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Imaging of Cardiac Transplantation Complications

¹ Department of Radiology (E3/311 CSC), University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792-3252.

View larger version (75K): [in a new window]   Figure 1a.  Orthotopic cardiac transplantation. (a) Diagram shows intraoperative appearance of native and donor hearts before surgical connection of the atria, pulmonary artery, and aorta. (b) Illustration shows the four anastomoses in the completed orthotopic cardiac transplantation. AO = aorta, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle, SVC = superior vena cava.

View larger version (115K): [in a new window]   Figure 1b.  Orthotopic cardiac transplantation. (a) Diagram shows intraoperative appearance of native and donor hearts before surgical connection of the atria, pulmonary artery, and aorta. (b) Illustration shows the four anastomoses in the completed orthotopic cardiac transplantation. AO = aorta, LA = left atrium, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle, SVC = superior vena cava.

View larger version (137K): [in a new window]   Figure 2.  Orthotopic cardiac transplantation in a 64-year-old woman with ischemic cardiomyopathy. AP recumbent chest radiograph obtained immediately after transplantation shows an enlarged cardiac silhouette, pulmonary edema, and bibasilar atelectasis. Bilateral thoracostomy tubes, endotracheal tube, esophageal temperature probe, left subclavian venous catheter, pulmonary artery catheter, and sternal wires are also seen.

View larger version (91K): [in a new window]   Figure 3a.  Mediastinal lipomatosis in a 61-year-old man who underwent orthotopic cardiac transplantation for ischemic cardiomyopathy 3 years before. (a) AP upright chest radiograph shows a wide mediastinum, an appearance consistent with mediastinal adenopathy or mediastinal lipomatosis. (b) Nonenhanced chest CT scan shows a superior redundant main pulmonary artery (arrowhead), a large space (large arrow) between the recipient superior vena cava and donor ascending aorta, and aortic anastomosis suture lines (small arrows) and helps confirm that mediastinal lipomatosis accounts for the wide mediastinum. (c) CT scan obtained inferior to b shows pulmonic anastomosis suture lines (arrows).

View larger version (115K): [in a new window]   Figure 3b.  Mediastinal lipomatosis in a 61-year-old man who underwent orthotopic cardiac transplantation for ischemic cardiomyopathy 3 years before. (a) AP upright chest radiograph shows a wide mediastinum, an appearance consistent with mediastinal adenopathy or mediastinal lipomatosis. (b) Nonenhanced chest CT scan shows a superior redundant main pulmonary artery (arrowhead), a large space (large arrow) between the recipient superior vena cava and donor ascending aorta, and aortic anastomosis suture lines (small arrows) and helps confirm that mediastinal lipomatosis accounts for the wide mediastinum. (c) CT scan obtained inferior to b shows pulmonic anastomosis suture lines (arrows).

View larger version (109K): [in a new window]   Figure 3c.  Mediastinal lipomatosis in a 61-year-old man who underwent orthotopic cardiac transplantation for ischemic cardiomyopathy 3 years before. (a) AP upright chest radiograph shows a wide mediastinum, an appearance consistent with mediastinal adenopathy or mediastinal lipomatosis. (b) Nonenhanced chest CT scan shows a superior redundant main pulmonary artery (arrowhead), a large space (large arrow) between the recipient superior vena cava and donor ascending aorta, and aortic anastomosis suture lines (small arrows) and helps confirm that mediastinal lipomatosis accounts for the wide mediastinum. (c) CT scan obtained inferior to b shows pulmonic anastomosis suture lines (arrows).

View larger version (96K): [in a new window]   Figure 4a.  Anastomotic connections in a 45-year-old man who underwent orthotopic cardiac transplantation for idiopathic cardiomyopathy. (a, b) Sequential contrast material–enhanced CT scans reveal change in caliber from the recipient to donor ascending aorta (arrow). (c) CT scan obtained inferior to b shows remnant donor superior vena cava (large arrow) posterior to the donor ascending aorta (arrowhead) and medial to the recipient superior vena cava (small arrow).

