Classic imaging signs of congenital cardiovascular abnormalities

Supracardiac type of total anomalous pulmonary venous connection: Diagnosis and demonstration by multidetector CT angiography

Pulmonary venous developmental anomalies have historically been evaluated using echocardiography and catheter-based angiography. In recent years, however, multidetector CT angiography (MDCTA) and MR angiography have become increasingly important tools for detailed characterization of these anomalies. This case report provides an in-depth review of the radiologic findings in a 15-year-old patient diagnosed with the supracardiac type of Total Anomalous Pulmonary Venous Connection (TAPVC). The report emphasizes the imaging features that were instrumental in the diagnosis and underscores the crucial role of advanced imaging techniques in the management of this serious congenital heart defect.

Pulmonary Hypertension in Chronic Lung Diseases: What Role Do Radiologists Play?

Pulmonary hypertension (PH) is a pathophysiological disorder, defined by a mean pulmonary arterial pressure (mPAP) > 20 mmHg at rest, as assessed by right heart catheterization (RHC). PH is not a specific disease, as it may be observed in multiple clinical conditions and may complicate a variety of thoracic diseases. Conditions associated with the risk of developing PH are categorized into five different groups, according to similar clinical presentations, pathological findings, hemodynamic characteristics, and treatment strategy. Most chronic lung diseases that may be complicated by PH belong to group 3 (interstitial lung diseases, chronic obstructive pulmonary disease, combined pulmonary fibrosis, and emphysema) and are associated with the lowest overall survival among all groups. However, some of the chronic pulmonary diseases may develop PH with unclear/multifactorial mechanisms and are included in group 5 PH (sarcoidosis, pulmonary Langerhans' cell histiocytosis, and neurofibromatosis type 1). This paper focuses on PH associated with chronic lung diseases, in which radiological imaging-particularly computed tomography (CT)-plays a crucial role in diagnosis and classification. Radiologists should become familiar with the hemodynamical, physiological, and radiological aspects of PH and chronic lung diseases in patients at risk of developing PH, whose prognosis and treatment depend on the underlying disease.

Total Anomalous Pulmonary Venous Return

Supplemental material is available for this article.

A percutaneous treatment strategy of an adult patient with a bicuspid aortic valve, coarctation of the aorta, and an exceptionally large aneurysm of a collateral artery: Case report and literature overview

Coarctation of the aorta (CoA) is a congenital heart defect that is associated with a bicuspid aortic valve (BAV), ascending aorta dilatation, intracerebral aneurysms, and premature atherosclerotic disease. The first presentation during late adulthood is rare and is frequently driven by late sequelae. Hypertrophic collateral arteries can develop aneurysms which are at risk for spontaneous rupture, however, treatment recommendations for these aneurysms are scarce. Here, we describe the clinical course and percutaneous treatment strategy of a patient with a late diagnosis of a pin-point CoA, a BAV with moderate regurgitation, and an exceptionally large aneurysm of a collateral artery. A 59-year-old woman was diagnosed with Streptococcus bovis endocarditis of a BAV with moderate aortic valve regurgitation and small vegetation (<5 mm) on the non-coronary cusp. Work-up revealed hypertension and adenocarcinoma in situ of the ascending colon, considered the bacteremia porte d'entrée, for which a curative hemicolectomy was performed. Echocardiography showed a narrowing of the aorta distal from the origin of the left subclavian artery with the antegrade diastolic flow with a pathognomonic "sawtooth" pattern and an estimated pressure gradient of >70 mmHg. Computed tomography angiography (CTA) showed a network of well-developed collateral arteries and a levoatriocardinal vein. One of the collateral arteries arising from the left subclavian artery revealed an exceptionally large aneurysmatic dilation (29 × 24 × 24 mm). The invasive assessment confirmed a hemodynamically significant CoA. Treatment involved balloon dilatation and placement of a covered stent at the site of the pin-point CoA and a percutaneous coronary intervention (PCI) of the stenosis in the left anterior descending artery. No residual gradient over the CoA was observed. Antihypertensive drugs could be discontinued, and CTA performed 4 months later showed regression and thrombosis of the numerous collaterals and, importantly, thrombosis of the large aneurysm. This case illustrates the late diagnosis of CoA with associated congenital heart defects and late sequelae including hypertension, BAV endocarditis, coronary artery disease, and aneurysm formation of the extensive collateral network. The patient underwent pharmacological and percutaneous treatment, ultimately resulting in the alleviation of the CoA, normalization of the blood pressure, reduction of collateral flow, and thrombosis of the large aneurysm of the collateral artery.

