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DR. MUHAMMAD BIN ZULFIQAR
PGR IV FCPS SIMS/SHL
radiombz@gmail.com
21 Non-ischaemic Acquired Heart
Disease Grainger and Allison
• FIGURE 21-1 ■ Summary of classification system
proposed by American Heart Association.
(Modified from Maron et al.1).
• FIGURE 21-2 ■ M-mode (A) and B-mode (B, C)
echocardiography in hypertrophic cardiomyopathy.
M-mode allows measurements of left ventricle
diastolic diameter (44 mm) and systolic diameter (28
mm), as well as thickened interventricular septum (28
mm). (B, C) Diastolic and systolic short-axis images,
with clear evidence of hypertrophic septum.
• FIGURE 21-2 ■ M-mode (A) and B-mode (B, C)
echocardiography in hypertrophic cardiomyopathy.
M-mode allows measurements of left ventricle
diastolic diameter (44 mm) and systolic diameter (28
mm), as well as thickened interventricular septum (28
mm). (B, C) Diastolic and systolic short-axis images,
with clear evidence of hypertrophic septum.
• FIGURE 21-3 ■ B-mode (A, B) and Doppler
echocardiography (C, D) horizontal long-axis views, in
hypertrophic cardiomyopathy. (A, B) B-mode images
show basal septal hypertrophy. (C) Doppler
interrogation in outflow tract demonstrates a rest
systolic gradient of 30 mmHg, while (D) transmitral
flow evaluation shows an impairment of diastolic
function, with reduced E wave equalised to A wave.
• FIGURE 21-3 ■ B-mode (A, B) and Doppler
echocardiography (C, D) horizontal long-axis views, in
hypertrophic cardiomyopathy. (A, B) B-mode images
show basal septal hypertrophy. (C) Doppler
interrogation in outflow tract demonstrates a rest
systolic gradient of 30 mmHg, while (D) transmitral
flow evaluation shows an impairment of diastolic
function, with reduced E wave equalised to A wave.
• FIGURE 21-4 ■ Hypertrophic cardiomyopathy.
(A) Cine-MRI frame showing typical localisation
at basal septum. (B) Late gadolinium
enhancement MRI short-axis image: thickened
interventricular septum with large amount of
fibrosis (hyperintense intramural foci).
• FIGURE 21-5 ■ Cardiac CT in hypertrophic
cardiomyopathy. Short axis mid ventricular
image shows a diffuse left ventricle myocardial
hypertrophy, with prevalent involvement of
anterior wall.
• FIGURE 21-6 ■ Gadolinium-enhanced MRI:
short axis. (A) First-pass frame showing
intramural perfusion defect in lateral wall
(arrow); (B) late enhancement due to fibrosis
is evident in the same segment.
• FIGURE 21-7 ■ Different late gadolinium
enhancement in hypertrophic phenotypes. First
column, large septal intramural late enhancement in
hypertrophic cardiomyopathy (HCM) (arrows). Second
column: intramural lateral wall late enhancement in
Fabry disease (arrow). Third column: subendocardial
diffuse late enhancement in amyloidosis (arrow in left
ventricle, white arrows in right ventricle). Fourth
column: T2w image (top) showing intramural
hyperintense foci and striae due to oedema; lower
image shows late enhancement in the same areas.
• FIGURE 21-7 ■ Different late gadolinium
enhancement in hypertrophic phenotypes. First
column, large septal intramural late enhancement in
hypertrophic cardiomyopathy (HCM) (arrows). Second
column: intramural lateral wall late enhancement in
Fabry disease (arrow). Third column: subendocardial
diffuse late enhancement in amyloidosis (arrow in left
ventricle, white arrows in right ventricle). Fourth
column: T2w image (top) showing intramural
hyperintense foci and striae due to oedema; lower
image shows late enhancement in the same areas.
• FIGURE 21-8 ■ Primary dilative cardiomyopathy.
(A) Frontal view and (B) lateral view show
overall increased cardiac size, with signs of left
atrial enlargement (black arrows in A, thin white
arrows in B), and left ventricle enlargement (thick
black arrows in A, thick white arrow in B).
• FIGURE 21-9 ■ Dilative cardiomyopathy.
Echocardiography shows enlarged left
ventricle.
• FIGURE 21-10 ■ Black-blood FSE T1w image
of dilated cardiomyopathy. Left atrial and left
ventricle enlargement is clearly evident
• FIGURE 21-12 ■ Late gadolinium
enhancement images in short-axis and four-
chamber view, showing septal intramural
contrast uptake in idiopathic dilated
cardiomyopathy
• FIGURE 21-12 ■ Late gadolinium
enhancement images in short-axis and four-
chamber view, showing septal intramural
contrast uptake in idiopathic dilated
cardiomyopathy
• FIGURE 21-11 ■ Ischaemic versus non-ischaemic
dilated cardiomyopathy. (A) Diastolic frame of two-
chamber cine-MRI showing dilated left ventricle with
inferoapical myocardial thinning. (B) Late enhancement
in subendocardial layer of basal, mid and apical inferior
segments, due to previous infarct in right coronary
artery territory. (C) Diastolic frame of two-chamber
cine-MRI showing dilated left Ventricle. (D) Short-axis
late enhancement image, showing no gadolinium
uptake.
• FIGURE 21-11 ■ Ischaemic versus non-ischaemic dilated
cardiomyopathy. (A) Diastolic frame of two-chamber cine-
MRI showing dilated left ventricle with inferoapical
myocardial thinning. (B) Late enhancement in
subendocardial layer of basal, mid and apical inferior
segments, due to previous infarct in right coronary artery
territory. (C) Diastolic frame of two-chamber cine-MRI
showing dilated left Ventricle. (D) Short-axis late
enhancement image, showing no gadolinium uptake.
• FIGURE 21-13 ■ MRI of dilated
cardiomyopathy complication. Thrombi in left
ventricle are evident in late enhancement
four- (A) and two-chamber (B) views
• FIGURE 21-14 ■ Cardiac CT in dilated cardiomyopathy.
(A) Left ventricle dilation in four-chamber view. (B, C)
MIP reformatted images of right coronary artery,
common trunk and left descending coronary artery
showing no atherosclerotic lesions.
• FIGURE 21-14 ■ Cardiac CT in dilated
cardiomyopathy. (A) Left ventricle dilation in
four-chamber view. (B, C) MIP reformatted
images of right coronary artery, common trunk
and left descending coronary artery showing no
atherosclerotic lesions.
• FIGURE 21-15 ■ 2D echocardiography in restrictive
cardiomyopathy. End-diastolic frame on left, end-systolic
frame on right. In both images an endocardial thickening
with thrombotic layer and calcifications are evident.
Thickening of mitral valve is also present
• FIGURE 21-16 ■ Restrictive cardiomyopathy.
(A) SE T1w image and (B) cine-MRI frame,
both showing tubular shape of ventricles and
enlarged atria. In (B) a flow void in the left
atrium due to mitral regurgitation is evident.
• FIGURE 21-17 ■ Restrictive cardiomyopathy
due to fibroelastosis. (A) SE T1w image shows
an apparent thickened myocardium; (B) STIR
image shows a thickened hyperintense
endocardium (arrows) with normal
myocardium.
• FIGURE 21-18 ■ Cardiac amyloidosis. (A, B)
Contiguous T1w axial slices show marked myocardial
thickening of both ventricles, with heterogeneous
signal intensity; a small amount of pericardial effusion
is present (arrows). (C) Late gadolinium enhancement
shortaxis image shows no myocardial suppression due
to increased extracellular space and interstitial amyloid
accumulation.