View larger version (104K): [in a new window]   Figure 4b.  Anastomotic connections in a 45-year-old man who underwent orthotopic cardiac transplantation for idiopathic cardiomyopathy. (a, b) Sequential contrast material–enhanced CT scans reveal change in caliber from the recipient to donor ascending aorta (arrow). (c) CT scan obtained inferior to b shows remnant donor superior vena cava (large arrow) posterior to the donor ascending aorta (arrowhead) and medial to the recipient superior vena cava (small arrow).

View larger version (120K): [in a new window]   Figure 4c.  Anastomotic connections in a 45-year-old man who underwent orthotopic cardiac transplantation for idiopathic cardiomyopathy. (a, b) Sequential contrast material–enhanced CT scans reveal change in caliber from the recipient to donor ascending aorta (arrow). (c) CT scan obtained inferior to b shows remnant donor superior vena cava (large arrow) posterior to the donor ascending aorta (arrowhead) and medial to the recipient superior vena cava (small arrow).

View larger version (105K): [in a new window]   Figure 5.  Heterotopic cardiac transplantation. Illustration shows the anastomoses and the relationship of the donor heart to the recipient heart. AO = aorta, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle, SVC = superior vena cava.

View larger version (118K): [in a new window]   Figure 6.  Heterotopic cardiac transplantation in a 55-year-old man with ischemic cardiomyopathy for whom orthotopic cardiac transplantation was precluded because of severe pulmonary hypertension. PA upright chest radiograph obtained 6 years after transplantation shows an enlarged cardiac silhouette, with the donor heart in the right hemothorax, lateral to the patient's native heart. Radiosynthetic patch encircles the aortic anastomosis (arrows).

View larger version (144K): [in a new window]   Figure 7a. Figures 7, 8. (7) Pulmonary A fumigatus infection in a 40-year-old man who developed dyspnea 10 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows numerous ill-defined nodular opacities in the right lung. (b) CT scan reveals multiple, fuzzy nodules in the right lung, consistent with pulmonary Aspergillus infection. Diagnosis was confirmed with bronchoalveolar lavage, and the patient recovered after a course of amphotericin. (8) Aspergillus pneumonia in a 60-year-old man who developed productive cough and dyspnea 8 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows a cavitary mass (arrows) in the right lower lobe and diffuse interstitial lung disease. (b) Thin-section CT scan shows the cavitary mass with a ground-glass "halo" (arrows) representing hemorrhage, a finding consistent with invasive Aspergillus infection. Basilar honeycombing is consistent with idiopathic pulmonary fibrosis.

View larger version (108K): [in a new window]   Figure 7b. Figures 7, 8. (7) Pulmonary A fumigatus infection in a 40-year-old man who developed dyspnea 10 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows numerous ill-defined nodular opacities in the right lung. (b) CT scan reveals multiple, fuzzy nodules in the right lung, consistent with pulmonary Aspergillus infection. Diagnosis was confirmed with bronchoalveolar lavage, and the patient recovered after a course of amphotericin. (8) Aspergillus pneumonia in a 60-year-old man who developed productive cough and dyspnea 8 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows a cavitary mass (arrows) in the right lower lobe and diffuse interstitial lung disease. (b) Thin-section CT scan shows the cavitary mass with a ground-glass "halo" (arrows) representing hemorrhage, a finding consistent with invasive Aspergillus infection. Basilar honeycombing is consistent with idiopathic pulmonary fibrosis.

View larger version (135K): [in a new window]   Figure 8a. Figures 7, 8. (7) Pulmonary A fumigatus infection in a 40-year-old man who developed dyspnea 10 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows numerous ill-defined nodular opacities in the right lung. (b) CT scan reveals multiple, fuzzy nodules in the right lung, consistent with pulmonary Aspergillus infection. Diagnosis was confirmed with bronchoalveolar lavage, and the patient recovered after a course of amphotericin. (8) Aspergillus pneumonia in a 60-year-old man who developed productive cough and dyspnea 8 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows a cavitary mass (arrows) in the right lower lobe and diffuse interstitial lung disease. (b) Thin-section CT scan shows the cavitary mass with a ground-glass "halo" (arrows) representing hemorrhage, a finding consistent with invasive Aspergillus infection. Basilar honeycombing is consistent with idiopathic pulmonary fibrosis.