Artificial Intelligence in Pediatric Cardiology: A Scoping Review

The evolution of AI and data science has aided in mechanizing several aspects of medical care requiring critical thinking: diagnosis, risk stratification, and management, thus mitigating the burden of physicians and reducing the likelihood of human error. AI modalities have expanded feet to the specialty of pediatric cardiology as well. We conducted a scoping review searching the Scopus, Embase, and PubMed databases covering the recent literature between 2002-2022. We found that the use of neural networks and machine learning has significantly improved the diagnostic value of cardiac magnetic resonance imaging, echocardiograms, computer tomography scans, and electrocardiographs, thus augmenting the clinicians' diagnostic accuracy of pediatric heart diseases. The use of AI-based prediction algorithms in pediatric cardiac surgeries improves postoperative outcomes and prognosis to a great extent. Risk stratification and the prediction of treatment outcomes are feasible using the key clinical findings of each CHD with appropriate computational algorithms. Notably, AI can revolutionize prenatal prediction as well as the diagnosis of CHD using the EMR (electronic medical records) data on maternal risk factors. The use of AI in the diagnostics, risk stratification, and management of CHD in the near future is a promising possibility with current advancements in machine learning and neural networks. However, the challenges posed by the dearth of appropriate algorithms and their nascent nature, limited physician training, fear of over-mechanization, and apprehension of missing the 'human touch' limit the acceptability. Still, AI proposes to aid the clinician tomorrow with precision cardiology, paving a way for extremely efficient human-error-free health care.

Le Cœur en Sabot: shape associations with adverse events in repaired tetralogy of Fallot

BACKGROUND

Maladaptive remodelling mechanisms occur in patients with repaired tetralogy of Fallot (rToF) resulting in a cycle of metabolic and structural changes. Biventricular shape analysis may indicate mechanisms associated with adverse events independent of pulmonary regurgitant volume index (PRVI). We aimed to determine novel remodelling patterns associated with adverse events in patients with rToF using shape and function analysis.

METHODS

Biventricular shape and function were studied in 192 patients with rToF (median time from TOF repair to baseline evaluation 13.5 years). Linear discriminant analysis (LDA) and principal component analysis (PCA) were used to identify shape differences between patients with and without adverse events. Adverse events included death, arrhythmias, and cardiac arrest with median follow-up of 10 years.

RESULTS

LDA and PCA showed that shape characteristics pertaining to adverse events included a more circular left ventricle (LV) (decreased eccentricity), dilated (increased sphericity) LV base, increased right ventricular (RV) apical sphericity, and decreased RV basal sphericity. Multivariate LDA showed that the optimal discriminative model included only RV apical ejection fraction and one PCA mode associated with a more circular and dilated LV base (AUC = 0.77). PRVI did not add value, and shape changes associated with increased PRVI were not predictive of adverse outcomes.

CONCLUSION

Pathological remodelling patterns in patients with rToF are significantly associated with adverse events, independent of PRVI. Mechanisms related to incident events include LV basal dilation with a reduced RV apical ejection fraction.

Coarctation of the Aorta: Delay in Diagnosis and Referral Basis from Infancy to Adulthood

OBJECTIVES

To assess the role of neonatal pulse oximetry screening and other bases of referral for patients of all ages with aortic coarctation referred to a tertiary care medical center.

STUDY DESIGN

Medical records were reviewed for 200 consecutive patients diagnosed and treated for CoA in either 2006-2011 or 2015-2019, before and after mandated pulse oximetry screening, respectively.

