QUESTION-1:
65 yo presents with chest pressure:
Correct Answer: Constrictive Pericarditis
- Calcified pericardium from remote Post-traumatic hemopericardium.
- Underlying etiologies of constrictive pericardial disease include previous pericardiotomy or hemopericardium, radiation, virus, TB, chronic renal failure, rheumatoid arthritis, neoplastic involvement, and idiopathic.
Pearls:
- CT can show calcification of the pericardium.
- A thickened pericardium (>4 mm) on its own does not indicate constrictive pericarditis.
- Contrast-enhanced CT may also show signs of cardiac failure such as septal flattening.
- May show retrograde flow of contrast into the dilated IVC.
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QUESTION-2:
7 day old with difficulty breathing:
Correct Answer: Patent ductus arteriosus
- Patent ductus arteriosus is a congenital cardiac anomaly where there is persistent patency of the ductus arteriosus, a normal connection of the fetal circulation between the aorta and the pulmonary arterial system.
Radiographic Features:
- LAE, LVE, Ao enlargement
- May have RVH from over circulation
Differential Diagnosis:
- Tetralogy of Fallot
- Eisenmenger syndrome
- Hypoplastic left heart
- Pulmonary atresia
Pearls:
- May have cardiomegaly; predominantly left atrial and left ventricular.
- Features of pulmonary edema may be evident.
- With tetralogy images would show chest radiographs with a "boot-shaped" heart with an upturned cardiac apex due to right ventricular hypertrophy and concave pulmonary arterial segment.
- Tetralogy may have pulmonary oligemia due to decreased pulmonary arterial flow. Right-sided aortic arch is seen in about 25%.
References:
- https://bit.ly/3j0alL5
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QUESTION-3:
In a patient with ASD, which of the following is most likely to be enlarged?:
Correct Answer: Pulmonary artery
- Most ASDs have left-to-right shunts. ASDs are classified under the acyanotic, increased PBF category of CHD. This category includes the following, in order of prevalence:
- VSD
- ASD
- PDA
- ECD
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QUESTION-4:
50 yo man with bicuspid aortic valve::
Correct Answer: Post ductal Coarctation
- Turner’s (XO)
- Preductal (infantile)
- Postductal (adult)
Differential Diagnosis:
- Pseudo-coarctation of the aorta
Chronic phase of Takayasu arteritis
Bicuspid aortic valve: most common associated defect and seen in 75-80%
Pearls:
- Contour abnormality of the aorta; figure 3 sign
- Inferior rib notching; called Roesler sign.
- Secondary to dilated intercostal collateral vessels.
- The dilated and tortuous vessels resulting in notching.
- Usually the 4th to 8th ribs are involved.
- If bilateral rib notching; coarctation must be distal to origin of both subclavian arteries.
Complications:
- Bicuspid aortic valve. The aortic valve separates the lower left chamber (left ventricle) of the heart from the aorta. A bicuspid aortic valve has two flaps (cusps) instead of the usual three. Many people with coarctation of the aorta have a bicuspid aortic valve.
- Sub-aortic stenosis. Sub-aortic stenosis occurs when there is a narrowing of the area below the aortic valve that obstructs blood flow from the left ventricle to the aorta. This narrowing may be in the form of a fibrous membrane.
- Patent ductus arteriosus. The ductus arteriosus is a blood vessel that connects a baby's left pulmonary artery to the aorta. It allows blood to bypass the lungs while the baby is growing in the womb. Shortly after birth, the ductus arteriosus usually closes. If it remains open, it's called a patent ductus arteriosus.
References:
- https://mayocl.in/2WczZ7n
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QUESTION-5:
62 yo with chronic fatigue :
Correct Answer: Scimitar Syndrome
- Hypoplasia of right lung with dextroposition
Hypoplastic Right Pulmonary artery
Anomalous arterial supply to right lower lobe from aorta
Anomalous pulmonary venous connection to inferior vena cava
Scimitar is characterized by a hypoplastic lung that is drained by an anomalous pulmonary vein into the systemic venous system.
