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CVS Cardio acquired Cardio (Acquired) By: Dr. Abdullah Nouh 1 CVS Cardio acquired Succeeding...

CVS Cardio acquired Cardio (Acquired) By: Dr. Abdullah Nouh 1 CVS Cardio acquired Succeeding Lower part of left heart border is formed by left ventricle which may show curvilinear calcification. Valvular calcification on CXR is seen within the heart shadow. Aortic & mitral valves are seen adjacent to the spine on CXR but aortic valve is usually seen horizontally while MV is seen vertically. On lateral CXR, If a line is drawn from carina to anterior CP angle, then AV lies to be seen above it & MV below the line. Atrial myxoma is a pedunculated mass commonly seen in left atrium attached to inter – atrial septum. Atrial myxoma is hypointense to myocardium on T1W1, hypo to blood pool & hyper to myocardium on SSFP, varying enhancement & prolapsed through mitral valve on cine gradient echo imaging on four chambered long axis view. Atrial myxoma prolapse through the mitral valve but a thrombus does not. Left atrial myxomas typically cause enlarged LA, calcified lung nodules & pulmonary edema. After 15 min of gadolinium, study should be commenced for cardiac MRI. Normal myocardium is dark, while ischemic appears bright. Too short TI results in loss of signal from both abnormal & normal myocardium. Too long TI causes loss of contrast. In early myocarditis, enhancement pattern is typically epicardial In hypertrophic cardiomyopathy, multifocal changes are seen, commonly left ventricular free wall & its junction with interventricular septum is seen Amyloidosis causes global & diffuse subendocardial involvement. Cardiac MRI shows dark rim artifact typically on endocardial aspect. Spike artifacts are sporadic & transient but RF artifacts are seen in all images of series. Gating is not very useful for assessing diastole function. Field inhomogenity artifacts are more common on 3T than 1.5T. Asymmetrical thickening with patchy enhancement of interventricular septum is seen in HOCM. Apposition of anterior mitral valve leaflet & interventricular septum is seen during systole. Irregularly thickened pericardium with pericardial effusion occurs mostly due to malignancy. Tricuspid regurgitation (& sometimes tricuspid stenosis) is associated with carcinoid syndrome. Left atrial appendage & LA enlargement is a specific feature of rheumatic disease. Left atrial enlargement is caused by MS, VSD, PDA, ASD with shunt reversal & left atrial myxoma. Post cardiac transplant, following non surgical complication can occur: Infections, rejections, accelerated atherosclerosis of graft & post transplant malignancy. One of the most common infection is aspergillosis causing cavitatory necrosis & a surrounding halo of ground glass haze. Systemic amphotericin is used. Focal delayed enhancement of myocardium in non-coronary artery distribution (involving anterior, lateral, inferior wall or apex of ventricle) with sparing of subendocardial region is seen in myocarditis. In myocardial sarcoidosis, increased focal signal intensity on T2W1 both early & delayed post contrast T1 high signal. Focal myocardial thickening is also seen. Hypertrophic cardiomyopathy shows involvement of IVS & LV & RV wall with delayed transmural enhancement. Amyloidosis shows restrictive (subendocardical aspect) cardiomyopathy. Left ventricular dilatation can be seen with severe mitral regurgitation. Constrictive pericarditis usually causes obliteration of pericardial cavity & hence signs of pericardial effusion are absent (effacement of heart borders, bilateral hilar overlay, filing in of retrosternal space & epicardial fat pad sign). Delayed enhancement is seen in myocardial infarction after few days of infarction. The myocardium appears hyperintense on T2WI. In HOCM, there can be good or hyperdynamic contractility with SAM partially obstructing subaortic region. Left atrial enlargement is seen in rheumatic aortic stenosis but not in calcific aortic stenosis. Arrythmogenic right ventricular dysplasia is characterized by fibro-fatty replacement of right ventricular myocardium. It causes sudden death in young adults (more in males) on MRI, high T2W1 with dilated right ventricle, right ventricular aneurysm & segmental hypokinesia. Uhl’s anomaly is a very rare condition. Shows paper thin right ventricle with complete absence of any musculature. Myocardial bridging is seen when a length of coronary artery (usually LAD) taken an intramyocardial course & can cause ischemia, infarction, arrythmia & even death. Thrombus (non enhancing) is most common cardiac mass but metastasis is most common enhancing cardiac mass. Angiosarcoma is most common primary malignant cardiac tumour. Cardiac sarcoid shows high T2 signal in myocardium with sparing of subendocardial region. Early & delayed enhancement is seen. 2 CVS Cardio acquired Two left sided bronchial arteries arise from aorta & solitary right bronchial artery arise from right third post intercoastal artery. Artery to SA node arises from right coronary artery in 60% cases & from left circumflex artery in 40% of cases. In hypertrophic cardiomyopathy, thickness > 30 mm should be of prognostic value & wall thickness is lost assessed on short axis views except for apex ( long axis is better ) & should be done at diastole. Left ventricular function, volume & mass is best seen on short axis oblique views. In myocardial perfusion imaging, adenosine is drug of choice but is not given in asthma patients (dobutamine is given). Pericardial thickening > 4 mm is seen in constrictive pericarditis but normal in restrictive cardiomyopathy (normal thickness is 2 mm). Mitral valve calcification with left atrial enlargement is always due to rheumatic disease. Aortic valve calcification occurs due to bicuspid valve, syphilis, ageing & ankylosing spondylitis. Dilated pulmonary veins are not seen in reversal of normal left to right shunt (Eisenmenger). Aortic valve calcification occurs due to bicuspid valve, syphilis, ageing & ankylosing spondylitis. (MSK) William syndrome is idiopathic hypercalcemia of infancy – It includes elfin like facies, renal stones, learning disability, colonic or bladder diverticuli, aortic & pulmonary valve stenosis, cardiac septal defects & osteosclerosis. Succeeding 6. With regards to imaging techniques in the detection of hibernating myocardium, which has the greatest specificity? A. 2-[18F]-fluoro-2-deoxy-d-glucose positron-emission tomography B. Thallium-201 rest-redistribution C. Technetium-99m perfusion imaging D. Dobutamine stress echocardiography E. Dobutamine stress magnetic resonance imaging 6. E Dobutamine stress MRI is a well-validated method for the assessment of myocardial hibernation (using a low dose protocol) and ischaemia (using a high-dose protocol). MRI provides superior spatial resolution when compared with echocardiography, and improvement in resting wall motion abnormality is considered a sign of myocardial hibernation. 17. A 25-year-old man is investigated with a history of recurrent syncope. Which of the following imaging findings on cardiac multidetector computed tomography would most support a diagnosis of Hypertrophic Obstructive Cardiomyopathy (HOCM)? A. Asymmetric thickening of the right ventricular myocardium particularly affecting the intraventricular septum B. Posterior displacement of the papillary muscles and mitral valve leaflets C. Separation of the anterior mitral valve leaflet and the intraventricular septum during systolic contraction D. Patchy enhancement of the intraventricular septum, carrying a worse prognosis E. Left ventricular outflow obstruction usually occurring at the supraaortic level 17. D Patchy enhancement of the asymmetrically thickened interventricular septal region is thought to represent intramyocardial scarring and confers a worse prognosis. Asymmetric thickening of the left ventricular myocardium particularly affects the interventricular septum with obstruction of the left ventricular outflow tract. The apposition of the anterior mitral valve leaflet and the interventricular septum during systolic contraction (systolic anterior motion) results in the onset of mitral regurgitation. The left ventricular outflow obstruction usually occurs at the subaortic level and is caused by ventricular septal hypertrophy with anterior displacement of the papillary muscles and the mitral valve leaflets. 19. A small pericardial metastatic deposit on the Magnetic Resonance Imaging (MRI) of a 55-year-old female demonstrates high-signal intensity on T1-weighted images. Which of the following is the most likely primary tumour? A. Breast B. Renal cell carcinoma C. Colorectal D. Melanoma E. Lymphoma 3 CVS Cardio acquired 19. D Pericardial effusion, thickening or mass may indicate metastatic involvement of the pericardium. Most neoplasms have a low-signal intensity on T1-weighted images and a high signal intensity on T2-weighted images, with the exception of metastatic melanoma. The most common tumors to metastasize to the pericardium are breast and lung, followed by lymphomas and melanomas. 28. A 65-year-old woman presents with palpitations and a heart murmur. Which of the following features are more in keeping with an atrial myxoma rather than thrombus as demonstrated on CT? A. Prolapse through the mitral valve on CT B. The presence of calcification C. The low attenuation of the lesion D. A lack of enhancement E. A smooth surface of the lesion 28. A On CT, prolapse through the mitral valve orifice is the only reliable discriminatory finding indicating myxoma. There is overlap in the features of calcification, mobility, attenuation characteristics, and location between myxoma and thrombus. 