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Anatomic Pitfalls of the Heart and Pericardium¹

¹ From the Department of Radiology, University of Wisconsin-Madison Medical School, E3/311 Clinical Science Center, 600 Highland Ave, Madison, WI 53792. Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received April 14, 2004; revision requested June 8 and received August 3; accepted August 5. All authors have no financial relationships to disclose.

View larger version (121K): [in a new window]   Figure 1.  Drawing illustrates a cutaway view of the right atrium. Note the eustachian valve remnant (solid arrow), the thebesian valve adjacent to the opening of the coronary sinus (open arrow), and the crista terminalis (arrowheads). IVC = inferior vena cava, SVC = superior vena cava, * = fossa ovalis.

 

View larger version (160K): [in a new window]   Figure 2.  Axial contrast material–enhanced CT scan obtained through the inferior aspect of the heart shows a fingerlike structure (arrow) projecting into the right atrium (RA). Note the coronary sinus emptying into the right atrium (arrowheads). The IVC is also seen entering the atrium at this level. The patient was referred for echocardiography, which revealed a prominent eustachian valve remnant. LV = left ventricle, RV = right ventricle.

 

View larger version (136K): [in a new window]   Figure 3.  Axial contrast-enhanced CT scan shows a filling defect (arrow) projecting from the lateral wall into the right atrium (RA). The filling defect is seen in the characteristic location of the crista terminalis. A = aorta, LA = left atrium, RV = right ventricle.

 

View larger version (87K): [in a new window]   Figure 4.  Axial contrast-enhanced CT scan shows soft tissue projecting into the left atrium (LA) due to an infolding of the wall of the left atrium between the left atrial appendage (LAA) anteriorly and the left superior pulmonary vein (arrow) posteriorly. Note the bulbous tip of the projection (arrowhead). AA = ascending aorta, DA = descending aorta.

 

View larger version (132K): [in a new window]   Figure 5.  Contrast-enhanced CT scan shows areas of fat attenuation within the interatrial septum (arrowheads), findings that are consistent with LHIS. The fat spares the fossa ovalis (arrow), which should not be mistaken for an atrial septal defect. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

 

View larger version (123K): [in a new window]   Figure 6a.  (a) Drawing illustrates a cutaway view of the right ventricle. Arrowheads indicate the anterior and posterior papillary muscles, open arrow indicates the moderator band. Note the smaller conal papillary muscle (solid arrow). (b, c) Axial contrast-enhanced CT scans show the anterior papillary muscle (arrowhead in b) and the moderator band (arrow in c).

 

View larger version (153K): [in a new window]   Figure 6b.  (a) Drawing illustrates a cutaway view of the right ventricle. Arrowheads indicate the anterior and posterior papillary muscles, open arrow indicates the moderator band. Note the smaller conal papillary muscle (solid arrow). (b, c) Axial contrast-enhanced CT scans show the anterior papillary muscle (arrowhead in b) and the moderator band (arrow in c).

 

View larger version (163K): [in a new window]   Figure 6c.  (a) Drawing illustrates a cutaway view of the right ventricle. Arrowheads indicate the anterior and posterior papillary muscles, open arrow indicates the moderator band. Note the smaller conal papillary muscle (solid arrow). (b, c) Axial contrast-enhanced CT scans show the anterior papillary muscle (arrowhead in b) and the moderator band (arrow in c).

 

View larger version (111K): [in a new window]   Figure 7a.  (a) Contrast-enhanced CT scan of the heart shows a modified long-axis view of the anterior papillary muscle (A). Note the thin chordae tendineae (arrows) extending to the anterior and posterior mitral valve leaflets. (b) Contrast-enhanced CT scan of the heart shows a modified long-axis view of the posterior papillary muscle (P) and chordae tendineae (arrows). (c) Reformatted image of the left ventricle from CT data shows a modified short-axis view of the anterior (A) and posterior (P) papillary muscles.

 

View larger version (138K): [in a new window]   Figure 7b.  (a) Contrast-enhanced CT scan of the heart shows a modified long-axis view of the anterior papillary muscle (A). Note the thin chordae tendineae (arrows) extending to the anterior and posterior mitral valve leaflets. (b) Contrast-enhanced CT scan of the heart shows a modified long-axis view of the posterior papillary muscle (P) and chordae tendineae (arrows). (c) Reformatted image of the left ventricle from CT data shows a modified short-axis view of the anterior (A) and posterior (P) papillary muscles.

