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. 2021 Jul-Aug;41(4):1022-1042.
doi: 10.1148/rg.2021200142. Epub 2021 Jun 11.

Transthoracic Echocardiography: Beginner's Guide with Emphasis on Blind Spots as Identified with CT and MRI

Matthew D Grant  1 , Ryan D Mann  1 , Scott D Kristenson  1 , Richard M Buck  1 , Juan D Mendoza  1 , Jason M Reese  1 , David W Grant  1 , Eric A Roberge  1
Affiliations

Transthoracic Echocardiography: Beginner's Guide with Emphasis on Blind Spots as Identified with CT and MRI

Matthew D Grant et al. Radiographics. 2021 Jul-Aug.

Abstract

Transthoracic echocardiography (TTE) is the primary initial imaging modality in cardiac imaging. Advantages include portability, safety, availability, and ability to assess the morphology and physiology of the heart in a noninvasive manner. Because of this, many patients who undergo advanced imaging with CT or MRI will have undergone prior TTE, particularly when cardiac CT angiography or cardiac MRI is performed. In the modern era, the increasing interconnectivity of picture archiving and communication systems (PACS) has made these images more available for comparison. Therefore, radiologists who interpret chest imaging studies should have a basic understanding of TTE, including its strengths and limitations, to make accurate comparisons and assist in rendering a diagnosis or avoiding a misdiagnosis. The authors present the standard TTE views along with multiplanar reformatted CT images for correlation. This is followed by examples of limitations of TTE, focusing on potential blind spots, which have been placed in seven categories on the basis of the structures involved: (a) pericardium (thickening, calcification, effusions, cysts, masses), (b) aorta (dissection, intramural hematoma, penetrating atherosclerotic ulcer), (c) left ventricular apex (infarcts, aneurysms, thrombus, apical hypertrophic cardiomyopathy), (d) cardiac valves (complications of native and prosthetic valves), (e) left atrial appendage (thrombus), (f) coronary arteries (origins, calcifications, fistulas, aneurysms), and (g) extracardiac structures (primary and metastatic masses). Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article . ©RSNA, 2021.

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Figures

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Graphical abstract
Standard echocardiographic windows in transthoracic echocardiography (TTE). The four standard windows are parasternal, apical, subcostal, and suprasternal. The parasternal and apical windows are generally used from the left side. The third or fourth intercostal space is most often used for the parasternal window, and the fifth intercostal space is most often used for the apical window. AO = aorta, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle. (Reprinted, with permission, from reference 9.)
Figure 1.
Standard echocardiographic windows in transthoracic echocardiography (TTE). The four standard windows are parasternal, apical, subcostal, and suprasternal. The parasternal and apical windows are generally used from the left side. The third or fourth intercostal space is most often used for the parasternal window, and the fifth intercostal space is most often used for the apical window. AO = aorta, LV = left ventricle, PA = pulmonary artery, RA = right atrium, RV = right ventricle. (Reprinted, with permission, from reference .)
Standard imaging planes. Drawing shows the four standard planes: long axis, short axis, apical four chamber, and apical two chamber. The long-axis plane corresponds to images acquired in the parasternal long-axis view, and the short-axis plane corresponds to images acquired in the parasternal short-axis view. The apical plane (both four chamber and two chamber) corresponds to images acquired from the apical window. (Reprinted, with permission, from reference 9.)
Figure 2.
Standard imaging planes. Drawing shows the four standard planes: long axis, short axis, apical four chamber, and apical two chamber. The long-axis plane corresponds to images acquired in the parasternal long-axis view, and the short-axis plane corresponds to images acquired in the parasternal short-axis view. The apical plane (both four chamber and two chamber) corresponds to images acquired from the apical window. (Reprinted, with permission, from reference .)
Normal parasternal long-axis LV view at TTE (a) and correlative cardiac CT angiography (CTA) (b). AR = aortic root, DAo = descending aorta, IVS = interventricular septum, LA = left atrium, arrow = mitral valve, arrowhead = aortic valve, * = LV outflow tract.
Figure 3a.
Normal parasternal long-axis LV view at TTE (a) and correlative cardiac CT angiography (CTA) (b). AR = aortic root, DAo = descending aorta, IVS = interventricular septum, LA = left atrium, arrow = mitral valve, arrowhead = aortic valve, * = LV outflow tract.