33. MRI of the pericardium of an adult male shows a pericardial effusion, low signal on T1-weighted spin-echo images and high intensity on GRE cine images. There is an irregular thickened pericardium, with nodularity. What is the most likely underlying cause? A. Hypothyroidism B. Traumatic injury C. Purulent infection D. Cardiac failure E. Malignancy 33. E An effusion is the most common manifestation of metastatic pericardial disease. On MRI images, most neoplasms have a low-signal intensity on T1-weighted images and a highsignal intensity on T2-weighted images, with the exception of metastatic melanoma, which may have high-signal intensity on T1-weighted images. 37. A CT chest scan of a young female reveals a pericardial mass. This is contiguous with the heart border, elliptical, thin walled and contains no internal septae. The average attenuation of its contents is 17HU and does not enhance post- contrast. The most likely diagnosis is: A. Tuberculous pericarditis B. Pericardial cyst C. Constrictive pericarditis D. Pericardial mesothelioma E. Pericardial metastasis 37. B The characteristic features of pericardial cysts include: lack of enhancement, water attenuation, round or elliptical shape, thin walled, sharply defined and being without internal septa. The most common location is at the cardiophrenic angles. Bronchogenic and thymic cysts may be indistinguishable. 42. On reviewing 4 chamber views of the heart on steady state free precession cine MR, a left ventricular aneurysm is noted. The contour of the left ventricle is normal but there is marked apical thinning. No thrombus is seen. No viable myocardium is seen as evidenced by full thickness gadolinium enhancement of the aneurysm wall. Which is the most common cause of a true left ventricular aneurysm? A. Dominant right coronary artery occlusion B. Acute left anterior descending artery occlusion C. Trauma D. Idiopathic endomyocardial dysplasia E. Sarcoidosis 42. B Although each of the stems are possible causes, a transmural infarct secondary to LAD occlusion is the most common cause. 4 CVS Cardio acquired 47. On reviewing a CT of a patient with extensive metastatic disease, a tumour is seen to extend from the IVC into the right atrium. Which of the following tumours is the most likely to cause such an appearance? A. Hepatocellular carcinoma B. Lymphoma C. Colorectal carcinoma D. Pancreatic adenocarcinoma E. Gastrointestinal stromal tumour 47. A The differential diagnosis for tumours extending from the IVC to the right atrium include leiomyosarcoma of the IVC, renal cell carcinoma and hepatocellular carcinoma. Get through 10) A 55-year-old presents with chest pain. His blood tests show a mild troponin rise, but an ECG is normal. A chest radiograph shows bilateral, symmetrical, hilar adenopathy but no other abnormality. Which feature on cardiac MRI would make cardiac sarcoid a more likely diagnosis than ischemia secondary to coronary artery disease? a. delayed hyperenhancement of lateral wall b. full-thickness, abnormal, high T2 signal in lateral wall c. reduced inferior wall motility d. partial-thickness, abnormal, high T2 signal with sub endocardial sparing at base of septum e. segmental area of reduced enhancement in lateral wall on early phase study 10) d. _____ Acute cardiac sarcoid is seen on MRI as high T2 signal in the myocardium, which may be associated with wall thickening secondary to edema. Early enhancement may also be seen with sarcoid on postcontrast scans. Delayed hyperenhancement can occur in acute sarcoid, but is also seen in non-viable myocardium secondary to ischemia. However, in non-ischemic conditions, it is often seen only involving the central section of the wall with sub endocardial sparing. Acute sarcoid may also cause nodular high-signal areas of high T2 signal. It usually involves the base of the septum and left ventricle, but rarely the papillary muscle or right ventricle. Distribution rarely conforms to vascular territories. 28) A 26-year-old intravenous drug user presents with reduced conscious level, associated pyrexia and malaise. Clinically, there is a systolic murmur, mild hypotension and an elevated white cell count. A chest radiograph shows multiple opacities in the mid and lower zones, some of which are cavitating. What is the most appropriate next investigation? a. CT of the thorax b. transthoracic echocardiogram c. white cell scan d. MRI of the heart e. transesophageal echocardiogram 28) e. __ In this clinical scenario the patient is most likely to have multiple septic emboli secondary to intravenous drug usage. Given the multiple pulmonary abscesses and pneumonia, tricuspid endocarditis should be considered and an echocardiogram should be performed. Transoesophageal echocardiogram is more sensitive to valvular vegetations and should be the investigation of choice. MRI of the heart may have some value in endocarditis, but as yet its value as a routine investigation has not been proven. 39) A 48-year-old female patient presents with mild dyspnea on exertion. A chest radiograph shows fine calcification overlying the cardiac silhouette adjacent to the left sternal edge at the level of the fourth intercostal space. What is the most likely cause? a. rheumatic heart disease b. bicuspid valve c. syphilis d. ankylosing spondylitis e. normal ageing 5 CVS Cardio acquired 39) a. _ The appearances are suggestive of mitral valve calcification, which is virtually always due to rheumatic heart disease, but occasionally may occur secondary to mitral valve prolapse. The differential diagnosis of this appearance includes calcification of the right coronary artery or left circumflex artery. Bicuspid valve, syphilis, ankylosing spondylitis and normal ageing are all causes of aortic valve calcification. 54) Which of the following is the most typical description of a myxoma? a. left atrial mass, no atrial enlargement, pulmonary edema b. right atrial mass, enlarged right atrium, clear lungs c. left atrial mass, enlarged left atrium, calcified lung nodules, pulmonary edema d. right atrial mass, enlarged right atrium, pulmonary edema e. left atrial mass, dilated superior vena cava, inferior vena cava and azygos vein 54) c. ___ Myxomas are more common in the left atrium (75–80%) and present with obstruction of the mitral valve. They cause pulmonary hypertension and edema, left atrial enlargement and ossified lung nodules. They may also cause systemic emboli. Right-sided myxomas cause tricuspid obstruction, right atrial enlargement, dilatation of the SVC, IVC and azygos veins, and reduced pulmonary vascularity. They may also cause pulmonary emboli. (MSK) 72) The hypoperfusion complex, seen in patients who have suffered major blunt abdominal trauma, includes all but which of the following radiological signs on contrast-enhanced CT? a. hyperenhancement of the adrenal glands b. hyperenhancement of the pancreas c. hyperenhancement of the spleen d. collapsed inferior vena cava e. small aorta 72) c. ____ The hypoperfusion complex is a marker of severe injury and is an important prognostic indicator related to radiological signs on CT following blunt abdominal trauma. The features are of hypovolaemia, with small arterial and collapsed venous vessels indicating reduced circulating volume. Hyperenhancement of the kidneys, adrenal glands, pancreas and bowel wall is seen, but the spleen may be small and hypodense. If injury to the vascular pedicle is not present, nonenhancement of the spleen could be 2ry to severe vasoconstriction and poor perfusion. 85) A 62-year-old male presents with increasing shortness of breath. Clinically, he has edematous ankles, raised central venous pressure, ascites and hepatomegaly. Blood tests show mildly raised inflammatory markers. Which feature on CT would make restrictive cardiomyopathy a more likely diagnosis than constrictive pericarditis? a. dilated inferior vena cava b. pleural effusions c. normal pericardial thickness d. pericardial calcification e. previous coronary artery surgery 85) c. ____ Both restrictive cardiomyopathy (RCM) and constrictive pericarditis (CP) present in the same way, with signs and symptoms of reduced heart filling and venous congestion. Distinguishing between these causes is important, as CP can be cured. Pericardial calcification occurs in CP and is seen in 50% of cases on chest radiograph. Pericardial thickening of.4mm is usually seen with CP. A normal pericardial thickness excludes CP and makes RCM a likely diagnosis instead. Previous cardiac surgery is a cause of CP. Barret1 7- A 32-year-old male patient has a routine CXR for insurance purposes. The film is well centered, the right heart border is indistinct and appears rotated. The lung parenchyma and vasculature appear normal. What is the most likely cause? (a) Absent left pericardium (b) Pectus excavatum (c) Poor patient positioning (d) Pulmonary artery enlargement (e) Situs solitus 6 CVS Cardio acquired 7(a) Congenital absence of the pericardium may be partial (91%) or total (9%). Large defects can cause strangulation and have the appearance of the large cardiac silhouette seen in pericardial effusions, small defects are usually asymptomatic. Partial defects are more common on the left (complete left-sided absence 35%, foraminal defect left side 35%). In complete left-sided absence, the heart is shifted to the left and rotated, the PA view of the heart mimics an RAO view and the heart is separated from the sternum on the lateral view. In foraminal left-sided defects, there may only be prominence of the left atrial appendage (appears as left hilar mass, may mimic left PA enlargement). They are associated with bronchogenic cysts (30%), VSD, P DAs, CDHs and mitral stenosis. 