View larger version (115K): [in a new window]   Figure 8b. Figures 7, 8. (7) Pulmonary A fumigatus infection in a 40-year-old man who developed dyspnea 10 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows numerous ill-defined nodular opacities in the right lung. (b) CT scan reveals multiple, fuzzy nodules in the right lung, consistent with pulmonary Aspergillus infection. Diagnosis was confirmed with bronchoalveolar lavage, and the patient recovered after a course of amphotericin. (8) Aspergillus pneumonia in a 60-year-old man who developed productive cough and dyspnea 8 months after cardiac transplantation for idiopathic cardiomyopathy. (a) PA upright chest radiograph shows a cavitary mass (arrows) in the right lower lobe and diffuse interstitial lung disease. (b) Thin-section CT scan shows the cavitary mass with a ground-glass "halo" (arrows) representing hemorrhage, a finding consistent with invasive Aspergillus infection. Basilar honeycombing is consistent with idiopathic pulmonary fibrosis.

View larger version (102K): [in a new window]   Figure 9.  Fungal pneumonia in a 46-year-old woman who developed pleuritic right-sided chest pain 3 months after cardiac transplantation for ischemic cardiomyopathy. Thin-section CT scan shows multiple 1–3-mm subpleural nodules (small arrows) and a nodule in the medial right lower lobe (large arrow), compatible with systemic spread of a rare fungal (Exophiala) infection of her toe that responded to multidrug antifungal therapy.

View larger version (112K): [in a new window]   Figure 10.  CMV pneumonia in a 57-year-old woman who developed fever and shortness of breath 10 weeks after cardiac transplantation for restrictive cardiomyopathy. Contrast-enhanced CT scan reveals a consolidated right lower lobe with air bronchograms and a small right pleural effusion. Transbronchial biopsy specimens from the right lung showed large CMV intracytoplasmic inclusion bodies.

View larger version (106K): [in a new window]   Figure 11.  Haemophilus influenzae pneumonia in a 60-year-old man who presented with productive cough, fever, and chills 8 weeks after cardiac transplantation. Nonenhanced CT scan shows bilateral pleural effusions and left lower lobe consolidation. Sputum cultures were positive for H influenzae, and the patient responded to intravenous treatment with antibiotics.

View larger version (114K): [in a new window]   Figure 12.  Pulmonary abscess in a 44-year-old man who developed increasing shortness of breath and fatigue after cardiac transplantation for familial cardiomyopathy. Nonenhanced CT scan shows a 3.5-cm mass in the right upper lobe with a central area of low attenuation consistent with necrosis and surrounding air-space disease. The patient developed gram-negative sepsis leading to multisystem organ failure and died 8 days later.

View larger version (105K): [in a new window]   Figure 13a.  Acute allograft rejection in a 62-year-old man who developed hypotension and congestive heart failure 10 weeks after cardiac transplantation for dilated cardiomyopathy. (a) AP upright chest radiograph shows an enlarged cardiac silhouette, pulmonary edema, and bilateral pleural effusions. The postoperative image also reveals sternal wires, endotracheal tube, nasogastric tube, right subclavian venous catheter, and pulmonary artery catheter in the distal right lower lobe interlobar pulmonary artery. (b) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows diffuse lymphocytic infiltration of the myocardium with patchy myocyte necrosis.

View larger version (159K): [in a new window]   Figure 13b.  Acute allograft rejection in a 62-year-old man who developed hypotension and congestive heart failure 10 weeks after cardiac transplantation for dilated cardiomyopathy. (a) AP upright chest radiograph shows an enlarged cardiac silhouette, pulmonary edema, and bilateral pleural effusions. The postoperative image also reveals sternal wires, endotracheal tube, nasogastric tube, right subclavian venous catheter, and pulmonary artery catheter in the distal right lower lobe interlobar pulmonary artery. (b) High-power photomicrograph (original magnification, x400; hematoxylin-eosin stain) shows diffuse lymphocytic infiltration of the myocardium with patchy myocyte necrosis.

View larger version (124K): [in a new window]   Figure 14a.  Lymphoproliferative disorder in a 65-year-old man who presented without symptoms after cardiac transplantation for ischemic cardiomyopathy. (a) PA upright chest radiograph reveals a lingular mass and small left pleural nodular opacity (arrow). (b) Nonenhanced CT scan reveals a left pleural-based nodule. (The patient's allergy to contrast material prevented its use.) (c) CT scan obtained inferior to b reveals a mass abutting the left atrium (arrow). (d) T1-weighted magnetic resonance image shows frank invasion of the mass into the left atrium. Findings from open lung endomyocardial biopsy were consistent with lymphoproliferative disorder. The patient died 7 months later of an arrhythmia.

