CAD and prior Myocardial Infarction
FAT AND CALCIUM IN THE HEART
56 year old male with history of coronary artery disease. Axial CT through the heart shows apical curvilinear fat (yellow arrowheads, ( a and b) associated with apical myocardial dystrophic calcification (green arrowheads c and d) both indicating prior apical MI. In addition there mitral annular calcification (red arrowhead, b) and multifocal fatty deposits in the RV (white arrowheads, a and b) usually depicting age related degenerative changes,
Ashley Davidoff MD

 

Unusual cases
Pericardial Lipoma

LIPOMA OF THE PERICARDIUM
CXR shows widening of the left main bronchus and a vague lucency at the apex of the heart,  CT shows lipoma  posterior to the LA

Lipoma at the SVC RA junction
LIPOMA OF THE SVC -RA JUNCTION
This image of a coronally acquired T1 weighted MRI image of the heart shows a high intensity mass surrounding the SVC and the entrance right atrium (RA) with narrowing of the SVC. There were no symptoms of SVC syndrome in this patient with known COPD. Note that the mass has the intensity of subcutaneous fat. An atrial lipoma is the most likely diagnosis.
Courtesy Jorge Medina
38449c
KEY WORDS
Cardiac, heart, vein, SVC , RA, mass, fat, lipoma, tumor, neoplasm, benign, imaging, radiology, MRI
LIPOMA OF THE SVC AND RA
This series of axial T1 weighted MRI images of the heart show a high intensity mass surrounding the SVC (blue arrowhead) and the entrance to the right atrium (RA). There were no symptoms of SVC syndrome in this patient with known COPD. Note that the mass has the intensity of subcutaneous fat. An atrial lipoma is the most likely diagnosis.
Courtesy Jorge Medina
LIPOMA OF THE SVC AND RA
This series of axial and coronal T1 weighted MRI images of the heart show a high intensity mass surrounding the SVC and the entrance to the right atrium. There were no symptoms of SVC syndrome in this patient with known COPD. Note that the mass has the intensity of the subcutaneous fat. An atrial lipoma is the most likely diagnosis.
Courtesy Jorge Medina
38449c
KEY WORDS
Cardiac, heart, vein, SVC , RA, mass, fat, lipoma, tumor, neoplasm, benign, imaging, radiology, MRI

FAT NECROSIS-Target shaped

EPICARDIAL FAT NECROSIS
79-year male with asymptomatic finding on axial CT of a focal sclerotic ring surround the epicardial fat on the right side of the heart (yellow arrowhead). This most likely reflects chronic epicardial fat necrosis
Ashley Davidoff MD

EPICARDIAL FAT NECROSIS
79-year male with asymptomatic finding on coronally reformatted CT of a focal sclerotic ring surround the epicardial fat on the right side of the heart (yellow arrowhead). This most likely reflects chronic epicardial fat necrosis
Ashley Davidoff MD
EPICARDIAL FAT NECROSIS
79-year male with asymptomatic finding on sagittally reformatted CT of a focal sclerotic ring surround the epicardial fat on the right side of the heart (yellow arrowhead). This most likely reflects chronic epicardial fat necrosis
Ashley Davidoff MD

Lipoma of the LV

PROBABLE LIPOMA OF THE LV
37 year old male with no history of CAD with a fat containing nodule at the LV apex most likely representing a lipoma of the myocardium
Ashley Davidoff MD

Kimura et al  Myocardial Fat at Cardiac Imaging: How Can We Differentiate Pathologic from Physiologic Fatty Infiltration?  RadioGraphicsVol. 30, No. 6

We should distinguish pathologically between  biventricular infiltration and hypertrophy

Biventricular hypertrophy is  really rare event
Biventricular thickening /infiltration is also uncommon but should be what we think about when both ventricles are thick

  • So first question to address
    • Normal thickness of LV in diastole (number to remember is 1.2  but upper limits 1.4cms)
    • Normal thickness of RV in diastole (hard to measure but 3-5mms)
  • next question
    • What are the infiltrative cardiomyopathies that can cause biventricular infiltration
    • Most important to remember are
      • amyloidosis
      • sarcoidosis
      • Less commonly
        • Hemochromatosis
        • Fabry disease,
        • Danon disease, and
        • Friedreich’s ataxia.
    • How do they affect function
      • primarily affect diastolic function and
      • less commonly systolic function

Examples of  Biventricular Thickening/Infiltration?