• FIGURE 21-19 ■ Iron overload in major
thalassaemia. Multi-echo fast gradient-echo
sequence for T2* quantification; from a short
TE (1.1 ms, top left) to a long TE (18 ms,
bottom right), a rapid decay of myocardium
signal intensity
• FIGURE 21-20 ■ Constrictive pericarditis. (A) This axial
black-blood FSE image shows a diffuse pericardial
thickening (5 mm), more evident anteriorly. Note also
incomplete blood suppression in right atrium due to
slow flow. (B) Axial unenhanced cardiac CT confirms
pericardial thickening but also the presence of small
calcifications
• FIGURE 21-21 ■ European Society of Cardiology
classification of primary cardiomyopathies.
(Modified from Elliott et al.2).
• FIGURE 21-22 ■ Arrhythmogenic right ventricular cardiomyopathy.
Black-blood axial image shows a complete fatty substitution of right
ventricle free wall (high signal intensity tissue); similar foci are
evident in left ventricle apex and basal lateral wall (arrows).
• FIGURE 21-23 ■ T1w axial image in a patient receiving
intensive steroid treatment. An increased amount of
fat is evident in the mediastinum, prepericardial and
subepicardial spaces, but normal right ventricle
myocardium is visible.
• FIGURE 21-24 ■ Arrhythmogenic right
ventricular cardiomyopathy. Cine-MRI axial
(A) and short-axis (B) images show huge right
ventricle dilation with small free-wall bulges
(arrows in A).
• FIGURE 21-25 ■ Echocardiography. Two-chamber view
shows thickened endocardium and increased trabeculation
of left ventricle apex (arrows
• FIGURE 21-26 ■ Left ventricular non-
compaction. (A) T1w black-blood vertical long-
axis image shows increased number and
thickness of myocardial trabeculae in mid and
apical left ventricle regions. (B) Cine-MRI frame in
horizontal long axis with measurement of non-
compacted and compacted myocardium.
• FIGURE 21-27 ■ Left ventricular non-compaction. Late
enhancement images show contrast uptake in
compacted myocardium (mostly at septal level), with
subendocardial sparing, due to fibrotic changes. As an
ancillary finding, multiple thrombi are visible.
• FIGURE 21-28 ■ Takotsubo cardiomyopathy. (A)
T2w image in vertical long axis shows diffuse
hyperintensity of the myocardium, due to
oedema (arrows); (B) late enhancement image in
the same plane shows no contrast uptake,
demonstrating absence of any irreversible lesion.
• FIGURE 21-29 ■ Acute myocarditis. (A) T2w STIR short-axis
image shows a subepicardial hyperintense area in inferior
wall; (B) late enhancement image in corresponding plane
shows contrast uptake with a non-ischaemic pattern.
Patient presented 36 h before in emergency unit with chest
pain and slight increase in cardiac enzymes; emergency
coronary angiography was negative.
• FIGURE 21-30 ■ Chronic myocarditis in patients
presenting with new-onset severe tachyarrhythmia.
(A) T2w STIR short-axis image shows no evidence of
oedema; (B) late enhancement image in the same
plane shows septal intramural contrast uptake. Septal
endomyocardial biopsy demonstrated a lymphocytic
infiltrate with interstitial fibrosis
• FIGURE 21-31 ■ Chest X-ray, frontal view, in
intensive care unit shows signs of alveolar
pulmonary oedema without cardiac enlargement.
• FIGURE 21-32 ■ Chest X-ray shows left atrial appendage
enlargement (arrow) in mitral regurgitation; subcarinal
opacity with slight dislocation of upper left main bronchus
is also evident due to left atrium enlargement
• FIGURE 21-33 ■ Mitral prolapse.
Echocardiography (parasternal long axis)
shows wide anterior leaflet prolapse of the
mitral valve.
• FIGURE 21-34 ■ Mitral regurgitation. Echo
colour Doppler shows severe regurgitation in
the left atrium and marked left ventricle
enlargement (mitral annulus dilation).
• FIGURE 21-35 ■ Mitral regurgitation. Echo
colour Doppler shows severe mitral
regurgitation (apical 4C). Mosaic effect is
evident with complete occupation of the left
atrium.
• FIGURE 21-36 ■ Cine-MRI frame of functional
mitral regurgitation (black jet directed from left
ventricle to left atrium) in dilated cardiomyopathy
• FIGURE 21-37 ■ Mitral stenosis.
Echocardiography (parasternal long axis) shows
marked thickening of mitral leaflets with
restricted mitral valve orifice (doming anterior
leaflet). Left atrial (LA) enlargement is evident.
• FIGURE 21-38 ■ Cine-MRI frame of mitral stenosis. A
small flow void directed from left atrium (LA) to left
ventricle (LV) is visible (arrows), due to mild mitral
stenosis. Left atrium is enlarged.
• FIGURE 21-39 ■ Tricuspid regurgitation. Echo
colour Doppler demonstrates severe tricuspid
insufficiency with mosaic effect occupying
entirely the right atrium.
• FIGURE 21-40 ■ Cine-MRI frame of tricuspid
regurgitation. A retrograde black jet directed
from right ventricle to right atrium is evident
(arrowheads).
• FIGURE 21-41 ■ Chest X-ray of aortic stenosis shows rounded profile of
left ventricle (left third cardiac arch, white arrows), with slight
enlargement of ascending aorta (right first cardiac arch, arrowheads).
• FIGURE 21-42 ■ B-mode echocardiography,
horizontal long axis, in aortic stenosis.
Hyperechoic calcified aortic leaflets; mitral
annulus calcification is also evident.
• FIGURE 21-43 ■ Cardiac CT. Multiplanar short-axis reformation
aortic valve shows leaflet calcification with reduced systolic orifice.
Manual contouring of the orifice allows stenosis quantification
(moderate to severe: 187 mm2).
• FIGURE 21-44 ■ Cine-MRI frame in aortic
stenosis. In this threechamber view, a large flow
void due to blood flow acceleration is evident in
ascending aorta
• FIGURE 21-45 ■ (A) Cardiac CT and (B) cine-
MRI of a bicuspid aortic valve. In both images
only two semilunar leaflets are evident.
• FIGURE 21-46 ■ Chest X-rays of aortic
regurgitation. Frontal and lateral views
demonstrate left ventricle enlargement, as left
third cardiac arch widening in the frontal view,
and second posterior arch in the lateral view
(arrows).
• FIGURE 21-47 ■ Aortic regurgitation. Echo colour
Doppler shows aortic insufficiency, with a wide
jet, while continuous Doppler interrogation
shows a steep decay of the curve indicating
severity of regurgitation (rapid pressure drop
during diastole). Pressure half-time is <250 ms.
• FIGURE 21-48 ■ Cine-MRI frames of aortic
regurgitation. Retrograde jets in left ventricle
are evident as flow voids, in (A) with normal
aortic bulb, in (B) with annuloaortic ectasia.
• FIGURE 21-49 ■ MRI velocity map of mild
aortic regurgitation. Flow is measured in
ascending (red line) and descending aorta
(white line); area under the curve below zero
(green line) represents regurgitant flow.
• FIGURE 21-50 ■ Cardiac CT of aortic
regurgitation. Multiplanar short-axis reformation
of aortic valve demonstrates incomplete
coaptation of leaflets, with central orifice.
• FIGURE 21-51 ■ Examples of biological (A, B)
and mechanical (C, D) valvular prostheses.
• FIGURE 21-51 ■ Examples of biological (A, B)
and mechanical (C, D) valvular prostheses.
• FIGURE 21-52 ■ Chest X-rays, lateral views, of
mechanical (A) and biological (B) mitral valve
prostheses.
• FIGURE 21-53 ■ Chest X-rays, lateral views, of
mechanical (A) and biological (B) aortic valve
prostheses.
• FIGURE 21-54 ■ Chest X-rays, frontal views,
demonstrate the different orientation of the
left atrioventricular vector and the left
ventriculoaortic vector (black lines),
respectively, in (A) mitral and (B) aortic valve
replacements
• FIGURE 21-55 ■ Echocardiography of a
monoleaflet mitral valve, four-chamber view.
