Non Coronary Cardiac CT

Dr.Sahar Gamal El-Dr.Sahar Gamal El-Din,CBCCTDin,CBCCT

National Heart InstituteNational Heart Institute

AgendaAgenda

• Assessment of Myocardial / Pericardial Assessment of Myocardial / Pericardial

DiseaseDisease

• Evaluation of Valvular Heart DiseaseEvaluation of Valvular Heart Disease

• Assessment of Cardiac and Thoracic Assessment of Cardiac and Thoracic

MassesMasses

CT Imaging of Myocardial DiseaseCT Imaging of Myocardial Disease• Dilated & Ischemic CardiomyopathyDilated & Ischemic Cardiomyopathy

• Besides the reconstructed CT data at Besides the reconstructed CT data at specific diastolic (and/or systolic) phases specific diastolic (and/or systolic) phases of the cardiac cycle for evaluation of the of the cardiac cycle for evaluation of the CA and cardiac morphology, a multiphase CA and cardiac morphology, a multiphase data set, which reconstructs the entire data set, which reconstructs the entire cardiac cycle at 5–10 % intervals, allows cardiac cycle at 5–10 % intervals, allows for viewing images in cinematic mode. for viewing images in cinematic mode. This multiphase reconstruction allows for This multiphase reconstruction allows for assessment of LV & RV systolic function assessment of LV & RV systolic function in any orientation, including all of the in any orientation, including all of the standard echocardiographic planes . standard echocardiographic planes .

• Thus, CCT can assess myocardial thickness , Thus, CCT can assess myocardial thickness , ventricular shape & volume, global and regional ventricular shape & volume, global and regional ventricular function with excellent correlation ventricular function with excellent correlation to echocardiography and cardiac MRI . to echocardiography and cardiac MRI .

• Additionally, patients with severely reduced LV Additionally, patients with severely reduced LV function are at risk for the development of function are at risk for the development of mural thrombus. Given its inherently high mural thrombus. Given its inherently high contrast to noise ratio and excellent spatial contrast to noise ratio and excellent spatial resolution, CCT can readily identify such mural resolution, CCT can readily identify such mural thrombi.thrombi.

LV functionLV function

Dilated cardiomyopathyDilated cardiomyopathy

Dilated cardiomyopathy with LV Dilated cardiomyopathy with LV aneurysmaneurysm

Left Ventricular NoncompactionLeft Ventricular Noncompaction (LVNC)LVNC)

• LV non-compaction is a rare myocardial LV non-compaction is a rare myocardial disorder characterized by excessive & disorder characterized by excessive & prominent trabeculations associated prominent trabeculations associated with deep recesses that communicate with deep recesses that communicate with the ventricular cavity.with the ventricular cavity.

• Prominent trabeculations are a normal Prominent trabeculations are a normal feature of the developing myocardium in feature of the developing myocardium in utero, and LVNC is thought to result utero, and LVNC is thought to result from a failure of trabecular regression from a failure of trabecular regression that occurs during normal embryonic that occurs during normal embryonic development.development.

• Left ventricular noncompaction is a Left ventricular noncompaction is a cardiomyopathy characterized by a 2-cardiomyopathy characterized by a 2-layered myocardium: a thin compacted layered myocardium: a thin compacted layer and a thick noncompacted layer. The layer and a thick noncompacted layer. The ratio of noncompacted to compacted ratio of noncompacted to compacted myocardium has been reported to be myocardium has been reported to be greater than or equal to greater than or equal to 2.3:12.3:1 by cardiac by cardiac MRI in cases of non-compaction.MRI in cases of non-compaction.

• The hypertrabeculations of the The hypertrabeculations of the noncompacted myocardium, as well as noncompacted myocardium, as well as thrombi that may form within the recesses, thrombi that may form within the recesses, are easily delineated with CCT due to its are easily delineated with CCT due to its favorable contrast-to noise ratio.favorable contrast-to noise ratio.

Left Ventricular NoncompactionLeft Ventricular Noncompaction

Arrhythmogenic Right VentricularArrhythmogenic Right Ventricular dysplasia (ARVD) dysplasia (ARVD)

• ARVC is an unusual cardiomyopathy ARVC is an unusual cardiomyopathy characterized by abnormal right characterized by abnormal right ventricular function, fibrofatty deposition ventricular function, fibrofatty deposition into the right ventricular myocardium, & into the right ventricular myocardium, & abnormal electrocardiographic changes, abnormal electrocardiographic changes, which predispose these patients to SCD.which predispose these patients to SCD.