Our case with SLE, Sjogrens Raynauds
Biventricular Infiltration
Two other more common causes of biventricular infiltration and thickening
    • Amyloidosis of the heart
    • Sarcoidosis of the heart

 

Left Ventricular Septal and Free Wall Thickening Atrial Septal Thickening

CARDIAC AMYLOIDOSIS with LV THICKENING – INFILTRATION VS LVH

Non gated axial CT through the opening of the mitral valve suggests early diastole confirms concentric thickening. The septum measures 24.1mms while the free wall measures 19.7mms. Upper limits normal is 14mms.

Cardiac Amyloidosis with Right Ventricular InfiltrationCARDIAC AMYLOIDOSIS

Non gated sagittal CT through the RVOT shows RVH (right ventricular thickening) wall measuring between 6-7mm  involving both the RV inflow as well as the outflow See Case 006

Delayed gadolinium in Short Axis Shows Diffuse Dominantly Subendocardial and Myocardial LGE in both LV and RV
CARDIAC AMYLOIDOSIS LGE SEQUENCE
Gated short axis delayed gadolinium sequence through the base LV during diastole and shows subendocardial LGE (red arrowheads in a,b,c, and d, diffuse mid myocardial LGE (white arrowheads) (a,b,c,d) and subepicardial LGE in the RV (yellow arrowheads (b,c)
Ashley Davidoff MD See Case 006
  • Key Issues for Cardiac Amyloid
    • The hallmark of CA
      • increased left ventricular thickness
      • but can be LV and RV and
      • BIatrial dilatation
      • Subendocardial LGE
      • Apical sparing
  • Difficult to null
Sarcoid Cardiomyopathy with Thickening of Both Ventricles Due to Biventricular Infiltration and Subepicardial LGE
BI-VENTRICULAR INFILTRATION WITH THICKENING

 

Key Issues  for Sarcoidosis
  • Similar affinity for lymphatics as in sarcoid of the lungs
    • Lymphatics of the heart are subepicardial
      • LGE characteristically subepicardial
    • Also patchy, multifocal  nodular mid myocardial
    • most characteristic
      • free wall and
      • medial basal septum (conduction abnormalities)

25-30% cardiac involvement

 

  • Other Infiltrative Disease with Biventricular Infiltration and Thickening
      • hemochromatosis
      • Less commonly
        • Fabry disease,
        • Danon disease, and
        • Friedreich’s ataxia.
AD will discuss the following diagrams
“A” is for congo red Amyloid
“A” INSIDE the HEART is for CONGO RED AMYLOIDOSIS
The hallmark of cardiac amyloidosis  is LGE involving subendocardial regions with apical sparing and sometimes the atria
Ashley Davidoff MD
Re Other Chamber Involvement with Wall Thickening and Enlargement
CARDIAC MUSCLE INFILTRATION OF CONGO RED AMYLOIDOSIS
In cardiac amyloidosis increased LV thickness is common , but may involve RV and atrial septum with bilateral atrial enlargement.
Ashley Davidoff MD
and Sarcoidosis
Disease Location and Form
“S” STARTING SUPERFICIALLY NEAR THE SURFACE OF THE HEART
The hallmark of cardiac sarcoidosis is LGE involving subepicardial regions of lateral free wall as well as medial basal septum but also mid myocardial with linear patchy and nodular forms.
Biventricular involvement is common
BIVENTRICULAR INFILTRATION
Sarcoidosis involves both ventricles and may cause bi-ventricular thickening
Ashley Davidoff MD

 

Would like you to tackle the concept of diastolic heart failure in our patient  who is a 65 year old female with SLE and an infiltrative cardiomyopathy and presenting with dyspnea  She does have CAD but also has an infiltrative disease

So the question is does she have diastolic heart failure to account for her symptoms

Diastolic Heart Failure
aka
Heart failure with preserved ejection fraction (HFpEF). 

 

  • Structural Abnormality
    • Thick Wall Small cavity
    • Enlarged Left Atrium
  • Physiology
    • Low Cardiac Output
    • Elevated End Diastolic Pressures

Many causes

  • Most common
  • We have established in our patient that
    • both her ventricles are thick walled
    • making infiltrative disease most likely
LVH
MRI with 4 chamber view from “black blood” T2 weighted imaging of a 65 year old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s presented with 2 weeks of dyspnea and elevated troponins suggestive of a STEMI. Cardiac cath showed 2 vessel disease and she was referred for CABG. At surgery there were adhesions and the surgeon was unable to identify the coronaries as a result of the fibrosis. She was closed without surgery. She subsequently had a diagnostic MRI and endomyocardial biopsy which showed chloroquine related cardiomyopathy
Ashley Davidoff MD
  • Regarding other criteria
    • Is the cavity small?  and
    • What does her ejection fraction look like?
      • Systole to left and diastole to right
SYSTOLE AND DIASTOLE 2 CHAMBER AND LVOT DIASTOLIC HEART FAILURE IS SUGGESTED
The images on the right are taken at peak systole and those on the left are peak diastole.  It would appear that volume in the cavity at peak systole on both views is about 1/2 the original volume suggesting  an EF of about 50%