Right atrium (RA) enlargement with tricuspid
leaflet thickening is also evident.
• FIGURE 21-56 ■ Cardiac CT of mechanical
valvular prosthesis. (A) Coronal reformatted
image; (B) axial reformatted image of the
valve; (C) corresponding image of the valve.
• FIGURE 21-56 ■ Cardiac CT of mechanical
valvular prosthesis. (A) Coronal reformatted
image; (B) axial reformatted image of the valve;
(C) corresponding image of the valve.
• FIGURE 21-56 ■ Cardiac CT of mechanical
valvular prosthesis. (A) Coronal reformatted
image; (B) axial reformatted image of the
valve; (C) corresponding image of the valve.
• FIGURE 21-57 ■ Cine-MRI frames (A, short-
axis view; B, three-chamber view) show the
typical susceptibility artefact generated by
the mechanical aortic valve prostheses.
• FIGURE 21-58 ■ Transoesophageal
echocardiography in paravalvular aortic
abscess. An anechoic rim anterior to a
mechanical prosthesis is evident (arrows).
• FIGURE 21-59 ■ Cardiac CT of paravalvular aortic
leak. (A) Oblique coronal reformatted image of
ascending aorta and (B) short-axis reformatted
image of aortic valve demonstrate paravalvular
extravasation of contrast medium around the
prosthesis (arrows).
• FIGURE 21-60 ■ MRI of huge paravalvular leak after aortic
valve replacement. A large blood collection is evident,
adjacent to aortic root, due to a paravalvular leak. (A, B)
T1w axial and coronal oblique images show no signal in the
collection because of flowing blood (the small amount of
signal in the central part is due to slow turbulent flow). (C,
D) Gadolinium enhanced gradient-echo images in the same
planes demonstrate the passage of contrast medium in the
collection; the susceptibility artefact of the mechanical
valve is evident.
• FIGURE 21-60 ■ MRI of huge paravalvular leak after aortic
valve replacement. A large blood collection is evident,
adjacent to aortic root, due to a paravalvular leak. (A, B)
T1w axial and coronal oblique images show no signal in the
collection because of flowing blood (the small amount of
signal in the central part is due to slow turbulent flow). (C,
D) Gadolinium enhanced gradient-echo images in the same
planes demonstrate the passage of contrast medium in the
collection; the susceptibility artefact of the mechanical
valve is evident.
• FIGURE 21-61 ■ Pericardial involvement in mediastinal
malignant thymoma. (A) T1w axial image demonstrates an
oval-shaped mediastinal lesion adjacent to thickened
pericardium; lateral left pericardium shows a plaque-
thickening due to tumour diffusion (white arrow). (B) T2w
image shows high and heterogeneous signal intensity of the
mass. A left pleural effusion is also present.
• FIGURE 21-62 ■ Cystic teratoma of the pericardium,
with right atrium involvement. (A) T2w axial image
shows a large right paracardiac cystic tumour with
eccentric solid component; extracapsular tissue (black
arrows) also invades epicardial fat and abuts superior
vena cava (*), contacting the right coronary artery
(white arrow). (B) Post-contrast T1w corresponding
axial image demonstrates enhancement of the solid
components of the tumour
• FIGURE 21-63 ■ Two black-blood short-axis
T1w MRI images of mediastinal NHL, with
great vessel encasement, pericardial and
myocardial infiltration (arrow) and inferior
pericardial effusion (*).
• FIGURE 21-64 ■ T1w axial image shows a rounded slightly
hyperintense lesion in the left ventricle, arising from left
lateral wall (white arrows). A small amount of pericardial
effusion is evident (black arrow).
• FIGURE 21-65 ■ Left ventricle lung cancer metastasis. (A)
Contrast-enhanced CT image shows a heterogeneous mass
in the left ventricle. (B, C) T1w and T2w horizontal long-axis
MRI demonstrate the large implant of the lesion, involving
the lateral wall of the left ventricle, with T2 high signal
heterogeneity. (D) The left superior sulcus tumour is
evident on the coronal T1w image
• FIGURE 21-65 ■ Left ventricle lung cancer
metastasis. (A) Contrast-enhanced CT image
shows a heterogeneous mass in the left
ventricle. (B, C) T1w and T2w horizontal long-axis
MRI demonstrate the large implant of the lesion,
involving the lateral wall of the left ventricle, with
T2 high signal heterogeneity. (D) The left superior
sulcus tumour is evident on the coronal T1w
image
• FIGURE 21-66 ■ 2D echocardiography of
neoplastic thrombus from renal cell
carcinoma in inferior vena cava and right
atrium
• FIGURE 21-67 ■ Enhanced CT image shows
direct invasion of left atrium from a left
lower lobe bronchogenic carcinoma
• FIGURE 21-68 ■ Echocardiography (2D and 3D)
of atrial myxoma. On the left, systolic and
diastolic frames show a large hyperechoic
tumour of the left atrium passing through the
mitral valve; on the right, a 3D short-axis image
shows the tumour across the mitral valve.
• FIGURE 21-69 ■ (A) FSE T1w horizontal long-axis view
of left atrial myxoma: typical localisation in the area
of fossa ovalis, with heterogeneous signal intensity;
central hypointense area is due to calcifications. (B) FSE
T2w fat-suppressed image, same plane: lesion shows
heterogeneous hyperintensity with central dark area
• FIGURE 21-70 ■ Same case as described in the
caption to Fig. 21-45. (A) On SSFP image slight
heterogeneous hyperintensity of the lesion
compared with myocardium is evident; (B) late
gadolinium enhancement image shows tiny foci
of contrast uptake caused by fibrotic changes
• FIGURE 21-71 ■ Atrial myxoma of fossa
ovalis. (A, B) Axial T1 and T2 images show
heterogeneity in signal intensity of the lesion.
(C) and (D) are systolic and diastolic frames of
cine-MRI: prolapse of the pedunculated
myxoma through the mitral orifice is evident
• FIGURE 21-71 ■ Atrial myxoma of fossa
ovalis. (A, B) Axial T1 and T2 images show
heterogeneity in signal intensity of the lesion.
(C) and (D) are systolic and diastolic frames of
cine-MRI: prolapse of the pedunculated
myxoma through the mitral orifice is evident
• FIGURE 21-72 ■ Atrial septum lipoma. (A) Cardiac CT shows a
marked hypodense well-defined lesion; (B) T1w image
demonstrates marked hyperintensity of the lesion, completely
suppressed in STIR image (C). In (D) a frame from cine-SSFP shows
high to intermediate signal intensity of the tumour, while post-
contrast T1 GRE image does not demonstrate enhancement (E).
Furthermore, in all the MR images, a subpleural lipoma is evident
(*). (F) A different case of lipomatous infiltration of the interatrial
septum is reported, just to show the classical sparing of the fossa
ovalis (arrows).
• FIGURE 21-72 ■ Atrial septum lipoma. (A) Cardiac CT shows a
marked hypodense well-defined lesion; (B) T1w image
demonstrates marked hyperintensity of the lesion, completely
suppressed in STIR image (C). In (D) a frame from cine-SSFP shows
high to intermediate signal intensity of the tumour, while post-
contrast T1 GRE image does not demonstrate enhancement (E).
Furthermore, in all the MR images, a subpleural lipoma is evident
(*). (F) A different case of lipomatous infiltration of the interatrial
septum is reported, just to show the classical sparing of the fossa
ovalis (arrows).
• FIGURE 21-72 ■ Atrial septum lipoma. (A) Cardiac CT shows a marked
hypodense well-defined lesion; (B) T1w image demonstrates marked
hyperintensity of the lesion, completely suppressed in STIR image (C). In
(D) a frame from cine-SSFP shows high to intermediate signal intensity of
the tumour, while post-contrast T1 GRE image does not demonstrate
enhancement (E). Furthermore, in all the MR images, a subpleural lipoma
is evident (*). (F) A different case of lipomatous infiltration of the
interatrial septum is reported, just to show the classical sparing of the
fossa ovalis (arrows).
