Non coronary cardiac CT

1. Non Coronary Cardiac CT
Dr.Sahar Gamal El-Din,CBCCTDr.Sahar Gamal El-Din,CBCCT
National Heart InstituteNational Heart Institute

2. AgendaAgenda
• Assessment of Myocardial / Pericardial DiseaseAssessment of Myocardial / Pericardial Disease
• Evaluation of Valvular Heart DiseaseEvaluation of Valvular Heart Disease
• Assessment of Cardiac and Thoracic MassesAssessment of Cardiac and Thoracic Masses

4. CT Imaging of Myocardial DiseaseCT Imaging of Myocardial Disease
• Dilated & Ischemic CardiomyopathyDilated & Ischemic Cardiomyopathy
• Besides the reconstructed CT data at specificBesides the reconstructed CT data at specific
diastolic (and/or systolic) phases of the cardiacdiastolic (and/or systolic) phases of the cardiac
cycle for evaluation of the CA and cardiaccycle for evaluation of the CA and cardiac
morphology, a multiphase data set, whichmorphology, a multiphase data set, which
reconstructs the entire cardiac cycle at 5–10 %reconstructs the entire cardiac cycle at 5–10 %
intervals, allows for viewing images inintervals, allows for viewing images in
cinematic mode. This multiphase reconstructioncinematic mode. This multiphase reconstruction
allows for assessment of LV & RV systolicallows for assessment of LV & RV systolic
function in any orientation, including all of thefunction in any orientation, including all of the
standard echocardiographic planes .standard echocardiographic planes .

5. • Thus, CCT can assess myocardial thickness ,Thus, CCT can assess myocardial thickness ,
ventricular shape & volume, global and regionalventricular shape & volume, global and regional
ventricular function with excellent correlation toventricular function with excellent correlation to
echocardiography and cardiac MRI .echocardiography and cardiac MRI .
• Additionally, patients with severely reduced LVAdditionally, patients with severely reduced LV
function are at risk for the development of muralfunction are at risk for the development of mural
thrombus. Given its inherently high contrast tothrombus. Given its inherently high contrast to
noise ratio and excellent spatial resolution, CCTnoise ratio and excellent spatial resolution, CCT
can readily identify such mural thrombi.can readily identify such mural thrombi.

7. LV functionLV function

8. Dilated cardiomyopathyDilated cardiomyopathy

9. Dilated cardiomyopathy with LV aneurysmDilated cardiomyopathy with LV aneurysm

10. Left Ventricular NoncompactionLeft Ventricular Noncompaction (LVNC)LVNC)
• LV non-compaction is a rare myocardialLV non-compaction is a rare myocardial
disorder characterized by excessive &disorder characterized by excessive &
prominent trabeculations associated with deepprominent trabeculations associated with deep
recesses that communicate with the ventricularrecesses that communicate with the ventricular
cavity.cavity.
• Prominent trabeculations are a normal featureProminent trabeculations are a normal feature
of the developing myocardium in utero, andof the developing myocardium in utero, and
LVNC is thought to result from a failure ofLVNC is thought to result from a failure of
trabecular regression that occurs during normaltrabecular regression that occurs during normal
embryonic development.embryonic development.

11. • Left ventricular noncompaction is aLeft ventricular noncompaction is a
cardiomyopathy characterized by a 2-layeredcardiomyopathy characterized by a 2-layered
myocardium: a thin compacted layer and a thickmyocardium: a thin compacted layer and a thick
noncompacted layer. The ratio of noncompactednoncompacted layer. The ratio of noncompacted
to compacted myocardium has been reported toto compacted myocardium has been reported to
be greater than or equal tobe greater than or equal to 2.3:12.3:1 by cardiac MRIby cardiac MRI
in cases of non-compaction.in cases of non-compaction.
• The hypertrabeculations of the noncompactedThe hypertrabeculations of the noncompacted
myocardium, as well as thrombi that may formmyocardium, as well as thrombi that may form
within the recesses, are easily delineated withwithin the recesses, are easily delineated with
CCT due to its favorable contrast-to noise ratio.CCT due to its favorable contrast-to noise ratio.