RESULTS

In both groups, ∼50% of patients were diagnosed within the first 5 days. Diagnosis by fetal echocardiography was more frequent in the 2015-2019 group (30.5% vs 20.5%; P < .03); obstruction often developed only as the ductus arteriosus closed. In each group, ∼25% of patients were diagnosed at age >1 year and 7% had an incidental diagnosis. Pulse oximetry screening was documented as abnormal in only 8 of 47 patients and was not performed in those with a fetal diagnosis. Evaluation of a murmur was the second most frequent basis for referral. Moderate to severe left ventricular dysfunction occurred mainly in infants in the first month, with a similar frequency in the 2 groups; these patients often had tachypnea or poor weight gain. Decreased femoral pulses or systemic hypertension were infrequently documented by referring physicians. Hypertension typically was ascribed to a renal or essential basis. Exercise symptoms occurred mainly in patients age >10 years.

CONCLUSIONS

Although fetal echocardiography and neonatal pulse oximetry contribute to the diagnosis of coarctation, physical examination has an important complementary role. Evaluation of peripheral pulses on initial and early follow-up neonatal examinations, along with consideration of coarctation in any patient with hypertension, are needed to improve timely detection.

CT of transposition of the great arteries in adults

Transposition of the great arteries is one of the most common cyanotic congenital heart diseases. It is characterised by an abnormal connection of the ventricles and great arteries, so that the aorta arises from the morphological right ventricle and the pulmonary artery arises from the morphological left ventricle. Historically, as with many congenital heart diseases, patients with transposition of the great arteries had poor life expectancy. Advances in surgical and medical management have resulted in patients surviving into adulthood. As these patients are living longer, they will be encountered more frequently in practice. The purpose of this article is to familiarise the general radiologist with the expected postoperative anatomy, and the appearance on cross-sectional imaging as well as the long-term complications in this group of patients.

Pulmonary Vein: Embryology, Anatomy, Function and Disease

Four pulmonary veins come from respective lung lobes drain oxygen-rich blood back to the left atrium. Failure of incorporation with the left atrium can lead to a condition, called Cor triatriatum sinister, that the left atrium is separated into two chambers by an abortive fibrous tissue. The venous system of lung and whole body communicate with each other in the earlier time and they will be disconnected in the following developmental process. Total or partial anomalous pulmonary venous connection refers to that there is/are some degree of the communication exists after birth, which can occur in different sites. In the veterinary field, retrospective studies and several case reports have been published to describe these rare congenital cardiovascular diseases in several species. More cases are need for better understanding their clinical manifestation, treatment options and outcomes.

Pediatric rib pathologies: clinicoimaging scenarios and approach to diagnosis

Pathologies involving the ribs are diverse in nature, including entities specific to the pediatric population as well as shared pathologies with adults. These can be either localized within or adjacent to the rib, but may also cause rib alteration as a component of a systemic process. To better understand these disorders, we discuss several common rib pathologies in the context of their clinical presentation and pertinent imaging findings. In addition, we review the imaging modalities that may be used to evaluate the ribs. Encompassing both the clinical and imaging aspects of pediatric rib pathologies, this review aims to increase pediatric and musculoskeletal radiologists' awareness of the spectrum of disease and how to leverage a pattern-based approach.

Multimodality Imaging of Transposition of the Great Arteries

Transposition of the great arteries (TGA) is a congenital conotruncal abnormality characterized by discordant connections between the ventricles and great arteries, with the aorta originating from the right ventricle (RV), and the pulmonary artery (PA) originating from the left ventricle (LV). The two main types of TGA are complete transposition or dextro-transposition of the great arteries (D-TGA), commonly referred to as d-loop, and congenitally corrected transposition (CCTGA), commonly referred to as l-loop or L-TGA. In D-TGA, the connections between the ventricles and atria are concordant, whereas in CCTGA they are discordant, with the left atrium connected to the RV, and the right atrium connected to the LV. D-TGA manifests during the neonatal period and can be surgically managed by atrial switch operation (AtrSO), arterial switch operation (ASO), Rastelli procedure, or Nikaidoh procedure. Arrhythmia, systemic ventricular dysfunction, baffle stenosis, and baffle leak are the common complications of AtrSO, whereas supravalvular pulmonary or branch PA stenosis, neoaortic dilatation, and coronary artery narrowing are the common complications of ASO. CCTGA may manifest late in life, even in adulthood. Surgeries for associated lesions such as tricuspid regurgitation, subpulmonic stenosis, and ventricular septal defect may be performed. A double-switch operation that includes both the atrial and arterial switch operations constitutes anatomic correction for CCTGA. Imaging plays an important role in the evaluation of TGA, both before and after surgery, for helping define the anatomy, quantify hemodynamics, and evaluate complications. Transthoracic echocardiography is the first-line imaging modality for presurgical planning in children with TGA. MRI provides comprehensive morphologic and functional information, particularly in adults after surgery. CT is performed when MRI is contraindicated or expected to generate artifacts. The authors review the imaging appearances of TGA, with a focus on pre- and postsurgical imaging. Online supplemental material is available for this article. ^©RSNA, 2021.