• FIGURE 21-73 ■ 2D echocardiographic subcostal
view shows a typical rhabdomyoma
(hyperechoic rounded lesion) attached to the
basal interventricular septum (calipers).
• FIGURE 21-74 ■ B-mode echocardiography
shows a small hyperechoic lesion (calipers)
attached to valve leaflets. At surgery a
fibroelastoma was found and resected.
• FIGURE 21-75 ■ Angiosarcoma of right ventricle. (A) Axial
T1w image shows a large tumour with irregular margins,
involving free wall of right ventricle, right atrioventricular
groove, tricuspid annulus and right atrium wall;
furthermore, multiple nodules are visible in both lungs,
with large consolidation in left inferior lobe; (B) T2w image
demonstrates high signal intensity of the tumour. (C, D)
Pre- and post-contrast T1w short-axis images show strong
enhancement of the tumour and the lung metastasis.
Biopsy confirmed the suspected angiosarcoma
• FIGURE 21-75 ■ Angiosarcoma of right ventricle. (A) Axial T1w
image shows a large tumour with irregular margins, involving free
wall of right ventricle, right atrioventricular groove, tricuspid
annulus and right atrium wall; furthermore, multiple nodules are
visible in both lungs, with large consolidation in left inferior lobe;
(B) T2w image demonstrates high signal intensity of the tumour. (C,
D) Pre- and post-contrast T1w short-axis images show strong
enhancement of the tumour and the lung metastasis. Biopsy
confirmed the suspected angiosarcoma
• FIGURE 21-76 ■ Interatrial mass, involving both atria. (A)
T1w axial image shows an isointense lesion, while (B) the
T2w image demonstrates a marked hyperintensity. (C) In
post-contrast T1w image a strong and homogeneous
enhancement of the mass is visible. Biopsy revealed an
angiosarcoma; compared with the case shown and
described in Fig. 21-49, this localisation is uncommon.
• FIGURE 21-76 ■ Interatrial mass, involving both atria. (A)
T1w axial image shows an isointense lesion, while (B) the
T2w image demonstrates a marked hyperintensity. (C) In
post-contrast T1w image a strong and homogeneous
enhancement of the mass is visible. Biopsy revealed an
angiosarcoma; compared with the case shown and
described in Fig. 21-49, this localisation is uncommon.
• FIGURE 21-77 ■ 2D echocardiographic subcostal
image in a case of rhabdomyosarcoma shows a
hyperechoic mass infiltrating the right
atrioventricular groove (white arrow). Pericardial
effusion is also evident (black arrows
• FIGURE 21-78 ■ T1w axial images show the
dark line of the pericardium (with a small
amount of fluid within) between the high
signal intensity of the prepericardial and
subepicardial fat.
• FIGURE 21-78 ■ T1w axial images show the
dark line of the pericardium (with a small
amount of fluid within) between the high
signal intensity of the prepericardial and
subepicardial fat.
• FIGURE 21-78 ■ T1w axial images show the
dark line of the pericardium (with a small
amount of fluid within) between the high
signal intensity of the prepericardial and
subepicardial fat.
• FIGURE 21-79 ■ Pericardial cyst. Contiguous
black-blood T1w axial images show a well-
defined lesion close to superior vena cava
and right atrium, with intermediate signal
intensity due to proteinaceous fluid content.
• FIGURE 21-79 ■ Pericardial cyst. Contiguous
black-blood T1w axial images show a well-
defined lesion close to superior vena cava
and right atrium, with intermediate signal
intensity due to proteinaceous fluid content.
• FIGURE 21-79 ■ Pericardial cyst. Contiguous
black-blood T1w axial images show a well-
defined lesion close to superior vena cava
and right atrium, with intermediate signal
intensity due to proteinaceous fluid content.
• FIGURE 21-79 ■ Pericardial cyst. Contiguous
black-blood T1w axial images show a well-
defined lesion close to superior vena cava
and right atrium, with intermediate signal
intensity due to proteinaceous fluid content.
• FIGURE 21-80 ■ Partial pericardial agenesis. (A) Chest
X-ray, frontal view, shows prominent left second
cardiac arch, with deep incisure between first and
second left cardiac arch; main pulmonary trunk is
deeply located in the lung. (B-D) Serial T1w axial MR
images show pulmonary trunk (B, C) out of mediastinal
margins (acute angle with anterior mediastinal fat)
while the heart (D) is completely rotated towards the
left, occupying the left hemithorax.
• FIGURE 21-80 ■ Partial pericardial agenesis. (A)
Chest X-ray, frontal view, shows prominent left
second cardiac arch, with deep incisure between
first and second left cardiac arch; main
pulmonary trunk is deeply located in the lung. (B-
D) Serial T1w axial MR images show pulmonary
trunk (B, C) out of mediastinal margins (acute
angle with anterior mediastinal fat) while the
heart (D) is completely rotated towards the left,
occupying the left hemithorax.
• FIGURE 21-81 ■ Pericardial effusion, chest X-
rays. (A) Frontal view shows double
contouring of left third cardiac arch (small
arrows); (B) lateral view demonstrates a
retrosternal opacity (arrows), contoured by fat
radiolucency (prepericardial and epicardial).
• FIGURE 21-82 ■ B-mode echocardiography
shows anterior anechoic fluid collection (*).
• FIGURE 21-83 ■ Pericardial effusion in
pericarditis. (A) T1w short-axis image shows no
signal in the effusion, with mild thickening of
the pericardium. (B) Cine-MRI frame shows
hyperintense signal of the effusion, due to its
prolonged T2 (SSFP signal is T2/ T1-dependent
• FIGURE 21-84 ■ Pericardial haematoma (post-
endomyocardial biopsy). (A) T1w horizontal
long-axis image shows well-circumscribed high
signal pericardial collection, abutting right atrium.
(B) T2w fat-saturated short-axis image
demonstrates the high signal of the collection
due to acute bleeding.
• FIGURE 21-85 ■ Pericarditis. (A) Cine-MRI
frame, short-axis image demonstrates mild
pericardial effusion (arrows). (B) Delayed
postgadolinium enhancement, same plane,
shows contrast uptake of pericardial layers,
due to inflammation
• FIGURE 21-86 ■ Constrictive pericarditis. (A) Chest X-ray, lateral
view, shows thick pericardial calcifications. (B, C) CT images
demonstrate the presence, site and thickness of pericardial
calcifications in a patient with pleuro-pulmonary tuberculosis
• FIGURE 21-86 ■ Constrictive pericarditis. (A) Chest X-
ray, lateral view, shows thick pericardial calcifications.
(B, C) CT images demonstrate the presence, site and
thickness of pericardial calcifications in a patient with
pleuro-pulmonary tuberculosis
• FIGURE 21-86 ■ Constrictive pericarditis. (A) Chest X-ray, lateral view,
shows thick pericardial calcifications. (B, C) CT images demonstrate the
presence, site and thickness of pericardial calcifications in a patient with
pleuro-pulmonary tuberculosis
• FIGURE 21-87 ■ Constrictive pericarditis. Axial
craniocaudal T1w images show a marked and
diffuse pericardial thickening in patient with
previous tuberculosis. Right atrial enlargement is
evident in the images B and C.
• FIGURE 21-87 ■ Constrictive pericarditis. Axial
craniocaudal T1w images show a marked and
diffuse pericardial thickening in patient with
previous tuberculosis. Right atrial enlargement is
evident in the images B and C.