 

View larger version (129K): [in a new window]   Figure 7c.  (a) Contrast-enhanced CT scan of the heart shows a modified long-axis view of the anterior papillary muscle (A). Note the thin chordae tendineae (arrows) extending to the anterior and posterior mitral valve leaflets. (b) Contrast-enhanced CT scan of the heart shows a modified long-axis view of the posterior papillary muscle (P) and chordae tendineae (arrows). (c) Reformatted image of the left ventricle from CT data shows a modified short-axis view of the anterior (A) and posterior (P) papillary muscles.

 

View larger version (111K): [in a new window]   Figure 8a.  (a) Axial contrast-enhanced CT scan shows an outward bulge (arrow) along the expected location of the left aortic sinus. This finding should not be misinterpreted as an aneurysm in a sinus of Valsalva. (b) Coronal reformatted image from CT data better demonstrates the aortic anatomy. Note that the aortic valve plane (dashed line) is oriented oblique to the axial plane. (c) Oblique axial reformatted image of the aortic valve from CT data shows the normal appearance of the aortic sinuses (arrow).

 

View larger version (121K): [in a new window]   Figure 8b.  (a) Axial contrast-enhanced CT scan shows an outward bulge (arrow) along the expected location of the left aortic sinus. This finding should not be misinterpreted as an aneurysm in a sinus of Valsalva. (b) Coronal reformatted image from CT data better demonstrates the aortic anatomy. Note that the aortic valve plane (dashed line) is oriented oblique to the axial plane. (c) Oblique axial reformatted image of the aortic valve from CT data shows the normal appearance of the aortic sinuses (arrow).

 

View larger version (152K): [in a new window]   Figure 8c.  (a) Axial contrast-enhanced CT scan shows an outward bulge (arrow) along the expected location of the left aortic sinus. This finding should not be misinterpreted as an aneurysm in a sinus of Valsalva. (b) Coronal reformatted image from CT data better demonstrates the aortic anatomy. Note that the aortic valve plane (dashed line) is oriented oblique to the axial plane. (c) Oblique axial reformatted image of the aortic valve from CT data shows the normal appearance of the aortic sinuses (arrow).

 

View larger version (143K): [in a new window]   Figure 9a.  (a) Axial contrast-enhanced CT scan obtained in an 80-year-old woman with a history of a previously malpositioned Swan-Ganz catheter shows a bulge in the pulmonary artery (arrow), a finding that raised suspicion for a pseudoaneurysm. (b) Coronal oblique reformatted image from CT data again shows the bulge in the proximal pulmonary artery (arrow). (c) One of a series of oblique axial CT scans obtained along the longitudinal axis of the pulmonary artery helps confirm the absence of a pseudoaneurysm (arrow).

 

View larger version (162K): [in a new window]   Figure 9b.  (a) Axial contrast-enhanced CT scan obtained in an 80-year-old woman with a history of a previously malpositioned Swan-Ganz catheter shows a bulge in the pulmonary artery (arrow), a finding that raised suspicion for a pseudoaneurysm. (b) Coronal oblique reformatted image from CT data again shows the bulge in the proximal pulmonary artery (arrow). (c) One of a series of oblique axial CT scans obtained along the longitudinal axis of the pulmonary artery helps confirm the absence of a pseudoaneurysm (arrow).

 

View larger version (142K): [in a new window]   Figure 9c.  (a) Axial contrast-enhanced CT scan obtained in an 80-year-old woman with a history of a previously malpositioned Swan-Ganz catheter shows a bulge in the pulmonary artery (arrow), a finding that raised suspicion for a pseudoaneurysm. (b) Coronal oblique reformatted image from CT data again shows the bulge in the proximal pulmonary artery (arrow). (c) One of a series of oblique axial CT scans obtained along the longitudinal axis of the pulmonary artery helps confirm the absence of a pseudoaneurysm (arrow).

 

View larger version (77K): [in a new window]   Figure 10.  Drawing illustrates a cutaway view of the anterior aspect of the heart. Note how the pericardium extends superiorly to cover the great vessels (arrows). AA = ascending aorta, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle, SVC = superior vena cava.