25- Regarding the primary cardiac tumor myxoma, which of the following statements is true? (a) 40% occur in the right atrium (b) Enlargement of the atrial appendage may be seen on CXR (c) The majority are sessile (d) Most tumors arise from the septum (e) It typically presents in teenage years 25 (d) Myxoma is the most common primary cardiac tumor in adults. 90% Of patients are between 30—60 years at presentation. The majority occur in the left atrium (80%), with 75% of these arising from the interatrial septum near the fossa ovalis. They are typically villous, pedunculated tumors, with only 25% seen as a sessile mass; the average size at presentation is 6 cm. Patients present with constitutional symptoms such as fever, weight loss, or syncope- Myxomas may also produce anemia, emboli, and obstruction of the mitral valve, which can lead to pulmonary venous hypertension and pulmonary edema. There is enlargement of the left atrium, but not of the atrial appendage. 36- A patient undergoes myocardial perfusion imaging and you are shown the standard short axis view. Which part of the myocardium is uppermost as you look at it? (a) Anterior wall (b) Interventricular septum (c) Posterior wall (d) Inferior wall (e) Lateral wall 36 (a) The short axis view shows a circle of myocardium. The lateral wall is on your right, the septum on your left and the inferior wall at the bottom Barret2 25 With regard to coronary artery calcium scoring, which of the following is not true? (a) The absence of calcification makes atherosclerotic disease very unlikely (b) Calcification is highly specific for atherosclerotic disease (c) Calcium is expressed as the Hounsfield score (d) Calcification may progress at up to 25% per year (e) Lipid lowering drugs may stop progression of calcification 25 (c) Coronary artery calcification is expressed as the Agatston score. The greater the degree of calcification, the greater the risk of a cardiac event. 65 A 37 year old man presents with non-specific symptoms of malaise. A whole body CT demonstrates a mass of soft tissue density within the right atrium. No other abnormality is seen. What is the most likely diagnosis? (a) Myxoma (b) Rhabdomyosarcoma (c) Thrombus (d) Metastasis (e) Lymphoma 7 CVS Cardio acquired 65 (a) Myxomas are by far the commonest cardiac tumours, typically arising on a pedicle from the interatrial septum. They may prolapse in to the ventricle and obstruct the mitral or tricuspid valves. Currie 9. A 38 year old man with progressive dyspnoea and chest pain undergoes an echocardiogram which reveals a pedunculated intracardiac mass which is hypointense to myocardium on T1-weighted images and markedly hyperintense on T2-weighted images. The most likely intracardiac location of the lesion would be: a. Right atrium b. Right ventricle c. Left atrium d. Under-surface of tricuspid valve e. Anterior papillary muscle 9. c. Left atrium The case describes an atrial myxoma, which is more common in the left atrium (75–80% of cases). These tumours are usually attached to the inter-atrium septum. 19. A 40 year old man with a known malignancy presents with pericardial metastases and pericardial effusion. The metastatic deposits are high signal on T1-weighted imaging. Which is the likely primary diagnosis? a. Lymphoma b. Lung cancer c. Melanoma d. Fibrosarcoma e. Colorectal cancer 19. c. Melanoma Whilst most metastases are low on T1-weighted and high on T2-weighted imaging, metastases from melanoma have a high signal on T1-weighted imaging due to the paramagnetic effects of melanin. 25. A 54 year old man presents with breathlessness and palpitations. Clinical examination reveals a mid-diastolic murmur with presystolic accentuation. Echocardiography confirms the presence of a mobile intracardiac mass in the left atrium attached to the septum by means of a stalk. Which of the following is the most likely feature of the lesion on MRI? a. Hypointense relative to myocardium on T1-weighted images b. Uniform hyperintense to myocardium on T2-weighted images c. Uniform enhancement following gadolinium d. Hyperintense to blood pool and hypointense to myocardium on steady-state free precession (SSFP) images e. Prolapse of the mass through the mitral valve, best demonstrated on the short axis views 25. a. Hypointense relative to myocardium on T1-weighted images The lesion described is a left atrial myxoma which has a heterogenous appearance on most MRI sequences and usually demonstrates varying enhancement following gadolinium injection. This is due to varying amounts of myxomatous tissue, fibrous tissue, blood products and tumour necrosis. The majority of the lesion will be hypointense to myocardium on T1-weighted images. On SSFP images, it is hypointense to blood pool and hyperintense to myocardium. The tumour prolapses through the mitral valve and is best seen on cinegradient echo imaging with a four-chambered long axis view 35. A 52 year old with cardiomyopathy is referred for delayed contrast-enhanced cardiovascular MR (DE-CMR). The following are all false except: a. An inversion recovery pulse of an appropriate TI is applied to nullify the signal from the ischaemic myocardium b. A long TI would nullify the signal from both the normal and diseased tissue c. A TI of 200 ms would nullify the signal intensity from the normal myocardium d. Imaging should be commenced immediately after contrast injection e. The images are T1-weighted ECG-gated fast spin-echo sequences with an inversion recovery sequence 35. c. A TI of 200 ms would nullify the signal intensity from the normal myocardium After an initial LV function study, gadolinium is administered and imaging is commenced 100 minutes later in the same spatial location as the preceding LV study. Inversion recovery pulse is used to nullify the signal from the normal myocardium with a TI of approximately 200 ms. The healthy myocardium appears dark, whilst the ischaemic myocardium appears bright. Too short a TI results in loss of signal from both abnormal and normal myocardium, whilst too long a TI would result in loss of contrast. The images are T1-weighted ECG-gated fast gradient echo images. 8 CVS Cardio acquired 36. In the same patient (with cardiomyopathy), which underlying cause and corresponding enhancement pattern are inappropriate? a. Ischaemic cardiomyopathy – subendocardial pattern in a coronary artery territory b. Early myocarditis – patchy, focal subendocardial pattern c. Hypertrophic cardiomyopathy – patchy multifocal changes, commonly the right ventricular free wall and its junction with the interventricular septum d. Amyloidosis – global and diffuse, commonly subendocardial e. Dilated cardiomyopathy – midwall myocardial enhancement 36. b. Early myocarditis – patchy, focal subendocardial pattern In early myocarditis, the enhancement pattern is typically epicardial. 46. A 45 year old female patient with history of rheumatic fever as a child presents with progressive shortness of breath and paroxysmal nocturnal dyspnoea. Clinical examination reveals a pansystolic murmur associated with a mid-diastolic murmur with presystolic accentuation best heard over the cardiac apex. Clinical examination and plain film do not reveal evidence of heart failure, but several features of left atrial enlargement are noted. Which of the following is not one of those? a. Double atrial shadow on the right b. Straightening of the right heart border c. Elevation of the left main bronchus d. Splaying of the carina e. Displacement of the descending aorta to the left 46. b. Straightening of the right heart border Left atrial enlargement results in straightening of the left heart border as a result of enlargement of the left atrial appendage. This is especially a feature of rheumatic mitral valve disease. 60. A 32 year old patient with congenital heart disease is referred for a cardiac MR examination. Regarding cardiac MR imaging, which of the following applies? a. Dark rim artefacts are typically seen on the epicardial aspect on perfusion imaging b. Radiofrequency artefacts are typically sporadic and transient, affecting few images in a series c. Field inhomogeneity artefacts are more common on a 3T scanner than a 1.5T scanner d. Of the two cine MR imaging techniques, at the same bandwidth, image acquisition is quicker with an SSFP sequence than spoiled GRE imaging e. Prospective gating is preferred for assessing diastolic dysfunction 60. c. Field inhomogeneity artefacts are more common on a 3T scanner than a 1.5T Scanner Dark rim artefacts are typically seen on the endocardial aspect on cardiac MR imaging. Spike artefacts are typically sporadic and transient, whilst RF artefacts usually involve all images of the series. At the same bandwidth, image acquisition is quicker with spoiled GRE acquisition. However, often, a lower bandwidth has to be used to improve the signalto- noise ratio of these sequences and so SSFP imaging may be quicker. In prospective gating, to compensate for physiologic variations in heart rate, the acquisition window is usually 10–20% shorter than the average RR interval, missing out on the end diastole, and hence it is not very useful for assessing diastolic dysfunction. Grainger Oxford 73. A 28-year-old patient is admitted from the dermatology clinic where she is being treated for basal cell carcinoma. She suffered an episode of ventricular tachycardia and imaging is requested secondary to the results of echocardiography. CXR reveals bifid ribs. Cardiac MRI reveals a well circumscribed abnormality, which is low signal on both T1WI and T2WI and shows delayed enhancement, within the myocardium of the left ventricular free wall. CT reveals a soft-tissue attenuation mass with calcification. What is the most likely diagnosis? A. Myxoma. B. Paraganglioma. C. Fibroma. D. Fibroelastoma. E. Lipoma. 