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cases of the week 2018

 

NUMBER 18-07: THE DIAGNOSTIC VALUE OF CMR IN A PATIENT WITH CONGENITAL HEART DISEASE AND INFECTIOUS ENDOCARDITIS

A four-year old patient with pulmonary atresia and ventricular septal defect (PA/VSD) after surgical repair with Contegra conduit (bovine jugular vein graft, Medtronic, Minneapolis, MN) at the age of 2 years underwent repeated CMR scan under general anesthesia for evaluation of aortic regurgitation and assessment of left ventricular volumes. CMR showed significant aortic regurgitation through a perforation in the right coronary cusp with mild left ventricular dilatation and mildly impaired left ventricular systolic function. Surprisingly, severe stenosis of the pulmonary conduit due to a mobile mass with severe dilatation and severe dysfunction of the right ventricle was recognized. These findings were not seen on echocardiogram performed 2 months before and were suspicious of infectious endocarditis (IE).

NUMBER 18-06: A LEFT VENTRICULAR PSEUDOANEURYSM BEFORE AND AFTER SURGICAL CORRECTION

A 71 year old female was seen at the outpatient clinic with complaints of exertional dyspnea. Her medical history noted an inferior myocardial infarction 2 years earlier, for which primary percutaneous coronary intervention of the right coronary artery (RCA) was performed. This procedure had been compromised by cardiac tamponade, thought to have been caused by perforation of the RCA through wire exit. A subxyphoidal drainage was performed removing 300ml of blood and thrombi, after which patient was treated conservatively.

Two months after this episode, the patient presented to the emergency department with dyspnea. A CT scan was performed under suspicion of pulmonary embolism, which proved not to be the case. A left ventricular pseudoaneurysm was visible on this scan, but wasn’t reported and thus remained unrecognized.

NUMBER 18-05: how to image the heart when it is in the abdomen: a case of pentalogy of cantrell

A 40-year-old man with pentalogy of Cantrell including omphalocele, epicordis with ventral herniation into the abdominal cavity, chest wall deformities, and congenital heart disease presented to our adult congenital heart disease clinic with lower extremity swelling. His complex congenital heart disease consisted of double outlet right ventricle (DORV) with D-malposition of the great arteries, severe left pulmonary artery stenosis, severe pulmonary insufficiency, cor triatrium sinister and ventricular herniation into the abdominal cavity.

 

NUMBER 18-04: swollen inter-ventricular septum: a phenotype mimicking hcm

A 32-year-old male patient with no relevant medical history presented with acute onset of chest pain. His initial ECG showed ST segment elevation in leads V1 to V3 with reciprocal ST segment depression in inferior leads
 

NUMBER 18-03: LOWER EXTREMITY EDEMA: LONG TERM COMPLICATION OF PARTIAL ANOMALOUS PULMONARY VENOUS RETURN REPAIR

A 57 year old woman with a history of sinus venosus atrial septal defect and partial anomalous pulmonary venous return (PAPVR) repaired in childhood presented to the adult congenital heart disease clinic with junctional rhythm and significant lower extremity swelling. She had three surgeries during childhood for congenital heart disease. She did not have consistent care for her heart disease and her surgical history was not clear at presentation. In addition to her congenital heart disease she had known active hepatitis C infection. A month before presentation, she was evaluated for dizziness with bradycardia. She continued to have intermittent bouts of dizziness without syncope. 

NUMBER 18-02: MANAGEMENT OF A NEARLY OCCLUSIVE NEONATAL PULMONARY ARTERY THROMBUS

A term male infant with a birth weight of 3,623 grams failed a routine pulse oximetry screening at approximately 36 hours of life.  There were no pregnancy complications aside from maternal tobacco use.  Pre- and post-ductal saturations were 94% and 86-88%, respectively.  An echocardiogram was notable for a large mass in the right pulmonary artery.

NUMBER 18-01: An unusual presentation of behÇet's disease

A 22-year old Caucasian gentleman was transferred as an emergency to our cardiac surgical center with a large unexplained right ventricular mass, with evidence of a large pulmonary embolus. He had a 6-week history of fevers and rigors following a dental infection and had been admitted to another hospital 10 days previously for investigation. He was otherwise fit and well, with no previous medical history or medications. He had been treated with a course of penicillin V at the time of initial dental infection, and had presented a number of times to his local emergency department in the preceding weeks with fevers, mouth ulcers, pleuritic chest pain and had raised inflammatory markers (white cell count of 18 cells per cubic millimeter of blood with neutrophilia, C-reactive protein (standard assay) of 120 mg/mL, erythrocyte sedimentation rate of 80 mm/hr) with negative blood cultures and no localizing signs of infection.
 

CASES OF THE WEEK 2017
 

NUMBER 17-12: A SWINGING HEART

A 71-year old male with a previous history of working-exposure to glass components was admitted to our hospital with persistent complaints of chest tightness, shortness of breath and edema in the lower limbs that started 3 months prior to his admission. An echocardiogram from a local hospital identified a nodule on the right-sided of the pericardium and large pericardial and pleural effusions. Percutaneous drainage was performed and 30 mL were obtained from the pericardium and 500 mL from the pleurae, both of hemorrhagic appearance. Biochemical analysis of pericardial and pleural fluids was not performed and cytological analysis was negative for malignant cells. Medical treatment was initiated and the patient remained asymptomatic for the following 3 days. The patient’s symptoms recurred and rapidly worsened so he was admitted to our institution for further examination and treatment.