Normal parasternal long-axis LV view at TTE (a) and correlative cardiac CT angiography (CTA) (b). AR = aortic root, DAo = descending aorta, IVS = interventricular septum, LA = left atrium, arrow = mitral valve, arrowhead = aortic valve, * = LV outflow tract.
Figure 3b.
Normal parasternal long-axis LV view at TTE (a) and correlative cardiac CT angiography (CTA) (b). AR = aortic root, DAo = descending aorta, IVS = interventricular septum, LA = left atrium, arrow = mitral valve, arrowhead = aortic valve, * = LV outflow tract.
Normal parasternal long-axis RV inflow view at TTE (a) and correlative cardiac CTA (b). IVC = inferior vena cava, arrow = tricuspid valve, arrowhead = eustachian valve, * = coronary sinus.
Figure 4a.
Normal parasternal long-axis RV inflow view at TTE (a) and correlative cardiac CTA (b). IVC = inferior vena cava, arrow = tricuspid valve, arrowhead = eustachian valve, * = coronary sinus.
Normal parasternal long-axis RV inflow view at TTE (a) and correlative cardiac CTA (b). IVC = inferior vena cava, arrow = tricuspid valve, arrowhead = eustachian valve, * = coronary sinus.
Figure 4b.
Normal parasternal long-axis RV inflow view at TTE (a) and correlative cardiac CTA (b). IVC = inferior vena cava, arrow = tricuspid valve, arrowhead = eustachian valve, * = coronary sinus.
Normal parasternal short-axis view at the aortic valve level at TTE (a) and correlative cardiac CTA (b). LAA = left atrial appendage, LC = left coronary cusp, MPA = main pulmonary artery, NC = noncoronary cusp, RC = right coronary cusp, arrow = tricuspid valve, arrowhead = pulmonary valve.
Figure 5a.
Normal parasternal short-axis view at the aortic valve level at TTE (a) and correlative cardiac CTA (b). LAA = left atrial appendage, LC = left coronary cusp, MPA = main pulmonary artery, NC = noncoronary cusp, RC = right coronary cusp, arrow = tricuspid valve, arrowhead = pulmonary valve.
Normal parasternal short-axis view at the aortic valve level at TTE (a) and correlative cardiac CTA (b). LAA = left atrial appendage, LC = left coronary cusp, MPA = main pulmonary artery, NC = noncoronary cusp, RC = right coronary cusp, arrow = tricuspid valve, arrowhead = pulmonary valve.
Figure 5b.
Normal parasternal short-axis view at the aortic valve level at TTE (a) and correlative cardiac CTA (b). LAA = left atrial appendage, LC = left coronary cusp, MPA = main pulmonary artery, NC = noncoronary cusp, RC = right coronary cusp, arrow = tricuspid valve, arrowhead = pulmonary valve.
Normal parasternal short-axis view at the mitral valve level in diastole at TTE (a) and correlative cardiac CTA (b). Arrow = anterior mitral valve leaflet, arrowhead = posterior mitral valve leaflet.
Figure 6a.
Normal parasternal short-axis view at the mitral valve level in diastole at TTE (a) and correlative cardiac CTA (b). Arrow = anterior mitral valve leaflet, arrowhead = posterior mitral valve leaflet.
Normal parasternal short-axis view at the mitral valve level in diastole at TTE (a) and correlative cardiac CTA (b). Arrow = anterior mitral valve leaflet, arrowhead = posterior mitral valve leaflet.
Figure 6b.
Normal parasternal short-axis view at the mitral valve level in diastole at TTE (a) and correlative cardiac CTA (b). Arrow = anterior mitral valve leaflet, arrowhead = posterior mitral valve leaflet.
Normal parasternal short-axis view at the papillary muscle level at TTE (a) and correlative cardiac CTA (b). Arrow = anterolateral papillary muscle, arrowheads = posteromedial papillary muscle.
Figure 7a.
Normal parasternal short-axis view at the papillary muscle level at TTE (a) and correlative cardiac CTA (b). Arrow = anterolateral papillary muscle, arrowheads = posteromedial papillary muscle.