Utility of three-dimensional printing in preoperative planning for children with anomalous pulmonary venous connection: a single center experience

Background

This study sought to assess the application of three-dimensional (3D) printing in preoperative planning for anomalous pulmonary venous connection (APVC).

Methods

From November 2017 to January 2019, 17 children diagnosed with APVC were enrolled in this study (total APVC supracardiac type in 10 children, intracardiac type in 2 children, infracardiac type in 1 child, mixed type in 1 child, partial APVC in 3 children). The age was ranged 2 days to 20 months old (median age 1 m 5 d). Before operation, 3D-printed patient-specific heart models were created based on a cardiac computed tomography (CCT) data set with photosensitive resin materials in stereolithography (SLA) technology. These 3D models were used for presurgical decision making and navigation in the operation room. After surgery, the roles of the 3D models were evaluated with questionnaires.

Results

All 17 children successfully underwent surgeries. 3D heart models accurately demonstrated the malformations, which were all confirmed consistent with surgery findings. The final surgery programs were in accord with presurgical planning. Modeling took 0.5-2 h, with an average of 0.9±0.4 h. Printing took 2-5 h, with an average of 3.4±1.2 h. All these children were discharged without adverse events. During follow-up, 2 children suspect of anastomotic stenosis were performed cardiac CT, and 3D printed heart models were created. Results confirmed there was no obvious anastomotic stenosis. Questionnaire results indicate that 3D printing is a promising technique in clinical practice.

Conclusions

3D printing is beneficial for preoperative planning and post-surgery follow-up in APVC.

Imaging of Pulmonary Hypertension: Pictorial Essay

Pulmonary hypertension (PH) is an end result of a diverse array of complex clinical conditions that invoke hemodynamic and pathophysiological changes in the pulmonary vasculature. Many patients' symptoms begin with dyspnea on exertion for which screening tests such as chest roentgenograms and more definitive noninvasive tests such as CT scans are ordered initially. It is imperative that clinicians are cognizant of subtle clues on these imaging modalities that alert them to the possibility of PH. These clues may serve as a stepping stone towards more advanced noninvasive (echocardiogram) and invasive (right heart catheterization) testing. On the CT scan, the signs are classified into mediastinal and lung parenchymal abnormalities. In addition to suspecting the diagnosis of PH, this paper provides a pictorial essay to guide health care professionals in identifying the etiology of PH. This paper also provides concrete definitions, wherever possible, of what constitutes abnormalities in PH, such as dilated pulmonary arteries, pruning of vessels, and increased thickness of free wall of the right ventricle. The sensitivities and specificities of each sign are enumerated. The common radiographic and clinical features of many different etiologies of PH are tabulated for the convenience of the readers. Some newer imaging modalities such as dual-energy CT of the chest that hold promise for the future are also described.

Coarctation of Aorta in Children

Coarctation of aorta (CoA) is a discrete narrowing in aorta causing obstruction to the flow of blood. It accounts for 6–8% of all congenital heart diseases. With advances in fetal echocardiography rate of prenatal diagnosis of coarctation of aorta has improved but it still remains a challenging diagnosis to make prenatally. Transthoracic echocardiography is mainstay of making initial diagnosis and routine follow-up. Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) are great advanced imaging tools for two-dimensional and three-dimensional imaging of aortic arch in complex cases. Based on type of coarctation, size of patient, severity of lesion, and associated abnormalities various management options like surgical treatment, transcatheter balloon angioplasty and transcatheter stent implantation are available. There is significant improvement in long-term survival from pre-surgical era to post-surgical era. But, among the postsurgical era patients, the long-term survival has not significantly changed between older and contemporary cohort. Patients with coarctation of aorta need lifelong follow-up event after successful initial intervention.

