ACR Inservice Recall

1. Section VIII – Cardiac
Figure 1A
314. You are shown a frontal (Figure 1A) and a lateral (Figure 1B) radiograph of a 36-year-old woman complaining
of shortness of breath and palpitations. Which one of the following is the MOST likely diagnosis?
A. Aortic stenosis
B. Mitral valve disease
C. Atrial septal defect
D. Primary pulmonary hypertension
E. Total anomalous pulmonary venous return
Diagnostic In-Training Exam 2003 1

2. Section VIII – Cardiac
Figure 1B
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3. Section VIII – Cardiac
Question #314
Findings: This standard chest radiograph of a 36-year-old female demonstrates the presence of moderate
cardiomegaly. Further inspection reveals that there is left atrial and specifically left atrial appendage enlargement as
evidence by a bulge along the left side of the heart just below the main pulmonary artery. There is increase in the
subcarinal angle because of left atrial dilatation. In addition, there is pulmonary vascular redistribution indicating
pulmonary venous hypertension.
Rationales:
A) Incorrect. Left atrial enlargement is not a feature of aortic stenosis. In addition, in aortic stenosis there is
frequently post-stenotic dilatation of the ascending aorta and calcification in the area of the aortic valve,
findings that are lacking in this particular case.
B) Correct. Mitral valve disease is usually a sequela of rheumatic inflammation of the valve leaflets. The mitral
valve is most commonly affected, and it takes several years for clinical manifestations to appear. Decreased flow
thru the mitral orifice result in progressive pulmonary venous hypertension and variable enlargement of the left
atrial chamber, particularly the appendage. Most cases present as a combination of stenosis and regurgitation,
thus the generic term “mitral valve disease” should be used, particularly if there is left atrial enlargement which
is more characteristic of insufficiency.
C) Incorrect. A defect in the interatrial septum results in left to right shunting of blood and shunt vascularity
consequently. Due to decompression of the left atrium into the right side, the left atrial chamber does not
enlarge in atrial septal defect.
D) Incorrect. Although the age and gender of this patient would suggest the diagnosis of primary pulmonary
hypertension, the radiographic findings do not. Left atrial enlargement is not a characteristic feature of primary
pulmonary hypertension. In primary pulmonary hypertension, the central pulmonary arteries are enlarged and
there is tapering of the distal branches. The heart size remains normal except in later stages when dilatation of
the right heart chambers develops as CO pulmonale ensues.
E) Incorrect. Depending on the level of the total anomalous pulmonary venous return, the radiographic findings
are going to vary. In type I (supra cardiac) the superior mediastinum is prominent because of enlargement of
the brachiocephalic veins. This produces the so-called “snowman” configuration. If the venous return is directly
into the coronary sinus or right atrium, there is enlargement of those chambers. The only type of anomalous
pulmonary venous return that can produce pulmonary findings of venous hypertension similar to those of
mitral valve disease is the infradiaphragmatic type. None of the types of total anomalous venous return cause
left atrial enlargement for exclusion of that chamber constitutes the essence of those anomalies.
Citations:
Higgins CB: Essentials of cardiac radiology and imaging. Philadelphia, 1992, JB Lippincott
Amplatz K: The roentgenographic diagnosis of mitral and aortic valvular disease. Am Heart J 64; 556-566. 1962
Diagnostic In-Training Exam 2003 3