NUMBER 17-11: THE VENTRICAL CARDIAC 'FLOP' - A CMR SIGN IN CONGENITAL ABSENCE

A 64-year old Caucasian lady was seen at the rapid access chest pain clinic with a 6-month history of atypical chest pain. Her risk factors for cardiovascular disease were smoking, hypertension and familial risk. She was referred for coronary angiography that revealed moderate right coronary artery/posterior descending artery stenosis while left ventriculography suggested an unusual cardiac orientation with a laterally displaced and vertically oriented heart. She was referred to us for stress perfusion cardiovascular magnetic resonance (CMR) imaging.

NUMBER 17-10: Cardiac involvement of myeloid sarcoma

A 64-year-old male with history of Acute Myelogenous Leukemia (AML) status post bone marrow transplant (BMT) in complete remission presented with dyspnea when laying on his right side which resolved when supine or in the left lateral decubitus position. He also reported occasional shortness of breath with mild exertion. Only tachycardia was noted on clinical examination. There were no clinical signs of SVC syndrome.

NUMBER 17-09: CONCEALED RIGHT VENTRICULAR INFARCTION REVEALED BY CARDIAC MRI

A 59 year old male patient, diabetic, hypertensive presented with a non ST-segment elevation myocardial infarction (NSTEMI) (Image 1). The peak troponin I was 5.9 ng/ml (reference level up to 0.02 ng/ml). Coronary angiography, performed within four hours from the onset of chest pain, showed a significant proximal left anterior descending (LAD) artery lesion for which two drug eluting stents were deployed. The right coronary artery (RCA) was dominant with sluggish flow and an insignificant proximal lesion. No stents or angioplasty were performed on the RCA (Movie 1,2). ECG was recorded after catheterization (Image 2).

 

NUMBER 17-08: intra-myocardial haemangioma mimicking hypertrophic cardiomyopathy-evaluation by multimodality imaging

A 57-year-old female presented with atypical chest pain. Her past medical history was unremarkable. Initial ECG (Figure 1) revealed inferolateral T wave inversion without evidence of left ventricle hypertrophy by voltage criteria; however, serial cardiac enzymes were negative.  

Acute coronary syndrome was ruled out and the patient was referred for stress echocardiography. The stress echocardiogram revealed normal LV size and systolic function with no resting or inducible regional wall motion abnormality. However there was an incidental finding of asymmetric thickening of the distal inter-ventricular septum raising suspicion for atypical hypertrophic cardiomyopathy.
 

NUMBER 17-07: invisible cardiac lesion

A 43 year old female with a past medical history significant for hypertension and mild rheumatoid arthritis and no known cardiac disease experienced the sudden onset of chest pain, malaise, and pre-syncope at an airport. Paramedics were alerted and she was found to have inferior ST- segment elevations on an ECG (see Figure 1). The patient was immediately taken to the nearest cardiac catheterization laboratory and was found to have no significant coronary artery lesions. Her peak CK-MB was in the 50s ng/mL and her peak Troponin was 15 ng/mL. A transthoracic echocardiogram demonstrated an inferior wall motion abnormality and a left ventricular ejection fraction of 35-45% (see Figures 2-6). Her symptoms and inferior ST segment elevations subsequently resolved. She was diagnosed with coronary vasospasm and treated with diltiazem, carvedilol, aspirin, clopidogrel, nitroglycerin, simvastatin, and lisinopril. After discharge, she participated in cardiac rehabilitation but reported low energy and fluid retention that was managed with low-dose diuretics.

NUMBER 17-06: UNEXPECTED JEOPARDY: CMR IN ATYPICAL CHEST PAIN BUT CHRONIC AORTIC DISSECTION WITH CARDIAC SCHWANNOMA

A 60-year-old, obese woman with diabetes and hypertension presented with dyspnea on exertion and atypical chest pain for weeks. The physical examination was unremarkable. No ischemic changes were observed on the electrocardiogram. The sensitive Troponin-T level was less than 50.0 ng/L (0.0-100.0). 

NUMBER 17-05: CARDIOVASCULAR MAGNETIC RESONANCE IMAGING OF A RIGHT ATRIAL MASS - A CASE REPORT

A 71-year old woman, without relevant medical history, initially presented with progressive dyspnea and orthopnea due to new onset heart failure (New York Heart Association functional class III). Her blood pressure at admission was 170/105 mmHg. A chest X-ray revealed cardiomegaly and pulmonary edema. A transthoracic echocardiogram was performed and moderately reduced left ventricular function and an echodense mass in the right atrium were observed. For differentiation of various etiologies and diagnosis of the mass, cardiovascular magnetic resonance (CMR) imaging was the next step in the diagnostic strategy.