Differential Diagnosis:
- General imaging differential considerations include:
- Pulmonary sequestration
- Right middle lobe atelectasis (on AP plain radiograph)
- Unilateral absence of pulmonary artery (UAPA)
Pearls:
- Anomalous vein usually drains into: inferior vena cava: most common
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QUESTION-6:
42 yo with worsening dyspnea and palpitations:
Correct Answer: Atrial septal defect
- Ostium Secundum most common 60%
- Radiology
- Inc PBF
- RVE
- Inc MPA
- NO left heart enlargement
Differential Diagnosis:
- Atrioventricular septal defect
- Ventricular septal defect
- Cyanotic congenital heart disease (sinus venosus defects and coronary sinus defects)
- Total anomalous pulmonary venous return
- Pulmonary stenosis
- Truncus arteriosus
- Tricuspid atresia
Pearls:
- Signs of increased pulmonary flow:
- enlarged pulmonary vessels
- upper zone vascular prominence
- vessels visible to the periphery of the film
- eventual signs of pulmonary arterial hypertension
References:
- https://bit.ly/3zyzhQa
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QUESTION-7:
With an ASD, which of the following is most likely to be enlarged?:
Correct Answer: Pulmonary artery
- Most ASDs have left-to-right shunts. ASDs are classified under the acyanotic, increased PBF category of CHD. This category includes the following, in order of prevalence:
- VSD
- ASD
- PDA
- ECD
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QUESTION-8:
New born to mother with maternal lithium carbonate injection has been postulated:
Correct Answer: Ebstein’s Anomaly
- Severe right-sided cardiomegaly due to an elongated and enlarged right atrium which may result in an elevated apex.
- Heart is described as having a "box shape" on a frontal chest image.
- Pulmonary flow is decreased
- Cyanosis is present in the neonate
- One of the few conditions to produce cardiomegaly in the first few days of life.
- POSTERIOR and SEPTAL cusps of tricuspid valve are displaced into the Right ventricle which makes Right ventricle smaller
- Massive Heart from RAE
- Decreased PBF
Differential Diagnosis:
- Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/ARVC)
- Pediatric Tricuspid Atresia
- Tetralogy of Fallot
- Uhl Anomaly
Pearls:
- Ebstein’s is a congenital malformation in which two of the three tricuspid valve leaflets are tethered to the RV (“atrialization” of the RV). The RV is small, the RA is large (sometimes huge), and there is reduced PBF.
- Ebstein’s patients sometimes have the largest hearts of any patient population.
References:
- https://bit.ly/2UOhllQ
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QUESTION-9:
48 year old woman with progressive dyspnea that is precipitated by sudden palpitations:
Correct Answer: Mitral valve stenosis
- LAE
- MPA enlargement/PVC
- Mitral valve Ca
- RVE
Radiographic Features:
- Left atrial enlargement convexity or straightening of the left atrial appendage just below the main pulmonary artery.
- May see double density sign: the right side of the enlarged left atrium pushes into the adjacent lung and creates an addition contour superimposed over the right heart.
- Splaying of the carina.
- Upper zone venous enlargement due to pulmonary venous hypertension.
- Rheumatic Fever m/c
- Mimics
- LA thrombus
- Atrial Myxoma
- Cor Triatriatum
Differential Diagnosis:
- Pulmonary hypertension
- Restrictive cardiomyopathy
- Mitral regurgitation
- Aortic regurgitation
- Cor triatriatum
- Left atrial myxoma
- Endocarditis (eg, acute bacterial)
Pearls:
- Mitral stenosis
- Most common causes of left atrial enlargement:
- 1. CHF
- 2. Mitral stenosis
- 3. Mitral regurgitation
- 4. Prolapsed mitral valve
- 5. Papillary muscle dysfunction (e.g., from MI)
- 6. Left atrial myxoma
References:
- http://www.learningradiology.com/lectures/cardiaclectures/ddxsincardiacpdf.pdf
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Correct Answer Explanation
QUESTION-10:
52 year old with reduced exercise tolerance:
Correct Answer: Pericardial effusion
- Globular enlargement of the cardiac shadow giving a water bottle configuration
- Lateral CXR may show Oreo cookie sign behind the sternum (pericardial fat) anteriorly from a similar lucent vertical lucent line (epicardial fat) posteriorly.