4. Section VIII – Cardiac
Figure 2A
Figure 2B
315. You are shown two CT images (Figures 2A and 2B) of a 42-year-old patient admitted to the hospital with
complete heart block. Which one of the following is the MOST likely diagnosis?
A. d-Transposition of the great arteries
B. l-Transposition of the great arteries
C. Truncus arteriosus
D. Coarctation of the aorta
E. Pseudocoarctation of the aorta
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5. Section VIII – Cardiac
Question #315
Findings: This contrast-enhanced CT demonstrates the ascending aorta anterior and to the left of the pulmonary
artery.
Rationales:
A) Incorrect. d-Transposition of the great arteries is a cyanotic condition in which the atrioventricular connections
are concordant (right atrium connected to right ventricle and left atrium connected to the left ventricle),
but there is ventriculoarterial discordance (right ventricle connected to aorta, left ventricle connected to the
pulmonary artery). As a result, the ascending aorta arises anteriorly and to the right of the main pulmonary
artery.
B) Correct. In l-transposition of the great arteries there is atrioventricular discordance (right atrium connected
to left ventricle, left atrium connected to the right ventricle) and ventriculoarterial discordance (right ventricle
connected to aorta, left ventricle connected to the pulmonary artery). The hallmark of this congenital defect
is the ascending aorta arising anteriorly and to the left of the pulmonary artery as this case illustrates. These
patients also frequently present with heart block.
C) Incorrect. Truncus arteriosus is a cyanotic heart condition characterized by lack of septation of the aortic root
and main pulmonary artery thus resulting in a common arterial trunk arising from the heart. Invariably a
ventricular septal defect allows mixing of blood from both ventricular chambers. Unless totally repaired in
infancy, adult survival is extremely unusual. In truncus arteriosus, the great vessels are not transposed.
D) Incorrect. In coarctation of the aorta there is a stenosis of the aorta (usually near the origin of the left subclavian
artery) that produces variable obstruction to blood flow and if severe enough heart failure particularly in
newborns. In adult patients, collateral vessels around the obstruction can lead to the formation of rib notching.
This case demonstrates a normal diameter of the aorta with no collaterals.
E) Incorrect. Pseudocoarctation of the aorta refers to a condition in which the aortic arch is elongated producing
a characteristic S-shaped deformity of the aortic arch. The relationship of the aorta and the pulmonary artery
is otherwise preserved.
Citations:
Reedy GP, Caputo GR: _Diagnosis Please. Case 15: Congenitally Corrected Transposition of the Great Arteries.
Radiology 1999; 213:102
Diagnostic In-Training Exam 2003 5

6. Section VIII – Cardiac
Figure 3A
Figure 3B
316. You are shown two images of a contrast-enhanced CT scan (Figures 3A and 3B) of a 62-year-old woman who
developed hypotension several days after coronary by-pass graft surgery. Which one of the following is the
MOST likely diagnosis?
A. Cardiac volvulus
B. Pericardial cyst
C. Constrictive pericarditis
D. Hemopericardium
E. Post-pericardiotomy syndrome
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7. Section VIII – Cardiac
Question #316
Findings: Two contrast-enhanced CT images of the chest demonstrate the presence of high attenuation collection
within the pericardial cavity producing mass-effect and displacement of the heart to the right. n addition, Figure 3B
demonstrates a brightly enhancing structure on the inferior surface of the heart next to a metallic surgical clip near
the distal portion of the posterior descending coronary artery.
Rationales:
A) Incorrect. Although the heart is displaced to the right inside the pericardiac sac, there is no volvulus effect thus
excluding the diagnosis.
B) Incorrect. Pericardial cysts are usually located in the right cardiophrenic angle and are usually filled with clear
fluid. Although they can attain significant size, they do not displace the heart.
C) Incorrect. Constrictive pericarditis can be excluded based on a normal thickness pericardium in this case.
Pericardial constriction would in addition be very unusual to present clinically several days after surgery, as is
the case with this patient. The fluid filled pericardial cavity and heart displacement of this case are atypical for
constrictive pericarditis.
D) Correct. The presence of high attenuation material in the pericardiac sac is characteristic of hemopericardium.
Pericardial hemorrhage was a result of a pseudoaneurysm formation at the distal graft anastomosis to the
posterior descending branch, which explains the finding on Figure B. Associated bilateral pleural effusions and
heterogeneity of the liver are the result of associated congestive changes from cardiac tamponade physiology.
E) Incorrect. In the post-pericardiotomy syndrome, clinical findings of chest pain and fever develops several days
or weeks after cardiac or pericardial injury of all kinds including trauma, catheter perforation, or surgery.
Treatment usually consists of aspirin or other non-steroidal anti-inflammatory drugs.
Citations:
D. Bryk, IG Kroop, J Budow; The effect of heart size cardiac tamponade and phase of the cardiac cycle in the
distribution of pericardial fluid. Radiology 1996 93; 273-278
Spodick DH The Pericardium A Comprehensive Textbook. _Marcel Dekker, Inc. New York 1997.
Diagnostic In-Training Exam 2003 7

8. Section VIII – Cardiac
Figure 4A
317. You are shown three contrast-enhanced images of a chest CT of a patient with atypical chest pain (Figures 4A,
4B and 4C). Which one of the following is the MOST likely diagnosis?
A. Lipomatous hypertrophy of the interatrial septum
B. Atrial lipoma
C. Atrial myxoma
D. Bland thrombus in the right atrium
E. Atrial liposarcoma
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9. Section VIII – Cardiac
Figure 4B
Figure 4C
Diagnostic In-Training Exam 2003 9

