Section XI Cardiac Radiology

Figure 1
225. You are shown a transverse MIP image from a cardiac CT (Figure 1). What type
of atrial septal defect is shown?
A. Sinus venosus
A defect is present superior and posterior in the interatrial septum and has associated
partial anomalous pulmonary venous connection on the right.
B. Septum secundum
C. Septum primum
D. Coronary sinus
Figure 2 Figure 3
226. You are shown PA and lateral chest radiographs (Figures 2 and 3) of a 70-year-old
man. What is the MOST LIKELY diagnosis?
A. Constrictive pericarditis
B. Calcified mitral annulus
C. Aortic valvular stenosis
Dense calcification is present in the anatomic location of the aortic valve. When
calcification of the aortic valve is visible on chest radiograph, it typically indicates the
presence of clinically significant aortic stenosis.
D. Ascending aortic aneurysm

Figure 4
227. You are shown an axial T1-weighted image of the great vessels (Figure 4). What is
the MOST LIKELY diagnosis?
A. Takayasu arteritis
Axial T1-weighted MR shows abnormal thickening of the ascending aorta and the
pulmonary artery, a finding seen in patients with Takayasu arteritis.
B. Aortic coarctation
C. Aortic aneurysm
D. Kawasaki disease
Figure 5
228. A steady-state free precession image in the three-chamber plane from a cardiac
MRI is shown in Figure 5. What structure is indicated by the black arrowhead?
A. Anterior cusp of the mitral valve
The structure denoted in the image is the mitral valve. This is apparent as it is located
between the left atrium and the thick-walled left ventricle. The anterior cusp of the mitral
valve is interposed between the left atrioventricular orifice and the left ventricular outflow
tract. Knowledge of the appearance of this valve and its relationship to the left ventricular
outflow tract is important in the assessment of asymmetric septal hypertrophic
cardiomyopathy. In this condition, the hypertrophied basal left ventricular septum results
in narrowing of the LV outflow tract, and can result in systolic anterior motion of the
anterior mitral valve cusp due to the Bernoulli principle, and further LV outflow
obstruction.
B. Posterior cusp of the mitral valve
C. Anterior cusp of the tricuspid valve
D. Posterior cusp of the aortic valve

Figure 6 Figure 7
Figure 8 Figure 9
229. The images shown are from a cardiac MRI performed on an 18-year-old woman
presenting with heart failure. Figures 6 and 7 are vertical long axis (two-chamber)
steady-state free precession images obtained at end-diastole and end-systole,
respectively. Figures 8 and 9 are short axis, steady-state free precession images
obtained at end-diastole and end-systole, respectively. What is the MOST
LIKELY diagnosis?
A. Myocardial noncompaction
Myocardial noncompaction is a rare disorder characterized by the failure of the
myocardium to undergo appropriate compaction during embryogenesis. This compaction
typically occurs during the fifth through eighth embryologic weeks, where the developing
myocardium transitions from a loosely organized collection of myocardial fibers into a
discrete muscular chamber. Failure of this mechanism results in a left ventricle
comprised, in whole or in part, of noncompacted myocardial fibers, typically involving
the inferior and lateral walls. This can result in heart failure, dysrhythmias, and
thromboembolic disease. Imaging, either with MRI or echocardiography, reveals a ratio
of noncompacted myocardium to normal myocardium of at least 2:1 in affected areas.
B. Hypertrophic cardiomyopathy
C. Constrictive pericarditis
D. Restrictive cardiomyopathy

Figure 10
230. A 26-year-old man presents with chest pain, dyspnea, and ventricular dysrhythmia.
A four-chamber, delayed, postcontrast, phase-sensitive inversion recovery MR
image (Figure 10) was obtained. What is the MOST LIKELY diagnosis?
A. Hypertrophic cardiomyopathy
B. Sarcoidosis
Sarcoidosis is a multisystem disorder characterized by non-caseating granuloma
deposition. Cardiac involvement is noted in approximately 5% of affected patients who
typically present with heart block or other dysrhythmia. MRI can be a useful tool for
diagnosis in patients with sarcoidosis and dysrhythmia. Granuloma deposition in the
myocardium in the acute setting demonstrates increased T2 signal intensity and delayed
myocardial enhancement. CT scan of this patient (not shown) demonstrated bulky
mediastinal adenopathy and pulmonary nodules. The patient was subsequently found to
have elevated ACE levels and granulomas were found on lymph node biopsy.
C. Myocardial infarction
D. Arrhythmogenic right ventricular dysplasia
Figure 11
231. You are shown an axial contrast-enhanced CT image of the heart (Figure 11).
What abnormality is depicted by the arrow?
A. Myocardial infarction
There is an irregular, curvilinear calcification of the left ventricular apex and
interventricular septum typical of dystrophic calcification of a prior myocardial infarction.
B. False aneurysm
C. Pericardial calcification
D. Mediastinal fat necrosis