NUMBER 17-04: AORTITIS MASQUERADING AS PERICARDIAL EFFUSION

Early diagnosis of aortitis is crucial for proper management of the disease and prevention of future sequelae. Clinical presentation of aortitis is often nonspecific and patients with early stages of aortitis are often asymptomatic. Traditionally, the diagnosis of aortitis is invasive often requiring arterial biopsy. However, advanced imaging can be an invaluable tool to assist clinicians in the evaluation of patients for possible aortitis with high specificity, and sensitivity [4]. In this case report, we present a patient with atypical presentation of aortitis, and describe how different imaging modalities can be used to assist in the diagnosis of aortitis.

A 43-year-old female with a history of asthma and uterine fibroids presented with shortness of breath. She reported chest tightness and was awakened from sleep with chest pain that radiated down her left arm. She had no prior history of cardiac diseases. There was recent history of fever, and productive cough.

NUMBER 17-03: CONGENITAL MALFORMATION OF THE CORONARY DRAINAGE SYSTEM AND TRABECULAR ARCHITECTURE DETECTED BY CARDIOVASCULAR MAGNETIC RESONANCE

A 55-year-old Caucasian female presented with typical angina-like symptoms. Cardiovascular examination revealed a diastolic murmur, loudest at the left sternal edge. Her past medical history included mild hypercholesterolaemia only. Electrocardiography showed sinus rhythm with no ischaemic changes.

Coronary angiography showed unobstructed but markedly dilated high flow coronary arteries draining directly into the left ventricle (LV) through a plexus of small vessels arising from both coronaries (coronary-cameral communications). This mimicked aortic regurgitation on aortography (Figure 2; prompt LV opacification but not through the valve). No epicardial venous system enhanced.
 

NUMBER 17-02: CARDIAC INVOLVEMENT IN EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

A 34 year old female presented with a history of loss of appetite, unintended weight loss, and heart failure. Her past history was remarkable for a diagnosis of eosinophilic polyangiitis (EGPA). She also had a prior bout of middle cerebral artery syndrome earlier in the year of uncertain etiology, although a coexisting PFO was found and thought to possibly represent a source of paradoxical embolism. A CT of the chest was performed to evaluate suspected pulmonary involvement, and demonstrated left ventricular enlargement. A transthoracic echocardiogram depicted a thrombus in the left ventricle.

A CMR exam was then performed to further evaluate this finding, assess left ventricular function, and determine possible cardiac involvement by EGPA.
 

NUMBER 17-01: LARGE PERICARDIAL BRONCHOGENIC DUPLICATION CYST: UTILITY OF CARDIAC MRI IN DIAGNOSIS OF A RARE ENTITY

A 31 month old female was diagnosed with a large secundum atrial septal defect (ASD) following evaluation for a murmur as neonate. At that time, a separate “third chamber” was noted that appeared contiguous with the lateral left atrium that was believed to represent a cor triatriatum membrane. One pulmonary vein was seen draining into the left atrium. The other pulmonary veins were thought to drain into the “third chamber” however transthoracic echocardiography never definitively resolved this by color flow Doppler. She remained clinically asymptomatic although notably required three admissions for upper respiratory infections during the previous year. She was scheduled for elective closure of the ASD and resection of the cor triatriatum membrane. An intraoperative transesophageal echocardiogram was performed, which demonstrated normal pulmonary venous return and concern for a large extracardiac mass compressing the left atrium. The operative repair was delayed and the patient was transferred under anesthesia to the MRI suite to obtain a cardiac MRI for further evaluation of the mass prior to same day resection.

CASES OF THE WEEK 2016

NUMBER 16-13: INFILTRATIVE MASS: CARDIAC MRI TO ASSESS FOR AUTOTRANSPLANTATION CANDIDACY

A 55 year old previously healthy woman was evaluated for progressive dyspnea on exertion with associated chest tightness. She denied fevers, chills, and night sweats. She underwent a 2D-Echocardiogram which showed a large pericardial effusion with thickening of the right atrial wall and a mass just below the posterior tricuspid leaflet. Left and right ventricular systolic function was normal. Pericardiocentesis yielded 850 mL of hemorrhagic fluid, analysis of which was nondiagnostic. A CT of the chest, abdomen, and pelvis demonstrated numerous lung nodules, ground glass lesions and diffuse mediastinal lymphadenopathy. In addition, the cardiac mass was visualized. To define the probable etiology of the mass, cardiac MRI was performed for more precise localization and tissue characterization.

NUMBER 16-12: Hypertrophic cardiomyopathy, apical aneurysm, and inducible ischemia

The case of a 85 year-old lady is presented who complain of atypical chest pain.  After a markedly abnormal ECG showing high voltage R waves and deep, inverted T waves on precordial leads, an echocardiographic study is performed, suggesting non-obstructive hypertrophic cardiomyopathy (HCM).

A CMR exam is requested to: 1) confirm the diagnosis; 2) precisely determine the extent of the process; 3) establish the presence or not of myocardial fibrosis;  and 4) to rule out myocardial ischemia.
 