10. Section VIII – Cardiac
Question #317
Findings: Contrast-enhanced CT images through the heart demonstrate the presence of diffuse thickening of the
interatrial septum with thinning at the level of the fossa ovalis as seen on Figure 4C. The septal thickening is
characterized by very low attenuation tissue characteristic of fat.
Rationales:
A. Correct. Lipomatous hypertrophy of the interatrial septum is characterized by deposition of non-encapsulated
fat in the interatrial septum, sparing the fossa ovalis, a characteristic feature. It can be associated with
arrhythmias.
B. Incorrect. Atrial lipoma can occur in any portion of the atria including the atrial septum. However, they do not
spare the fossa ovalis as this case illustrates. Lipomas consist of encapsulated mature adipose cells, can grow to
significant size, and are considered distinct from lipomatous hypertrophy of the interatrial septum.
C. Incorrect. Atrial myxomas are soft tissue benign tumors of the heart that can be found in any chamber, but are
most commonly seen in the left atrium, attached to the interatrial septum. The fatty nature of this case excludes
the diagnosis of myxoma.
D. Incorrect. The fatty appearance of the atrial infiltration excludes the diagnosis of bland thrombus of the right
atrium.
E. Incorrect. Liposarcoma of the heart is extremely rare, and as liposarcomas at other sites is characterized by
strands of soft tissue within the fatty tumoral mass. Again, the pure fatty nature of the tumor and sparing of the
fossa ovalis excludes liposarcoma as a diagnosis.
Citations:
Araoz PA, Mulvagh SL, Tazelaar HD, Julsrud PR, Bree JF; CT and MR imaging of Benign Primary Cardiac
Neoplasms with Echocardiographic Correlation. Radiographics 2000 20:1303-1319
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11. Section VIII – Cardiac
Figure 5A
318. You are shown coronal CINE images in diastole (Figure 5A) and systole (Figure 5B) of a patient with chest
pain. Which one of the following is the MOST likely diagnosis?
A. Type A aortic dissection
B. Syphilitic aortitis
C. Aortic stenosis
D. Aortic regurgitation
E. Atherosclerotic aortic aneurysm
Diagnostic In-Training Exam 2003 11

12. Section VIII – Cardiac
Figure 5B
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13. Section VIII – Cardiac
Question #318
Findings: Cardiac cine images in diastole and systole demonstrate the presence of a focal area of dark “jetting”
arising from the aortic valve during systole (Figure 5B). No other areas of signal abnormalities are seen.
Rationales:
A. Incorrect. Other than the systolic signal abnormality arising from the aortic valve during ventricular systole, the
aorta has normal appearance without intimal flaps that are the hallmark of aortic dissection.
B. Incorrect. Syphilitic aortitis is a rare delayed sequela of tertiary syphilis frequently occurring 15-30 years after
the primary infection. Most cases involve the aortic root or arch and calcifications are common. The aortic
leaflets are usually spared, and aneurysms are common.
C. Correct. Aortic stenosis is usually a consequence of degeneration of a bicuspid aortic valve, a condition seen in
about 2% of the population. The presence of turbulent jetting across the aortic valve during ventricular systole
makes this the most plausible diagnosis.
D. Incorrect. Lack of signal below the aortic valve during diastole (Figure 5A) implies a competent aortic valve
thus excluding regurgitation as an alternative.
E. Incorrect. The aorta does not show any aneurysm formation in this case thus excluding the diagnosis. In
addition, atherosclerosis does not typically involve the aortic valve.
Citations:
Dominique Didier, Osman Ratib, René Lerch, and Beat Friedli. Detection and Quantification of Valvular Heart
Disease with Dynamic Cardiac MR Imaging. RadioGraphics 2000 20: 1279-1299.
VB Ho and MR Prince. Thoracic MR aortography: imaging techniques and strategies. RadioGraphics 1998 18:
287-309.
SA Rebergen, RA Niezen, WA Helbing, EE van der Wall, and A de Roos. Cine gradient-echo MR imaging and MR
velocity mapping in the evaluation of congenital heart disease. RadioGraphics 1996 16: 467-481
Diagnostic In-Training Exam 2003 13