• CCT has an advantage over CCT has an advantage over echocardiography in its ability to visualize echocardiography in its ability to visualize the right ventricle and thus to evaluate the right ventricle and thus to evaluate right ventricular morphology and systolic right ventricular morphology and systolic function, similar to MRI. function, similar to MRI.

• However, MRI has superior tissue However, MRI has superior tissue characterization capabilities & remains the characterization capabilities & remains the modality of choice for evaluating suspected modality of choice for evaluating suspected ARVC.ARVC.

• CCT becomes the modality of choice when CCT becomes the modality of choice when metal implants or claustrophobia preclude metal implants or claustrophobia preclude MRI.MRI.

• CCT can reliably characterize RV dimensions CCT can reliably characterize RV dimensions as well as focal aneurysms of the as well as focal aneurysms of the myocardium, increased trabeculations, and/or myocardium, increased trabeculations, and/or areas of right ventricular dysfunction, all areas of right ventricular dysfunction, all confirmatory findings in RV dysplasia.confirmatory findings in RV dysplasia.

• Importantly, CCT can also detect fatty Importantly, CCT can also detect fatty infiltration as areas of infiltration as areas of hypoattenuation, confirmed by CT hypoattenuation, confirmed by CT attenuation measurements. However, attenuation measurements. However, the finding of fat is sensitive but not the finding of fat is sensitive but not specific for ARVC .specific for ARVC .

• Hence, CCT findings must be Hence, CCT findings must be correlated with clinical and electro-correlated with clinical and electro-cardiographic data to establish the cardiographic data to establish the diagnosis of ARVC.diagnosis of ARVC.

Arrhythmogenic right ventricular Arrhythmogenic right ventricular dysplasia (ARVD)dysplasia (ARVD)

Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy• This most commonly involves asymmetric This most commonly involves asymmetric

septal hypertrophy, although other variants septal hypertrophy, although other variants exist, including apical and mid-ventricular exist, including apical and mid-ventricular hypertrophy.hypertrophy.

• In patients with dynamic LVOT obstruction, In patients with dynamic LVOT obstruction, CCT delineates the systolic anterior motion CCT delineates the systolic anterior motion of the anterior mitral valve leaflet on the of the anterior mitral valve leaflet on the multiphase images. multiphase images.

• While poor acoustic windows may limit While poor acoustic windows may limit echocardiography, CCT can reliably identify echocardiography, CCT can reliably identify all areas of the myocardium and provide all areas of the myocardium and provide accurate, reproducible measurements of wall accurate, reproducible measurements of wall thickness.thickness.

HCM with normal coronary anatomy of HCM with normal coronary anatomy of the left anterior descending (LAD) the left anterior descending (LAD) artery.artery.

CT Imaging of Pericardial DiseaseCT Imaging of Pericardial Disease• The pericardium is a double-layered The pericardium is a double-layered

membrane normally measuring <2 mm in membrane normally measuring <2 mm in thickness that forms a sac which surrounds thickness that forms a sac which surrounds the heart and the origins of the great vessels.the heart and the origins of the great vessels.

• Pericardial diseases can present clinically as Pericardial diseases can present clinically as acute pericarditis , pericardial effusion, acute pericarditis , pericardial effusion, cardiac tamponade, & constrictive pericarditis.cardiac tamponade, & constrictive pericarditis.

• Structural abnormalities including congenitally Structural abnormalities including congenitally absent pericardium & pericardial cysts are absent pericardium & pericardial cysts are usually asymptomatic & are uncommon.usually asymptomatic & are uncommon.

• CT allows reliable identification of CT allows reliable identification of pericardial anatomy on non-contrast-pericardial anatomy on non-contrast-enhanced scans. enhanced scans.

• CT scans performed with intravenous CT scans performed with intravenous contrast administration provide additional contrast administration provide additional anatomic information, including anatomic information, including associated myocardial disease and associated myocardial disease and evidence of inflammation with pericardial evidence of inflammation with pericardial enhancement.enhancement.