9 CVS Cardio acquired 73. C. Fibroma. This patient has Gorlin’s syndrome (nevoid basal cell carcinoma syndrome, NBCCS). This may result in abnormalities of the skin (basal cell carcinoma), skeletal (jaw odontogenic keratocysts, bifid, fused, or markedly splayed ribs), and genitourinary (ovarian fibromas) systems, as well as cardiac fibroma (relatively rare) and calcification of the falx. Medulloblastoma is a relatively less common manifestation. The imaging characteristics of cardiac fibromas reflect their fibrous nature: low signal on T1WI and T2WI with delayed enhancement on MRI. Most are well circumscribed with a surrounding rim of compressed myocardium. On CT they manifest as mildly enhancing soft tissue attenuation masses. Foci of calcification are present in up to 50% of cases. Although benign they may cause ventricular arrhythmias and even sudden death secondary to interference with conduction pathways. Atrial myxomas are of mixed signal on T1WI and T2WI sequences. They are most commonly found within the left atrium (80%), with 15% in the right atrium. On CT a low attenuation intracavitary mass with a smooth or slightly villous surface is seen. Cardiac paragangliomas are well encapsulated, hypervascular (intensely enhancing), and 3–8cm in size. They are isointense to myocardium on T1WI and markedly hyperintense on T2WI. Presentation is with symptoms of catecholamine excess. They are found in the posterior wall of the left atrium, atrioventricular groove, and root of the great vessels. Fibroelastomas arise from endocardial surfaces, most commonly the aortic and mitral valves. They are a recognized cause of sudden death and immediate resection is warranted. Trans-oesophageal echocardiography is the optimal means of visualization due to their small size and highly mobile nature. Cardiac lipomas have characteristic imaging features consistent with fat on MRI and CT. MasterPass1 4 A 50-year-old man who is an outpatient had a chest radiograph that demonstrates globular cardiomegaly suspicious of a pericardial effusion. What would be the next appropriate investigation to further investigate this finding? a Magnetic resonance imaging b Echocardiogram C Computed tomography examination d Electrocardiogram e Myocardial perfusion scan 4 Answer B: Echocardiogram The easiest and safest way to determine the presence and extent of pericardial fluid is with an echocardiogram. 7 A 39-year-old male smoker was referred to a cardiologist with chest pain. A cardiac magnetic resonance examination was requested as part of his workup. This showed patchy multifocal delayed hyperenhancement within the basal interventricular septum. What is the most likely diagnosis? a Sarcoidosis b Amyloidosis c Ischaemic myocardium d Myocarditis e Hypertrophic cardiomyopathy 7 Answer E: Hypertrophic cardiomyopathy The location and pattern of enhancement is typical of this diagnosis. In amyloidosis the hyperenhancement is global and in sarcoidosis and myocarditis it affects the epicardial or midmyocardial regions. 8 A 25-year-old male was referred for a routine testicular screening ultrasound. He is known to have a cardiac myxoma and has multiple pigmented lesions on his face and lips. What is the most likely unifying diagnosis? a Carney's syndrome b Peutz Jeghers syndrome c Waardenburg's syndrome d Cronkhite-Canada syndrome e Gorlin's syndrome 8 Answer A: Carney's Syndrome Carney's Syndrome or Complex refers to a familial neoplastic lentiginous syndrome consisting of the following: primary pigmented nodular adrenocortical disease, lentigines, ephelides, blue nevi of the skin and mucosa, various tumours (including myxomas of the skin, heart and breast) and Sertoli-cells tumours of the testes. 10 CVS Cardio acquired 9 Regarding multidetector computed tomography for coronary artery disease, which of the following statements is true? a It has a low negative predictive value b It is ideally used in a population with a low pre-test probability of coronary artery disease c It is accurate in detecting stenosis in small vessels d The Rockford scoring system is used e It is less accurate than magnetic resonance imaging in detecting extent of calcification 9 Answer B: It is ideally used in a population with a low pre-test probability of coronary artery disease It has a high negative predictive value and is ideally used in the population with a low pre-test probability of CAD as it prevents unnecessary invasive procedures. The Agatston scoring system is used to quantify coronary calcification. 10 A 58-year-old male who frequently attends the Emergency Department presents with dyspnoea and chest wall pain. His chest radiograph demonstrates cardiomegaly, multiple rib fractures of varying ages and right lower lobe consolidation. What is the most likely unifying diagnosis? a Chronic alcohol abuse b Sickle cell anaemia c Congestive cardiac failure d Amyloidosis e X-linked cardioskeletal myopathy 10 Answer A: Chronic alcohol abuse This is the most logical explanation for these appearances. 12 A 56-year-old female was referred to the cardiology outpatient clinic with recent onset exertional dyspnoea. An echocardiogram showed left ventricular dysfunction and a cardiac MRI was requested to identify the cause. Cine images revealed focal hypokinesis in the anteroseptal wall and delayed enhanced images show increased signal in the subendocardium. What is the most likely diagnosis? a Myocarditis b Myocardial infarction C Hypertrophic cardiomyopathy d Amyloidosis e Tako-tsubo cardiomyopathy 12 Answer B: Myocardial infarction Purely subendocardial delayed hyperenhancement in a recognised vascular territory is classical of myocardial infarction. The anteroseptal wall is supplied by the left anterior descending artery. 14 A 59-year-old female patient presented with malaise, chest pain and dyspnoea. Her chest radiograph was normal. An echocardiogram demonstrated a mobile echogenic mass attached to the intra-atrial septum by a stalk. What is the most likely diagnosis? a Pulmonary embolism b Papillary fibroelastoma C Sarcoma d Fibrovillous adenoma e Cardiac myxoma 14 Answer E: Cardiac myxoma The differential diagnosis of a pedunculated intracardiac lesion includes atrial myxoma and papillary fibroelastoma. Papillary fibroelastomas are rare lesions that are typically asymptomatic. 15 A 67-year-old retired musician was admitted to the acute medical ward at 7.00 am with dyspnoea. Examination revealed central cyanosis, tachypnoea and bilateral crepitations, which were most marked at the bases. Initial investigations revealed hypoxia, tachycardia and an abnormal ECG. A chest radiograph demonstrated perihilar alveolar opacification, interstitial thickening, small bibasal effusions and upper lobe blood diversion. On further questioning it is apparent that the patient had been increasingly breathless for several months and subsequent echocardiography demonstrated cardiomyopathy. What echocardiographic finding would be most suggestive of a restrictive rather than a dilated cause for the cardiomyopathy? a Decreased systolic function b Isolated diastolic dysfunction C Cardiac mural thrombus d Reduced cardiac output e Increased LV cavity size 11 CVS Cardio acquired 15 Answer B: Isolated diastolic dysfunction One of the hallmarks of restrictive cardiomyopathy is diastolic dysfunction, whereas systolic dysfunction is typical of dilated cardiomyopathy. The presence of mural thrombus and increased LV cavity size can be seen in both forms of cardiomyopathy. 18 A 27-year-old female with gradually worsening exercise tolerance had a chest radiograph as part of her work-up. She has a past history of rheumatic heart disease. The chest radiograph shows an increased cardiothoracic diameter with a double right heart border and upper lobe blood diversion. There was an area of calcification projected over the cardiac shadow. Which valvular condition is most likely? a Aortic stenosis b Aortic regurgitation c Mitral stenosis d Tricuspid stenosis e Tricuspid regurgitation 18 Answer C: Mitral stenosis The description is most compatible with rheumatic mitral stenosis. Rheumatic heart disease usually develops 5-15 years after the initial episode of rheumatic fever. Other signs to consider include splaying of the carina and rightward displacement of the oesophagus on an oesophagram. 20 A 63-year-old gentleman was diagnosed with a q-wave acute myocardial infarction and underwent a cardiac MRI the following day. What is the most likely signal intensity of the infarcted region on T2-weighted imaging? a Signal void b Low C Isointense d High e Variable 20 Answer D: High With an acute myocardial infarction there will be a high intensity focus in the region of the infracted tissue on T2- weighted imaging with no change or mildly decreased signal intensity on T1 due to myocardial oedema post infarction. 21 A 62-year-old gentleman with exertional dyspnoea was referred by his cardiologist for a stress cardiac MR study. His medical history includes hyperlipidaemia, asthma and hypertension. Which of the following pharmacological stress agents is best suited for this patient? a Adenosine b Dobutamine c Atenolol d Verapamil e Dopamine 21 Answer B: Dobutamine In patients with asthma or bronchospastic conditions, dobutamine can be used as a pharmacological stress agent. Dobutamine primarily acts on beta-1 receptors with its peak effect occurring within 10 minutes. 