12. Left Ventricular NoncompactionLeft Ventricular Noncompaction

13. Arrhythmogenic Right VentricularArrhythmogenic Right Ventricular
dysplasia (ARVD)dysplasia (ARVD)
• ARVC is an unusual cardiomyopathyARVC is an unusual cardiomyopathy
characterized by abnormal right ventricularcharacterized by abnormal right ventricular
function, fibrofatty deposition into the rightfunction, fibrofatty deposition into the right
ventricular myocardium, & abnormalventricular myocardium, & abnormal
electrocardiographic changes, whichelectrocardiographic changes, which
predispose these patients to SCD.predispose these patients to SCD.
• CCT has an advantage over echocardiographyCCT has an advantage over echocardiography
in its ability to visualize the right ventricle andin its ability to visualize the right ventricle and
thus to evaluate right ventricular morphologythus to evaluate right ventricular morphology
and systolic function, similar to MRI.and systolic function, similar to MRI.

14. • However, MRI has superior tissue characterizationHowever, MRI has superior tissue characterization
capabilities & remains the modality of choice forcapabilities & remains the modality of choice for
evaluating suspected ARVC.evaluating suspected ARVC.
• CCT becomes the modality of choice when metalCCT becomes the modality of choice when metal
implants or claustrophobia preclude MRI.implants or claustrophobia preclude MRI.
• CCT can reliably characterize RV dimensions asCCT can reliably characterize RV dimensions as
well as focal aneurysms of the myocardium,well as focal aneurysms of the myocardium,
increased trabeculations, and/or areas of rightincreased trabeculations, and/or areas of right
ventricular dysfunction, all confirmatory findingsventricular dysfunction, all confirmatory findings
in RV dysplasia.in RV dysplasia.

15. • Importantly, CCT can also detect fattyImportantly, CCT can also detect fatty
infiltration as areas of hypoattenuation,infiltration as areas of hypoattenuation,
confirmed by CT attenuation measurements.confirmed by CT attenuation measurements.
However, the finding of fat is sensitive but notHowever, the finding of fat is sensitive but not
specific for ARVC .specific for ARVC .
• Hence, CCT findings must be correlated withHence, CCT findings must be correlated with
clinical and electro-cardiographic data toclinical and electro-cardiographic data to
establish the diagnosis of ARVC.establish the diagnosis of ARVC.

16. Arrhythmogenic right ventricular dysplasia (ARVD)Arrhythmogenic right ventricular dysplasia (ARVD)

17. Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy
• This most commonly involves asymmetric septalThis most commonly involves asymmetric septal
hypertrophy, although other variants exist,hypertrophy, although other variants exist,
including apical and mid-ventricularincluding apical and mid-ventricular
hypertrophy.hypertrophy.
• In patients with dynamic LVOT obstruction, CCTIn patients with dynamic LVOT obstruction, CCT
delineates the systolic anterior motion of thedelineates the systolic anterior motion of the
anterior mitral valve leaflet on the multiphaseanterior mitral valve leaflet on the multiphase
images.images.
• While poor acoustic windows may limitWhile poor acoustic windows may limit
echocardiography, CCT can reliably identify allechocardiography, CCT can reliably identify all
areas of the myocardium and provide accurate,areas of the myocardium and provide accurate,
reproducible measurements of wall thickness.reproducible measurements of wall thickness.

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

20. CT Imaging of Pericardial DiseaseCT Imaging of Pericardial Disease
• The pericardium is a double-layered membraneThe pericardium is a double-layered membrane
normally measuring <2 mm in thickness thatnormally measuring <2 mm in thickness that
forms a sac which surrounds the heart and theforms a sac which surrounds the heart and the
origins of the great vessels.origins of the great vessels.
• Pericardial diseases can present clinically as acutePericardial diseases can present clinically as acute
pericarditis , pericardial effusion, cardiacpericarditis , pericardial effusion, cardiac
tamponade, & constrictive pericarditis.tamponade, & constrictive pericarditis.
• Structural abnormalities including congenitallyStructural abnormalities including congenitally
absent pericardium & pericardial cysts are usuallyabsent pericardium & pericardial cysts are usually
asymptomatic & are uncommon.asymptomatic & are uncommon.