Pictorial review of the pulmonary vasculature: from arteries to veins

Pathology of the pulmonary vasculature involves an impressive array of both congenital and acquired conditions. While some of these disorders are benign, disruption of the pulmonary vasculature is often incompatible with life, making these conditions critical to identify on imaging. Many reviews of pulmonary vascular pathology approach the pulmonary arteries, pulmonary veins and bronchial arteries as individual topics. The goal of this review is to provide an integrated overview of the high-yield features of all major disorders of the pulmonary vasculature. This approach provides a more cohesive and comprehensive conceptualisation of respiratory pathology. In this review, we present both the salient clinical and imaging features of congenital and acquired disorders of the pulmonary vasculature, to assist the radiologist in identifying pathology and forming a robust differential diagnosis tailored to the presenting patient. TEACHING POINTS: • Abnormalities of the pulmonary vasculature are both congenital and acquired. • Pathology of a single pulmonary vascular territory often affects the entire pulmonary vasculature. • Anomalous pulmonary venous flow is named as a function of its location and severity. • Bronchial arteries often undergo dilatation secondary to cardio-respiratory pathology.

Imaging of anomalous pulmonary venous connections by multidetector CT angiography using third-generation dual source CT scanner

Abnormal embryological development of the pulmonary veins can manifest as either partial or total anomalous drainage into the systemic venous circulation. Echocardiography does not provide adequate information in all cases as the optimal visualization of anomalous structures is limited by the availability of acoustic window; also it is highly operator dependent. However, multidetector CT angiography, with its multiplanar reformatting and volume rendering techniques, offers precise information about the three-dimensional anatomy and spatial relationships of the cardiovascular structures. With advent of dual source CT scanners and use of advanced dose reduction techniques, this information can be obtained in a short time with minimal radiation dose. In this pictorial essay, we present the multidetector CT imaging findings of the spectrum of total and partial anomalous pulmonary venous connections, using a third-generation dual source CT scanner.

Comprehensive Cross-sectional Imaging of the Pulmonary Veins

The pulmonary veins carry oxygenated blood from the lungs to the heart, but their importance to the radiologist extends far beyond this seemingly straightforward function. The anatomy of the pulmonary veins is variable among patients, with several noteworthy variant and anomalous patterns, including supernumerary pulmonary veins, a common ostium, anomalous pulmonary venous return, and levoatriocardinal veins. Differences in pulmonary vein anatomy and the presence of variant or anomalous anatomy can be of critical importance, especially for preoperative planning of pulmonary and cardiac surgery. The enhancement or lack of enhancement of the pulmonary veins can be a clue to clinically important disease, and the relationship of masses to the pulmonary veins can herald cardiac invasion. The pulmonary veins are also an integral part of thoracic interventions, including lung transplantation, pneumonectomy, and radiofrequency ablation for atrial fibrillation. This fact creates a requirement for radiologists to have knowledge of the pre- and postoperative imaging appearances of the pulmonary veins. Many of these procedures are associated with important potential complications involving the pulmonary veins, for which diagnostic imaging plays a critical role. A thorough knowledge of the pulmonary veins and a proper radiologic approach to their evaluation is critical for the busy radiologist who must incorporate the pulmonary veins into a routine "search pattern" at computed tomography (CT) and magnetic resonance imaging. This article is a comprehensive CT-based imaging review of the pulmonary veins, including their embryology, anatomy (typical and anomalous), surgical implications, pulmonary vein thrombosis, pulmonary vein stenosis, pulmonary vein pseudostenosis, and the relationship of tumors to the pulmonary veins. Online supplemental material is available for this article. ^©RSNA, 2017.

Emergency Computed Tomography Angiogram of the Chest, Abdomen, and Pelvis

In the setting of blunt trauma, the rapid assessment of internal injuries is essential to prevent potentially fatal outcomes. Computed tomography is a useful diagnostic tool for both screening and diagnosis. In addition to trauma, acute chest syndromes often warrant emergent computed tomographic angiography, looking for etiologies such as aortic aneurysms or complications of aortic aneurysms, or both, pulmonary emboli, as well as other acute vascular process like aortic dissection and Takayasu aortitis. With continued improvements in diagnostic imaging, computed tomographic angiography of the chest, abdominal and pelvis proves to be an effective modality to image the aorta and other major vascular structures.