• FIGURE 21-88 ■ Cystic teratoma of the pericardium,
with right atrium involvement. (A) T2w axial image
shows a large right paracardiac cystic tumour with
eccentric solid component; extracapsular tissue (black
arrows) invades also epicardial fat and abuts superior
vena cava (*), contacting the right coronary artery
(white arrow). (B) Post-contrast T1w corresponding
axial image demonstrates enhancement of the solid
components of the tumour
THANK
YOU

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21 non ischaemic acquired Dr.Muhammad Bin Zulfiqar

  • 1. DR. MUHAMMAD BIN ZULFIQAR PGR IV FCPS SIMS/SHL radiombz@gmail.com 21 Non-ischaemic Acquired Heart Disease Grainger and Allison
  • 2. • FIGURE 21-1 ■ Summary of classification system proposed by American Heart Association. (Modified from Maron et al.1).
  • 3. • FIGURE 21-2 ■ M-mode (A) and B-mode (B, C) echocardiography in hypertrophic cardiomyopathy. M-mode allows measurements of left ventricle diastolic diameter (44 mm) and systolic diameter (28 mm), as well as thickened interventricular septum (28 mm). (B, C) Diastolic and systolic short-axis images, with clear evidence of hypertrophic septum.
  • 4. • FIGURE 21-2 ■ M-mode (A) and B-mode (B, C) echocardiography in hypertrophic cardiomyopathy. M-mode allows measurements of left ventricle diastolic diameter (44 mm) and systolic diameter (28 mm), as well as thickened interventricular septum (28 mm). (B, C) Diastolic and systolic short-axis images, with clear evidence of hypertrophic septum.
  • 5. • FIGURE 21-3 ■ B-mode (A, B) and Doppler echocardiography (C, D) horizontal long-axis views, in hypertrophic cardiomyopathy. (A, B) B-mode images show basal septal hypertrophy. (C) Doppler interrogation in outflow tract demonstrates a rest systolic gradient of 30 mmHg, while (D) transmitral flow evaluation shows an impairment of diastolic function, with reduced E wave equalised to A wave.
  • 6. • FIGURE 21-3 ■ B-mode (A, B) and Doppler echocardiography (C, D) horizontal long-axis views, in hypertrophic cardiomyopathy. (A, B) B-mode images show basal septal hypertrophy. (C) Doppler interrogation in outflow tract demonstrates a rest systolic gradient of 30 mmHg, while (D) transmitral flow evaluation shows an impairment of diastolic function, with reduced E wave equalised to A wave.
  • 7. • FIGURE 21-4 ■ Hypertrophic cardiomyopathy. (A) Cine-MRI frame showing typical localisation at basal septum. (B) Late gadolinium enhancement MRI short-axis image: thickened interventricular septum with large amount of fibrosis (hyperintense intramural foci).
  • 8. • FIGURE 21-5 ■ Cardiac CT in hypertrophic cardiomyopathy. Short axis mid ventricular image shows a diffuse left ventricle myocardial hypertrophy, with prevalent involvement of anterior wall.
  • 9. • FIGURE 21-6 ■ Gadolinium-enhanced MRI: short axis. (A) First-pass frame showing intramural perfusion defect in lateral wall (arrow); (B) late enhancement due to fibrosis is evident in the same segment.
  • 10. • FIGURE 21-7 ■ Different late gadolinium enhancement in hypertrophic phenotypes. First column, large septal intramural late enhancement in hypertrophic cardiomyopathy (HCM) (arrows). Second column: intramural lateral wall late enhancement in Fabry disease (arrow). Third column: subendocardial diffuse late enhancement in amyloidosis (arrow in left ventricle, white arrows in right ventricle). Fourth column: T2w image (top) showing intramural hyperintense foci and striae due to oedema; lower image shows late enhancement in the same areas.
  • 11. • FIGURE 21-7 ■ Different late gadolinium enhancement in hypertrophic phenotypes. First column, large septal intramural late enhancement in hypertrophic cardiomyopathy (HCM) (arrows). Second column: intramural lateral wall late enhancement in Fabry disease (arrow). Third column: subendocardial diffuse late enhancement in amyloidosis (arrow in left ventricle, white arrows in right ventricle). Fourth column: T2w image (top) showing intramural hyperintense foci and striae due to oedema; lower image shows late enhancement in the same areas.
  • 12. • FIGURE 21-8 ■ Primary dilative cardiomyopathy. (A) Frontal view and (B) lateral view show overall increased cardiac size, with signs of left atrial enlargement (black arrows in A, thin white arrows in B), and left ventricle enlargement (thick black arrows in A, thick white arrow in B).
  • 13. • FIGURE 21-9 ■ Dilative cardiomyopathy. Echocardiography shows enlarged left ventricle.
  • 14. • FIGURE 21-10 ■ Black-blood FSE T1w image of dilated cardiomyopathy. Left atrial and left ventricle enlargement is clearly evident
  • 15. • FIGURE 21-12 ■ Late gadolinium enhancement images in short-axis and four- chamber view, showing septal intramural contrast uptake in idiopathic dilated cardiomyopathy
  • 16. • FIGURE 21-12 ■ Late gadolinium enhancement images in short-axis and four- chamber view, showing septal intramural contrast uptake in idiopathic dilated cardiomyopathy
  • 17. • FIGURE 21-11 ■ Ischaemic versus non-ischaemic dilated cardiomyopathy. (A) Diastolic frame of two- chamber cine-MRI showing dilated left ventricle with inferoapical myocardial thinning. (B) Late enhancement in subendocardial layer of basal, mid and apical inferior segments, due to previous infarct in right coronary artery territory. (C) Diastolic frame of two-chamber cine-MRI showing dilated left Ventricle. (D) Short-axis late enhancement image, showing no gadolinium uptake.
  • 18. • FIGURE 21-11 ■ Ischaemic versus non-ischaemic dilated cardiomyopathy. (A) Diastolic frame of two-chamber cine- MRI showing dilated left ventricle with inferoapical myocardial thinning. (B) Late enhancement in subendocardial layer of basal, mid and apical inferior segments, due to previous infarct in right coronary artery territory. (C) Diastolic frame of two-chamber cine-MRI showing dilated left Ventricle. (D) Short-axis late enhancement image, showing no gadolinium uptake.
  • 19. • FIGURE 21-13 ■ MRI of dilated cardiomyopathy complication. Thrombi in left ventricle are evident in late enhancement four- (A) and two-chamber (B) views
  • 20. • FIGURE 21-14 ■ Cardiac CT in dilated cardiomyopathy. (A) Left ventricle dilation in four-chamber view. (B, C) MIP reformatted images of right coronary artery, common trunk and left descending coronary artery showing no atherosclerotic lesions.
  • 21. • FIGURE 21-14 ■ Cardiac CT in dilated cardiomyopathy. (A) Left ventricle dilation in four-chamber view. (B, C) MIP reformatted images of right coronary artery, common trunk and left descending coronary artery showing no atherosclerotic lesions.
  • 22. • FIGURE 21-15 ■ 2D echocardiography in restrictive cardiomyopathy. End-diastolic frame on left, end-systolic frame on right. In both images an endocardial thickening with thrombotic layer and calcifications are evident. Thickening of mitral valve is also present
  • 23. • FIGURE 21-16 ■ Restrictive cardiomyopathy. (A) SE T1w image and (B) cine-MRI frame, both showing tubular shape of ventricles and enlarged atria. In (B) a flow void in the left atrium due to mitral regurgitation is evident.
  • 24. • FIGURE 21-17 ■ Restrictive cardiomyopathy due to fibroelastosis. (A) SE T1w image shows an apparent thickened myocardium; (B) STIR image shows a thickened hyperintense endocardium (arrows) with normal myocardium.
  • 25. • FIGURE 21-18 ■ Cardiac amyloidosis. (A, B) Contiguous T1w axial slices show marked myocardial thickening of both ventricles, with heterogeneous signal intensity; a small amount of pericardial effusion is present (arrows). (C) Late gadolinium enhancement shortaxis image shows no myocardial suppression due to increased extracellular space and interstitial amyloid accumulation.