View larger version (120K): [in a new window]   Figure 14b.  Lymphoproliferative disorder in a 65-year-old man who presented without symptoms after cardiac transplantation for ischemic cardiomyopathy. (a) PA upright chest radiograph reveals a lingular mass and small left pleural nodular opacity (arrow). (b) Nonenhanced CT scan reveals a left pleural-based nodule. (The patient's allergy to contrast material prevented its use.) (c) CT scan obtained inferior to b reveals a mass abutting the left atrium (arrow). (d) T1-weighted magnetic resonance image shows frank invasion of the mass into the left atrium. Findings from open lung endomyocardial biopsy were consistent with lymphoproliferative disorder. The patient died 7 months later of an arrhythmia.

View larger version (115K): [in a new window]   Figure 14c.  Lymphoproliferative disorder in a 65-year-old man who presented without symptoms after cardiac transplantation for ischemic cardiomyopathy. (a) PA upright chest radiograph reveals a lingular mass and small left pleural nodular opacity (arrow). (b) Nonenhanced CT scan reveals a left pleural-based nodule. (The patient's allergy to contrast material prevented its use.) (c) CT scan obtained inferior to b reveals a mass abutting the left atrium (arrow). (d) T1-weighted magnetic resonance image shows frank invasion of the mass into the left atrium. Findings from open lung endomyocardial biopsy were consistent with lymphoproliferative disorder. The patient died 7 months later of an arrhythmia.

View larger version (143K): [in a new window]   Figure 14d.  Lymphoproliferative disorder in a 65-year-old man who presented without symptoms after cardiac transplantation for ischemic cardiomyopathy. (a) PA upright chest radiograph reveals a lingular mass and small left pleural nodular opacity (arrow). (b) Nonenhanced CT scan reveals a left pleural-based nodule. (The patient's allergy to contrast material prevented its use.) (c) CT scan obtained inferior to b reveals a mass abutting the left atrium (arrow). (d) T1-weighted magnetic resonance image shows frank invasion of the mass into the left atrium. Findings from open lung endomyocardial biopsy were consistent with lymphoproliferative disorder. The patient died 7 months later of an arrhythmia.

View larger version (104K): [in a new window]   Figure 15a.  Lymphoma in a 64-year-old man who developed shortness of breath 13 months after cardiac transplantation. (a) PA chest radiograph shows a right paratracheal mass (arrow) and right pleural effusion. (b) Contrast-enhanced CT scan shows the large anterior mediastinal mass lateral to and abutting the aortic arch, causing extrinsic compression on the superior vena cava and left brachiocephalic vein. Analysis of right thoracentesis fluid revealed findings consistent with monoclonal large cell lymphoma. The patient developed sepsis and died 3 weeks later of a major retroperitoneal hemorrhage while receiving heparin for pulmonary embolus.

View larger version (105K): [in a new window]   Figure 15b.  Lymphoma in a 64-year-old man who developed shortness of breath 13 months after cardiac transplantation. (a) PA chest radiograph shows a right paratracheal mass (arrow) and right pleural effusion. (b) Contrast-enhanced CT scan shows the large anterior mediastinal mass lateral to and abutting the aortic arch, causing extrinsic compression on the superior vena cava and left brachiocephalic vein. Analysis of right thoracentesis fluid revealed findings consistent with monoclonal large cell lymphoma. The patient developed sepsis and died 3 weeks later of a major retroperitoneal hemorrhage while receiving heparin for pulmonary embolus.

View larger version (110K): [in a new window]   Figure 16a.  Bronchogenic carcinoma in a 65-year-old man who developed shortness of breath 3 months after cardiac transplantation for ischemic cardiomyopathy. (a) PA upright chest radiograph shows recurrent right pleural effusion, a left upper lobe mass (arrow), and peripheral interstitial disease. (b) CT scan shows air bronchograms within the left upper lobe mass, as well as low-attenuation areas throughout the lung parenchyma consistent with emphysema and superimposed interstitial disease consistent with amiodarone toxicity. Findings from transbronchial biopsy were consistent with bronchogenic carcinoma. The patient died of cardiopulmonary arrest related to metastatic bronchogenic carcinoma 1 week later.