 

View larger version (84K): [in a new window]   Figure 11a.  Pericardial recesses and sinuses. (a) Drawing illustrates the pericardial sac with the heart removed. Note that the transverse sinus (T) and oblique sinus (*) are separated by pericardial reflections. Note also the extension of the pericardium superiorly. The pulmonic vein recesses (arrows) lie between the superior and inferior pulmonary veins. (b, c) Axial contrast-enhanced cardiac-gated images of the heart obtained at (b) and inferior to (c) the level of the right inferior pulmonary vein show areas of fluid attenuation anterior, posterior, and inferior to the vein (arrowheads). (d, e) Sagittal (d) and coronal (e) reformatted images from CT data show the relationship between the fluid in the pulmonic vein recess (arrowhead) and the pulmonary vein.

 

View larger version (80K): [in a new window]   Figure 11b.  Pericardial recesses and sinuses. (a) Drawing illustrates the pericardial sac with the heart removed. Note that the transverse sinus (T) and oblique sinus (*) are separated by pericardial reflections. Note also the extension of the pericardium superiorly. The pulmonic vein recesses (arrows) lie between the superior and inferior pulmonary veins. (b, c) Axial contrast-enhanced cardiac-gated images of the heart obtained at (b) and inferior to (c) the level of the right inferior pulmonary vein show areas of fluid attenuation anterior, posterior, and inferior to the vein (arrowheads). (d, e) Sagittal (d) and coronal (e) reformatted images from CT data show the relationship between the fluid in the pulmonic vein recess (arrowhead) and the pulmonary vein.

 

View larger version (79K): [in a new window]   Figure 11c.  Pericardial recesses and sinuses. (a) Drawing illustrates the pericardial sac with the heart removed. Note that the transverse sinus (T) and oblique sinus (*) are separated by pericardial reflections. Note also the extension of the pericardium superiorly. The pulmonic vein recesses (arrows) lie between the superior and inferior pulmonary veins. (b, c) Axial contrast-enhanced cardiac-gated images of the heart obtained at (b) and inferior to (c) the level of the right inferior pulmonary vein show areas of fluid attenuation anterior, posterior, and inferior to the vein (arrowheads). (d, e) Sagittal (d) and coronal (e) reformatted images from CT data show the relationship between the fluid in the pulmonic vein recess (arrowhead) and the pulmonary vein.

 

View larger version (61K): [in a new window]   Figure 11d.  Pericardial recesses and sinuses. (a) Drawing illustrates the pericardial sac with the heart removed. Note that the transverse sinus (T) and oblique sinus (*) are separated by pericardial reflections. Note also the extension of the pericardium superiorly. The pulmonic vein recesses (arrows) lie between the superior and inferior pulmonary veins. (b, c) Axial contrast-enhanced cardiac-gated images of the heart obtained at (b) and inferior to (c) the level of the right inferior pulmonary vein show areas of fluid attenuation anterior, posterior, and inferior to the vein (arrowheads). (d, e) Sagittal (d) and coronal (e) reformatted images from CT data show the relationship between the fluid in the pulmonic vein recess (arrowhead) and the pulmonary vein.

 

View larger version (48K): [in a new window]   Figure 11e.  Pericardial recesses and sinuses. (a) Drawing illustrates the pericardial sac with the heart removed. Note that the transverse sinus (T) and oblique sinus (*) are separated by pericardial reflections. Note also the extension of the pericardium superiorly. The pulmonic vein recesses (arrows) lie between the superior and inferior pulmonary veins. (b, c) Axial contrast-enhanced cardiac-gated images of the heart obtained at (b) and inferior to (c) the level of the right inferior pulmonary vein show areas of fluid attenuation anterior, posterior, and inferior to the vein (arrowheads). (d, e) Sagittal (d) and coronal (e) reformatted images from CT data show the relationship between the fluid in the pulmonic vein recess (arrowhead) and the pulmonary vein.

 

View larger version (108K): [in a new window]   Figure 12a.  (a) Axial contrast-enhanced CT scan shows fluid in the anterior portion of the superior aortic recess (arrow), a finding that can sometimes be mistaken for aortic dissection. A small amount of fluid is also seen posterior to the ascending aorta (A) in the posterior portion of the superior aortic recess (arrowhead). (b) Axial contrast-enhanced CT scan obtained cephalad to a shows the superior extension of the superior aortic recess (arrowhead), which now lies in a right paratracheal location. Fluid in this location can be mistaken for an enlarged lymph node. (c) Coronal reformatted image from CT data shows the superior extension of the superior aortic recess (arrowhead) lateral to the aorta (A). Fluid (arrow) is also identified in the anterior portion of the superior aortic recess between the aorta and the main pulmonary artery (PA). (d) Sagittal reformatted image from CT data again shows the superior extension of the superior aortic recess (arrowhead). SVC = superior vena cava, T = trachea.