Differential Diagnosis:
- Acute Pericarditis
- Cardiogenic Pulmonary Edema
- Constrictive Pericarditis
- Dilated Cardiomyopathy
- Effusive-Constrictive Pericarditis
- Myocardial Infarction
- Pulmonary Embolism (PE)
Pearls:
- Pericardial effusion= infection (TB, viral), uremia, CVD (SLE, RA), mets, post-MI/post-pericardiotomy (dressler’s syndrome usually after2wks—also assoc with pleural effusion and parenchymal opacities).
- Malignant effusion i.e. pleural dissemination or pleural nodules (not direct pleural invasion) and/or Malignant pericardial.
References:
- https://bit.ly/3zx7H66
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QUESTION-11:
Incidental finding on imaging, no VSD seen on ultrasound:
Correct Answer: Right side aortic arch
- Will have congenital heart disease 98% of time
- Due to interruption of the left arch just distal to Ductus Arteriosus
- There will be NO posterior impression on the trachea or the barium-filled esophagus
- Descending aorta will be on the right
Radiographic Features:
- left aortic contour is absent
- tracheal bowing to the left at the level of the right aortic arch
- soft tissue indentation on the right side of the distal trachea
- right-sided descending aorta
Pearls:
- Right Arch:
- Kommerell diverticulum (at origin of L subclavian) and Dysphagia Lusoria
- Higher association with truncus but TOF overall more common 2 types: mirror image(worse b/c association cardiac anomalies like truncus or TOF) vs R arch with aberrant LS
- Can be complete ring if intact ligament arteriosus or open PDA
- Transposition of the great vessels is the most common cyanotic congenital cardiac anomaly presenting during the newborn period, with cyanosis in the first 24 hours of life.
- Truncus arteriosus is a cyanotic congenital heart anomaly in which a single trunk supplies both the pulmonary and systemic circulation.
- Almost always associated with a ventricular septal defect (VSD) to allow circulatory flow circuit completion.
References:
- https://bit.ly/2WgXU5M
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Correct Answer Explanation
QUESTION-12:
A left-sided SVC typically empties where?:
Correct Answer: Coronary sinus
- A left SVC is found in about 0.3% of healthy individuals and 4.4% of patients with congenital heart disease.
References:
- http://www.auntminnie.com/index.asp?sec=ref&sub=thi&pag=car&itemid=53686&d=1
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Correct Answer Explanation
QUESTION-13:
56 yo with chronic shortness of breath:
Correct Answer: Ebstein’s anomaly
- Massive cardiomegaly
- Decreased pulmonary vascularity
- Posterior and Septal leaflets of tricuspid valve displaced into RV
- RV proximal to valve leaflets is thin (“atrialized right ventricle”)
- ASD with R-to-L shunt & cyanosis is common in Ebstein’s patients
Findings:
- – Cardiomegaly
- – Enlarged RA
- – Tricuspid valve displaced into RV cavity
- – Small RV
- – Small pericardial effusion
Pearls:
- Ebstein’s is a congenital malformation in which two of the three tricuspid valve leaflets are tethered to the RV (“atrialization” of the RV). The RV is small, the RA is large (sometimes huge), and there is reduced PBF.
- Ebstein’s patients sometimes have the largest hearts of any patient population.
- Mild forms of Ebstein anomaly might not cause symptoms until later in adulthood. Signs and symptoms might include:
- Shortness of breath, especially with exertion
- Fatigue
- Heart palpitations or abnormal heart rhythms (arrhythmias)
- Bluish discoloration of the lips and skin caused by low oxygen (cyanosis)
References:
- https://mayocl.in/3C2bo
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