21. • CT allows reliable identification ofCT allows reliable identification of
pericardial anatomy on non-contrast-pericardial anatomy on non-contrast-
enhanced scans.enhanced scans.
• CT scans performed with intravenousCT scans performed with intravenous
contrast administration provide additionalcontrast administration provide additional
anatomic information, including associatedanatomic information, including associated
myocardial disease and evidence ofmyocardial disease and evidence of
inflammation with pericardial enhancement.inflammation with pericardial enhancement.
• CCT is exquisitely sensitive to the detection ofCCT is exquisitely sensitive to the detection of
calcium and thus can be useful in identifyingcalcium and thus can be useful in identifying
pericardial calcification, a finding that can bepericardial calcification, a finding that can be
associated with constrictive pericarditisassociated with constrictive pericarditis

22. Congenital Absence of PericardiumCongenital Absence of Pericardium
• Rarely, individuals demonstrate a congenitalRarely, individuals demonstrate a congenital
absence of the pericardium. While this canabsence of the pericardium. While this can
present as a complete absence of pericardialpresent as a complete absence of pericardial
tissue, most cases demonstrate only partialtissue, 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, interposition ofrotation of the heart to the left, interposition of
lung tissue in the aorto-pulmonary window, andlung tissue in the aorto-pulmonary window, and
bulging of the left atrial appendage through thebulging of the left atrial appendage through the
pericardial defectpericardial defect.

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

24. Absent pericardiumAbsent pericardium

25. Pericardial Effusion on CT ScanPericardial Effusion on CT Scan
• Echocardiography remains the modality of choice forEchocardiography remains the modality of choice for
the initial evaluation of pericardial effusion. However,the initial evaluation of pericardial effusion. However,
several findings make further evaluation with CCTseveral findings make further evaluation with CCT
useful, such as a loculated effusion, hemorrhagicuseful, such as a loculated effusion, hemorrhagic
effusion, or equivocal findings on echocardiography.effusion, or equivocal findings on echocardiography.
• Pericardial effusions may be characterized with CCTPericardial effusions may be characterized with CCT
by measuring their CT attenuation.by measuring their CT attenuation.
• A CT attenuation close to water (e.g., 0 HounsfieldA CT attenuation close to water (e.g., 0 Hounsfield
Units, HU) suggests a simple pericardial effusion. IfUnits, HU) suggests a simple pericardial effusion. If
the CT attenuation is greater than that of water, thethe CT attenuation is greater than that of water, the
effusion may represent hemorrhage, purulence, or aeffusion may represent hemorrhage, purulence, or a
malignant/cellular process.malignant/cellular process.

26. Pericardial effusionPericardial effusion

27. Pericardial MassesPericardial Masses
• Pericardial masses include cysts and neoplasms.Pericardial masses include cysts and neoplasms.
• Pericardial cysts are mostly congenital and arePericardial cysts are mostly congenital and are
usually found at the right costophrenic angle.usually found at the right costophrenic angle.
They tend to be asymptomatic smooth-walledThey tend to be asymptomatic smooth-walled
simple cysts that do not enhance after contrastsimple cysts that do not enhance after contrast
administration.administration.
• However, sometimes pericardial cyst canHowever, sometimes pericardial cyst can
present on left side and can compress the leftpresent on left side and can compress the left
atrium with clinical symptoms of dyspneaatrium with clinical symptoms of dyspnea

28. Pericardial cystPericardial cyst

29. • With regard to neoplasms, metastases are far moreWith regard to neoplasms, metastases are far more
common than primary pericardial tumors.common than primary pericardial tumors.
• Neighboring structures, such as the lung andNeighboring structures, such as the lung and
breast, are most commonly the source of metastaticbreast, are most commonly the source of metastatic
disease to the pericardium.disease to the pericardium.
• Other findings associated with metastatic diseaseOther findings associated with metastatic disease
include pericardial effusion and an irregularlyinclude pericardial effusion and an irregularly
thickened pericardium .thickened pericardium .
• Primary neoplasms of the pericardium occurPrimary neoplasms of the pericardium occur
infrequently & may be benign (fibroma, teratoma,infrequently & may be benign (fibroma, teratoma,
lipoma, hemangioma) or malignant (mesothelioma,lipoma, hemangioma) or malignant (mesothelioma,
lymphoma, sarcoma, & liposarcoma)lymphoma, sarcoma, & liposarcoma)

30. Pericardial mesotheliomaPericardial mesothelioma

31. Pericardial sarcomaPericardial sarcoma

32. Constrictive pericarditisConstrictive pericarditis
• The current reference standard for the non-The current reference standard for the non-
invasive evaluation of pericardial constrictioninvasive evaluation of pericardial constriction
is cardiac MRI.is cardiac MRI.
• The characteristic anatomic changes associatedThe characteristic anatomic changes associated
with constrictive pericardial disease (elongatedwith constrictive pericardial disease (elongated
and narrow right ventricle, enlargement of theand narrow right ventricle, enlargement of the
right atrium and inferior cava, and pericardialright atrium and inferior cava, and pericardial
thickening) are clearly identified with boththickening) are clearly identified with both
MRI and CCT.MRI and CCT.