Multimodality imaging of aortic coarctation: From the fetus to the adolescent

Aortic coarctation is a local narrowing of the aortic lumen, which is located at the level of the isthmus in 95% of patients. Aortic coarctation accounts for 5 to 8% of all congenital heart diseases. It may have an acute presentation in the form of heart failure in the neonate or may be discovered incidentally in adult because of severe treatment-resistant hypertension. Ultrasound may reveal the presence of aortic coarctation during the antenatal period. In this situation, associated abnormalities should be investigated (including karyotype), because they influence prognosis and indicates whether or not the birth should occur in a center with pediatric cardiology expertise. Postnatally, ultrasound and chest radiography are the basic imaging work-up. Computed tomography is often the second line imaging investigation in infants and young children for whom magnetic resonance imaging fails to confirm the diagnosis. Magnetic resonance imaging with cardiac synchronization is the preferred imaging tool in the post-treatment period. Aortic coarctation may be treated surgically or by endovascular techniques. Potential complications should be searched for using ultrasound and magnetic resonance imaging.

Pediatric Chest MR Imaging: Sedation, Techniques, and Extracardiac Vessels

Thoracic MR imaging in the pediatric population provides unique challenges requiring tailored protocols and a practical approach to pediatric issues, such as patient motion and sedation. Concern regarding the use of ionizing radiation in the pediatric population has continued to advance the use of MR imaging despite these challenges. This article provides a practical approach to thoracic vascular MR imaging with special attention paid to pediatric-specific issues such as sedation. Thoracic vascular anatomy and pathology are discussed with an emphasis on protocols that can facilitate accurate diagnosis.

Radiologic Considerations in Heterotaxy: The Need for Detailed Anatomic Evaluation

So-called "heterotaxy" is a laterality defect characterized by isomerism of the thoracic organs and random arrangement of the abdominal organs. These findings go beyond anatomic curiosity and have functional implications. It is, thus, of the utmost importance to be able to properly identify these findings. Radiologic studies can be invaluable in determining anomalies in the central nervous, pulmonary, cardiovascular, gastrointestinal, genitourinary, and immunologic systems in patients with isomerism. Here, we review findings associated with isomerism and their importance in the setting of isomerism with the aim of ensuring that radiologists effectively describe findings in these patients and that cardiologists understand the wide variety of congenital malformations that may be present.

Ebstein Anomaly: An Overview for Nursing

Ebstein anomaly is a rare congenital heart defect. Many nurses have probably never encountered this anomaly, with very few able to accurately depict the pathological anatomy of the condition. As technology further develops, providers are better equipped to recognize and manage Ebstein anomaly. There are important considerations for nurses when caring for an individual with Ebstein anomaly. The aim of this article is to give an overview of the condition exploring the pathophysiology, how patients typically present, and how to effectively care for a patient with Ebstein anomaly regarding medical and surgical courses of treatment. It is important for nurses to have a resource to reference on Ebstein anomaly, and the majority of current literature is solely based for medical providers. Furthermore, Ebstein patients may be seen on a variety of units in the hospital beyond cardiology (i.e., pregnant patient with a diagnosis of Ebstein anomaly).

Congenital bronchopulmonary vascular malformations, "sequestration" and beyond

Congenital bronchopulmonary vascular malformations (BPVMs) include a broad spectrum of disorders that involve abnormalities in the form of disruptions of normal communication and/or presence of abnormal communication between one or more of the three main systems of the lung, namely, the airways, arteries, and veins. The establishment of abnormal communications by means of small openings or anastomoses is termed as malinosculation. The aim of this pictorial essay is to illustrate the imaging appearances of the various types of pulmonary malinosculation.