NUMBER 16-11: magnetic resonance late gadolinium enhancement detects acute aortic intramural hematoma

An 81-year-old male patient presented with sudden and intense chest pain. On the emergency ward, a transthoracic echocardiogram was performed showing an enlarged and wall-thickened thoracic aorta. Computed tomography angiography confirmed the enlarged and wall-thickened thoracic aorta. In non-contrast images, a high-attenuation crescentic thickening of the aortic wall suggested an intramural hematoma or aortitis (Figure 1). 18F-FDG-PET suggested that there was no overt inflammation but findings were equivocal (Figure 1). The patient was stable without pericardial effusion, periaortic hematoma, or large aortic aneurysm; therefore, a cardiac magnetic resonance imaging study was performed in the next 12 hours to rule out aortitis (1).

NUMBER 16-10: Organization of intracardiac thrombus: insights from inside a giant left ventricular pseudoaneurysm

A 57-year-old homeless man presented to the emergency room after a syncopal episode. He reported a two-day history of shortness of breath and upper back pain. He was noted to be hypotensive with a blood pressure of 92/69 mmHg. An electrocardiogram showed ST-segment elevations in the inferolateral leads. Emergent coronary angiography revealed diffuse obstructive disease in the left anterior descending coronary artery, occlusion of the distal left circumflex coronary artery and complete total occlusion of the proximal right coronary artery. The left circumflex lesion was felt to be the culprit and it was treated with balloon angioplasty. Echocardiography revealed a left ventricular ejection fraction (LVEF) of 15-20% with a contained rupture and pseudoaneurysm involving the lateral wall. He was recommended coronary artery bypass graft surgery and repair of the left ventricular (LV) pseudoaneurysm, which he refused. He was discharged with medical treatment and presented with NYHA Class III heart failure symptoms 4 months later. He was agreeable to surgery at this time and for surgical planning, he underwent a cardiovascular magnetic resonance (CMR) study.

NUMBER 16-09: SUBARACHNOID HEMORRHAGE UNMASKS AORTIC COARCTATION IN A YOUNG MAN

A 20-year-old male with a history of hypertension presented to the emergency department because of a severe headache. On examination, the patient was confused and disoriented. His BP was 135/61 mmHg, temperature 35.6°C (97.9°F), pulse 78, and respiratory rate 24. Cardiovascular exam showed a regular heart rhythm, a grade III/VI diastolic murmur heard best in the third left intercostal space, strong pulse, no edema, warm skin, and capillary refill of < 3 seconds. No lower extremity blood pressures were obtained.

NUMBER 16-08: LARGE ANEURYSMAL CORONARY ARTERY FISTULA: A UTILITY OF CARDIAC MRI IN DIAGNOSIS 

History: A 64 year old female presented with a long history of vague dyspnea on exertion and intermittent palpitations. She had a history of mild exercise intolerance for the last 50 years with difficulty keeping up with her peers as early as high school. She had a normal physical exam with no murmur or gallop. A recent 24 hour Holter monitor was concerning for intermittent supraventricular tachycardia with possible atrial fibrillation. Her transthoracic echocardiogram showed left atrial dilation and concern for possible cor triatriatum with a membrane across the mid left atrium. A nuclear stress test was negative with no evidence of infarct or ischemia. She had a transesophageal echocardiogram that showed no evidence of cor triatriatum, severe left atrial dilation, dilated right coronary artery ostium, and continuous unidentified flow into the left atrium. A cardiac MRI and chest MRA was performed to evaluate the etiology of left atrial dilation in the setting of a dilated coronary artery.

 

number 16-07: UHL’S ANOMALY: YOU’LL RECOGNIZE IT WHEN YOU SEE IT

History: A 19-year old male with no previous cardiovascular history presented with NYHA Class III heart failure symptoms. Electrocardiogram on presentation showed normal sinus rhythm with Himalayan P waves (P waves > 5 mm and peaked in lead II), right bundle branch block and right axis deviation. 
 

NUMBER 16-06: CARDIOVASCULAR MAGNETIC RESONANCE IMAGING IN VENTRICULAR TACHYCARDIA: SEARCH FOR THE CULPRIT 

History: A 55-year old female patient presented after an episode of syncope secondary to polymorphic ventricular tachycardia (pVT). Her medical history included impaired glucose tolerance and deep venous thrombosis 17 years ago. She did not use any medication. On examination, vital signs were normal and only raccoon eyes were observed. CT-cerebrum excluded intracranial pathology. During the hospital stay she experienced six episodes of pVT with minimal prolongation of the QT interval, which converted to sinus rhythm either spontaneously or with defibrillation.

NUMBER 16-05: THE ROLE OF MULTI-MODAL IMAGING IN THE DIAGNOSIS AND MANAGEMENT OF A CARDIAC VASCULAR MALFORMATION

An asymptomatic 4-month-old male infant was referred for assessment of a heart murmur. An echocardiogram demonstrated a large (19x11 mm) mass arising from the basal inter-ventricular septum, encroaching on the right ventricular outflow tract (RVOT), producing mild RVOT obstruction.
 