33. • Since patients with true constrictiveSince patients with true constrictive
pericarditis typically present with orthopnea, itpericarditis typically present with orthopnea, it
is often difficult for them to lie flat in the MRIis often difficult for them to lie flat in the MRI
scanner for up to 1 h.scanner for up to 1 h.
• CCT may offer another option for evaluatingCCT may offer another option for evaluating
constrictive pericarditis, with shortconstrictive pericarditis, with short
examination times representing one of itsexamination times representing one of its
major advantages.major advantages.
• The excellent spatial resolution of CCT allowsThe excellent spatial resolution of CCT allows
for accurate measurement of pericardialfor accurate measurement of pericardial
thickness.thickness.

34. • Pericardial thickness of >4 mm is consideredPericardial thickness of >4 mm is considered
pathological and in the appropriate clinicalpathological and in the appropriate clinical
context is suggestive of pericardial constriction.context is suggestive of pericardial constriction.
• However, it is important to note that neitherHowever, it is important to note that neither
pericardial calcification nor thickening ispericardial calcification nor thickening is
diagnostic of constrictive pericarditis.diagnostic of constrictive pericarditis.
• Pericardial thickening may be found in thePericardial thickening may be found in the
absence of constriction (e.g., acute pericarditis,absence of constriction (e.g., acute pericarditis,
uremia, collagen vascular diseases).uremia, collagen vascular diseases).

35. Pericardial constrictionPericardial constriction

36. Heavily calcified pericardiumHeavily calcified pericardium

37. Evaluation in Valvular Heart DiseaseEvaluation in Valvular Heart Disease
• Echocardiography is the initial imaging modalityEchocardiography is the initial imaging modality
of choice, allowing for a complete diagnosis inof choice, allowing for a complete diagnosis in
the majority of patients.the majority of patients.
• CT has a limited role for the evaluation of VHDCT has a limited role for the evaluation of VHD
as the primary indication. It may occasionally beas the primary indication. It may occasionally be
employed as such when echocardiographicemployed as such when echocardiographic
results are incomplete and the patient is not aresults are incomplete and the patient is not a
good candidate for MRI. However, CT isgood candidate for MRI. However, CT is
increasingly used for noninvasive coronaryincreasingly used for noninvasive coronary
angiography, and useful information on valveangiography, and useful information on valve
anatomy and function can simultaneously beanatomy and function can simultaneously be
obtained from a coronary examination.obtained from a coronary examination.

38. VALVE ASSESSMENTVALVE ASSESSMENT
. CalcificationCalcification
. Anatomy. Anatomy
. Function. Function
VENTRICULARVENTRICULAR
ASSESSMENTASSESSMENT
. Volumes. Volumes
. Ejection fraction. Ejection fraction
. Mass. Mass
CORONARYCORONARY
ASSESSMENTASSESSMENT
VHDVHD
REPERCUSSION. .AtrialREPERCUSSION. .Atrial
size / thrombussize / thrombus
. Pulmonary hypertension. Pulmonary hypertension
. Left / right heart failure. Left / right heart failure

39. Specific Valvular AbnormalitiesSpecific Valvular Abnormalities
• Aortic Stenosis:Aortic Stenosis: AS is often accompanied byAS is often accompanied by
cusp calcification.cusp calcification.
• Aortic valve calcification can be accuratelyAortic valve calcification can be accurately
quantified using CT.quantified using CT.
• The amount of calcification is directly correlatedThe amount of calcification is directly correlated
with the severity of AS.with the severity of AS.
• The incremental value of the information derivedThe incremental value of the information derived
from the aortic valve calcium score may befrom the aortic valve calcium score may be
particularly useful to evaluate stenosis severity inparticularly useful to evaluate stenosis severity in

40. • Willmann et al. staged the severity of AVCWillmann et al. staged the severity of AVC
burden as the following :burden as the following :
• Grade 1,Grade 1, no calcification.no calcification.
• Grade 2,Grade 2, mild calcification (small isolated spotsmild calcification (small isolated spots
of calcification).of calcification).
• ƒGrade 3,ƒGrade 3, moderate calcification (multiple largermoderate calcification (multiple larger
spots of calcification).spots of calcification).
• Grade 4,Grade 4, heavy calcification (extensiveheavy calcification (extensive
calcification of all aortic valve leaflets).calcification of all aortic valve leaflets).

