Chapter A8: Atlas of Noninvasive Imaging

A 48-year-old man with new-onset substernal chest pain. Echocardiography shows evidence of acute anterior myocardial infarction involving the interventricular septum and apex secondary to an occlusion of the left anterior descending coronary artery seen from the parasternal long axis view (left) and the apical four-chamber view (right). LV, left ventricle; RV, right ventricle. (See Videos A8-1 and A8-2.)

A 55-year-old man with exertional chest discomfort and dyspnea. He exercised for 12 min on a standard Bruce protocol, experiencing typical chest pain and ST-segment depression in V₂–V₅. End-systolic frame of a stress echocardiogram shows apical four-chamber view at rest (left) and after exercise (right). After exercise, there is a clear regional wall motion abnormality in the distal septum through the apex, consistent with a stenosis in the left anterior descending artery distribution (arrows). LV, left ventricle. (See Videos A8-3 and A8-4.)

Exercise single-photon emission computed tomography (SPECT) myocardial perfusion technetium-99m (^99mTc) sestamibi scan in a 54-year-old male with a history of coronary artery disease and a prior coronary stent. The stress images (left and middle) show a large defect involving the apex, all apical segments, mid-inferior, mid-inferoseptum, and mid-anteroseptum (arrowheads), which is completely reversible at rest (right), reflecting a large area of exercise-induced myocardial ischemia throughout the left anterior descending coronary territory. The bull’s eye displays on the right panel depict the semiquantitative extent of ischemia (light yellow and blue areas represent the extent and severity of ischemia).

Coronary computed tomography angiography (CTA). Curved multiplanar reformations demonstrating coronary artery disease severity, defined as normal (no plaque or stenosis), mild (<40%), moderate (40–69%), and severe (>70%) luminal narrowing. By guidelines for CTA reporting, alternative classification provides for stenosis grading as normal, minimal (1–24%), mild (25–49%), moderate (50–69%), severe (70–99%), and occluded (100%). (From GL Raff et al: SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography. J Cardiovasc Comput Tomogr 3:122, 2009; with permission.)

^99mTechnetium Pyrophosphate (^99mTc PYP) scans. The study on the left corresponds to a 76-year-old male presenting with heart failure and atrial fibrillation, and left ventricular hypertrophy on a two-dimensional (2D) echocardiogram. The whole body anterior image of the ^99mTc PYP scan demonstrates normal radiotracer uptake in the axial and appendicular skeleton without evidence of retention in the heart. The study on the right corresponds to an 82-year-old male presenting with heart failure and atrial fibrillation, low voltage ECG, and left ventricular hypertrophy on a 2D echocardiogram. The whole body anterior image of the ^99mTc PYP scan demonstrates normal radiotracer uptake in the axial and appendicular skeleton with evidence of significant abnormal retention in the heart (uptake equal to uptake in the sternum), consistent with cardiac amyloidosis.

Cardiac magnetic resonance (CMR) stress myocardial perfusion images in a 60-year-old patient with atypical chest pain. Cine movie short-axis image (left upper panel) shows normal left ventricle size and global and regional function at rest. During vasodilator stress, there is marked reduction of lateral wall perfusion (white arrow, right upper panel) as well as a mild defect in the septal wall. This region is confirmed to be viable by matching late gadolinium enhancement imaging (left lower panel), which demonstrated no evidence of infarction in the lateral wall. These findings are consistent with a severe coronary stenosis in the left circumflex artery. On angiography performed subsequently, there is a tight lesion in the left circumflex artery (red arrow, right lower panel). (See Videos A8-5 and A8-6.)

A case of microvascular dysfunction in a 51-year-old male with a history of coronary artery disease, type 1 diabetes mellitus, diabetic nephropathy status postrenal transplantation, and recent ST elevation myocardial infarction followed by stenting of the proximal left anterior descending (LAD) coronary artery, presenting with atypical angina and dyspnea. The stress positron emission tomography (PET) myocardial perfusion images (left upper panel) show a medium-sized perfuion defect involving the inferior and inferoseptal walls (arrowheads), which is completely reversible at rest (lower row). This is consistent with a moderate stress-induced ischemia in the right coronary artery (RCA) territory. The right upper panel summarizes the myocardial blood flow (in mL/min per g of tissue) at peak stress and at rest, and the coronary flow reserve (ratio of stress/rest myocardial blood flow). The global coronary flow reserve is severely reduced (i.e., ≤1.5). The ECG gated myocardial (left lower panel) perfusion images show severe global hypokinesis during stress with a marked decrease in the left ventricular ejection fraction (LVEF) and transient enlargement of the left ventricular end systolic volume (ESV). The coronary angiographic images (right lower panel) demonstrate only moderate stenosis in the RCA (arrows). LCX, left circumflex. (See Video A8-7.)