Severe Left Atrioventricular Valve Regurgitation Due to Discontinuity between the Leaflets of the Aortic and Left Atrioventricular Valves in a Patient with Endocardial Cushion Defect: A Rare Case Report

Discontinuities between the leaflets of the aortic and left atrioventricular valves are uncommon congenital malformations. The anomaly may be discovered during surgery without preoperative diagnosis. It represents a spectrum of anomalies that result from interruption of the normal development of the endocardial cushions during the fetal life. We describe a rare case of Down syndrome with transient complete atrioventricular block and discontinuity between the leaflets of the aortic and left atrioventricular valves without intervening fibrous band, leading to separation and detachment between them. It caused severe eccentric jet of regurgitation originated from left ventricular outflow tract and base of anterior leaflet of left atrioventricular valve into the left atrium. He underwent cardiopulmonary bypass, and the defect between left atrioventricular valve and aortic annuli was sewn. Permanent epicardial pacing was inserted during cardiac surgery. To the best of our knowledge, such a case has not been previously reported in the literature.

Imaging findings in Down syndrome

Down syndrome, or trisomy 21, is the most common chromosomal anomaly and is characterized by intellectual disability and a typical facies. People with Down syndrome can have abnormalities of multiple organ systems. Cardiac and respiratory system involvement is the most common cause of morbidity and mortality, although every organ system can be affected. Patients may present prenatally with findings on screening sonography. If the diagnosis is not made prenatally, it is apparent at birth because of the characteristic facial features and musculoskeletal findings. Children with Down syndrome present to the radiology department at various ages depending on the severity of the specific finding. The purpose of this paper is to review the most common antenatal and postnatal imaging findings of Down syndrome as they manifest throughout the body.

Imaging evaluation of hemoptysis in children

Hemoptysis is an uncommon but distressing symptom in children. It poses a diagnostic challenge as it is difficult to elicit a clear history and perform thorough physical examination in a child. The cause of hemoptysis in children can vary with the child's age. It can range from infection, milk protein allergy and congenital heart disease in early childhood, to vasculitis, bronchial tumor and bronchiectasis in older children. Acute lower respiratory tract infections are the most common cause of pediatric hemoptysis. The objective of imaging is to identify the source of bleeding, underlying primary cause, and serve as a roadmap for invasive procedures. Hemoptysis originates primarily from the bronchial arteries. The imaging modalities available for the diagnostic evaluation of hemoptysis include chest radiography, multi-detector computed tomography (MDCT), magnetic resonance imaging (MRI) and catheter angiography. Chest radiography is the initial screening tool. It can help in lateralizing the bleeding with high degree of accuracy and can detect several parenchymal and pleural abnormalities. However, it may be normal in up to 30% cases. MDCT is a rapid, non-invasive multiplanar imaging modality. It aids in evaluation of hemoptysis by depiction of underlying disease, assessment of consequences of hemorrhage and provides panoramic view of the thoracic vasculature. The various structures which need to be assessed carefully include the pulmonary parenchyma, tracheobronchial tree, pulmonary arteries, bronchial arteries and non-bronchial systemic arteries. Since the use of MDCT entails radiation exposure, optimal low dose protocols should be used so as to keep radiation dose as low as reasonably achievable. MRI and catheter angiography have limited application.

Routine Chest X-ray: Still Valuable for the Assessment of Left Ventricular Size and Function in the Era of Super Machines?

Objectives:

The development of technologically advanced, expensive techniques has progressively reduced the value of chest X-ray in clinical practice for the assessment of left ventricular (LV) dilatation and dysfunction. Although controversial data are reported on the role of this widely available technique in cardiac assessment, it is known that the cardio-thoracic ratio is predictive of risk of progression in the NYHA Class, hospitalization, and outcome in patients with LV dysfunction. This study aimed to evaluate the reliability of the transverse diameter of heart shadow [TDH] by chest X-ray for detecting LV dilatation and dysfunction as compared to Magnetic Resonance Imaging (MRI) performed for different clinical reasons.

Materials and Methods:

In 101 patients, TDH was measured in digital chest X-ray and LV volumes and ejection fraction (EF) by MRI, both exams performed within 2 days.

Results:

A direct correlation between TDH and end-diastolic volumes (r = .75, P<0.0001) was reported. TDH cut-off values of 14.5 mm in females identified LV end-diastolic volumes >150 mL (sensitivity: 82%, specificity: 69%); in males a cut-off value of 15.5 mm identified LV end-diastolic volumes >210 mL (sensitivity: 84%; specificity: 72%). A negative relation was found between TDH and LVEF (r = -.54, P<0.0001). The above cut-off values of TDH discriminated patients with LV systolic dysfunction – LVEF <35% (sensitivity and specificity: 67% and 57% in females; 76% and 59% in males, respectively).