Normal parasternal short-axis view at the papillary muscle level at TTE (a) and correlative cardiac CTA (b). Arrow = anterolateral papillary muscle, arrowheads = posteromedial papillary muscle.
Figure 7b.
Normal parasternal short-axis view at the papillary muscle level at TTE (a) and correlative cardiac CTA (b). Arrow = anterolateral papillary muscle, arrowheads = posteromedial papillary muscle.
Normal parasternal short-axis view at the LV apex level at TTE (a) and correlative cardiac CTA (b). In this example, the RV is visible in addition to the LV, although this is not required.
Figure 8a.
Normal parasternal short-axis view at the LV apex level at TTE (a) and correlative cardiac CTA (b). In this example, the RV is visible in addition to the LV, although this is not required.
Normal parasternal short-axis view at the LV apex level at TTE (a) and correlative cardiac CTA (b). In this example, the RV is visible in addition to the LV, although this is not required.
Figure 8b.
Normal parasternal short-axis view at the LV apex level at TTE (a) and correlative cardiac CTA (b). In this example, the RV is visible in addition to the LV, although this is not required.
Normal apical four-chamber view at TTE (a) and correlative cardiac CTA (b). Owing to the parallel orientation of the interatrial septum to the ultra-sound beam, an atrial septal defect may be simulated where no actual defect is present. Additionally, valve leaflets may be difficult to visualize on cardiac CTA images. Straight arrow = mitral valve, curved arrow = tricuspid valve.
Figure 9a.
Normal apical four-chamber view at TTE (a) and correlative cardiac CTA (b). Owing to the parallel orientation of the interatrial septum to the ultra-sound beam, an atrial septal defect may be simulated where no actual defect is present. Additionally, valve leaflets may be difficult to visualize on cardiac CTA images. Straight arrow = mitral valve, curved arrow = tricuspid valve.
Normal apical four-chamber view at TTE (a) and correlative cardiac CTA (b). Owing to the parallel orientation of the interatrial septum to the ultra-sound beam, an atrial septal defect may be simulated where no actual defect is present. Additionally, valve leaflets may be difficult to visualize on cardiac CTA images. Straight arrow = mitral valve, curved arrow = tricuspid valve.
Figure 9b.
Normal apical four-chamber view at TTE (a) and correlative cardiac CTA (b). Owing to the parallel orientation of the interatrial septum to the ultra-sound beam, an atrial septal defect may be simulated where no actual defect is present. Additionally, valve leaflets may be difficult to visualize on cardiac CTA images. Straight arrow = mitral valve, curved arrow = tricuspid valve.
Normal apical five-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = aortic valve, * = LV outflow tract.
Figure 10a.
Normal apical five-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = aortic valve, * = LV outflow tract.
Normal apical five-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = aortic valve, * = LV outflow tract.
Figure 10b.
Normal apical five-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = aortic valve, * = LV outflow tract.
Normal apical two-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = mitral valve, * =
Figure 11a.
Normal apical two-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = mitral valve, * = left atrial appendage, arrow = pulmonary vein.
Normal apical two-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = mitral valve, * =
Figure 11b.
Normal apical two-chamber view at TTE (a) and correlative cardiac CTA (b). Arrowhead = mitral valve, * = left atrial appendage, arrow = pulmonary vein.
Normal apical three-chamber (long-axis) view at TTE (a) and correlative cardiac CTA (b). AR = aortic root, straight arrow = aortic valve, curved arrow = mitral valve.
Figure 12a.
Normal apical three-chamber (long-axis) view at TTE (a) and correlative cardiac CTA (b). AR = aortic root, straight arrow = aortic valve, curved arrow = mitral valve.
Normal apical three-chamber (long-axis) view at TTE (a) and correlative cardiac CTA (b). AR = aortic root, straight arrow = aortic valve, curved arrow = mitral valve.
Figure 12b.
Normal apical three-chamber (long-axis) view at TTE (a) and correlative cardiac CTA (b). AR = aortic root, straight arrow = aortic valve, curved arrow = mitral valve.
Normal subcostal four-chamber view at TTE (a) and correlative cardiac CTA (b).
Figure 13a.