Coronary computed tomography angiography (CTA) obtained on a 35-year-old female presenting to an outpatient clinic with a history of unexplained syncope and a 6-month complaint of intermittent, atypical chest pain occurring primarily during rest. Physical examination is normal. An exercise treadmill test is performed demonstrating good exercise capacity with no exertional chest pain or ischemic ECG changes. For persistent, unexplained symptoms, coronary CTA is obtained. A. Three-dimensional cardiac CT image reconstruction demonstrating anomalous right coronary artery (RCA) origin from the left coronary cusp with an acute angle takeoff (arrow) and an intraarterial course between the aorta (Ao) and main pulmonary artery (PA). B, C. Contrast-enhanced CTA in two-dimensional axial (B) and coronal oblique views (C) demonstrating proximal RCA intraarterial course between the Ao and main PA.

Coronary computed tomography angiography (CTA) obtained from a 13-year-old boy with a history of Kawasaki disease who presented with limited exercise capacity and occasional, atypical chest pain. A, B. Three-dimensional cardiac CT image reconstruction demonstrating large three-vessel coronary artery diffuse aneurysms with proximal, nondominant left circumflex (LCX) artery occlusion. C. Two-dimensional contrast-enhanced coronary CTA demonstrating mid-RCA and mid-LAD thrombi that are nonocclusive layered and near circumferential thrombi, respectively, and proximal LCX occlusion. Ao, aorta; CT, computed tomography; LAD, left anterior descending; RCA, right coronary artery.

A case of viability assessment in a patient with inferior myocardial infarction. The cine movie in the upper panel shows an area of inferior akinesis (yellow arrows). Magnetic resonance image demonstrates transmural contrast enhancement of the inferior wall (red arrows) and the right ventricle (white arrows), which is consistent with infarction. Imaging the heart 10–15 min after injection of gadolinium allows for the accumulation of gadolinium in infarcted tissue (red arrows), which identifies nonviable infarcted myocardium as bright. Viability assessment, as in this case, can provide guidance for any benefits of invasive coronary intervention. In this case, the inferior wall is nonviable. Apart from the inferior wall infarction (red arrows), there is extensive right ventricular infarction (white arrows). (See Video A8-8.)

Multimodality imaging of vascular inflammation. Left panel: Transaxial (A), sagittal (B), and coronal (C) computed tomography angiographic (CTA) images in a patient with aortitis, demonstrating marked concentric thickening (maximal wall thickness of 10 mm) of the ascending aortic wall to the level of the brachiocephalic origin, along with involvement of the ostia of the right and left coronary arteries, and a small pericardial effusion. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) images show intense metabolic activity corresponding to the areas of aortic wall thickening seen on CTA and consistent with active inflammation in a patient with aortitis. Right panel: 6 months after prednosine therapy, the CTA images demonstrate a mild reduction in aortic wall thickness (arrows, to 8 mm), with an interval resolution of pericardial effusion. However, the FDG PET images show a marked reduction in metabolic activity in the ascending aorta, consistent with reduced inflammation in response to steroid therapy. (Reproduced with permission from V Veeranna V et al. J Nucl Cardiol 23:590, 2016.)

A 70-year-old patient with known cardiac murmur and progressive shortness of breath and a recent episode of syncope. Echocardiography shows severe calcific aortic stenosis. A heavily calcified aortic valve (arrow) is shown in the parasternal long-axis views (top panels) and short-axis view (bottom left). Doppler interrogation shows a peak transaortic velocity of 5.2 m/s consistent with a peak instantaneous gradient of 109 mmHg and a mean gradient of 66 mmHg, and a corresponding aortic valve area of <0.6 cm² (lower right). Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle. (See Videos A8-9, A8-10, and A8-11.)

A 66-year-old patient with multiple myeloma and progressive shortness of breath. Echocardiography shows features typical of cardiac amyloidosis, including thickened myocardium with a “sparkly” appearance and left atrial enlargement. Systolic function is mildly reduced, and diastolic function is severely reduced. LA, left atrium; LV, left ventricle; RV, right ventricle. (See Videos A8-12 and A8-13.)

Magnetic resonance image with contrast enhancement in magnitude (A), and phase-sensitive reconstructed images (B) 5–10 min after injection of gadolinium in a patient with transthyretin (TTR)-mediated amyloidosis. The phase-sensitive reconstruction (B) enhances the region of abnormal collection of gadolinium, making gadolinium enhancement in the ventricle (red arrows) and the atrium (green arrows) more prominent. Amyloidosis causes accumulation of abnormal interstitial proteins, which results in late gadolinium enhancement in a diffuse subendocardial pattern (red arrows). Blood pool signal is characteristically dark (asterisk) owing to sequestration of gadolinium into other organs.