  • 26. • FIGURE 21-19 ■ Iron overload in major thalassaemia. Multi-echo fast gradient-echo sequence for T2* quantification; from a short TE (1.1 ms, top left) to a long TE (18 ms, bottom right), a rapid decay of myocardium signal intensity
  • 27. • FIGURE 21-20 ■ Constrictive pericarditis. (A) This axial black-blood FSE image shows a diffuse pericardial thickening (5 mm), more evident anteriorly. Note also incomplete blood suppression in right atrium due to slow flow. (B) Axial unenhanced cardiac CT confirms pericardial thickening but also the presence of small calcifications
  • 28. • FIGURE 21-21 ■ European Society of Cardiology classification of primary cardiomyopathies. (Modified from Elliott et al.2).
  • 29. • FIGURE 21-22 ■ Arrhythmogenic right ventricular cardiomyopathy. Black-blood axial image shows a complete fatty substitution of right ventricle free wall (high signal intensity tissue); similar foci are evident in left ventricle apex and basal lateral wall (arrows).
  • 30. • FIGURE 21-23 ■ T1w axial image in a patient receiving intensive steroid treatment. An increased amount of fat is evident in the mediastinum, prepericardial and subepicardial spaces, but normal right ventricle myocardium is visible.
  • 31. • FIGURE 21-24 ■ Arrhythmogenic right ventricular cardiomyopathy. Cine-MRI axial (A) and short-axis (B) images show huge right ventricle dilation with small free-wall bulges (arrows in A).
  • 32. • FIGURE 21-25 ■ Echocardiography. Two-chamber view shows thickened endocardium and increased trabeculation of left ventricle apex (arrows
  • 33. • FIGURE 21-26 ■ Left ventricular non- compaction. (A) T1w black-blood vertical long- axis image shows increased number and thickness of myocardial trabeculae in mid and apical left ventricle regions. (B) Cine-MRI frame in horizontal long axis with measurement of non- compacted and compacted myocardium.
  • 34. • FIGURE 21-27 ■ Left ventricular non-compaction. Late enhancement images show contrast uptake in compacted myocardium (mostly at septal level), with subendocardial sparing, due to fibrotic changes. As an ancillary finding, multiple thrombi are visible.
  • 35. • FIGURE 21-28 ■ Takotsubo cardiomyopathy. (A) T2w image in vertical long axis shows diffuse hyperintensity of the myocardium, due to oedema (arrows); (B) late enhancement image in the same plane shows no contrast uptake, demonstrating absence of any irreversible lesion.
  • 36. • FIGURE 21-29 ■ Acute myocarditis. (A) T2w STIR short-axis image shows a subepicardial hyperintense area in inferior wall; (B) late enhancement image in corresponding plane shows contrast uptake with a non-ischaemic pattern. Patient presented 36 h before in emergency unit with chest pain and slight increase in cardiac enzymes; emergency coronary angiography was negative.
  • 37. • FIGURE 21-30 ■ Chronic myocarditis in patients presenting with new-onset severe tachyarrhythmia. (A) T2w STIR short-axis image shows no evidence of oedema; (B) late enhancement image in the same plane shows septal intramural contrast uptake. Septal endomyocardial biopsy demonstrated a lymphocytic infiltrate with interstitial fibrosis
  • 38. • FIGURE 21-31 ■ Chest X-ray, frontal view, in intensive care unit shows signs of alveolar pulmonary oedema without cardiac enlargement.
  • 39. • FIGURE 21-32 ■ Chest X-ray shows left atrial appendage enlargement (arrow) in mitral regurgitation; subcarinal opacity with slight dislocation of upper left main bronchus is also evident due to left atrium enlargement
  • 40. • FIGURE 21-33 ■ Mitral prolapse. Echocardiography (parasternal long axis) shows wide anterior leaflet prolapse of the mitral valve.
  • 41. • FIGURE 21-34 ■ Mitral regurgitation. Echo colour Doppler shows severe regurgitation in the left atrium and marked left ventricle enlargement (mitral annulus dilation).
  • 42. • FIGURE 21-35 ■ Mitral regurgitation. Echo colour Doppler shows severe mitral regurgitation (apical 4C). Mosaic effect is evident with complete occupation of the left atrium.
  • 43. • FIGURE 21-36 ■ Cine-MRI frame of functional mitral regurgitation (black jet directed from left ventricle to left atrium) in dilated cardiomyopathy
  • 44. • FIGURE 21-37 ■ Mitral stenosis. Echocardiography (parasternal long axis) shows marked thickening of mitral leaflets with restricted mitral valve orifice (doming anterior leaflet). Left atrial (LA) enlargement is evident.
  • 45. • FIGURE 21-38 ■ Cine-MRI frame of mitral stenosis. A small flow void directed from left atrium (LA) to left ventricle (LV) is visible (arrows), due to mild mitral stenosis. Left atrium is enlarged.
  • 46. • FIGURE 21-39 ■ Tricuspid regurgitation. Echo colour Doppler demonstrates severe tricuspid insufficiency with mosaic effect occupying entirely the right atrium.
  • 47. • FIGURE 21-40 ■ Cine-MRI frame of tricuspid regurgitation. A retrograde black jet directed from right ventricle to right atrium is evident (arrowheads).
  • 48. • FIGURE 21-41 ■ Chest X-ray of aortic stenosis shows rounded profile of left ventricle (left third cardiac arch, white arrows), with slight enlargement of ascending aorta (right first cardiac arch, arrowheads).
  • 49. • FIGURE 21-42 ■ B-mode echocardiography, horizontal long axis, in aortic stenosis. Hyperechoic calcified aortic leaflets; mitral annulus calcification is also evident.
  • 50. • FIGURE 21-43 ■ Cardiac CT. Multiplanar short-axis reformation aortic valve shows leaflet calcification with reduced systolic orifice. Manual contouring of the orifice allows stenosis quantification (moderate to severe: 187 mm2).
  • 51. • FIGURE 21-44 ■ Cine-MRI frame in aortic stenosis. In this threechamber view, a large flow void due to blood flow acceleration is evident in ascending aorta
  • 52. • FIGURE 21-45 ■ (A) Cardiac CT and (B) cine- MRI of a bicuspid aortic valve. In both images only two semilunar leaflets are evident.
  • 53. • FIGURE 21-46 ■ Chest X-rays of aortic regurgitation. Frontal and lateral views demonstrate left ventricle enlargement, as left third cardiac arch widening in the frontal view, and second posterior arch in the lateral view (arrows).
  • 54. • FIGURE 21-47 ■ Aortic regurgitation. Echo colour Doppler shows aortic insufficiency, with a wide jet, while continuous Doppler interrogation shows a steep decay of the curve indicating severity of regurgitation (rapid pressure drop during diastole). Pressure half-time is <250 ms.
  • 55. • FIGURE 21-48 ■ Cine-MRI frames of aortic regurgitation. Retrograde jets in left ventricle are evident as flow voids, in (A) with normal aortic bulb, in (B) with annuloaortic ectasia.
  • 56. • FIGURE 21-49 ■ MRI velocity map of mild aortic regurgitation. Flow is measured in ascending (red line) and descending aorta (white line); area under the curve below zero (green line) represents regurgitant flow.
  • 57. • FIGURE 21-50 ■ Cardiac CT of aortic regurgitation. Multiplanar short-axis reformation of aortic valve demonstrates incomplete coaptation of leaflets, with central orifice.
  • 58. • FIGURE 21-51 ■ Examples of biological (A, B) and mechanical (C, D) valvular prostheses.
  • 59. • FIGURE 21-51 ■ Examples of biological (A, B) and mechanical (C, D) valvular prostheses.
  • 60. • FIGURE 21-52 ■ Chest X-rays, lateral views, of mechanical (A) and biological (B) mitral valve prostheses.
  • 61. • FIGURE 21-53 ■ Chest X-rays, lateral views, of mechanical (A) and biological (B) aortic valve prostheses.