View larger version (131K): [in a new window]   Figure 16b.  Bronchogenic carcinoma in a 65-year-old man who developed shortness of breath 3 months after cardiac transplantation for ischemic cardiomyopathy. (a) PA upright chest radiograph shows recurrent right pleural effusion, a left upper lobe mass (arrow), and peripheral interstitial disease. (b) CT scan shows air bronchograms within the left upper lobe mass, as well as low-attenuation areas throughout the lung parenchyma consistent with emphysema and superimposed interstitial disease consistent with amiodarone toxicity. Findings from transbronchial biopsy were consistent with bronchogenic carcinoma. The patient died of cardiopulmonary arrest related to metastatic bronchogenic carcinoma 1 week later.

View larger version (118K): [in a new window]   Figure 17.  Pneumothorax following endomyocardial biopsy in a 57-year-old man who developed shortness of breath after the biopsy 6 months after cardiac transplantation. AP upright chest radiograph reveals a large right pneumothorax. The patient recovered following chest tube placement and returned home 6 days later.

View larger version (106K): [in a new window]   Figure 18.  Hemothorax following endomyocardial biopsy in a 59-year-old man who developed mild shortness of breath after the biopsy. Nonenhanced CT scan shows a high-attenuation left pleural effusion consistent with hemothorax (arrow). The patient recovered without intervention.

View larger version (79K): [in a new window]   Figure 19a.  Sternal dehiscence in a 52-year-old man who sustained blunt chest trauma 17 months after cardiac transplantation. (a) CT scan shows distraction of sternal fragments. (b) CT scan obtained inferior to a shows anterior fluid collection consistent with resolving hematoma.

View larger version (109K): [in a new window]   Figure 19b.  Sternal dehiscence in a 52-year-old man who sustained blunt chest trauma 17 months after cardiac transplantation. (a) CT scan shows distraction of sternal fragments. (b) CT scan obtained inferior to a shows anterior fluid collection consistent with resolving hematoma.

View larger version (117K): [in a new window]   Figure 20a.  Pleuromediastinal cutaneous fistula in a 51-year-old man who developed coagulase-negative staphylococcal sternal wound infection 10 days after cardiac transplantation. (a) CT scan shows subcutaneous emphysema in the left chest wall. (b) Nonenhanced CT scan obtained inferior to a shows air in the sternal dehiscence and in infiltrated anterior mediastinal fat, findings consistent with infection. (c) CT scan obtained inferior to b shows more extensive pneumomediastinum and a right pneumothorax.

View larger version (105K): [in a new window]   Figure 20b.  Pleuromediastinal cutaneous fistula in a 51-year-old man who developed coagulase-negative staphylococcal sternal wound infection 10 days after cardiac transplantation. (a) CT scan shows subcutaneous emphysema in the left chest wall. (b) Nonenhanced CT scan obtained inferior to a shows air in the sternal dehiscence and in infiltrated anterior mediastinal fat, findings consistent with infection. (c) CT scan obtained inferior to b shows more extensive pneumomediastinum and a right pneumothorax.

View larger version (123K): [in a new window]   Figure 20c.  Pleuromediastinal cutaneous fistula in a 51-year-old man who developed coagulase-negative staphylococcal sternal wound infection 10 days after cardiac transplantation. (a) CT scan shows subcutaneous emphysema in the left chest wall. (b) Nonenhanced CT scan obtained inferior to a shows air in the sternal dehiscence and in infiltrated anterior mediastinal fat, findings consistent with infection. (c) CT scan obtained inferior to b shows more extensive pneumomediastinum and a right pneumothorax.