24 A 55-year-old hypertensive diabetic presented with chest pain and was found to have a myocardial infarct of his interventricular septum and apex. In which vessel territory is this area most likely to lie? a Left anterior descending artery b Left circumflex artery C Posterior descending artery d Conus artery e Acute marginal branches of the right coronary artery 24 Answer A: Left anterior descending artery The left anterior descending artery is a branch of the left coronary artery and travels along the anterior interventricular groove. It usually supplies the anterior two-thirds of the interventricular septum and the posterior descending artery the posterior third of the septum. 12 CVS Cardio acquired 26 A patient had a cardiac stress Myoview study and the nurse supervising the study was concerned that he could not continue. What would indicate that terminating the study is the appropriate thing to do? a Mild chest discomfort b Mild dizziness C ST segment depression of 1 mm d Increase in systolic blood pressure from baseline by 40 mmHg e Increase in diastolic blood pressure above 120 mmHg 26 Answer E: Increase in diastolic blood pressure above 120 mmHg Most patients experience mildly unpleasant symptoms during chemical stressing with adenosine or dobutamine. These should all be documented and can be correlated with any induced ECG changes. Obviously, the procedure should be stopped at the patient's request but forewarning about possible side-effects is helpful. ST segment depression of >3 mm is an indication to stop. Systolic decrease is also worrying but should be taken into account with any concurrent symptoms. 27 A 59-year-old lady with no previous cardiac history presented with intermittent chest pain on exertion not typical of cardiac pain. Her chest radiograph was normal and she is not taking any cardiac medication. She is otherwise well except for bilateral osteoarthritis in the knees. What is the best form of imaging to assess for cardiac ischaemia? a Tc Myoview rest and chemical stress b Tc Myoview rest only C Electrocardiogram d Exercise tolerance test with electrocardiogram e Cardiac gated CT 27 Answer A: Tc Myoview rest and chemical stress Cardiac gated CT is useful to assess anatomy and can be used for coronary calcification scoring. It will not demonstrate ischaemia. MR studies with stress can demonstrate myocardial ischaemia and contractility but are usually used for those with complex disease or anatomy. The atypical symptoms make her more appropriate for a nuclear medicine study. She would probably struggle with an exercise tolerance test and a resting only study would not show reversible ischaemia. MasterPass2 4 A 75-year-old female with dyspnoea had a chest radiograph on admission to the acute medical ward. This showed cardiomegaly with a prominent atrial appendage, a double heart border, a fine ring of calcification behind the cardiac shadow and prominent upper lobe blood vessels. What is the most likely diagnosis? a A ventricular septal defect b Mitral valve stenosis c Ischaemic heart disease d Aortic root dilatation e Left ventricular aneurysm 4 Answer B: Mitral valve stenosis The description is that of left atrial enlargement and with the calcification of the left atrium, this is most in keeping with mitral stenosis. 7 A 44-year-old female presented to the Emergency Department in heart failure. An electrocardiogram demonstrated Q waves in lead III and a VF consistent with a previous inferior myocardial infarction. A coronary angiogram was then performed. Which vessel is most likely to be responsible for the infarct? a Left main stem b Left anterior descending artery c Obtuse marginal artery d Right coronary artery e Circumflex artery 7 Answer D: Right coronary artery The right coronary artery supplies the posterior descending artery responsible for supplying the inferior wall in 85% of people. The circumflex is responsible in 10%. Co-dominance is responsible for the remaining 5%. 13 CVS Cardio acquired 8 A 34-year-old male presented to the Cardiology team with syncopal episodes and a family history of premature sudden death. A cardiac magnetic resonance examination was requested which showed a dilated right ventricle with a reduced ejection fraction but a normal left ventricle. There was also high signal within the right ventricular free wall on T1- weighted imaging, suggesting fatty replacement. What is the most likely diagnosis? a Uhl's syndrome b Brugada syndrome c Arrhythmogenic right ventricular dysplasia d Hypertrophic cardiomyopathy e Right ventricular outflow tract tachycardia 8 Answer C: Arrhythmogenic right ventricular dysplasia (ARVD) This is an uncommon disease which is often familial. It is characterised by the replacement of the myocardium by fatty and fibrous tissue. The commonest symptoms are syncopal episodes or sudden death. MRI has the advantage over echocardiography that it demonstrates the presence of fat as well as fibrous tissue on delayed enhancement imaging. 9 A 43-year-old male presented to the Cardiology team with a long history of coronary heart disease. His chest radiograph demonstrated enlargement of the left ventricular apex. What characteristic would make a diagnosis of a true ventricular aneurysm more likely than a false aneurysm? a A mouth considerably smaller than the maximal diameter b No myocardial fibres in the wall C An aneurysm that protruded only in systole d A previous history of myocardial infarction e Thrombus within the aneurysm 9 Answer C: An aneurysm that protruded only in systole Although most true aneurysms protrude in diastole and systole, a functional aneurysm protrudes only in systole. All false aneurysms protrude in diastole and systole. 10 A 57-year-old man with diabetes mellitus presented with anterior chest pain on minimal exertion and an exercise tolerance test was positive. Cardiac angiography demonstrated 70% stenosis of the circumflex, 90% stenosis of the left anterior descending and complete occlusion of the right coronary arteries. It was agreed with the patient that coronary artery bypass surgery was appropriate. Which of the following native grafts is most appropriate for bypassing the left anterior descending artery? a Saphenous vein b Left internal mammary artery C Left superior epigastric artery d Radial vein e An intercostal artery 10 Answer B: Left internal mammary artery The distal left anterior descending (LAD) artery lies anteriorly in the chest. The left internal mammary artery (LIMA) lies along the anterior chest wall and passes close to the LAD in the interventricular groove, which makes it an ideal graft. Additionally, arteries make more sustainable graft material. 12 A 55-year-old female presented to the Emergency Department with acute central chest pain and shortness of breath. Her daughter had died recently following a post-partum haemorrhage. She was hypotensive with signs of left cardiac failure and her troponin T was elevated. Coronary angiography demonstrated normal coronary arteries and cardiac MRI was performed. This revealed apical hypokinesis and dilatation with normal basal function. There was no myocardial delayed hyperenhancement. Subsequent echocardiography 12 weeks later showed improved left ventricular function. What is the most likely diagnosis? a Myocardial infarction involving the left anterior descending artery b Myocarditis C Hypertrophic cardiomyopathy d Coronary artery spasm e Tako-tsubo cardiomyopathy 12 Answer E: Tako-tsubo cardiomyopathy This description is classic of Tako-tsubo cardiomyopathy, which is also known as transient catecholaminergic myocardial stunning. It often occurs following a stressful event and most patients recover completely. 14 CVS Cardio acquired 17 A 23-year-old intravenous drug abuser presented to the Emergency Department with fever and swelling in his left groin. He was also noted to be short of breath at rest with peripheral cyanosis. A chest radiograph demonstrated widespread bilateral foci of consolidation. Ultrasound of his left groin demonstrated a superficial abscess with non- occlusive thrombus in the left common femoral vein. An echocardiogram performed by a cardiologist showed an echogenic intracardiac mass. What is the best explanation for these findings? a Tricuspid valve endocarditis and septic pulmonary emboli b Intracardiac bland thrombus and Mycoplasma pneumonia C Intracardiac bland thrombus and bland pulmonary emboli d Pulmonary valve endocarditis and septic pulmonary emboli e Mitral valve endocarditis and Mycoplasma pneumonia 17 Answer A: Tricuspid valve endocarditis and septic pulmonary emboli Intravenous drug abusers are prone to right-sided valvular endocarditis from organisms introduced to the venous system while injecting. These vegetations, seen most commonly on the tricuspid valve, often throw off emboli to the lungs. 18 A 25-year-old presented with shortness of breath after minimal exercise. His general practitioner (GP) examined his cardiovascular system and noted a harsh ejection systolic murmur in the left parasternal region. No other murmurs were detected and there were no other positive clinical findings. His chest radiograph showed calcification in the region of the aortic valve. Which of the following is the most likely aetiology? a Congenital bicuspid aortic valve b Aortic valve atherosclerosis c Rheumatic valve disease d Previous endocarditis e Patent ductus arteriosus 18 Answer A: Congenital bicuspid aortic valve The murmur description is consistent with aortic stenosis. In an otherwise young and healthy individual, a congenital bicuspid aortic valve is most likely. These individuals can become clinically symptomatic under the age of 30. Aortic valve calcification is a not uncommon finding on the chest radiograph. Atherosclerotic disease of the aortic valve presents later in life. Rheumatic aortic valve disease is rare in the absence of mitral valve disease. 