  • 62. • FIGURE 21-54 ■ Chest X-rays, frontal views, demonstrate the different orientation of the left atrioventricular vector and the left ventriculoaortic vector (black lines), respectively, in (A) mitral and (B) aortic valve replacements
  • 63. • FIGURE 21-55 ■ Echocardiography of a monoleaflet mitral valve, four-chamber view. Right atrium (RA) enlargement with tricuspid leaflet thickening is also evident.
  • 64. • FIGURE 21-56 ■ Cardiac CT of mechanical valvular prosthesis. (A) Coronal reformatted image; (B) axial reformatted image of the valve; (C) corresponding image of the valve.
  • 65. • FIGURE 21-56 ■ Cardiac CT of mechanical valvular prosthesis. (A) Coronal reformatted image; (B) axial reformatted image of the valve; (C) corresponding image of the valve.
  • 66. • FIGURE 21-56 ■ Cardiac CT of mechanical valvular prosthesis. (A) Coronal reformatted image; (B) axial reformatted image of the valve; (C) corresponding image of the valve.
  • 67. • FIGURE 21-57 ■ Cine-MRI frames (A, short- axis view; B, three-chamber view) show the typical susceptibility artefact generated by the mechanical aortic valve prostheses.
  • 68. • FIGURE 21-58 ■ Transoesophageal echocardiography in paravalvular aortic abscess. An anechoic rim anterior to a mechanical prosthesis is evident (arrows).
  • 69. • FIGURE 21-59 ■ Cardiac CT of paravalvular aortic leak. (A) Oblique coronal reformatted image of ascending aorta and (B) short-axis reformatted image of aortic valve demonstrate paravalvular extravasation of contrast medium around the prosthesis (arrows).
  • 70. • FIGURE 21-60 ■ MRI of huge paravalvular leak after aortic valve replacement. A large blood collection is evident, adjacent to aortic root, due to a paravalvular leak. (A, B) T1w axial and coronal oblique images show no signal in the collection because of flowing blood (the small amount of signal in the central part is due to slow turbulent flow). (C, D) Gadolinium enhanced gradient-echo images in the same planes demonstrate the passage of contrast medium in the collection; the susceptibility artefact of the mechanical valve is evident.
  • 71. • FIGURE 21-60 ■ MRI of huge paravalvular leak after aortic valve replacement. A large blood collection is evident, adjacent to aortic root, due to a paravalvular leak. (A, B) T1w axial and coronal oblique images show no signal in the collection because of flowing blood (the small amount of signal in the central part is due to slow turbulent flow). (C, D) Gadolinium enhanced gradient-echo images in the same planes demonstrate the passage of contrast medium in the collection; the susceptibility artefact of the mechanical valve is evident.
  • 72. • FIGURE 21-61 ■ Pericardial involvement in mediastinal malignant thymoma. (A) T1w axial image demonstrates an oval-shaped mediastinal lesion adjacent to thickened pericardium; lateral left pericardium shows a plaque- thickening due to tumour diffusion (white arrow). (B) T2w image shows high and heterogeneous signal intensity of the mass. A left pleural effusion is also present.
  • 73. • FIGURE 21-62 ■ Cystic teratoma of the pericardium, with right atrium involvement. (A) T2w axial image shows a large right paracardiac cystic tumour with eccentric solid component; extracapsular tissue (black arrows) also invades epicardial fat and abuts superior vena cava (*), contacting the right coronary artery (white arrow). (B) Post-contrast T1w corresponding axial image demonstrates enhancement of the solid components of the tumour
  • 74. • FIGURE 21-63 ■ Two black-blood short-axis T1w MRI images of mediastinal NHL, with great vessel encasement, pericardial and myocardial infiltration (arrow) and inferior pericardial effusion (*).
  • 75. • FIGURE 21-64 ■ T1w axial image shows a rounded slightly hyperintense lesion in the left ventricle, arising from left lateral wall (white arrows). A small amount of pericardial effusion is evident (black arrow).
  • 76. • FIGURE 21-65 ■ Left ventricle lung cancer metastasis. (A) Contrast-enhanced CT image shows a heterogeneous mass in the left ventricle. (B, C) T1w and T2w horizontal long-axis MRI demonstrate the large implant of the lesion, involving the lateral wall of the left ventricle, with T2 high signal heterogeneity. (D) The left superior sulcus tumour is evident on the coronal T1w image
  • 77. • FIGURE 21-65 ■ Left ventricle lung cancer metastasis. (A) Contrast-enhanced CT image shows a heterogeneous mass in the left ventricle. (B, C) T1w and T2w horizontal long-axis MRI demonstrate the large implant of the lesion, involving the lateral wall of the left ventricle, with T2 high signal heterogeneity. (D) The left superior sulcus tumour is evident on the coronal T1w image
  • 78. • FIGURE 21-66 ■ 2D echocardiography of neoplastic thrombus from renal cell carcinoma in inferior vena cava and right atrium
  • 79. • FIGURE 21-67 ■ Enhanced CT image shows direct invasion of left atrium from a left lower lobe bronchogenic carcinoma
  • 80. • FIGURE 21-68 ■ Echocardiography (2D and 3D) of atrial myxoma. On the left, systolic and diastolic frames show a large hyperechoic tumour of the left atrium passing through the mitral valve; on the right, a 3D short-axis image shows the tumour across the mitral valve.
  • 81. • FIGURE 21-69 ■ (A) FSE T1w horizontal long-axis view of left atrial myxoma: typical localisation in the area of fossa ovalis, with heterogeneous signal intensity; central hypointense area is due to calcifications. (B) FSE T2w fat-suppressed image, same plane: lesion shows heterogeneous hyperintensity with central dark area
  • 82. • FIGURE 21-70 ■ Same case as described in the caption to Fig. 21-45. (A) On SSFP image slight heterogeneous hyperintensity of the lesion compared with myocardium is evident; (B) late gadolinium enhancement image shows tiny foci of contrast uptake caused by fibrotic changes
  • 83. • FIGURE 21-71 ■ Atrial myxoma of fossa ovalis. (A, B) Axial T1 and T2 images show heterogeneity in signal intensity of the lesion. (C) and (D) are systolic and diastolic frames of cine-MRI: prolapse of the pedunculated myxoma through the mitral orifice is evident
  • 84. • FIGURE 21-71 ■ Atrial myxoma of fossa ovalis. (A, B) Axial T1 and T2 images show heterogeneity in signal intensity of the lesion. (C) and (D) are systolic and diastolic frames of cine-MRI: prolapse of the pedunculated myxoma through the mitral orifice is evident
  • 85. • FIGURE 21-72 ■ Atrial septum lipoma. (A) Cardiac CT shows a marked hypodense well-defined lesion; (B) T1w image demonstrates marked hyperintensity of the lesion, completely suppressed in STIR image (C). In (D) a frame from cine-SSFP shows high to intermediate signal intensity of the tumour, while post- contrast T1 GRE image does not demonstrate enhancement (E). Furthermore, in all the MR images, a subpleural lipoma is evident (*). (F) A different case of lipomatous infiltration of the interatrial septum is reported, just to show the classical sparing of the fossa ovalis (arrows).
  • 86. • FIGURE 21-72 ■ Atrial septum lipoma. (A) Cardiac CT shows a marked hypodense well-defined lesion; (B) T1w image demonstrates marked hyperintensity of the lesion, completely suppressed in STIR image (C). In (D) a frame from cine-SSFP shows high to intermediate signal intensity of the tumour, while post- contrast T1 GRE image does not demonstrate enhancement (E). Furthermore, in all the MR images, a subpleural lipoma is evident (*). (F) A different case of lipomatous infiltration of the interatrial septum is reported, just to show the classical sparing of the fossa ovalis (arrows).