View larger version (119K): [in a new window]   Figure 21a. Figures 21, 22. (21) Mediastinal abscess in a 62-year-old man who developed a substernal fluid collection 6 weeks after cardiac transplantation. (a) Lateral chest radiograph reveals retrosternal air bubbles (arrows) and a moderate left pleural effusion. (b) Contrast-enhanced CT scan shows the anterior mediastinal loculated fluid collection with air pockets. Specimen obtained from CT-guided drainage revealed gram-positive cocci, and the patient responded to antibiotic therapy and drainage. (22) Mediastinal abscess in a 55-year-old man who developed a candidal incisional infection requiring rectus abdominis muscle flap reconstruction, recurrent débridements, and antifungal therapy. (a) Nonenhanced CT scan reveals a small retrosternal fluid collection with air bubbles (arrow) and left pleural effusion. (b) Nonenhanced CT scan obtained 6 months later shows anterior rectus abdominis muscle flap (arrow), sternal dehiscence, and residual retrosternal fluid.

View larger version (101K): [in a new window]   Figure 21b. Figures 21, 22. (21) Mediastinal abscess in a 62-year-old man who developed a substernal fluid collection 6 weeks after cardiac transplantation. (a) Lateral chest radiograph reveals retrosternal air bubbles (arrows) and a moderate left pleural effusion. (b) Contrast-enhanced CT scan shows the anterior mediastinal loculated fluid collection with air pockets. Specimen obtained from CT-guided drainage revealed gram-positive cocci, and the patient responded to antibiotic therapy and drainage. (22) Mediastinal abscess in a 55-year-old man who developed a candidal incisional infection requiring rectus abdominis muscle flap reconstruction, recurrent débridements, and antifungal therapy. (a) Nonenhanced CT scan reveals a small retrosternal fluid collection with air bubbles (arrow) and left pleural effusion. (b) Nonenhanced CT scan obtained 6 months later shows anterior rectus abdominis muscle flap (arrow), sternal dehiscence, and residual retrosternal fluid.

View larger version (93K): [in a new window]   Figure 22a. Figures 21, 22. (21) Mediastinal abscess in a 62-year-old man who developed a substernal fluid collection 6 weeks after cardiac transplantation. (a) Lateral chest radiograph reveals retrosternal air bubbles (arrows) and a moderate left pleural effusion. (b) Contrast-enhanced CT scan shows the anterior mediastinal loculated fluid collection with air pockets. Specimen obtained from CT-guided drainage revealed gram-positive cocci, and the patient responded to antibiotic therapy and drainage. (22) Mediastinal abscess in a 55-year-old man who developed a candidal incisional infection requiring rectus abdominis muscle flap reconstruction, recurrent débridements, and antifungal therapy. (a) Nonenhanced CT scan reveals a small retrosternal fluid collection with air bubbles (arrow) and left pleural effusion. (b) Nonenhanced CT scan obtained 6 months later shows anterior rectus abdominis muscle flap (arrow), sternal dehiscence, and residual retrosternal fluid.

View larger version (89K): [in a new window]   Figure 22b. Figures 21, 22. (21) Mediastinal abscess in a 62-year-old man who developed a substernal fluid collection 6 weeks after cardiac transplantation. (a) Lateral chest radiograph reveals retrosternal air bubbles (arrows) and a moderate left pleural effusion. (b) Contrast-enhanced CT scan shows the anterior mediastinal loculated fluid collection with air pockets. Specimen obtained from CT-guided drainage revealed gram-positive cocci, and the patient responded to antibiotic therapy and drainage. (22) Mediastinal abscess in a 55-year-old man who developed a candidal incisional infection requiring rectus abdominis muscle flap reconstruction, recurrent débridements, and antifungal therapy. (a) Nonenhanced CT scan reveals a small retrosternal fluid collection with air bubbles (arrow) and left pleural effusion. (b) Nonenhanced CT scan obtained 6 months later shows anterior rectus abdominis muscle flap (arrow), sternal dehiscence, and residual retrosternal fluid.

View larger version (115K): [in a new window]   Figure 23a.  Pneumomediastinum in a 63-year-old man who developed extensive subcutaneous emphysema 4 days after cardiac transplantation. (a) AP upright chest radiograph shows right anterior pneumomediastinum (arrows) and left subcutaneous emphysema. (b) CT scan shows anterior mediastinal and bilateral subcutaneous air collections. The patient underwent mediastinal chest tube placement and recovered.