Normal subcostal four-chamber view at TTE (a) and correlative cardiac CTA (b).
Normal subcostal four-chamber view at TTE (a) and correlative cardiac CTA (b).
Figure 13b.
Normal subcostal four-chamber view at TTE (a) and correlative cardiac CTA (b).
Normal subcostal inferior vena cava (IVC) view at TTE (a) and correlative cardiac CTA (b). Arrowhead = eustachian valve.
Figure 14a.
Normal subcostal inferior vena cava (IVC) view at TTE (a) and correlative cardiac CTA (b). Arrowhead = eustachian valve.
Normal subcostal inferior vena cava (IVC) view at TTE (a) and correlative cardiac CTA (b). Arrowhead = eustachian valve.
Figure 14b.
Normal subcostal inferior vena cava (IVC) view at TTE (a) and correlative cardiac CTA (b). Arrowhead = eustachian valve.
Normal suprasternal long-axis view at TTE (a) and correlative cardiac CTA (b). Ao = aorta, BC = brachiocephalic artery, LCC = left common carotid artery, LSC = left subclavian artery, RPA = right pulmonary artery.
Figure 15a.
Normal suprasternal long-axis view at TTE (a) and correlative cardiac CTA (b). Ao = aorta, BC = brachiocephalic artery, LCC = left common carotid artery, LSC = left subclavian artery, RPA = right pulmonary artery.
Normal suprasternal long-axis view at TTE (a) and correlative cardiac CTA (b). Ao = aorta, BC = brachiocephalic artery, LCC = left common carotid artery, LSC = left subclavian artery, RPA = right pulmonary artery.
Figure 15b.
Normal suprasternal long-axis view at TTE (a) and correlative cardiac CTA (b). Ao = aorta, BC = brachiocephalic artery, LCC = left common carotid artery, LSC = left subclavian artery, RPA = right pulmonary artery.
Pericardial calcifications in a 57-year-old man with chronic orthopnea and dyspnea, suggestive of constrictive pericarditis. (a, b) Axial (a) and coronal (b) cardiac CTA images of the chest show pericardial calcifications, most notable along the RV (arrow) and adjacent to the mitral valve (arrowhead in a). (c) Apical four-chamber TTE view shows a hyperechoic lesion (arrow) adjacent to the mitral valve, which was seen only in retrospect. The echogenic appearance is most consistent with calcification, although prominent fat in the atrioventricular groove can have a similar appearance. The true extent of pericardial calcification is visualized much better at CT.
Figure 16a.
Pericardial calcifications in a 57-year-old man with chronic orthopnea and dyspnea, suggestive of constrictive pericarditis. (a, b) Axial (a) and coronal (b) cardiac CTA images of the chest show pericardial calcifications, most notable along the RV (arrow) and adjacent to the mitral valve (arrowhead in a). (c) Apical four-chamber TTE view shows a hyperechoic lesion (arrow) adjacent to the mitral valve, which was seen only in retrospect. The echogenic appearance is most consistent with calcification, although prominent fat in the atrioventricular groove can have a similar appearance. The true extent of pericardial calcification is visualized much better at CT.
Pericardial calcifications in a 57-year-old man with chronic orthopnea and dyspnea, suggestive of constrictive pericarditis. (a, b) Axial (a) and coronal (b) cardiac CTA images of the chest show pericardial calcifications, most notable along the RV (arrow) and adjacent to the mitral valve (arrowhead in a). (c) Apical four-chamber TTE view shows a hyperechoic lesion (arrow) adjacent to the mitral valve, which was seen only in retrospect. The echogenic appearance is most consistent with calcification, although prominent fat in the atrioventricular groove can have a similar appearance. The true extent of pericardial calcification is visualized much better at CT.
Figure 16b.
Pericardial calcifications in a 57-year-old man with chronic orthopnea and dyspnea, suggestive of constrictive pericarditis. (a, b) Axial (a) and coronal (b) cardiac CTA images of the chest show pericardial calcifications, most notable along the RV (arrow) and adjacent to the mitral valve (arrowhead in a). (c) Apical four-chamber TTE view shows a hyperechoic lesion (arrow) adjacent to the mitral valve, which was seen only in retrospect. The echogenic appearance is most consistent with calcification, although prominent fat in the atrioventricular groove can have a similar appearance. The true extent of pericardial calcification is visualized much better at CT.