NUMBER 16-04: CARDIAC SARCOIDOSIS: WHEN RHYTHM BECOMES AN ISSUE

A 50 year old mixed race man was admitted in Coronary Care Unit after an episode of syncope and sudden onset chest pain associated with palpitations.

NUMBER 16-03: HYPERTROPHIC CARDIOMYOPATHY PRESENTING AS AN INFLAMMATORY MYOCARDIAL DISEASE

A 52 year old man with a history of arterial hypertension was admitted because of sustained monomorphic ventricular tachycardia (Fig. A) reverted by amiodarone.
   

NUMBER 16-02: NEONATAL CARDIAC MASS: AN EXAMPLE OF THE UTILITY OF CARDIAC MRI IN TISSUE CHARACTERIZATION

The patient's mother presented at 33 weeks gestation for a fetal echocardiogram secondary to
a suspected cardiac abnormality on obstetrical ultrasound. 

NUMBER 16-01: A PECULIAR CASE OF MYOCARDITIS IN AN ADOLESCENT

A 17 year old male with a history of autism presented to the emergency room with a three day history of subjective fever, otitis media and acute onset of chest pain for one day

Cases of the Week 2015

Number 15-17: unenhanced cmr for suspected pulmonary embolism during the first trimester of pregnancy. when avoiding ionizating radiation and iodine contrast media really matters.

History: A case of PE at early pregnancy evaluated by CMR. When radiation and contrast media really matters. 

 

number 15-16: an incidental large ductus diverticulum 

History: An 85 year old male veteran had an incidental discovery of a large aneurysm in the region of a ductus diverticulum on a CT chest 2 years prior.

 

Number 15-15: Contained Cardiac Rupture Presenting With Syncope.

History: A 64-year-old male, a diabetic and a smoker, with no relevant cardiovascular history presented with a syncope during sexual intercourse after using sildenafil, with complete recovery after 10 minutes.

 

 

Number 15-14: Cardiac Involvement of Cystic Echinococcosis by Cardiac Magnetic Resonance Imaging.

 History: A 70-year-old female residing in a remote, rural part of Pakistan presented with several days of chest pain and dyspnea concerning for acute coronary syndrome.  

 

Number 15-13: Budd-Chiari: an unexpected imaging journey that ends with congenital CMR.

History: A 46 year old woman was referred to our hospital for investigation of vaginal blood loss. 

 

Number 15-12: Don’t always judge a heart by its echo

History: A 64 year old male presented one year after cardiac transplant for routine follow up. A 2D transthoracic echocardiogram revealed a mobile, echogenic lesion along the inferior wall of the right atrium. 

 

Number 15-11: Cardiac magnetic resonance is the technique to evaluate anatomically corrected malposition of the great arteries

History: A symptomatic 50 year old woman previously diagnosed as congenitally corrected transposition of great arteries (L-TGA) was referred to our department.

Number 15-10: Etiology of atrioventricular block visualized by cardiac magnetic resonance

History: An 8-year old girl presented with clinical signs of low cardiac output after symptoms of fever and emesis during a few days. ECG revealed a complete atrio-ventricular (AV) block with a ventricular rate of 35 bpm and wide QRS complexes (120 ms) with variable axis deviation and bundle branch block morphology.

NUMBER 15-09: are myocardial crypts a genetic phenonmenon related to hypertrophic cardiomyopathy?

History: A teenager who collapsed during athletic activity, has T wave inversion on ECG.

 

NUMBER 15-08: granulomatosis with polyangiitis (churg-strauss syndrome)

History: A 23 year-old gentleman presented to the coronary care unit with “dull aching” central chest pain without pleuritic or pericarditic features.

 

Number 15-07: Intrapulmonary Bronchogenic Cyst

History: An 84 year-old man presented after an out-of-hospital cardiac arrest and was successfully resuscitated.

Number 15-06: Atypical Variant of Apical Hypertrophic Cardiomyopathy with Relative Left Ventricular Hypertrophy

History: A 63 year old healthy man was seen in consultation for chest pain and an abnormal electrocardiogram (EKG).

Number 15-05: Endomyocardial fibrosis associated with apical hypertrophic cardiomyopathy.

History: An asymptomatic 42 year-old male is submitted for a CMR study after an echo scan showing asymmetric hypertrophy involving the apical segment of the left ventricle. A noticeable highly echogenic signal is described at the endocardial border of the thickened apical region.

Number 15-04: Metastatic renal cell carcinoma presenting as ST-segment elevation

History: 49-year-old gentleman diagnosed with T3aN0M1 metastatic renal cell carcinoma in September 2010, underwent a right-sided nephrectomy the same month. He presented to our emergency department with complaints of constant chest pain, which waxes and wanes in intensity and sharp in characteristic.

Number 15-03: Left Atrial Appendage Thrombus by CMR

History: A 70 year-old male had presented approximately 6 months prior to another hospital with fatigue, weakness, chest pain and dyspnea. At that time, left heart catheterization showed non-obstructive coronary artery disease and elevated left ventricular end-diastolic pressures with a restrictive filling pattern.

Number 15-02: Aneurysmal dilatation of aortic homograft in the Right Ventricular Outflow tract following Ross procedure

History: A 15-year-old boy presented with progressively worsening exertional dyspnea following balloon aortic valvotomy in infancy for congenital aortic stenosis.