20 A 73-year-old man underwent a contrast-enhanced cardiac MR examination. His ECG had not changed over the last six months and showed Q waves in leads II, III and AT. When would you expect peak differential enhancement of the myocardium in the right coronary artery territory following administration of iodinated contrast? a No enhancement will occur b Within 10 seconds C 20-30 seconds d 60-90 seconds e 10-15 minutes 20 Answer E: 10-15 minutes The ECG findings are consistent with inferior myocardial infarction within the right coronary artery territory. A perfusion defect will occur within 60-90 seconds after contrast administration. There will be delayed enhancement of the infarcted tissue, which is most visible at 10-15 minutes. The size of the enhanced area correlates well with the size of the infarction. 23 A 52-year-old female underwent a follow-up contrast-enhanced CT of her thorax after an episode of viral pericarditis. There was a well-demarcated rounded mass in the paracardiac region. The attenuation was 38 HU (hypodense to myocardium). Where is this mass most likely to be situated? a Right costophrenic angle b Anterior to the right ventricle C Right cardiophrenic angle d Left cardiophrenic angle e Posterior mediastinum 23 Answer C: Right cardiophrenic angle Pericardial cysts may develop as a sequelae of pericarditis. The majority of these lesions are located in the cardiophrenic angle and are three times more common on the right. Occasionally, they may occur in the mediastinum. They can change in shape and size with respiration and body position. 15 CVS Cardio acquired (Ped) 35 A five-year-old has a CT chest following surgery for a structural congenital heart abnormality. The CT shows a right atrial baffle and an anastomosis between the pulmonary artery and the right atrium. There are bilateral pleural effusions. Which of the following procedures has been performed? a Fontan procedure b Blalock-Taussig shunt C Aorticopulmonary window shunt d Glenn shunt e Norwood procedure 35 Answer A: Fontan procedure This is performed between three and five years old for tricuspid atresia. It causes raised central venous pressure and frequently chronic pleural effusions. MasterPass3 3 A 56-year-old man had a chest radiograph following several episodes of chest pain. This showed a soft tissue-density lesion in the left cardiophrenic angle that has an acute angle with the diaphragm. A CT was performed which showed this to be a well-defined mass with an average Hounsfield unit value of 25. Magnetic resonance imaging (MRI) was also performed as part of his chest pain work-up and the mass was of low signal on T1-weighted imaging. What is the most likely diagnosis? a A cardiophrenic fat pad b A lung sequestration C A pericardial lipoma d A pericardial cyst e A lymph node 3 Answer D: A pericardial cyst A pericardial cyst typically occurs in the cardiophrenic angle and is characteristically low signal on T1-weighted MRI. 4 A 46-year-old female presented to the Emergency Department in heart failure with a history of chest pain. A chest radiograph demonstrated an enlarged heart and bilateral pleural effusions. What imaging finding would suggest a diagnosis of constrictive pericarditis rather than restrictive cardiomyopathy? a A pericardial thickness on CT of 4mm b Dilated right atrium c Ascites d Absence of ventricular hypertrophy e Global subendocardial late gadolinium enhancement on MRI 4 Answer A: A pericardial thickness on CT of 4mm Although pericardial thickening does not confirm a diagnosis of constrictive pericarditis, when the differential is between that and a restrictive cardiomyopathy it favours the former. B, C and D are non-discriminatory. E is occasionally found in restrictive cardiomyopathy. 6 A45-year-old male with known ischaemic heart disease presented with increasing shortness of breath on exertion and peripheral oedema. Echocardiography showed impaired left ventricular function. A cardiac magnetic resonance study was performed. What finding would be most consistent with hibernating myocardium? a 75% Subendocardial delayed enhancement b Normal myocardial contractility at rest c No myocardial delayed enhancement d Epicardial hyperenhancement e Patchy hyperenhancement of myocardium 6 Answer C: No myocardial delayed enhancement Hibernation describes chronic contractile impairment secondary to chronic hypoperfusion, where the myocardium is still viable. Delayed hyperenhancement represents infarcted tissue, which is no longer viable. 16 CVS Cardio acquired 7 A one-year-old male presented to the Emergency Department following a syncopal episode. On clinical examination there was an audible murmur and the child subsequently had an echocardiogram, which demonstrated a solid echogenic mass closely applied to the right ventricular wall. What is the most likely diagnosis? a Teratoma b Myxoma c Rhabdomyoma d Angioma e Lymphoma 7 Answer C: Rhabdomyoma The commonest cardiac tumour in an infant is a rhabdomyoma. It is a hamartoma and therefore a benign tumour that in 50-80% of patients is associated with tuberous sclerosis. They are often multiple and usually involve the ventricular free walls or interventricular septum. They are only managed surgically if they cause obstruction of the outflow tract as they tend to regress over time. 11 A 68-year-old male presented to the Emergency Department with shortness of breath. A chest radiograph revealed a pacemaker box lying within the left pectoral pocket with three leads arising from it. The first two leads lie within the right atrial appendage and right ventricle and the distal tip of the third lead is projected over the left ventricle. In which structure is the third lead most likely to be positioned? a Interventricular septum b Epicardium C Coronary sinus d Cardiac vein e Persistent left superior vena cava 11 Answer D: Cardiac vein This appearance describes a cardiac resynchronisation pacemaker, used for cardiac failure in the presence of bundle branch block. The lead enters the coronary sinus from the right atrium then is placed within an appropriate cardiac vein adjacent to left ventricular myocardium. If cardiac venous anatomy is not suitable then surgically placed epicardial leads can be used. 12 A 24-year-old female was investigated for syncopal episodes. A 24-hour ECG was normal and a coronary angiogram was suspicious for anomalous coronary artery anatomy. A gated coronary artery CT was requested. What arterial course is most likely to cause haemodynamic compromise and therefore require intervention? a Right coronary artery arising from the left coronary sinus and passing anterior to the aorta b Right coronary artery arising from the left coronary sinus and passing posterior to the aorta C Circumflex artery arising from the right coronary sinus passing posterior d Circumflex artery arising from the left coronary artery and passing into the atrioventricular groove e Left main stem arising from the non-coronary sinus and passing anteriorly 12 Answer A: Right coronary artery arising from the left coronary sinus and passing anterior to the aorta This arterial course is between aorta and pulmonary artery, which can compress the vessel causing ischaemia and if symptomatic may require bypass surgery. The commonest anomalous coronary artery course is an aberrant circumflex arising from the right coronary and passing posteriorly into the left AV groove (option c). 14 A 23-year-old professional footballer presents with shortness of breath disproportionate to the level of exertion. He has not experienced any chest pain and on further questioning he states that his brother died suddenly at school during an athletics match. He has never known his father, but his mother is in good health. What imaging finding most suggests a diagnosis of hypertrophic cardiomyopathy (HCM) over arrythmogenic right ventricular dysplasia (ARVD): a Fibro-fatty infiltration of the right ventricular wall b Segmental right ventricular wall motion abnormality c Right ventricular aneurysm d Aortic root dilatation e Left ventricular outflow narrowing 14 Answer E: Left ventricular outflow narrowing Both conditions can be inherited. Options a) and b) are typical of ARVD. Aortic dilatation is not a feature of either disease. Other imaging findings in HCM include mitral regurgitation, systolic anterior motion of the anterior leaflet to the mitral valve (SAM), hyperkinetic LV free wall, hypokinetic interventricular septum and early closure of aortic valve. 17 CVS Cardio acquired 15 A 59-year-old truck driver presented with severe chest pain and dyspnoea. His ECG demonstrated ST segment elevation in leads V4-V6 and on biochemical analysis troponin levels were elevated. Following several days' stay in hospital he was discharged. On review at six weeks echocardiography demonstrates an akinetic portion of the left ventricular wall and delayed enhancement cardiac MR images demonstrate high signal at 10 minutes in same area of the left ventricular wall. What is the most likely explanation for these imaging findings? a LV aneurysm b `Stunned' myocardium C Focal myocarditis d Focal myocardial fibrosis e `Hibernating' myocardium 15 Answer D: Focal myocardial fibrosis The clinical scenario is one of acute myocardial infarction. The echocardiographic findings are those of a regional wall motion abnormality, which may be due to established infarction and scar formation, ischemia without infarction or aneurysm. The MRI findings are those of delayed hyperenhancement indicating an area of fibrosis/scarring due to the previous infarct. Viable myocardium will transiently enhance, but non-viable infarcted myocardium accumulates contrast and demonstrates high signal at 10-20 minutes. 