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

42. • Contrast-enhanced CT can precisely evaluateContrast-enhanced CT can precisely evaluate
valve morphology, accurately differentiatingvalve morphology, accurately differentiating
tri-leaflet from bicuspid valves .tri-leaflet from bicuspid valves .
• Planimetric determinations of the aortic valvePlanimetric determinations of the aortic valve
area have shown excellent correlation witharea have shown excellent correlation with
echocardiographic measurementsechocardiographic measurements

43. Transcatheter aortic valve implantation (TAVI)Transcatheter aortic valve implantation (TAVI)
• Recommendations about CT before TAVI/TAVRRecommendations about CT before TAVI/TAVR
• CT imaging should be performed in theCT imaging should be performed in the
evaluation process of:evaluation process of:
• Patients who are under consideration forPatients 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 with aCT datasets should be interpreted jointly with a
member of the TAVI/TAVR procedural team ormember of the TAVI/TAVR procedural team or
reviewed with the operator before the procedure.reviewed with the operator before the procedure.

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

45. • Recommendations for assessment of the accessRecommendations for assessment of the access
route by CT before TAVI/TAVR:route by CT before TAVI/TAVR:
• CT imaging should be performed for vascularCT 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 withCT examinations should be performed with
iodinated contrast medium.iodinated contrast medium.
• Qualitative assessment of vascular tortuosityQualitative assessment of vascular tortuosity
should be performed.should be performed.
• Qualitative assessment of vascular calcificationQualitative assessment of vascular calcification

46. • Consideration to varied thresholds of vesselConsideration to varied thresholds of vessel
size (sheath/femoral artery ratio) should besize (sheath/femoral artery ratio) should be
contemplated, depending on the presence andcontemplated, depending on the presence and
extent of vascular calcification.extent of vascular calcification.
• The left ventricle should be evaluated for theThe left ventricle should be evaluated for the
presence of thrombus and, if a transapicalpresence of thrombus and, if a transapical
access route is planned, for geometry andaccess route is planned, for geometry and
position of the apex.position of the apex.

47. • Recommendations for assessment of the aortaRecommendations for assessment of the aorta
• The entire aorta should be imaged and evaluated,The entire aorta should be imaged and evaluated,
unless a transapical access is planned.unless a transapical access is planned.
• Severe elongation and kinking of the aorta,Severe elongation and kinking of the aorta,
dissection, and obstructions caused by thrombus ordissection, and obstructions caused by thrombus or
other material should be reported.other material should be reported.

48. • Aortic annulusAortic annulus

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

50. Aortic annulus plane for fluoroscopyAortic annulus plane for fluoroscopy

52. • Aortic Regurgitation:Aortic Regurgitation: CT may be useful inCT may be useful in
evaluating the mechanism leading to AR.evaluating the mechanism leading to AR.
• AR caused by degenerative valve disease isAR caused by degenerative valve disease is
characterized by thickened &/or calcified leaflets,characterized by thickened &/or calcified leaflets,
and the area of lack of coaptation may beand the area of lack of coaptation may be
visualized in diastolic phase reconstructionsvisualized in diastolic phase reconstructions
centrally or at the commissures.centrally or at the commissures.
• In cases of AR secondary to enlargement of theIn cases of AR secondary to enlargement of the
aortic root, the regurgitant orifice is typicallyaortic root, the regurgitant orifice is typically
located centrallylocated centrally

54. • MitralMitral Stenosis:Stenosis:
• As in the case of aortic valve calcification, theAs in the case of aortic valve calcification, the
presence of calcium in the mitral annulus ispresence of calcium in the mitral annulus is
associated with systemic atherosclerosis andassociated with systemic atherosclerosis and
carries negative prognostic implications.carries negative prognostic implications.
• The amount of mitral annular calcium can alsoThe amount of mitral annular calcium can also
be quantified with CT.be quantified with CT.
• Planimetry of mitral valve opening by CTPlanimetry of mitral valve opening by CT
provides accurate assessment of MS severityprovides accurate assessment of MS severity

55. Short-axis view at the level of the mitral valve,Short-axis view at the level of the mitral valve,
showing extensive annular calcificationshowing extensive annular calcification

56. Contrast-enhanced CT scan in the four-chamber and shortaxisContrast-enhanced CT scan in the four-chamber and shortaxis
views (panels a and b , respectively) from a patient with rheumaticviews (panels a and b , respectively) from a patient with rheumatic
mitral stenosis. The typical thickening and restricted dome-shapedmitral stenosis. The typical thickening and restricted dome-shaped
opening of the leafl ets can be observed (opening of the leafl ets can be observed ( arrows and asterisk ).arrows and asterisk ).
PlanimetryPlanimetry of the valve (panel c ) demonstrated moderate stenosisof the valve (panel c ) demonstrated moderate stenosis
(( red contour ;red contour ; area = 1.3 cm 2 )area = 1.3 cm 2 )