• CCT is exquisitely sensitive to the detection CCT is exquisitely sensitive to the detection of calcium and thus can be useful in of calcium and thus can be useful in identifying pericardial calcification, a finding identifying pericardial calcification, a finding that can be associated with constrictive that can be associated with constrictive pericarditispericarditis

Congenital Absence of Congenital Absence of PericardiumPericardium

• Rarely, individuals demonstrate a congenital Rarely, individuals demonstrate a congenital absence of the pericardium. While this can absence of the pericardium. While this can present as a complete absence of pericardial present as a complete absence of pericardial tissue, most cases demonstrate only partial tissue, most cases demonstrate only partial pericardial defects, typically on the left side.pericardial defects, typically on the left side.

• Clues on CCT that suggest this diagnosis are Clues on CCT that suggest this diagnosis are : rotation of the heart to the left, : rotation of the heart to the left, interposition of lung tissue in the aorto-interposition of lung tissue in the aorto-pulmonary window, and bulging of the left pulmonary window, and bulging of the left atrial appendage through the pericardial atrial appendage through the pericardial defectdefect.

This figure compares normal pericardial This figure compares normal pericardial anatomy (right panels) with congenital anatomy (right panels) with congenital absence of the pericardium (left panels).absence of the pericardium (left panels).

Absent pericardiumAbsent pericardium

Pericardial Effusion on CT ScanPericardial Effusion on CT Scan• Echocardiography remains the modality of choice Echocardiography remains the modality of choice

for the initial evaluation of pericardial effusion. for the initial evaluation of pericardial effusion. However, several findings make further evaluation However, several findings make further evaluation with CCT useful, such as a loculated effusion, with CCT useful, such as a loculated effusion, hemorrhagic effusion, or equivocal findings on hemorrhagic effusion, or equivocal findings on echocardiography.echocardiography.

• Pericardial effusions may be characterized with Pericardial effusions may be characterized with CCT by measuring their CT attenuation. CCT by measuring their CT attenuation.

• A CT attenuation close to water (e.g., 0 Hounsfield A CT attenuation close to water (e.g., 0 Hounsfield Units, HU) suggests a simple pericardial effusion. Units, HU) suggests a simple pericardial effusion. If the CT attenuation is greater than that of water, If the CT attenuation is greater than that of water, the effusion may represent hemorrhage, the effusion may represent hemorrhage, purulence, or a malignant/cellular process.purulence, or a malignant/cellular process.

Pericardial effusionPericardial effusion

Pericardial MassesPericardial Masses• Pericardial masses include cysts and Pericardial masses include cysts and

neoplasms. neoplasms.

• Pericardial cysts are mostly congenital and Pericardial cysts are mostly congenital and are usually found at the right costophrenic are usually found at the right costophrenic angle. They tend to be asymptomatic angle. They tend to be asymptomatic smooth-walled simple cysts that do not smooth-walled simple cysts that do not enhance after contrast administration. enhance after contrast administration.

• However, sometimes pericardial cyst can However, sometimes pericardial cyst can present on left side and can compress the present on left side and can compress the left atrium with clinical symptoms of left atrium with clinical symptoms of dyspneadyspnea

Pericardial cystPericardial cyst

• With regard to neoplasms, metastases are far With regard to neoplasms, metastases are far more common than primary pericardial tumors. more common than primary pericardial tumors.

• Neighboring structures, such as the lung and Neighboring structures, such as the lung and breast, are most commonly the source of breast, are most commonly the source of metastatic disease to the pericardium.metastatic disease to the pericardium.

• Other findings associated with metastatic Other findings associated with metastatic disease include pericardial effusion and an disease include pericardial effusion and an irregularly thickened pericardium .irregularly thickened pericardium .

• Primary neoplasms of the pericardium occur Primary neoplasms of the pericardium occur infrequently & may be benign (fibroma, infrequently & may be benign (fibroma, teratoma, lipoma, hemangioma) or malignant teratoma, lipoma, hemangioma) or malignant (mesothelioma, lymphoma, sarcoma, & (mesothelioma, lymphoma, sarcoma, & liposarcoma)liposarcoma)

Pericardial Pericardial mesotheliomamesothelioma

Pericardial sarcomaPericardial sarcoma

Constrictive pericarditisConstrictive pericarditis

• The current reference standard for The current reference standard for the non-invasive evaluation of the non-invasive evaluation of pericardial constriction is cardiac pericardial constriction is cardiac MRI. MRI.