Pericardial calcifications in a 57-year-old man with chronic orthopnea and dyspnea, suggestive of constrictive pericarditis. (a, b) Axial (a) and coronal (b) cardiac CTA images of the chest show pericardial calcifications, most notable along the RV (arrow) and adjacent to the mitral valve (arrowhead in a). (c) Apical four-chamber TTE view shows a hyperechoic lesion (arrow) adjacent to the mitral valve, which was seen only in retrospect. The echogenic appearance is most consistent with calcification, although prominent fat in the atrioventricular groove can have a similar appearance. The true extent of pericardial calcification is visualized much better at CT.
Figure 16c.
Pericardial calcifications in a 57-year-old man with chronic orthopnea and dyspnea, suggestive of constrictive pericarditis. (a, b) Axial (a) and coronal (b) cardiac CTA images of the chest show pericardial calcifications, most notable along the RV (arrow) and adjacent to the mitral valve (arrowhead in a). (c) Apical four-chamber TTE view shows a hyperechoic lesion (arrow) adjacent to the mitral valve, which was seen only in retrospect. The echogenic appearance is most consistent with calcification, although prominent fat in the atrioventricular groove can have a similar appearance. The true extent of pericardial calcification is visualized much better at CT.
Pericardial cyst incidentally detected in a 67-year-old man without an acute complaint who underwent TTE and noncontrast chest CT within 2 weeks of each other. (a) Axial noncontrast chest CT image shows a circumscribed simple fluid-attenuation mass (arrow) at the right anterior cardiophrenic angle. No definite pericardial cyst was seen at TTE. (b) Apical four-chamber TTE view shows a questionable subtle hypoechoic structure possibly representing a cyst (arrow), which was seen retrospectively.
Figure 17a.
Pericardial cyst incidentally detected in a 67-year-old man without an acute complaint who underwent TTE and noncontrast chest CT within 2 weeks of each other. (a) Axial noncontrast chest CT image shows a circumscribed simple fluid-attenuation mass (arrow) at the right anterior cardiophrenic angle. No definite pericardial cyst was seen at TTE. (b) Apical four-chamber TTE view shows a questionable subtle hypoechoic structure possibly representing a cyst (arrow), which was seen retrospectively.
Pericardial cyst incidentally detected in a 67-year-old man without an acute complaint who underwent TTE and noncontrast chest CT within 2 weeks of each other. (a) Axial noncontrast chest CT image shows a circumscribed simple fluid-attenuation mass (arrow) at the right anterior cardiophrenic angle. No definite pericardial cyst was seen at TTE. (b) Apical four-chamber TTE view shows a questionable subtle hypoechoic structure possibly representing a cyst (arrow), which was seen retrospectively.
Figure 17b.
Pericardial cyst incidentally detected in a 67-year-old man without an acute complaint who underwent TTE and noncontrast chest CT within 2 weeks of each other. (a) Axial noncontrast chest CT image shows a circumscribed simple fluid-attenuation mass (arrow) at the right anterior cardiophrenic angle. No definite pericardial cyst was seen at TTE. (b) Apical four-chamber TTE view shows a questionable subtle hypoechoic structure possibly representing a cyst (arrow), which was seen retrospectively.
Aortic dissection in a 71-year-old man with a medical history significant for hypertension who presented to the emergency department (ED) with severe acute back pain. (a) Axial CTA image of the aorta shows an aortic dissection involving the aortic root and descending aorta (arrows) with extension to the large branch vessels (not shown). (b) Parasternal long-axis TTE view obtained earlier in the ED shows no gross abnormality. In particular, there is no dissection flap identified in the aortic root (arrow). LVOT = LV outflow tract.
Figure 18a.
Aortic dissection in a 71-year-old man with a medical history significant for hypertension who presented to the emergency department (ED) with severe acute back pain. (a) Axial CTA image of the aorta shows an aortic dissection involving the aortic root and descending aorta (arrows) with extension to the large branch vessels (not shown). (b) Parasternal long-axis TTE view obtained earlier in the ED shows no gross abnormality. In particular, there is no dissection flap identified in the aortic root (arrow). LVOT = LV outflow tract.