Number 15-01: Early Recognition of Hypertrophic Cardiomyopathy Phenotype by CMR

History: A 16-year-old boy was found to have an abnormal ECG during his appendectomy surgery. His background was remarkable for a small muscular VSD which had undergone spontaneous closure on an echocardiogram performed two years prior.

 

NUMBER 15-00: Etiology of antrioventricular block visualized by a cardiac magnetic resonance 

 

Cases of the Week 2014

Number 14-17: Just another routine follow-up Tetralogy of Fallot MRI

History: 15 year old boy with Tetralogy of Fallot (TOF) status post a valve-sparing repair who was referred for a cardiac MRI due to pulmonary valve insufficiency.

Number 14-16: Exercise Intolerance with d-Transposition of the Great Arteries

History: A 17 year-old male with a history of d-transposition of the great arteries status post arterial switch operation at age 3 days presented with increasing exercise intolerance.

Number 14-15: New Onset of Heart Failure in a Young Female

History: A 34 year-old female with a 2-month history of shortness of breath and new onset lower extremity edema presented to the emergency department for assessment.

Number 14-14: Late Presentation of Hemitruncus - the importance of XMR for clinical decision making

History: A three year old child presents with hemitruncus. This case illustrates the importance of an XMR facility for clinical decision-making in pediatric cardiology.

Number 14-13: Massive pericardial effusion due to cardiac angiosarcoma

History: A 58 year-old man was admitted to hospital with a short history of rapidly progressive breathlessness, haemoptysis, weight loss and fatigue.

Number 14-12: The Truth Behind False Aneurysms

History: An example of a false (pseudo) aneurysm and a true aneurysm in two different patients.

Number 14-11: Cardiac carcinoid metastasis: CMR evaluation

History: A 75-year-old Caucasian female, diagnosed with intestinal carcinoid tumor presented with a syncopal episode.

Number 14-10: Can cardiac magnetic resonance imaging alter management of idiopathic recurrent pleural effusions?

History: A 77-year-old man presented with a 2-week history of low-grade fever and dyspnea. Chest X-ray revealed large pleural effusions on the right side.

Number 14-09: Right Coronary Artery Encasement: A Sign For Detection Of Cardiac Lymphoma

History: A 77-year-old immuno-competent man was referred to our emergency room for onset of dyspnea, orthopnea and paroxysmal nocturnal dyspnea.

Number 14-08: Cardiovascular Magnetic Resonance with Pharmacological Induced Stress to Evaluate the Hemodynamic Response of a Previously Dilated Aortic Coarctation.

History: A 16 year old male previously dilated from congenital post-ductal aortic coarctation (AoCo) through balloon angioplasty at age of 1 year-old, was referred to cardiovascular imaging to rule out any possible complications derived from high-performance and continuous physical activity as a professional soccer player.

Number 14-07: Large Left Ventricular Aneurysm Before and After Surgical Intervention

History: A 70 year old man with hepatitis B, solitary kidney and remote coronary artery bypass grafting from 17 years prior presented with an inferior myocardial infarction.

Number 14-06: Infarct or imposter

History: A 62 year-old Caucasian man presented to the Cardiology Clinic for a routine perioperative evaluation prior to juxtarenal abdominal aortic aneurysm repair.

Number 14-05: Isolated Left Subclavian Artery from the Main Pulmonary Artery

History: A 3 year old girl was evaluated in clinic with a history of a previously diagnosed right aortic arch and a patent ductus arteriosus.

Number 14-04: Double chambered right ventricle or apical muscular VSD

History: A 22 year old female was seen for a routine follow up of her apical muscular ventricular septal defect (VSD).

Number 14-03: A case of an Inferior Sinus Venosus Atrial Septal Defect diagnosed utilizing multimodality imaging

History: An asymptomatic 3 year old was evaluated for a murmur. Physical examination was significant for a widely split second heart sound with an ejection systolic murmur in the left upper sternal border.

Number 14-02: Cardiac Aspergilloma Recognized by Cardiac Magnetic Resonance Imaging

History: Cardiac aspergilloma is a very rare entity. The diagnosis is usually made by direct observation of the fungal mass during surgery, biopsy, or pathology. We report the CMR findings in a patient with cardiac aspergilloma.

Number 14-01: Adenosine Stress Perfusion Imaging of a Systemic Right Ventricle post-Senning Repair

History: A 44 year old male status-post repair of dextro-transposition of the great arteries presented with atypical chest pain in the context of hypertension and hypercholesterolaemia.

 

Cases of the Week 2013

Number 13-16: Comprehensive Evaluation of a Quadricuspid Aortic Valve by CMR

History: A 33-year-old man was suspected of having a regurgitant quadricuspid aortic valve on the basis of transthoracic echocardiography following the incidental discovery of a diastolic murmur.

Number 13-15: Acute MI in Cardiac Amyloidosis- an example of muti-disease capability of CMR

History: A 70-year male presented with gradual deterioration, breathlessness, and peripheral oedema as well as bilateral pleural effusions. He had previous CABGx4(LIMA LAD, VG to OM, Diagonal and RCA).