  • 87. • FIGURE 21-72 ■ Atrial septum lipoma. (A) Cardiac CT shows a marked hypodense well-defined lesion; (B) T1w image demonstrates marked hyperintensity of the lesion, completely suppressed in STIR image (C). In (D) a frame from cine-SSFP shows high to intermediate signal intensity of the tumour, while post-contrast T1 GRE image does not demonstrate enhancement (E). Furthermore, in all the MR images, a subpleural lipoma is evident (*). (F) A different case of lipomatous infiltration of the interatrial septum is reported, just to show the classical sparing of the fossa ovalis (arrows).
  • 88. • FIGURE 21-73 ■ 2D echocardiographic subcostal view shows a typical rhabdomyoma (hyperechoic rounded lesion) attached to the basal interventricular septum (calipers).
  • 89. • FIGURE 21-74 ■ B-mode echocardiography shows a small hyperechoic lesion (calipers) attached to valve leaflets. At surgery a fibroelastoma was found and resected.
  • 90. • FIGURE 21-75 ■ Angiosarcoma of right ventricle. (A) Axial T1w image shows a large tumour with irregular margins, involving free wall of right ventricle, right atrioventricular groove, tricuspid annulus and right atrium wall; furthermore, multiple nodules are visible in both lungs, with large consolidation in left inferior lobe; (B) T2w image demonstrates high signal intensity of the tumour. (C, D) Pre- and post-contrast T1w short-axis images show strong enhancement of the tumour and the lung metastasis. Biopsy confirmed the suspected angiosarcoma
  • 91. • FIGURE 21-75 ■ Angiosarcoma of right ventricle. (A) Axial T1w image shows a large tumour with irregular margins, involving free wall of right ventricle, right atrioventricular groove, tricuspid annulus and right atrium wall; furthermore, multiple nodules are visible in both lungs, with large consolidation in left inferior lobe; (B) T2w image demonstrates high signal intensity of the tumour. (C, D) Pre- and post-contrast T1w short-axis images show strong enhancement of the tumour and the lung metastasis. Biopsy confirmed the suspected angiosarcoma
  • 92. • FIGURE 21-76 ■ Interatrial mass, involving both atria. (A) T1w axial image shows an isointense lesion, while (B) the T2w image demonstrates a marked hyperintensity. (C) In post-contrast T1w image a strong and homogeneous enhancement of the mass is visible. Biopsy revealed an angiosarcoma; compared with the case shown and described in Fig. 21-49, this localisation is uncommon.
  • 93. • FIGURE 21-76 ■ Interatrial mass, involving both atria. (A) T1w axial image shows an isointense lesion, while (B) the T2w image demonstrates a marked hyperintensity. (C) In post-contrast T1w image a strong and homogeneous enhancement of the mass is visible. Biopsy revealed an angiosarcoma; compared with the case shown and described in Fig. 21-49, this localisation is uncommon.
  • 94. • FIGURE 21-77 ■ 2D echocardiographic subcostal image in a case of rhabdomyosarcoma shows a hyperechoic mass infiltrating the right atrioventricular groove (white arrow). Pericardial effusion is also evident (black arrows
  • 95. • FIGURE 21-78 ■ T1w axial images show the dark line of the pericardium (with a small amount of fluid within) between the high signal intensity of the prepericardial and subepicardial fat.
  • 96. • FIGURE 21-78 ■ T1w axial images show the dark line of the pericardium (with a small amount of fluid within) between the high signal intensity of the prepericardial and subepicardial fat.
  • 97. • FIGURE 21-78 ■ T1w axial images show the dark line of the pericardium (with a small amount of fluid within) between the high signal intensity of the prepericardial and subepicardial fat.
  • 98. • FIGURE 21-79 ■ Pericardial cyst. Contiguous black-blood T1w axial images show a well- defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.
  • 99. • FIGURE 21-79 ■ Pericardial cyst. Contiguous black-blood T1w axial images show a well- defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.
  • 100. • FIGURE 21-79 ■ Pericardial cyst. Contiguous black-blood T1w axial images show a well- defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.
  • 101. • FIGURE 21-79 ■ Pericardial cyst. Contiguous black-blood T1w axial images show a well- defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.
  • 102. • FIGURE 21-80 ■ Partial pericardial agenesis. (A) Chest X-ray, frontal view, shows prominent left second cardiac arch, with deep incisure between first and second left cardiac arch; main pulmonary trunk is deeply located in the lung. (B-D) Serial T1w axial MR images show pulmonary trunk (B, C) out of mediastinal margins (acute angle with anterior mediastinal fat) while the heart (D) is completely rotated towards the left, occupying the left hemithorax.
  • 103. • FIGURE 21-80 ■ Partial pericardial agenesis. (A) Chest X-ray, frontal view, shows prominent left second cardiac arch, with deep incisure between first and second left cardiac arch; main pulmonary trunk is deeply located in the lung. (B- D) Serial T1w axial MR images show pulmonary trunk (B, C) out of mediastinal margins (acute angle with anterior mediastinal fat) while the heart (D) is completely rotated towards the left, occupying the left hemithorax.
  • 104. • FIGURE 21-81 ■ Pericardial effusion, chest X- rays. (A) Frontal view shows double contouring of left third cardiac arch (small arrows); (B) lateral view demonstrates a retrosternal opacity (arrows), contoured by fat radiolucency (prepericardial and epicardial).
  • 105. • FIGURE 21-82 ■ B-mode echocardiography shows anterior anechoic fluid collection (*).
  • 106. • FIGURE 21-83 ■ Pericardial effusion in pericarditis. (A) T1w short-axis image shows no signal in the effusion, with mild thickening of the pericardium. (B) Cine-MRI frame shows hyperintense signal of the effusion, due to its prolonged T2 (SSFP signal is T2/ T1-dependent
  • 107. • FIGURE 21-84 ■ Pericardial haematoma (post- endomyocardial biopsy). (A) T1w horizontal long-axis image shows well-circumscribed high signal pericardial collection, abutting right atrium. (B) T2w fat-saturated short-axis image demonstrates the high signal of the collection due to acute bleeding.
  • 108. • FIGURE 21-85 ■ Pericarditis. (A) Cine-MRI frame, short-axis image demonstrates mild pericardial effusion (arrows). (B) Delayed postgadolinium enhancement, same plane, shows contrast uptake of pericardial layers, due to inflammation
  • 109. • FIGURE 21-86 ■ Constrictive pericarditis. (A) Chest X-ray, lateral view, shows thick pericardial calcifications. (B, C) CT images demonstrate the presence, site and thickness of pericardial calcifications in a patient with pleuro-pulmonary tuberculosis
  • 110. • FIGURE 21-86 ■ Constrictive pericarditis. (A) Chest X- ray, lateral view, shows thick pericardial calcifications. (B, C) CT images demonstrate the presence, site and thickness of pericardial calcifications in a patient with pleuro-pulmonary tuberculosis
  • 111. • FIGURE 21-86 ■ Constrictive pericarditis. (A) Chest X-ray, lateral view, shows thick pericardial calcifications. (B, C) CT images demonstrate the presence, site and thickness of pericardial calcifications in a patient with pleuro-pulmonary tuberculosis
  • 112. • FIGURE 21-87 ■ Constrictive pericarditis. Axial craniocaudal T1w images show a marked and diffuse pericardial thickening in patient with previous tuberculosis. Right atrial enlargement is evident in the images B and C.
  • 113. • FIGURE 21-87 ■ Constrictive pericarditis. Axial craniocaudal T1w images show a marked and diffuse pericardial thickening in patient with previous tuberculosis. Right atrial enlargement is evident in the images B and C.
  • 114. • FIGURE 21-88 ■ Cystic teratoma of the pericardium, with right atrium involvement. (A) T2w axial image shows a large right paracardiac cystic tumour with eccentric solid component; extracapsular tissue (black arrows) invades also epicardial fat and abuts superior vena cava (*), contacting the right coronary artery (white arrow). (B) Post-contrast T1w corresponding axial image demonstrates enhancement of the solid components of the tumour