• The characteristic anatomic changes The characteristic anatomic changes associated with constrictive associated with constrictive pericardial disease (elongated and pericardial disease (elongated and narrow right ventricle, enlargement narrow right ventricle, enlargement of the right atrium and inferior cava, of the right atrium and inferior cava, and pericardial thickening) are clearly and pericardial thickening) are clearly identified with both MRI and CCT.identified with both MRI and CCT.

• Since patients with true constrictive Since patients with true constrictive pericarditis typically present with pericarditis typically present with orthopnea, it is often difficult for them orthopnea, it is often difficult for them to lie flat in the MRI scanner for up to 1 to lie flat in the MRI scanner for up to 1 h. h.

• CCT may offer another option for CCT may offer another option for evaluating constrictive pericarditis, with evaluating constrictive pericarditis, with short examination times representing short examination times representing one of its major advantages.one of its major advantages.

• The excellent spatial resolution of CCT The excellent spatial resolution of CCT allows for accurate measurement of allows for accurate measurement of pericardial thickness.pericardial thickness.

• Pericardial thickness of >4 mm is Pericardial thickness of >4 mm is considered pathological and in the considered pathological and in the appropriate clinical context is appropriate clinical context is suggestive of pericardial constriction.suggestive of pericardial constriction.

• However, it is important to note that However, it is important to note that neither pericardial calcification nor neither pericardial calcification nor thickening is diagnostic of constrictive thickening is diagnostic of constrictive pericarditis.pericarditis.

• Pericardial thickening may be found in Pericardial thickening may be found in the absence of constriction (e.g., acute the absence of constriction (e.g., acute pericarditis, uremia, collagen vascular pericarditis, uremia, collagen vascular diseases).diseases).

Pericardial constrictionPericardial constriction

Heavily calcified pericardiumHeavily calcified pericardium

Evaluation in Valvular Heart Evaluation in Valvular Heart DiseaseDisease• Echocardiography is the initial imaging Echocardiography is the initial imaging

modality of choice, allowing for a complete modality of choice, allowing for a complete diagnosis in the majority of patients.diagnosis in the majority of patients.

• CT has a limited role for the evaluation of VHD CT has a limited role for the evaluation of VHD as the primary indication. It may occasionally as the primary indication. It may occasionally be employed as such when echocardiographic be employed as such when echocardiographic results are incomplete and the patient is not a results are incomplete and the patient is not a good candidate for MRI. However, CT is good candidate for MRI. However, CT is increasingly used for noninvasive coronary increasingly used for noninvasive coronary angiography, and useful information on valve angiography, and useful information on valve anatomy and function can simultaneously be anatomy and function can simultaneously be obtained from a coronary examination.obtained from a coronary examination.

VALVE VALVE ASSESSMENTASSESSMENT

. CalcificationCalcification. Anatomy. Anatomy. Function . Function

VENTRICULARVENTRICULARASSESSMENT ASSESSMENT

. Volumes. Volumes. Ejection . Ejection fractionfraction. Mass. Mass

CORONARYCORONARYASSESSMENTASSESSMENT

VHD REPERCUSSION. VHD REPERCUSSION. .Atrial size / .Atrial size / thrombusthrombus. Pulmonary . Pulmonary hypertensionhypertension. Left / right heart . Left / right heart failurefailure

Specific Valvular AbnormalitiesSpecific Valvular Abnormalities• Aortic Stenosis:Aortic Stenosis: AS is often accompanied by AS is often accompanied by

cusp calcification.cusp calcification.

• Aortic valve calcification can be accurately Aortic valve calcification can be accurately quantified using CT.quantified using CT.

• The amount of calcification is directly The amount of calcification is directly correlated with the severity of AS.correlated with the severity of AS.