Number 13-14: Times they are [a] changin

History: A 23 year-old morbidly obese female presented with dyspnea on exertion. Shw was born with Down Syndrome, double outlet right ventricle, complete atrioventricular septal defect and pulmonary stenosis and underwent surgical correction at age 5. She also has a reported history of myocarditis at age 19 with resultant systolic dysfunction (EF 35-40%).

Number 13-13: Quadricuspid pulmonary valve

History: Clinical History: A 40 year-old male with no significant past medical history was referred for a chest CT due to the discovery of an enlarged pulmonary artery on routine chest x-ray.

Number 13-12: Takotsubo Cardiomyopathy Triggered by Myocardial Infarction in a Patient with Apical Hypertrophic Cardiomyopathy

History: This case report describes a case of co-incidental coronary disease, Takotsubo cardiomyopathy and hypertrophic cardiomyopathy, where cardiac magnetic resonance imaging (MRI) was crucial in establishing the diagnoses.

Number 13-11: Sawtooth Cardiomyopathy

History: 19yo asymptomatic male with an abnormal left ventricular finding and ectopy.

Number 13-10: Pediatric Lymphoblastic Lymphoma Presenting as a Cardiac Mass

History: A six year old girl was referred to pediatric cardiology for evaluation of a heart murmur.

Number 13-09: Mitro-aortic valvular fibrosa aneurysm

History: A fifteen years old girl with known bicuspid aortic valve was admitted with ineffective endocarditis due to Strept. Agalactiae and treated with antibiotic therapy.

Number 13-08: Isolated Right Ventricular Infarction Without Evidence of Occlusive Coronary Artery Disease

History: A 53 year-old man with no significant past medical history presented to our hospital reporting severe substernal chest pressure with associated diaphoresis that woke him up from sleep. A standard 12-lead electrocardiogram (figure 1) showed marked ST-segment elevation in leads V1, V2, and V3 and in the inferior leads II, III, and aVF, with ST depression in leads I, L, with T wave inversion in V5 and V6.

Number 13-07: An important tool before a tetralogy of Fallot reoperation

History: Progressive aortic root dilatation after repair of tetralogy of Fallot is a rare but recognized complication.The cardiovascular magnetic resonance in this case report represented a key tool for the surgical approach before a tetralogy of Fallot reoperation.

Number 13-06: Twisted atrioventricular connection in a fifteen-year-old boy with complete transposition of the great arteries who had arterial switch operation during infancy

History: An asymptomatic fifteen-year-old boy with dextrocardia and complete transposition of the great arteries (CTGA) who had arterial switch operation and closure of ventricular septal defect (VSD) during infancy.

Number 13-05: Partially anomalous pulmonary venous connection to the superior and inferior vena cavae

History: A previously healthy 18-year-old woman presented to an outside medical facility with fever and left scapular pain and was found to have an elevated D-dimer.

Number 13-04: Pericardial Agenesis

History: A 52 year old asymptomatic male affected by hypertension and without other remarkable past medical history presented to the outpatients clinic for check-up.

Number 13-03: Complicated isolated RV infarction – a diagnostic dilemma

History: 74 year old gentleman was discharged after an uneventful recovery following four vessel coronary artery bypass grafting, which was done for worsening angina pectoris and triple vessel disease.

Number 13-02: Pericystic fibrosis of a cardiac hydatid cyst

History: A 60-year-old man, originally from Sardinia, with diabetes and hypertension presented with sporadic, nonspecific precordial discomfort of short duration.

Number 13-01: Calcified aneurysm of Left ventricular apex in Apical Cardiomyopathy

History: A 65 year old, non-diabetic, normotensive and obese female complained of exertional angina of four years’ duration. She had a transient ischemic attack 15 days ago. Physical examination was unremarkable.

 

Cases of the Week 2012

Number 12-12: ‘Looking outside the box’

History: 59 yo female two months post abdominal hysterectomy, bilateral salpingo-oophorectomy for a high grade endometrial leimyosarcoma.

Number 12-11: Post Pericardiectomy for Constriction – Late Complication

History: A 61 year old gentleman presented with worsening breathlessness for 2 years. He had a past history of COPD and idiopathic pericardial constriction which had been treated many years earlier by pericardial stripping through a median sternotomy.

Number 12-10: Complex Congenitally Corrected TGA

History: We present a case of a 27 year old Native American male with a past medical history of complex congenitally corrected transposition of great arteries (CCTGA) with associated double outlet right ventricle (DORV), dextrocardia, subpulmonary stenosis, subpulmonary VSD and PDA.

Number 12-09: A Pseudo-“Alfieri” Aortic Valve Masquerading as Severe Aortic Stenosis

History: 69 year-old male with history of endovascular abdominal aortic aneurysm repair, COPD, and metastatic lung cancer status post resection on radiation therapy was referred to a cardiothoracic surgeon for consideration of aortic valve replacement (AVR) after a routine transthoracic echocardiography (TTE) at an outside facility revealed evidence of severe aortic stenosis (AS) with a peak gradient of 105 mmHg and aortic valve area (AVA) of 0.78 cm2.