Conclusions:

Chest X-ray may still be considered a reliable technique in predicting LV dilatation by the accurate measurement of TDH as compared to cardiac MRI. Technologically advanced, expensive, and less available imaging techniques should be performed on the basis of sound clinical requests.

Integration of imaging signs into RadLex

Imaging signs form an important part of the language of radiology, but are not represented in established lexicons. We sought to incorporate imaging signs into RSNA's RadLex® ontology of radiology terms. Names of imaging signs and their definitions were culled from books, journal articles, dictionaries, and biomedical web sites. Imaging signs were added into RadLex as subclasses of the term "imaging sign," which was defined in RadLex as a subclass of "imaging observation." A total of 743 unique imaging signs were added to RadLex with their 392 synonyms to yield a total of 1,135 new terms. All included definitions and related RadLex terms, including imaging modality, anatomy, and disorder, when appropriate. The information will allow RadLex users to identify imaging signs by modality (e.g., ultrasound signs) and to find all signs related to specific pathophysiology. The addition of imaging signs to RadLex augments its use to index the radiology literature, create and interpret clinical radiology reports, and retrieve relevant cases and images.

Prevalence of associated cardiovascular abnormalities in 500 patients with aortic coarctation referred for cardiovascular magnetic resonance imaging to a tertiary center

Coarctation of the aorta (CoA) is a common congenital defect whose overall incidence is 5-8% of all congenital cardiac anomalies. Associated cardiac anomalies have been well described in previous studies examining specific subgroups of CoA patients, particularly infants and necropsy specimens. The majority of studies, conducted from the 1970s to 1980s, excluded older children, adolescents, and adults. Given the advent of improved surgical and interventional techniques, many CoA patients are surviving into adulthood. This study examined a population of 500 CoA patients in the authors' cardiovascular magnetic resonance imaging (MRI) database involving a population of CoA survivors 5-79 years of age. This was to give a new perspective on the prevalence of associated cardiovascular abnormalities including the bicuspid aortic valve, arch hypoplasia, intracardiac shunts, and subaortic stenosis. These associated abnormalities are less prevalent than in previous studies, reflecting a milder spectrum of CoA. Cardiovascular MRI with its multiplanar imaging capabilities and lack of ionizing radiation is safe and suitable for evaluation and follow-up assessment of CoA patients. Evaluation of CoA by MRI should not be confined to the arch, but should include the heart and mediastinal vessels to assess for the presence and severity of any expected or unexpected associated anomalies.

Uncorrected pink tetralogy of Fallot in an adult patient: incidental CT findings

Tetralogy of Fallot (TOF), one of the most common congenital heart diseases, has four major components: right ventricular hypertrophy, overriding aorta, membranous ventricular septal defect, and right ventricular outflow tract obstruction. If not already present at birth, cyanosis develops in the first year of life. Survival of the patient depends on the degree of pulmonary obstruction and the pulmonary blood supply. Patients rarely survive after the fourth decade of life. Limitation of blood to the lungs combined with ventricular septal defect results in supply of oxygen-poor blood to the body, causing cyanosis (blue coloration) in the patient. If the pulmonary stenosis is mild and ventricular septal defect is in balance, however, the noncyanotic patient is referred as having "pink tetralogy of Fallot."

Imaging appearances of congenital thoracic lesions presenting in adulthood

Many congenital lesions of the thorax are detected for the first time in adulthood when they can simulate a wide range of pathologies, including infection and neoplasia. They can be broadly classified into tracheobronchial, parenchymal, vascular, and combined parenchymal/vascular abnormalities. An awareness of their typical imaging features enables a confident diagnosis and helps direct appropriate patient management.

Radiologic signs in thoracic imaging: case-based review and self-assessment module

OBJECTIVE

Chest imaging remains one of the most complicated sub-specialties of diagnostic radiology. The successful interpretation of thoracic imaging studies requires the recognition and understanding of the radiologic signs that are characteristic of many complex disease processes.

CONCLUSION

The educational objectives for this case-based self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of important thoracic radiologic signs that are useful in establishing the diagnosis of particular diseases of the chest.