20 A 65-year-old woman with a history of an inferior myocardial infarction nine months previously underwent a cardiac MRI. When would you expect peak enhancement of the myocardium in the left ventricular free wall following administration of gadolinium-based contrast? a No enhancement will occur b Within 10 seconds C 20-30 seconds d 5-7 minutes e 10-15 minutes 20 Answer C: 20-30 seconds The left ventricular free wall is unlikely to have been involved in the patient's infarct hence the answer is when normal myocardium enhances. 21 A 45-year-old gentleman presented with dyspnoea on exertion and was found to have a cardiac murmur. Echocardiography showed an atrial mass with internal Doppler signal. Where in the atrial cavity is this mass most likely to arise from? a Left atrial appendage b Attached by a thin stalk to the left side of the inter-atrial septum C Broad based on the right side of the inter-atrial septum d Bi-lobed appearance in both atria arising from both sides of the interatrial septum e On the atrial aspect of the mitral valve 21 Answer B: Attached by a thin stalk to the left side of the inter-atrial septum Atrial myxomas are the most common primary cardiac tumour. They usually have non-specific symptoms, making early diagnosis a challenge. They are usually solitary (90%) and occur in the left atrial cavity (80%). Multifocal cardiac myxomas are associated with Carney's syndrome. Right-sided myxomas calcify more frequently than left-sided myxomas. The majority of atrial myxomas are attached to the inter-atrial septum via a small pedicle, but they occasionally arise from the wall of the atria or the valve surface. 24 A 72-year-old gentleman with long-standing atrial fibrillation experienced several episodes of transient neurological deficits. An echocardiogram was performed as part of his work-up and an echogenic mass was seen that did not show any internal Doppler signal. Where is this mass most likely to be? a Atrial side of the tricuspid valve b Left ventricle, on the interventricular septum C Right atrium, on the inter-atrial septum d Left atrial appendage e Pulmonary valve 24 Answer D: Left atrial appendage In the absence of a shunt, left-sided cardiac thrombus is most likely to be implicated in transient ischaemic events. Right- sided cardiac thrombi are likely to be filtered by the pulmonary circulation. The left atrial appendage is the most frequent site for a thrombus, especially in the context of known atrial fibrillation. 18 CVS Cardio acquired 27 A 100-kg male patient underwent a cardiac rest and stress Myoview study to assess for reversible coronary arterial disease. The images showed reduced uptake in the inferior cardiac wall on both the rest and stress images. He tolerated the study well but experienced dizziness and a mild drop in his blood pressure during the stress phase. What is the likely cause for the appearances on the study? a Reversible ischaemia in the inferior wall - right coronary artery territory b Irreversible loss of cardiac viability in the left anterior descending territory C High-sitting diaphragm causing artefact d Reversible ischaernia in the left circumflex territory e Cardiac hibernation in the left anterior descending distribution 27 Answer C: High-sitting diaphragm causing artefact Large patients often display artefact from the diaphragm and this should be checked while post processing the data. The inferior wall is usually supplied by the right coronary artery. The fact that both the rest and stress images are similar suggests that the findings are a result of artefact. Breast tissue in female patients can lead to similar findings. 29 A two-year-old child underwent a palliative procedure for a cyanotic congenital heart abnormality. A post-operative CT demonstrated a poly- tetrafluoroethylene (PTFE) graft between the subclavian artery and the ipsilateral branch of the pulmonary artery. What surgical procedure has been performed? a Blalock-Hanlon procedure b Glenn procedure C Rashkind procedure d Norwood procedure e Blalock-Taussig shunt 29 Answer E: Blalock-Taussig shunt The Blalock-Taussig (B-T) shunt is an end-to-side anastomosis between the subclavian and pulmonary arteries performed for Tetralogy of Fallot and tricuspid atresia with pulmonary stenosis. 65 What isolated valve lesion is most likely to cause severe cardiomegaly on a chest radiograph? a Aortic regurgitation b Mitral stenosis C Tricuspid regurgitation d Pulmonary regurgitation e Rheumatic heart disease 65 Answer A: Aortic regurgitation The cardiothoracic ratio is used as a guide to left ventricular dilatation. Often, the left ventricular volume has to increase by half to two-thirds before an increased ratio is easily appreciated. The ratio increases with expiration and supine positioning. In isolated mitral stenosis, there is dilatation of the left atrial appendage but the left ventricular size is often not enlarged. Gupta 26. A 25-year-old man presents with persistent cough. The chest radiograph shows a smoothly marginated opacity in the right cardiophrenic recess. CT shows a 4 cm lesion abutting the pericardium and a small pericardial effusion. The lesion shows no contrast enhancement and contents have Hounsfield units of < 10. On MRI, the abnormality returns uniform high signal intensity on T2-weighted images. What is the most likely diagnosis? (a) Pericardial fat pad (b) Enlarged pericardial lymph nodes (c) Pericardial cyst (d) Haematoma (e) Thymolipoma 26. (c) Pericardial cyst These are usually incidental finding and contain fluid. A level of < 10 Hounsfield units is typical. ericardial fat pad and thymolipoma would show fat on CT with lower Hounsfield units. 19 CVS Cardio acquired 27. A 65-year-old man with history of stroke presents with chest pain. The chest radiograph shows a thin curvilinear area of calcification in the lower part of left heart border. What is the likely site of calcification? (a) Left atrium (b) Left ventricle (c) Right atrium (d) Left descending coronary artery (e) Mitral valve 27. (b) Left ventricle This is the typical site for left ventricular calcifications. Valvular calcifications are located within the heart. Coronary artery calcifications are seen along the upper part of left heart border and have a ‘tram-track’ appearance. 28. A 56-year-old patient with history of cardiac valve replacement presents with acute-onset chest pain. A frontal chest radiograph shows an enlarged heart with laterally displaced left cardiac apex and a metallic ring shadow is seen to be overlapping the spine and horizontally positioned. Which cardiac valve is this likely to be? (a) Aortic (b) Mitral (c) Tricuspid (d) Pulmonary (e) Mitral or aortic 28. (a) Aortic valve The aortic and mitral valves are seen adjacent to the spine and can be difficult to separate. However, the aortic valve is usually seen horizontally situated while the mitral valve is generally situated vertically. On a lateral projection, if a line is drawn from the carina to the anterior costophrenic angle, the aortic valve lies above this line and the mitral valve below it. 29. A 58-year-old man recently had a cardiac pacemaker. On frontal chest radiograph, the tip of the electrode lies 3 cm medial to the cardiac apex. What is the most likely site of the electrode tip? (a) Left atrial appendage (b) Right atrial appendage (c) Left ventricle (d) Right ventricle (e) Coronary sinus 29. (d) Right ventricle The tip of the ventricular lead is seen at the apex of right ventricle. 33. A 42-year-old woman with a history of stroke presents with bilateral peripheral oedema. The chest radiograph is normal. Contrast-enhanced CT chest shows an ovoid filling defect in the left atrium and appears to be attached to the atrial septum. On MRI, the lesion appears hypointense on T1 and hyperintense on T2. What is the most likely diagnosis? (a) Cardiac metastasis (b) Cardiac lipoma (c) Left atrial myxoma (d) Wegener’s granulomatosis (e) Sarcoidosis 33. (c) Left atrial myxoma Embolisation may lead to strokes in patients with left atrial myxoma. Wegener’s and sarcoidosis in the heart are very rare. Lipoma shows fat density and signal on imaging. 35. A specialty trainee from the medical ward shows you a CXR of a breathless patient. You observe splaying of the carina and a ’double right heart border’. What is the most likely underlying diagnosis? A. Mitral stenosis. B. Aortic stenosis. C. Tricuspid incompetence. D. Left ventricular aneurysm. E. Coarctation of the aorta. 20 CVS Cardio acquired 35. A. Mitral stenosis. The findings describe left atrial enlargement, which is caused by mitral valve disease (stenosis or incompetence), venticular septal defect (VSD), patent ductus arteriosus (PDA), atrial septaldefect (ASD) with shunt reversal, and left atrial myxoma. Aortic stenosis produces left ventricular hypertrophy and eventually dilatation, the latter producing a prominent left heart border with inferior displacement of the cardiac apex. A left ventricular aneurysm produces a prominent bulge of the left heart border. Tricuspid incompetence produces an enlarged right atrium and thus a prominent right heart border on plain film. Coarctation produces left ventricular enlargement and inferior rib notching of the fourth to eighth ribs bilaterally if conventional and a ‘reverse figure 3’ sign: a prominent ascending aorta/arch and a small descending aorta, with an intervening notch. 