 

View larger version (111K): [in a new window]   Figure 12b.  (a) Axial contrast-enhanced CT scan shows fluid in the anterior portion of the superior aortic recess (arrow), a finding that can sometimes be mistaken for aortic dissection. A small amount of fluid is also seen posterior to the ascending aorta (A) in the posterior portion of the superior aortic recess (arrowhead). (b) Axial contrast-enhanced CT scan obtained cephalad to a shows the superior extension of the superior aortic recess (arrowhead), which now lies in a right paratracheal location. Fluid in this location can be mistaken for an enlarged lymph node. (c) Coronal reformatted image from CT data shows the superior extension of the superior aortic recess (arrowhead) lateral to the aorta (A). Fluid (arrow) is also identified in the anterior portion of the superior aortic recess between the aorta and the main pulmonary artery (PA). (d) Sagittal reformatted image from CT data again shows the superior extension of the superior aortic recess (arrowhead). SVC = superior vena cava, T = trachea.

 

View larger version (116K): [in a new window]   Figure 12c.  (a) Axial contrast-enhanced CT scan shows fluid in the anterior portion of the superior aortic recess (arrow), a finding that can sometimes be mistaken for aortic dissection. A small amount of fluid is also seen posterior to the ascending aorta (A) in the posterior portion of the superior aortic recess (arrowhead). (b) Axial contrast-enhanced CT scan obtained cephalad to a shows the superior extension of the superior aortic recess (arrowhead), which now lies in a right paratracheal location. Fluid in this location can be mistaken for an enlarged lymph node. (c) Coronal reformatted image from CT data shows the superior extension of the superior aortic recess (arrowhead) lateral to the aorta (A). Fluid (arrow) is also identified in the anterior portion of the superior aortic recess between the aorta and the main pulmonary artery (PA). (d) Sagittal reformatted image from CT data again shows the superior extension of the superior aortic recess (arrowhead). SVC = superior vena cava, T = trachea.

 

View larger version (150K): [in a new window]   Figure 12d.  (a) Axial contrast-enhanced CT scan shows fluid in the anterior portion of the superior aortic recess (arrow), a finding that can sometimes be mistaken for aortic dissection. A small amount of fluid is also seen posterior to the ascending aorta (A) in the posterior portion of the superior aortic recess (arrowhead). (b) Axial contrast-enhanced CT scan obtained cephalad to a shows the superior extension of the superior aortic recess (arrowhead), which now lies in a right paratracheal location. Fluid in this location can be mistaken for an enlarged lymph node. (c) Coronal reformatted image from CT data shows the superior extension of the superior aortic recess (arrowhead) lateral to the aorta (A). Fluid (arrow) is also identified in the anterior portion of the superior aortic recess between the aorta and the main pulmonary artery (PA). (d) Sagittal reformatted image from CT data again shows the superior extension of the superior aortic recess (arrowhead). SVC = superior vena cava, T = trachea.

 

View larger version (69K): [in a new window]   Figure 13a.  (a) Axial contrast-enhanced CT scan shows a small amount of fluid in the transverse sinus (T) posterior to the ascending aorta (AA). The transverse sinus extends laterally, where it communicates with the left pulmonic recess (arrow) inferior to the left pulmonary artery. PA = main pulmonary artery. (b) Axial contrast-enhanced CT scan obtained slightly superior to a shows fluid in the left pulmonic recess (arrow). LSV = left superior pulmonary vein, PA = main pulmonary artery, RPA = right pulmonary artery.

 

View larger version (69K): [in a new window]   Figure 13b.  (a) Axial contrast-enhanced CT scan shows a small amount of fluid in the transverse sinus (T) posterior to the ascending aorta (AA). The transverse sinus extends laterally, where it communicates with the left pulmonic recess (arrow) inferior to the left pulmonary artery. PA = main pulmonary artery. (b) Axial contrast-enhanced CT scan obtained slightly superior to a shows fluid in the left pulmonic recess (arrow). LSV = left superior pulmonary vein, PA = main pulmonary artery, RPA = right pulmonary artery.

 

View larger version (77K): [in a new window]   Figure 14a.  (a) Axial contrast-enhanced CT scan shows a small collection of fluid (arrow) in the posterior pericardial recess located below the level of the carina. B = bronchus, RPA = right pulmonary artery. (b, c) Axial contrast-enhanced CT scans obtained inferior to a demonstrate the continuity between the posterior pericardial recess and the oblique sinus (arrow in c). LA = left atrium.