• The incremental value of the information The incremental value of the information derived from the aortic valve calcium score may derived from the aortic valve calcium score may be particularly useful to evaluate stenosis be particularly useful to evaluate stenosis severity in patients with low cardiac output and severity in patients with low cardiac output and reduced transvalvular gradientsreduced transvalvular gradients

• Willmann et al. staged the severity of Willmann et al. staged the severity of AVC burden as the following :AVC burden as the following :

• Grade 1,Grade 1, no calcification. no calcification.

• Grade 2, Grade 2, mild calcification (small mild calcification (small isolated spots of calcification).isolated spots of calcification).

• ƒGrade 3, ƒGrade 3, moderate calcification moderate calcification (multiple larger spots of calcification).(multiple larger spots of calcification).

• Grade 4, Grade 4, heavy calcification (extensive heavy calcification (extensive calcification of all aortic valve leaflets).calcification of all aortic valve leaflets).

Non-enhanced CT of severe AV calcification. Non-enhanced CT of severe AV calcification. Heavy AV calcification burden seen in (A) the axial Heavy AV calcification burden seen in (A) the axial & (B) reformatted plane of the AV, associated & (B) reformatted plane of the AV, associated with (C) severe thoracic aorta, (D & E) MV & (E & with (C) severe thoracic aorta, (D & E) MV & (E & F) CA calcifications.F) CA calcifications.

• Contrast-enhanced CT can precisely Contrast-enhanced CT can precisely evaluate valve morphology, accurately evaluate valve morphology, accurately differentiating tri-leaflet from bicuspid differentiating tri-leaflet from bicuspid valves .valves .

• Planimetric determinations of the aortic Planimetric determinations of the aortic valve area have shown excellent valve area have shown excellent correlation with echocardiographic correlation with echocardiographic measurementsmeasurements

Transcatheter aortic valve Transcatheter aortic valve implantation (TAVI)implantation (TAVI)• Recommendations about CT before Recommendations about CT before

TAVI/TAVRTAVI/TAVR

• CT imaging should be performed in the CT imaging should be performed in the evaluation process of:evaluation process of:

• Patients who are under consideration for Patients who are under consideration for TAVI/TAVR unless there is a contraindication.TAVI/TAVR unless there is a contraindication.

• CT datasets should be interpreted jointly CT datasets should be interpreted jointly with a member of the TAVI/TAVR procedural with a member of the TAVI/TAVR procedural team or reviewed with the operator before team or reviewed with the operator before the procedure.the procedure.

Implanted CoreValve (A) and Edwards Implanted CoreValve (A) and Edwards Sapien valve (B) in contrast-enhanced, Sapien valve (B) in contrast-enhanced, multiplanar reformatted CT.multiplanar reformatted CT.

• Recommendations for assessment of the Recommendations for assessment of the access route by CT before TAVI/TAVR:access route by CT before TAVI/TAVR:

• CT imaging should be performed for vascular CT imaging should be performed for vascular access assessment (pelvic arteries and aorta) access assessment (pelvic arteries and aorta) when not contraindicated.when not contraindicated.

• CT examinations should be performed with CT examinations should be performed with iodinated contrast medium.iodinated contrast medium.

• Qualitative assessment of vascular tortuosity Qualitative assessment of vascular tortuosity should be performed.should be performed.

• Qualitative assessment of vascular calcification Qualitative assessment of vascular calcification should be performed.should be performed.

• Consideration to varied thresholds of Consideration to varied thresholds of vessel size (sheath/femoral artery vessel size (sheath/femoral artery ratio) should be contemplated, ratio) should be contemplated, depending on the presence and depending on the presence and extent of vascular calcification.extent of vascular calcification.

• The left ventricle should be evaluated The left ventricle should be evaluated for the presence of thrombus and, if a for the presence of thrombus and, if a transapical access route is planned, transapical access route is planned, for geometry and position of the apex.for geometry and position of the apex.

• Recommendations for assessment of the Recommendations for assessment of the aortaaorta

• The entire aorta should be imaged and The entire aorta should be imaged and evaluated, unless a transapical access is evaluated, unless a transapical access is planned.planned.

• Severe elongation and kinking of the aorta, Severe elongation and kinking of the aorta, dissection, and obstructions caused by dissection, and obstructions caused by thrombus or other material should be reported.thrombus or other material should be reported.

• Aortic annulusAortic annulus

Measurement of the distance of the Measurement of the distance of the coronary ostia from the aortic annulus coronary ostia from the aortic annulus plane.plane.