View larger version (133K): [in a new window]   Figure 23b.  Pneumomediastinum in a 63-year-old man who developed extensive subcutaneous emphysema 4 days after cardiac transplantation. (a) AP upright chest radiograph shows right anterior pneumomediastinum (arrows) and left subcutaneous emphysema. (b) CT scan shows anterior mediastinal and bilateral subcutaneous air collections. The patient underwent mediastinal chest tube placement and recovered.

View larger version (89K): [in a new window]   Figure 24.  Sternal wire protrusion in a 34-year-old man that developed 17 months after cardiac transplantation. Contrast-enhanced CT scan reveals the tip of a sternal wire (arrow) protruding through the anterior skin surface (arrowheads) and right pleural effusion. The wire was surgically removed and the patient recovered.

View larger version (130K): [in a new window]   Figure 25.  Mediastinal bleeding in a 61-year-old man who developed sudden decrease in hematocrit level 1 day after cardiac transplantation. AP supine chest radiograph shows a massive right hemothorax and wide mediastinum. The patient recovered after repair of right atrial and aortic anastomosis suture line bleeding sites.

View larger version (104K): [in a new window]   Figure 26a.  Aortic dissection in a 60-year-old man who developed severe low back pain and hypertension 17 months after cardiac transplantation for ischemic cardiomyopathy. (a) Baseline PA upright chest radiograph obtained 9 months after surgery shows minimal left lower lobe atelectasis. (b) PA upright chest radiograph reveals the newly enlarged aortic arch. (c) Contrast-enhanced CT scan shows an aortic dissection involving the aortic arch and descending thoracic aorta. The intimal flap (arrows) separates the medial true channel from the lateral false channel. The patient was managed medically as he was not considered a surgical candidate and died 16 months later of disseminated Aspergillus infection.

View larger version (113K): [in a new window]   Figure 26b.  Aortic dissection in a 60-year-old man who developed severe low back pain and hypertension 17 months after cardiac transplantation for ischemic cardiomyopathy. (a) Baseline PA upright chest radiograph obtained 9 months after surgery shows minimal left lower lobe atelectasis. (b) PA upright chest radiograph reveals the newly enlarged aortic arch. (c) Contrast-enhanced CT scan shows an aortic dissection involving the aortic arch and descending thoracic aorta. The intimal flap (arrows) separates the medial true channel from the lateral false channel. The patient was managed medically as he was not considered a surgical candidate and died 16 months later of disseminated Aspergillus infection.

View larger version (106K): [in a new window]   Figure 26c.  Aortic dissection in a 60-year-old man who developed severe low back pain and hypertension 17 months after cardiac transplantation for ischemic cardiomyopathy. (a) Baseline PA upright chest radiograph obtained 9 months after surgery shows minimal left lower lobe atelectasis. (b) PA upright chest radiograph reveals the newly enlarged aortic arch. (c) Contrast-enhanced CT scan shows an aortic dissection involving the aortic arch and descending thoracic aorta. The intimal flap (arrows) separates the medial true channel from the lateral false channel. The patient was managed medically as he was not considered a surgical candidate and died 16 months later of disseminated Aspergillus infection.

View larger version (98K): [in a new window]   Figure 27a.  Pulmonary embolus in a 64-year-old man who developed shortness of breath 13 months after cardiac transplantation. (a) AP upright chest radiograph shows a relatively lucent left upper lobe, representing the Westermark sign of decreased perfusion due to pulmonary embolus. Fullness in the right paratracheal region represents lymphoma adjacent to the aorta. (b) Anterior lung perfusion scan shows relative decreased perfusion to the left upper lobe with normal ventilation in the left upper lobe, findings consistent with a high probability of pulmonary embolus. The patient was treated with heparin but died related to a major retroperitoneal hemorrhage 9 days later.

View larger version (92K): [in a new window]   Figure 27b.  Pulmonary embolus in a 64-year-old man who developed shortness of breath 13 months after cardiac transplantation. (a) AP upright chest radiograph shows a relatively lucent left upper lobe, representing the Westermark sign of decreased perfusion due to pulmonary embolus. Fullness in the right paratracheal region represents lymphoma adjacent to the aorta. (b) Anterior lung perfusion scan shows relative decreased perfusion to the left upper lobe with normal ventilation in the left upper lobe, findings consistent with a high probability of pulmonary embolus. The patient was treated with heparin but died related to a major retroperitoneal hemorrhage 9 days later.