Number 12-08: A severe ductal aneurysm in a neonate

History: A four week old male infant was noted to be dysmorphic including hypertelorism, bilateral inguinal herniae, umbilical hernia and bilateral club feet. A right axillary mass was noted on examination; ultrasound revealed the mass to be a dilated and tortuous vessel but could not conclude definitively whether it was venous or arterial.

Number 12-07: The Study of Last Resort

History: History: A 46-year-old man with history of Hodgkin’s lymphoma treated with radiation 20 years ago. Four years previously he had undergone pleurodesis for recurrent pleural effusions. He recently developed worsening dyspnea, lower extremity edema, and ascites. At another facility, he was treated initially for interstitial lung disease with bronchodilators without improvement of his symptoms. He was referred to our center for further evaluation.

Number 12-06: Long segment severe coarctation of the aorta in a 9 year old child

History: The patient is a previously healthy 9 year old child who presented to her primary care doctor with complaints of her feet turning white.

Number 12-05: Angiosarcoma presenting as a large right atrial mass

History: Patient presenting with constitutional symptoms and right atrial mass. Several differential diagnosis and CMR helped to point the correct diagnosis and plan treatment

Number 12-04: Heterotaxy and Tetralogy of Fallot

History: 27 year-old male with the history of heterotaxy syndrome, Tetralogy of Fallot with pulmonary atresia, and right aortic arch.

Number 12-03: Branch pulmonary artery flow curves in repaired Tetralogy of Fallot

History: A 51 year old man was referred for a CMR study. He had repair of Tetralogy of Fallot in childhood.

Number 12-02: Echo and CMR in Acromegalic Cardiomyopathy

History: A 49 year-old male presented with a 10-day history of worsening shortness of breath, paroxysmal nocturnal dyspnea and orthopnea

Number 12-01: Ruptured Left Ventricular Aneurysm

History: 68 year old female, smoker, with a history of hyperlipidemia, and type 2 diabetes mellitus. In 2007 she suffered from a myocardial infarction with incomplete revascularization.

 

Cases of the Week 2011

Number 11-24: Myocardial fatty focus in a patient with tuberous sclerosis

History: a 18 year old male with tuberous sclerosis presents for cardiac MR after an abnormal echogenic foci was identified on echocardiogram.

Number 11-23: Left Atrial Sarcoma

History: 53yo male with dyspnea and left atrial prolapsing sarcoma.

Number 11-22: Ebstein Anomaly in an Asymptomatic Air Force Professional

History: A 28 year old woman with history of Wolf-Parkinson-White syndrome status-post ablation of a right posterolateral bypass tract in four years earlier who was referred to us for evaluation of an abnormal transthoracic echocardiogram.

Number 11-21: Utility of Cardiac MRI in Carcinoid Heart Disease

History: A 65 year old patient presented with symptoms of worsening right heart failure. Transthoracic echocardiography showed right heart dilatation and severe tricuspid regurgitation with grossly abnormal, thickened and retracted tricuspid valve leaflets.

Number 11-20: Not Just Another Apical HCM

History: 63 year old male patient initially presented to the outpatient clinic with fatigue and progressive shortness of breath.

Number 11-19: Giant Left Ventricular Aneurysm

History: 69-year-old male with a history of previous myocardial infarction developed increasing exertional dyspnoea and angina four years after initial presentation. CMR demonstrated a left ventricular aneurysm with thrombus.

Number 11-18: CMR advancing towards the new reference standard in cardiac sarcoidosis

History: A 43-year old man with no remarkable past medical history presented with progressive dyspnea and peripheral edema. ECG showed frequent polymorphic ventricular ectopic beats Echocardiogram showed LV systolic dysfunction.

Number 11-17: Myocardial Contusion

History: Myocardial contusion is a ubiquitous cause of hospitalization. The most common etiologies are auto-pedestrian accident, CPR, fall from heights>20’, and motor vehicle accidents.The majority of patients will have a troponin leak and may have EKG changes. Since the right ventricle is the most anterior portion of the heart it is commonly traumatized.

Number 11-15: Mitral valve prolapse-widening views onto the myocardium by cardiovascular magnetic resonance

History: We describe two cases with known and previously documented mitral valve (MV)prolapse on transthoracic echocardiography.

Number 11-14: Anterior Mitral Valve Cleft in the Presence of a Primum ASD

History: Anterior Mitral Valve Cleft in the Presence of a Primum ASD.

Number 11-13: Fibro-fatty replacement and other abnormalities in suspected ARVC.

History: A 38 year-old man without symptoms. His father was diagnosed with right ventricular arrythmogenic cardiomyopathy after heart transplant for ventricular arrhythmias and dilated cardiomyopathy.

Number 11-12: Oral Iron Supplementation: A Curious Contraindication to Cardiovascular Magnetic Resonance

History: 72 yo female with susceptibility artifact from oral iron ingestion.

Number 11-11: Chest pain in a young patient

History: An 18-year-old African American male was admitted to our Emergency Department after developing sudden and severe chest pain.

 
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