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

58. • Mitral Regurgitation:Mitral Regurgitation:
• In patients with mitral valve prolapse, CT canIn patients with mitral valve prolapse, CT can
demonstrate the presence of leaflet thickening ordemonstrate the presence of leaflet thickening or
the degree and location of prolapse.the degree and location of prolapse.
• In cases of MR secondary to annular enlargementIn cases of MR secondary to annular enlargement
(often accompanying dilated cardiomyopathy),(often accompanying dilated cardiomyopathy),
dimensions of the annulus can be accuratelydimensions of the annulus can be accurately
quantified, and a central area of insufficientquantified, and a central area of insufficient
leaflet coaptation may be observed.leaflet coaptation may be observed. AlthoughAlthough
quantifying MR severity may be difficult, a recentquantifying MR severity may be difficult, a recent
study suggested that planimetry of the regurgitantstudy suggested that planimetry of the regurgitant
orifice by CT correlates well withorifice by CT correlates well with
echocardiographic grading of MR severityechocardiographic grading of MR severity

59. MVP PlanesMVP Planes

61. • Infective Endocarditis:Infective Endocarditis:
• The diagnosis of infective endocarditis usuallyThe diagnosis of infective endocarditis usually
relies on the visualization of vegetations, andrelies on the visualization of vegetations, and
transthoracic and transesophagealtransthoracic and transesophageal
echocardiography are usually superior to CT dueechocardiography are usually superior to CT due
to higher temporal resolution.to higher temporal resolution.
• However, CT can be particularly useful in theHowever, CT can be particularly useful in the
demonstration of perivalvular abscesses as fluid-demonstration of perivalvular abscesses as fluid-
filled collections.filled collections.
• In patients with AV endocarditis with highlyIn patients with AV endocarditis with highly
mobile vegetations, CT offers an alternative tomobile vegetations, CT offers an alternative to
invasive coronary angiography for evaluation ofinvasive coronary angiography for evaluation of

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

63. • Prosthetic Valves :Prosthetic Valves :
• Recently, cardiac CT has been recognized as anRecently, cardiac CT has been recognized as an
alternative to evaluation of prosthetic valvealternative to evaluation of prosthetic valve
complications including valve thrombosis,complications including valve thrombosis,
dehiscence, pannus development, endocarditis,dehiscence, pannus development, endocarditis,
and paravalvular leak.and paravalvular leak.
• Some valves, such as ball in cage valves, are notSome valves, such as ball in cage valves, are not
readily evaluable by CT because of extremereadily evaluable by CT because of extreme
beam hardening artifact from the thicker metalbeam hardening artifact from the thicker metal
struts found in these models.struts found in these models.

64. • Motion artifact is worst for AV prosthesis duringMotion artifact is worst for AV prosthesis during
ventricular systole and for MV prosthesis duringventricular systole and for MV prosthesis during
end-diastole. Thus, it has been found thatend-diastole. Thus, it has been found that
imaging inimaging in mid-diastolemid-diastole is the most ideal foris the most ideal for
prosthetic valve evaluation.prosthetic valve evaluation.
• CT is particularly useful for the evaluation ofCT is particularly useful for the evaluation of
some types of mechanical valves.some types of mechanical valves.
• In Prostheses with two discs should openIn Prostheses with two discs should open
symmetrically.symmetrically.
• In those with a single disc, the angle of openingIn 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,

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

66. Assessment of Cardiac and Thoracic MassesAssessment of Cardiac and Thoracic Masses
• Interpreting Cardiac Masses:Interpreting Cardiac Masses:
• Key descriptors for cardiac masses include theKey descriptors for cardiac masses include the
following: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

69. MyxomaMyxoma

70. Right atrial lipomaRight atrial lipoma

71. lipomatous hypertrophy of interatrial septumlipomatous hypertrophy of interatrial septum

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

74. Giant LAD aneurysmGiant LAD aneurysm

76. Right atrial and right ventricular angiosarcomaRight atrial and right ventricular angiosarcoma
extending into the main pulmonary arteryextending into the main pulmonary artery

78. Left ventricular thrombusLeft ventricular thrombus

79. LA & RA thrombiLA & RA thrombi

80. Papillary fibroelastomasPapillary fibroelastomas