Aortic annulus plane for fluoroscopyAortic annulus plane for fluoroscopy

• Aortic Regurgitation: Aortic Regurgitation: CT may be CT may be useful in evaluating the mechanism useful in evaluating the mechanism leading to AR. leading to AR.

• AR caused by degenerative valve disease AR caused by degenerative valve disease is characterized by thickened &/or is characterized by thickened &/or calcified leaflets, and the area of lack of calcified leaflets, and the area of lack of coaptation may be visualized in diastolic coaptation may be visualized in diastolic phase reconstructions centrally or at the phase reconstructions centrally or at the commissures. commissures.

• In cases of AR secondary to enlargement In cases of AR secondary to enlargement of the aortic root, the regurgitant orifice of the aortic root, the regurgitant orifice is typically located centrallyis typically located centrally

• Mitral Mitral Stenosis: Stenosis: • As in the case of aortic valve As in the case of aortic valve

calcification, the presence of calcium in calcification, the presence of calcium in the mitral annulus is associated with the mitral annulus is associated with systemic atherosclerosis and carries systemic atherosclerosis and carries negative prognostic implications.negative prognostic implications.

• The amount of mitral annular calcium The amount of mitral annular calcium can also be quantified with CT.can also be quantified with CT.

• Planimetry of mitral valve opening by Planimetry of mitral valve opening by CT provides accurate assessment of MS CT provides accurate assessment of MS severityseverity

Short-axis view at the level of the Short-axis view at the level of the mitral valve, showing extensive mitral valve, showing extensive annular calcificationannular calcification

Contrast-enhanced CT scan in the four-chamber and Contrast-enhanced CT scan in the four-chamber and shortaxisshortaxisviews (panels a and b , respectively) from a patient with views (panels a and b , respectively) from a patient with rheumaticrheumaticmitral stenosis. The typical thickening and restricted dome-mitral stenosis. The typical thickening and restricted dome-shapedshapedopening of the leafl ets can be observed ( opening of the leafl ets can be observed ( arrows and arrows and asterisk ). Planimetry asterisk ). Planimetry of the valve (panel c of the valve (panel c ) demonstrated moderate stenosis ( ) demonstrated moderate stenosis ( red contour ; red contour ; area = area = 1.3 cm 2 )1.3 cm 2 )

• The presence or absence of thrombus The presence or absence of thrombus in the left atrial appendage can be in the left atrial appendage can be determined after contrast determined after contrast administration with very high administration with very high sensitivity although lower specificity sensitivity although lower specificity since slow flow may impair since slow flow may impair opacification, which may be increased opacification, which may be increased by adding delayed imaging .by adding delayed imaging .

• Mitral Regurgitation: Mitral Regurgitation: • In patients with mitral valve prolapse, CT can In patients with mitral valve prolapse, CT can

demonstrate the presence of leaflet thickening demonstrate the presence of leaflet thickening or the degree and location of prolapse.or the degree and location of prolapse.

• In cases of MR secondary to annular In cases of MR secondary to annular enlargement (often accompanying dilated enlargement (often accompanying dilated cardiomyopathy), dimensions of the annulus cardiomyopathy), dimensions of the annulus can be accurately quantified, and a central area can be accurately quantified, and a central area of insufficient leaflet coaptation may be of insufficient leaflet coaptation may be observed.observed. Although quantifying MR severity Although quantifying MR severity may be difficult, a recent study suggested that may be difficult, a recent study suggested that planimetry of the regurgitant orifice by CT planimetry of the regurgitant orifice by CT correlates well with echocardiographic grading correlates well with echocardiographic grading of MR severityof MR severity

MVP PlanesMVP Planes

• Infective Endocarditis: Infective Endocarditis: • The diagnosis of infective endocarditis usually The diagnosis of infective endocarditis usually

relies on the visualization of vegetations, and relies on the visualization of vegetations, and transthoracic and transesophageal transthoracic and transesophageal echocardiography are usually superior to CT echocardiography are usually superior to CT due to higher temporal resolution.due to higher temporal resolution.

• However, CT can be particularly useful in the However, CT can be particularly useful in the demonstration of perivalvular abscesses as demonstration of perivalvular abscesses as fluid-filled collections. fluid-filled collections.