57. A 65-year-old man presents to the A&E department with acute shortness of breath. He has a CXR performed and this demonstrates a ‘bat-wing’ pattern of pulmonary oedema. Which of the following is the most likely cause? A. Fat embolism. B. Diffuse alveolar damage. C. Adult respiratory distress syndrome. D. Acute mitral valve insufficiency. E. Left ventricular failure. 57. D. Acute mitral valve insufficiency. ‘Bat-wing’ oedema refers to a central, non-gravitational alveolar oedema, which is seen in less than 10% of cases of pulmonary oedema. It generally occurs with rapidly developing severe cardiac failure, such as that seen with acute mitral valve insufficiency or renal failure. It develops so rapidly that it is initially observed as an alveolar infiltrate and the preceding interstitial phase of pulmonary oedema goes undetected radiologically. ARDS and diffuse alveolar damage may overlap pathophysiologically, and along with fat embolism show radiographic changes of a non-cardiogenic pulmonary oedema. These are similar to the standard radiographic features of cardiogenic pulmonary oedema affecting the lung parenchyma, except that GGO tends to be more confluent and consolidative, the changes tend to be less dependent, and subfissural thickening/septal lines are uncommon. 50. A 42-year-old male presents with chest pain, dyspnoea and palpitations. He undergoes cardiac MRI, which reveals extensive scattered delayed enhancement in the anterior, lateral and inferior wall and apex of the left ventricle. This enhancement occurs in the midwall with relative sparing of the subendocardial region. T2WI is unremarkable. What is the most likely diagnosis? A. Acute myocardial infarction. B. Sarcoidosis. C. Myocarditis. D. Hypertrophic cardiomyopathy. E. Amyloidosis. 50. C. Myocarditis. This is defined as inflammation of the heart muscle. A large variety of infections, systemic diseases, drugs, and toxins have been associated with this condition. The diagnosis is based on a combination of clinical and imaging features. The presence of focal delayed enhancement on cardiac MRI in a non-coronary artery distribution, together with wall motion abnormalities, correlates strongly with myocarditis in the correct clinical setting. Many patients present with a non- specific illness characterized by fatigue, dyspnoea, and myalgia. An antecedent viral syndrome is present in more than 50% of patients. Myocarditis lesions occur typically in the lateral free wall and originate from the epicardial quartile of the ventricular wall. The subendocardial area is spared, a pattern that is otherwise typical for myocardial infarction (in the latter case the lesion would also correspond to a coronary artery territory). In myocarditis the enhancement pattern has been described as becoming less intense and more diffuse over weeks and months. In acute myocardial sarcoidosis, increased focal signal intensity can be observed on T2WI (secondary to oedema due to inflammation) and both early and delayed post-contrast T1 weighted imaging (T1WI). Focal myocardial thickening is often seen due to the oedema and can mimic hypertrophic cardiomyopathy (HCM). HCM will reveal marked hypertrophy of the interventricular septum and left ventricular wall, with associated transmural delayed enhancement in the hypertrophied areas. The latter finding corresponds to the scattered fibrosis present and the amount of enhancement will inversely correlate with regional contractivity. Cardiac amyloidosis leads to a restrictive cardimyopathy. MR imaging shows functional impairment, biventricular hypertrophy, and non-specific inhomogenous gadolinium enhancement. 21 CVS Cardio acquired 55. A 34-year-old man presents with chest pain and palpitations. An electrocardiogram (ECG) reveals a ventricular tachycardia with left bundle branch block (LBBB). A T1WI sequence shows transmural high signal and thinning of the myocardium of the right ventricle, with dilatation of the right ventricle and right ventricular outflow tract. What is the most likely diagnosis? A. Tricuspid stenosis. B. Uhl’s anomaly. C. Pericardial effusion. D. Arrhythmogenic right ventricular dysplasia. E. Melanoma metastasis. 55. D. Arrhythmogenic right ventricular dysplasia. This is part of the group of cardiomyopathies and is characterized by fibro-fatty replacement of the right ventricular myocardium and clinically by right ventricular arrhythmias of the LBBB pattern. It has a variety of clinical presentations, including mechanical dysfunctions and ventricular arrhythmia, and is a cause of sudden cardiac death in young adults. Pathogenesis is not yet understood. Diagnosis is based on structural, histologic, electrocardiographic, and genetic factors. There are major and minor criteria for diagnosis. Angiography and echocardiography lack sensitivity and specificity. MRI provides the most important morphological, anatomic, and functional criteria for the diagnosis of ARVD with one investigation. Findings can include fatty or fibro-fatty replacement of the right ventricular free wall myocardium (hence the high T1WI signal), dilatation of the right ventricle or right ventricular outflow tract,right ventricular aneurysms, and segmental hypokinesia. Positive MRI findings should be used as important additional criteria in the diagnosis of ARVD, but the absence of MRI findings does not exclude the diagnosis. Uhl’s anomaly is very rare (less than 100 reported cases in the 20th century) and consists of a paper-thin right ventricle, with complete absence of any musculature. It can be distinguished from ARVD as it has no gender predisposition or familial occurrence (ARVD is more common in males). Tricuspid stenosis produces dilatation of the right atrium. A pericardial effusion will result in high T2WI and low T1WI signal (unless the effusion is proteinaceous) within the pericardium. Melanoma metastases may well be high signal on T1WI, but they are rare to the heart and would not be expected to cause myocardial thinning. 64. A 45-year-old woman presents with chest pain, typical of angina. Her ECG and troponin are normal. She is a non-smoker and does not have hypertension or diabetes. Her resting heart rate is 56 beats per minute (bpm). To best assess her further, what do you decide to perform next? A. CT calcium score. B. Exercise stress testing. C. Contrast enhanced cardiac MRI. D. Retrospectively ECG-gated CT coronary angiography. E. Prospectively ECG-gated CT coronary angiography. 64. A. CT calcium score. The NICE guidelines on chest pain of recent onset were published in March 2010. Given the history typical of angina, but lack of risk factors and her age, this lady will fall into the 10–29% estimated likelihood of coronary artery disease (CAD) category (i.e. 10–29% pretest probability of CAD). NICE recommends that these patients should first undergo CT calcium scoring. If the calcium score is 0, other causes of chest pain should be investigated. If the score lies between 1 and 400, they should proceed to CT coronary angiography, in which case, because of her low resting heart rate, a prospective study is possible and would provide a significantly smaller radiation dose than a retrospective one. If the score is greater than 400, she should be treated as for 61–90% CAD risk: catheter angiography if revascularization is appropriate. It remains to be seen in practice whether clinicians will proceed to catheter angiography on the basis of the calcium score if CT coronary angiography is available to select those who will actually require intervention. For those with uncertain results from invasive or CT coronary angiography, or a pretest probability of CAD of 30–59%, functional imaging (e.g. myocardial perfusion imaging with SPECT, stress echo, MR perfusion, or MRI to assess for stress-induced wall motion abnormalities) is advised. If the pre-test probability is >90% with typical features of angina, treatment as angina is recommended (with regard to the NICE guidelines on stable angina, to be published in 2011). If the pre-test probability is 50% at presentation. (e) Have a low signal on gradient-echo MRI sequences. Answers: (a) Correct (b) Not correct (c) Not correct (d) Not correct (e) Correct Explanation: Approximately 75% of myxomas are located in left atrium, 20% in right atrium and rare cases are found in ventricles. The classical clinical triad of obstructive cardiac symptoms, embolic phenomena and constitutional symptoms has been described and majority of the patients have at least one of these symptoms at presentation. Cardiac myxomas are endocardial based masses that do not infiltrate the underlying tissues. 44. Which of the following are correct regarding pericardial disease: (a) Rheumatoid arthritis is a cause of pericarditis. (b) Elevation of the jugular venous pressure on inspiration is a sign of chronic pericarditis. (c) A pericardium of 3mm thickness is normal. (d) In chronic pericarditis, CT shows curvature of the interventricular septum to the right. (e) Renal failure is a cause of pericardial effusion. Answers: (a) Correct (b) Correct (c) Correct (d) Not correct (e) Correct Explanation: Curvature of the interventricular septum to the left is seen in chronic pericarditis on CT. 24