A 34-year-old woman with known cardiac murmur and syncope with a family history of sudden cardiac death. Echocardiogram shows classic findings of hypertrophic cardiomyopathy, including marked left ventricular wall thickness, particularly in the interventricular septum, notable in the parasternal long-axis view (upper left) and apical view (upper right). Note reverse septal curvature in the apical view (upper left). There is substantial flow acceleration through the left ventricular outflow tract (lower left) with evidence of a late peaking systolic gradient (arrow, lower right) caused by outflow tract obstruction. Ao, aorta; IVS, interventricular septum; LA, left atrium; LV, left ventricle; PW, posterior wall; RV, right ventricle. (See Videos A8-14, A8-15, and A8-16.)

Magnetic resonance image with contrast enhancement in a patient with hypertrophic cardiomyopathy. Note the marked thickened anteroseptal wall (black arrows, left panel) consistent with asymmetric septal hypertrophy. After contrast is injected, this region demonstrated heterogeneous foci of contrast enhancement (right panel, red arrows) consistent with myocardial fibrosis due to myofibril disarray in this condition. This typical enhancement pattern of hypertrophic cardiomyopathy is found in the areas of maximum wall thickness, typically at the anteroseptum as in this case. (See Video A8-17.)

A 54-year-old patient with cardiac sarcoidosis who presents with syncope while driving. The rest ECG (left upper panel) is normal. The MRI images (right upper panel) demonstrate focal areas of subepicardial gadolinium enhancement involving the interventricular septum (arrows). The rest myocardial perfusion and metabolism fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography scan (lower panel) demonstrates relatively normal myocardial perfusion. However, the FDG images demonstrated a focal area of intense glucose uptake in the interventricular septum, corresponding to the area of late enhancement on MRI. This is consistent with focal active myocardial inflammation sarcoidosis. LV, left ventricle; RV, right ventricle.

A 46-year-old patient with malignant melanoma who presents with acute shortness of breath. Echocardiogram reveals a large pericardial effusion (arrow, upper left) with evidence of cardiac tamponade. M-mode echocardiography (upper right) shows evidence of collapse of the right ventricular free wall during diastole (arrow). Doppler echocardiography (lower panel) shows evidence of respiratory flow variation, consistent with a pulsus paradoxus. LA, left atrium; LV, left ventricle; RV, right ventricle. (See Video A8-18.)

Diffuse pericardial thickening (left; red arrows) and circumferential effusion (right; white arrows) associated with effusive-constrictive pericarditis. Effusive-constrictive pericarditis is a progressive condition that has varying degrees of hemodynamic consequences due initially to the collection of pericardial fluid and ultimately to pericardial constriction. It is typically suspected in cases where pericardiocentesis fails to normalize intracardiac pressures. In this example, pericardial fluid analysis resulted in a sterile exudate of leukocytes and erythrocytes. LV, left ventricle; RV, right ventricle.

A 48-year-old woman with severe idiopathic pulmonary hypertension. Echocardiography reveals evidence of marked right ventricular volume and pressure overload as evidenced by enlarged right ventricle (upper left and right), small left ventricle (upper left and upper right), and flattening of the interventricular septum (D-shaped septum) in systole and diastole (upper right). Tricuspid regurgitation velocity, which reflects the pressure gradient between the right ventricle and the left ventricle, is markedly elevated at 5 m/s, consistent with a right ventricle to right atrial pressure gradient of 100 mmHg, which is consistent with systemic right-sided pressures. LA, left atrium; LV, left ventricle; RV, right ventricle. (See Videos A8-19 and A8-20.)

Metastatic cardiac tumor diagnosed by cardiac magnetic resonance (MR) in a patient who presented with chest pain and inferior ST elevation. Left heart catheterization was normal. Cardiac MR demonstrates extensive myocardial edema (A, white arrows) with marked reduction in first perfusion (B) and accumulation of gadolinium within the cardiac mass 10–15 min after injection of gadolinium (C, red arrows). D. Positron emission tomography scan showed increased fluorodeoxyglucose uptake in a lung mass as well as in the cardiac mass, consistent with cardiac metastasis. Biopsy of the lung mass revealed adenosquamous carcinoma of the lung. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. (See Videos A8-21 and A8-22.)

Fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in a 52-year-old male with a prior aortic valve replacement who presented with fever and was found to have Haemophilus parainfluenzae bacteremia. The multiplanar reformatted fused PET/CT images demonstrate intense FDG uptake surrounding the aortic valve prosthesis (arrowheads), compatible with a paravalvular abscess. The patient was found to have purulent fluid around the valve during surgery, and he underwent an aortic valve replacement. Ao, aorta; AV, aortic valve; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Cardiac computed tomography (CT) pulmonary vein mapping in a 62-year-old male with symptomatic, paroxysmal atrial fibrillation referred for cardiac CT for pulmonary vein mapping prior to planned pulmonary vein isolation. Three-dimensional image reconstruction, demonstrating (A) normal pulmonary vein anatomy and (B) common variant with presence of separate right middle pulmonary vein (RMPV) ostium. LLPV, left lower pulmonary vein; LUPV, left upper pulmonary vein; RLPV, right lower pulmonary vein; RUPV, right upper pulmonary vein.