• In patients with AV endocarditis with highly In patients with AV endocarditis with highly mobile vegetations, CT offers an alternative mobile vegetations, CT offers an alternative to invasive coronary angiography for to invasive coronary angiography for evaluation of the coronary arteries.evaluation of the coronary arteries.

Diastolic (Panel A) and systolic (Panel B) reconstructions Diastolic (Panel A) and systolic (Panel B) reconstructions of a contrast-enhanced MDCT study in a patient with a of a contrast-enhanced MDCT study in a patient with a bioprosthesis in the aortic position. A large, mobile bioprosthesis in the aortic position. A large, mobile vegetation that prolapses into the ascending aorta in vegetation that prolapses into the ascending aorta in systole can be noted (black arrows). In addition, systole can be noted (black arrows). In addition, perivalvularperivalvularthickening and fluid-filled collections can be noted (white thickening and fluid-filled collections can be noted (white arrows), indicating the presence of a perivalvular abscessarrows), indicating the presence of a perivalvular abscess

• Prosthetic Valves : Prosthetic Valves : • Recently, cardiac CT has been Recently, cardiac CT has been

recognized as an alternative to recognized as an alternative to evaluation of prosthetic valve evaluation of prosthetic valve complications including valve complications including valve thrombosis, dehiscence, pannus thrombosis, dehiscence, pannus development, endocarditis, and development, endocarditis, and paravalvular leak.paravalvular leak.

• Some valves, such as ball in cage Some valves, such as ball in cage

valves, are not readily evaluable by CT valves, are not readily evaluable by CT because of extreme beam hardening because of extreme beam hardening artifact from the thicker metal struts artifact from the thicker metal struts found in these models.found in these models.

• Motion artifact is worst for AV prosthesis during Motion artifact is worst for AV prosthesis during ventricular systole and for MV prosthesis during ventricular systole and for MV prosthesis during end-diastole. Thus, it has been found that end-diastole. Thus, it has been found that imaging in imaging in mid-diastolemid-diastole is the most ideal for is the most ideal for prosthetic valve evaluation.prosthetic valve evaluation.

• CT is particularly useful for the evaluation of CT is particularly useful for the evaluation of some types of mechanical valves. some types of mechanical valves.

• In Prostheses with two discs should open In Prostheses with two discs should open symmetrically. symmetrically.

• In those with a single disc, the angle of opening In those with a single disc, the angle of opening can also be measured . Also, heterografts & can also be measured . Also, heterografts & homografts can be evaluated completely, homografts can be evaluated completely, including the distal anastomosis & the patency including the distal anastomosis & the patency of the coronary arteries if these were of the coronary arteries if these were reimplanted.reimplanted.

Normal & mal-functioning mechanical Normal & mal-functioning mechanical prosthesis in the mitral position.prosthesis in the mitral position.

Assessment of Cardiac and Thoracic Assessment of Cardiac and Thoracic MassesMasses

• Interpreting Cardiac Masses:Interpreting Cardiac Masses:• Key descriptors for cardiac masses Key descriptors for cardiac masses

include the following:include the following:• • LocationLocation• • Single versus multiple lesionsSingle versus multiple lesions• • SizeSize• • Border descriptionBorder description• • Presence of fluid, blood, calcium, or fatPresence of fluid, blood, calcium, or fat• • Contrast enhancement patternContrast enhancement pattern• • Relation to functionRelation to function• • Non-cardiac-related findingsNon-cardiac-related findings

MyxomMyxomaa

Right atrial lipomaRight atrial lipoma

lipomatous hypertrophy of interatrial lipomatous hypertrophy of interatrial septumseptum

Hematoma 9.4cm×8.5cm×5.9cm Hematoma 9.4cm×8.5cm×5.9cm compressing the vena cava and right compressing the vena cava and right atrium (A, C and D)atrium (A, C and D)

Giant LAD aneurysmGiant LAD aneurysm

Right atrial and right ventricular Right atrial and right ventricular angiosarcoma extending into the main angiosarcoma extending into the main pulmonary arterypulmonary artery

Left ventricular thrombusLeft ventricular thrombus

LA & RA thrombiLA & RA thrombi

Papillary fibroelastomasPapillary fibroelastomas