232. Concerning obstructive hypertrophic cardiomyopathy, which one of the following
is TRUE?
A. Asymmetric thickening of the interventricular septum causes aortic valvular
stenosis.
B. Systolic anterior motion of the anterior mitral leaflet contributes
to obstruction.
While a variable finding, systolic anterior motion (SAM) of the anterior mitral
valve leaflet often contributes to left ventricular outflow obstruction with the
leaflet sometimes touching the interventricular septum.
C. It is a sporadic and not an inherited disease.
D. Cardiomegaly is a common feature on chest
radiograph.
233. Which one of the following arteries typically supplies the sinoatrial node?
A. Right coronary artery
The SA nodal branch arises from the proximal RCA in approximately 65% of the
population coursing posteriorly toward the region of the SA node.
B. Proximal left anterior descending artery
C. Proximal circumflex artery
D. Posterior descending artery
234. What is the MOST common neoplasm to arise from the cardiac valves?
A. Fibroelastoma
Papillary fibroelastoma is a collection of avascular fronds of dense connective tissue lined
by endothelium. Fibroelastomas account for approximately 10% of all primary cardiac
tumors, with about 90% of them arising at valvular surfaces.
B. Elastofibroma
C. Carcinoid
D. Myxoma
235. What is the MOST common malignant cardiac neoplasm in adults?
A. Metastasis
Cardiac metastases are far more common than primary cardiac neoplasms.
B. Myxoma
C. Lymphoma
D. Rhabdomyosarcoma

236. Regarding the management of heart rate in cardiac CT, which one of the following
is TRUE?
A. Beta-blockers can be administered to patients
with asthma.
B. The optimal heart rate is less than 70 beats per minute.
Numerous studies have demonstrated that heart rates below 70 BPM drastically reduce
image degradation caused by cardiac motion.
C. Atrial fibrillation is a contraindication to beta-blockers.
D. Verapamil is not a useful beta-blocker alternative.
237. Which of the following is the MOST common cause of cyanotic congenital heart
disease?
A. Ventricular septal defect
B. Truncus arteriosus
C. Patent ductus arteriosus
D. Tetralogy of Fallot
Tetralogy of Fallot is the most common cyanotic heart disease presenting during the first
month of life.
238. Concerning acute aortic intramural hematoma, which of the following is TRUE?
A. Conservative treatment is indicated regardless of the location within the aorta.
B. Penetrating atheromatous ulcers are a common cause.
Penetrating atheromatous ulcer is a major cause of intramural hematoma.
C. The ascending aorta is most commonly involved.
D. It is best identified with contrast-enhanced multidetector CT.
239. The two major factors that influence the in-plane spatial resolution in a CT
scanner are which of the following?
A. kVp and mA
B. Focal spot and acquisition field of view
The focal spot size will determine geometric blurring, and the acquisition FOV will
determine the effective sampling pitch of the projection data at the isocenter. These two
components will have the major impact on the spatial resolution that can be reconstructed
by the computer.
C. Scan time and acquisition pitch
D. Beam hardening and scatter

240. In patients with mitral valve stenosis, what is the MOST LIKELY cause of right
atrial enlargement?
A. Tricuspid valve prolapse
B. Tricuspid valve stenosis
C. Pulmonary valve stenosis
D. Tricuspid valve regurgitation
In patients with mitral stenosis, chronic pulmonary hypertension leads to elevation of
pulmonary arterial and right ventricular pressures. If severe, this will result in right
ventricular failure and dilatation which typically causes tricuspid regurgitation.
241. Regarding congenital heart disease, which of the following congenital defects is
MOST common?
A. Ventricular septal defect
B. Atrial septal defect
C. Tetralogy of Fallot
D. Bicuspid aortic valve
Bicuspid aortic valve is the most common congenital heart defect and occurs at a rate of
50-200 per 10,000 live births.
242. Regarding aortic pseudocoarctation, which of the following statements is TRUE?
A. Pseudocoarctation begins proximal to the origin of the left
subclavian artery.
B. Significant pressure gradient across the stenosis is characteristic.
C. Poststenotic aneurysmal dilation may progress over time.
Areas of aneurysmal dilation may occur distal to areas of narrowing in pseudocoarctation.
These may become progressively dilated, and should be followed.
D. Patients are symptomatic and typically present with chest pain.
243. Polysplenia is characterized by which one of the following?
A. Bilateral atrial appendages with triangular morphology and wide ostia
B. More severe and complex cardiac anomalies than asplenia
C. An association with azygous continuation of the inferior vena cava
The most common cardiovascular anomaly associated with polysplenia is azygous
continuation of the inferior vena cava.
D. Bilateral eparterial mainstem bronchi

244. Regarding congenital absence of the pericardium, which one of the following is
TRUE?
A. Complete absence is more common than partial absence.
B. Partial absence occurs more commonly on the left.
In patients with partial absence of the pericardium, the a left-sided defect is more common
than a right-sided defect.
C. Pulmonary arterial stenosis is the most common complication.
D. The left ventricle is the most commonly entrapped chamber.
245. Which one of the following is characteristic of cardiac tamponade?
A. Decreased diastolic filling pressures
B. Dilatation of the vena cavae
As a result of increased diastolic filling pressures, the vena cavae become dilated.
C. Dilatation of the coronary sinus
D. Left ventricular dilatation
246. What is the MOST consistent feature of Ebstein anomaly on chest radiography?
A. Aortic enlargement
B. Pulmonary trunk enlargement
C. Left atrial enlargement
D. Right atrial enlargement
The underlying malformation in Ebstein anomaly is the downward displacement of the
posterior and septal leaflets of the tricuspid valve into the right ventricle. Severe tricuspid
regurgitation results in massive dilatation of the right heart. On chest radiograph, the left
atrium is normal in size, the aorta is generally small, and the pulmonary trunk is generally
not seen.