Aortic dissection in a 71-year-old man with a medical history significant for hypertension who presented to the emergency department (ED) with severe acute back pain. (a) Axial CTA image of the aorta shows an aortic dissection involving the aortic root and descending aorta (arrows) with extension to the large branch vessels (not shown). (b) Parasternal long-axis TTE view obtained earlier in the ED shows no gross abnormality. In particular, there is no dissection flap identified in the aortic root (arrow). LVOT = LV outflow tract.
Figure 18b.
Aortic dissection in a 71-year-old man with a medical history significant for hypertension who presented to the emergency department (ED) with severe acute back pain. (a) Axial CTA image of the aorta shows an aortic dissection involving the aortic root and descending aorta (arrows) with extension to the large branch vessels (not shown). (b) Parasternal long-axis TTE view obtained earlier in the ED shows no gross abnormality. In particular, there is no dissection flap identified in the aortic root (arrow). LVOT = LV outflow tract.
Apical aneurysm in a 69-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial steady-state free-precession (SSFP) MR image shows apical myocardial thinning and ballooning (arrow), consistent with an LV apical aneurysm. (b) Apical two-chamber TTE view obtained 2 days later shows no definite apical aneurysm or thinning (arrow).
Figure 19a.
Apical aneurysm in a 69-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial steady-state free-precession (SSFP) MR image shows apical myocardial thinning and ballooning (arrow), consistent with an LV apical aneurysm. (b) Apical two-chamber TTE view obtained 2 days later shows no definite apical aneurysm or thinning (arrow).
Apical aneurysm in a 69-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial steady-state free-precession (SSFP) MR image shows apical myocardial thinning and ballooning (arrow), consistent with an LV apical aneurysm. (b) Apical two-chamber TTE view obtained 2 days later shows no definite apical aneurysm or thinning (arrow).
Figure 19b.
Apical aneurysm in a 69-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial steady-state free-precession (SSFP) MR image shows apical myocardial thinning and ballooning (arrow), consistent with an LV apical aneurysm. (b) Apical two-chamber TTE view obtained 2 days later shows no definite apical aneurysm or thinning (arrow).
Apical thrombus in an 81-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial SSFP MR image shows a flat hypointensity (arrow) in an otherwise morphologically normal LV. (b) Apical two-chamber TTE view obtained 1 day earlier shows a questionable area of hyperechogenicity (arrow) near the LV apex, without a definite apical thrombus visualized.
Figure 20a.
Apical thrombus in an 81-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial SSFP MR image shows a flat hypointensity (arrow) in an otherwise morphologically normal LV. (b) Apical two-chamber TTE view obtained 1 day earlier shows a questionable area of hyperechogenicity (arrow) near the LV apex, without a definite apical thrombus visualized.
Apical thrombus in an 81-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial SSFP MR image shows a flat hypointensity (arrow) in an otherwise morphologically normal LV. (b) Apical two-chamber TTE view obtained 1 day earlier shows a questionable area of hyperechogenicity (arrow) near the LV apex, without a definite apical thrombus visualized.
Figure 20b.
Apical thrombus in an 81-year-old man with a history of coronary artery disease and prior myocardial infarction. (a) Axial SSFP MR image shows a flat hypointensity (arrow) in an otherwise morphologically normal LV. (b) Apical two-chamber TTE view obtained 1 day earlier shows a questionable area of hyperechogenicity (arrow) near the LV apex, without a definite apical thrombus visualized.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Figure 21a.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Figure 21b.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Figure 21c.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Figure 21d.
Aortic valve vegetation in a 58-year-old man with septicemia and a history of prior septic emboli to the brain. (a) Axial CTA image of the aortic valve shows an irregular vegetation of the noncoronary cusp (arrow). (b) Sagittal oblique (three-chamber) white-blood SSFP MR image shows the irregular vegetation involving the noncoronary cusp (arrow). AR = aortic root. (c, d) Parasternal long-axis (c) and short-axis (d) TTE views through the level of the aortic valve (arrow in c, AV in d) show normal-appearing leaflets without definite thickening or vegetation. The imaging findings in this clinical setting are consistent with infective endocarditis. LVOT in c = LV outflow tract.