 

View larger version (76K): [in a new window]   Figure 14b.  (a) Axial contrast-enhanced CT scan shows a small collection of fluid (arrow) in the posterior pericardial recess located below the level of the carina. B = bronchus, RPA = right pulmonary artery. (b, c) Axial contrast-enhanced CT scans obtained inferior to a demonstrate the continuity between the posterior pericardial recess and the oblique sinus (arrow in c). LA = left atrium.

 

View larger version (77K): [in a new window]   Figure 14c.  (a) Axial contrast-enhanced CT scan shows a small collection of fluid (arrow) in the posterior pericardial recess located below the level of the carina. B = bronchus, RPA = right pulmonary artery. (b, c) Axial contrast-enhanced CT scans obtained inferior to a demonstrate the continuity between the posterior pericardial recess and the oblique sinus (arrow in c). LA = left atrium.

 

View larger version (65K): [in a new window]   Figure 15a.  Fibrosing mediastinitis with obstruction of the medial left brachiocephalic vein and SVC in a 34-year-old woman. (a) Axial contrast-enhanced CT scan demonstrates occlusion of the SVC and left brachiocephalic vein. (b, c) Axial contrast-enhanced CT scans obtained at the level of the aortic root (b) and ventricles (c) show the pericardiophrenic vein (arrow) coursing along the lateral aspect of the heart. (d) On an axial CT scan, the pericardiophrenic vein is seen to connect with the inferior phrenic vein (arrowhead), at which point it drains into the IVC (arrow).

 

View larger version (103K): [in a new window]   Figure 15b.  Fibrosing mediastinitis with obstruction of the medial left brachiocephalic vein and SVC in a 34-year-old woman. (a) Axial contrast-enhanced CT scan demonstrates occlusion of the SVC and left brachiocephalic vein. (b, c) Axial contrast-enhanced CT scans obtained at the level of the aortic root (b) and ventricles (c) show the pericardiophrenic vein (arrow) coursing along the lateral aspect of the heart. (d) On an axial CT scan, the pericardiophrenic vein is seen to connect with the inferior phrenic vein (arrowhead), at which point it drains into the IVC (arrow).

 

View larger version (94K): [in a new window]   Figure 15c.  Fibrosing mediastinitis with obstruction of the medial left brachiocephalic vein and SVC in a 34-year-old woman. (a) Axial contrast-enhanced CT scan demonstrates occlusion of the SVC and left brachiocephalic vein. (b, c) Axial contrast-enhanced CT scans obtained at the level of the aortic root (b) and ventricles (c) show the pericardiophrenic vein (arrow) coursing along the lateral aspect of the heart. (d) On an axial CT scan, the pericardiophrenic vein is seen to connect with the inferior phrenic vein (arrowhead), at which point it drains into the IVC (arrow).

 

View larger version (116K): [in a new window]   Figure 15d.  Fibrosing mediastinitis with obstruction of the medial left brachiocephalic vein and SVC in a 34-year-old woman. (a) Axial contrast-enhanced CT scan demonstrates occlusion of the SVC and left brachiocephalic vein. (b, c) Axial contrast-enhanced CT scans obtained at the level of the aortic root (b) and ventricles (c) show the pericardiophrenic vein (arrow) coursing along the lateral aspect of the heart. (d) On an axial CT scan, the pericardiophrenic vein is seen to connect with the inferior phrenic vein (arrowhead), at which point it drains into the IVC (arrow).

 

View larger version (96K): [in a new window]   Figure 16a.  Sequential axial contrast-enhanced CT scans demonstrate the bilateral venae cavae. The left vena cava (arrow in a and b) courses along the lateral aspect of the heart and drains into the right atrium via the coronary sinus, which is enlarged (arrowhead in c). RA = right atrium, * = right SVC.

 

View larger version (106K): [in a new window]   Figure 16b.  Sequential axial contrast-enhanced CT scans demonstrate the bilateral venae cavae. The left vena cava (arrow in a and b) courses along the lateral aspect of the heart and drains into the right atrium via the coronary sinus, which is enlarged (arrowhead in c). RA = right atrium, * = right SVC.

 

View larger version (115K): [in a new window]   Figure 16c.  Sequential axial contrast-enhanced CT scans demonstrate the bilateral venae cavae. The left vena cava (arrow in a and b) courses along the lateral aspect of the heart and drains into the right atrium via the coronary sinus, which is enlarged (arrowhead in c). RA = right atrium, * = right SVC.

 

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