 

Yes the LV cavity is small both by measurement and subjective assessment
  • Re EF (subjective)
    • the end systolic volume is small but is about 1/2 the volume  of the end diastolic volume
  • Re EF (objective)
    • Calculated EF was 60%
  • Re LAE?
  • NORMAL SIZED ATRIAL CHAMBERS

    Both LA and RA look normal

Cardiac Output/Index

Calculated cardiac Index was 2.8 L/min/m2 ( normal range for CI is 2.5 to 4 L/min/m2.)

  • So she has some features of diastolic heart failure

    • Small LV cavity
    • Thick walled LV
    • CI lower limits normal
  • But
    • LA is normal in size
    • Calculated wedge pressure is normal

Nulling the Myocardium

Normal

The MRI shows 3 images with different IR inversion times to try and individualize the maximal nulling of the myocardium prior to the evaluation for delayed gadolinium enhancement.

Our Patient
difficulty with nulling on inversion recovery sequences at different times

We were unable to null the myocardium (both LV and RV) because of diffuse infiltration  This appearance is highly characteristic of amyloid of the heart

Conclusion

SUMMARY CHLOROQUINE CARDIOMYOPATHY

So we know we have diffuse infiltration of both the LV and RV infiltration  based on our nulling attempts Amyloidosis is the classical example of this entity

Amyloidosis Leading Diagnosis

However

PRE AND POST GAD SHORT AXIS
Short axis during first pass while still in RV (above) and then delayed post gadolinium shows diffuse mid myocardial circumferential LGE enhancement consistent with an infiltrative cardiomyopathy
Ashley Davidoff MD
SHORT AXIS POST GAD with RINGS OF MID MYOCARDIAL ENHANCEMENT
Short axis images on the delayed post Gad images show 3 rings of LGE. Image b (correlate with image a) is through the body of the LV and shows mid myocardial LGE seen as an almost complete ring of diffuse accumulation (green arrowheads), a thin ring of more peripheral mid myocardial LGE (yellow arrowhead) together with probable pericardial LGE (yellow arrow head)
In image d (correlate with image c) near the apex of the heart, there are 2 distinct rings of a linear morphology in the mid myocardium. The inner ring (green arrowhead) has some focal nodularity and an outer mid myocardial ring (yellow arrowhead) . Subepicardial or pericardial enhancement is suggested as well (pink arrowhead).
Ashley Davidoff MD
“A” INSIDE the HEART is for CONGO RED AMYLOIDOSIS
The hallmark of cardiac amyloidosis  is
LGE involving subendocardial regions with apical sparing
Ashley Davidoff MD

As we learned

CARDIAC MUSCLE INFILTRATION OF CONGO RED AMYLOIDOSIS
In cardiac amyloidosis increased LV thickness is common , but may involve RV and atrial septum with bilateral atrial enlargement.
Ashley Davidoff MD
SHORT AXIS COMPARISON OF CHLOROQUINE AND AMYLOID CARDIOMYOPATHY
It was difficult to null the myocardium on both these patients.
The images are organized from the atria (top images through the bases, bodies and apices (lowest images) of the left ventricles.
The chloroquine cardiomyopathy shows no LGE of the atria, but progressive linear circumferential mid- ventricular LGE through to the apex
The amyloid cardiomyopathy hase LGE in both atrial walls, circumferential LGE through the base and body o the LV but sparing of the apex.
Ashley Davidoff MD
amyloid case 131429

 

Summary

Notes Scales and Music

JACCOUD’S ARTHROPATHY
65 year old female with longstanding history of SLE, Lupus Sjogren’s and Raynaud’s presented with 2 weeks of dyspnea and elevated troponins suggestive of a STEMI. Cardiac cath showed 2 vessel disease and she was referred for CABG. At surgery there were adhesions and the surgeon was unable to identify the coronaries as a result of the fibrosis. She was closed without surgery. She subsequently had a diagnostic MRI and endomyocardial biopsy which showed chloroquine related cardiomyopathy
Ashley Davidoff MD

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