Hypoattenuating leaflet thickening (HALT) in a 62-year-old woman with a history significant for transcatheter aortic valve replacement (TAVR) secondary to aortic insufficiency. (a) Axial oblique CTA image of the aortic valve shows a metallic TAVR with appropriate positioning (arrowhead). The noncoronary leaflet is notably thickened with hypoattenuating material (arrow) present. (b, c) Parasternal short-axis (b) and long-axis (c) TTE views through the aortic valve show poor characterization of the valve prosthesis secondary to the echogenic nature of metal and posterior acoustic shadowing (arrow) without definite correlation with the CT finding. The patient had no clinical signs of infection and was subsequently diagnosed with HALT.
Figure 22a.
Hypoattenuating leaflet thickening (HALT) in a 62-year-old woman with a history significant for transcatheter aortic valve replacement (TAVR) secondary to aortic insufficiency. (a) Axial oblique CTA image of the aortic valve shows a metallic TAVR with appropriate positioning (arrowhead). The noncoronary leaflet is notably thickened with hypoattenuating material (arrow) present. (b, c) Parasternal short-axis (b) and long-axis (c) TTE views through the aortic valve show poor characterization of the valve prosthesis secondary to the echogenic nature of metal and posterior acoustic shadowing (arrow) without definite correlation with the CT finding. The patient had no clinical signs of infection and was subsequently diagnosed with HALT.
Hypoattenuating leaflet thickening (HALT) in a 62-year-old woman with a history significant for transcatheter aortic valve replacement (TAVR) secondary to aortic insufficiency. (a) Axial oblique CTA image of the aortic valve shows a metallic TAVR with appropriate positioning (arrowhead). The noncoronary leaflet is notably thickened with hypoattenuating material (arrow) present. (b, c) Parasternal short-axis (b) and long-axis (c) TTE views through the aortic valve show poor characterization of the valve prosthesis secondary to the echogenic nature of metal and posterior acoustic shadowing (arrow) without definite correlation with the CT finding. The patient had no clinical signs of infection and was subsequently diagnosed with HALT.
Figure 22b.
Hypoattenuating leaflet thickening (HALT) in a 62-year-old woman with a history significant for transcatheter aortic valve replacement (TAVR) secondary to aortic insufficiency. (a) Axial oblique CTA image of the aortic valve shows a metallic TAVR with appropriate positioning (arrowhead). The noncoronary leaflet is notably thickened with hypoattenuating material (arrow) present. (b, c) Parasternal short-axis (b) and long-axis (c) TTE views through the aortic valve show poor characterization of the valve prosthesis secondary to the echogenic nature of metal and posterior acoustic shadowing (arrow) without definite correlation with the CT finding. The patient had no clinical signs of infection and was subsequently diagnosed with HALT.
Hypoattenuating leaflet thickening (HALT) in a 62-year-old woman with a history significant for transcatheter aortic valve replacement (TAVR) secondary to aortic insufficiency. (a) Axial oblique CTA image of the aortic valve shows a metallic TAVR with appropriate positioning (arrowhead). The noncoronary leaflet is notably thickened with hypoattenuating material (arrow) present. (b, c) Parasternal short-axis (b) and long-axis (c) TTE views through the aortic valve show poor characterization of the valve prosthesis secondary to the echogenic nature of metal and posterior acoustic shadowing (arrow) without definite correlation with the CT finding. The patient had no clinical signs of infection and was subsequently diagnosed with HALT.
Figure 22c.
Hypoattenuating leaflet thickening (HALT) in a 62-year-old woman with a history significant for transcatheter aortic valve replacement (TAVR) secondary to aortic insufficiency. (a) Axial oblique CTA image of the aortic valve shows a metallic TAVR with appropriate positioning (arrowhead). The noncoronary leaflet is notably thickened with hypoattenuating material (arrow) present. (b, c) Parasternal short-axis (b) and long-axis (c) TTE views through the aortic valve show poor characterization of the valve prosthesis secondary to the echogenic nature of metal and posterior acoustic shadowing (arrow) without definite correlation with the CT finding. The patient had no clinical signs of infection and was subsequently diagnosed with HALT.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Figure 23a.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Figure 23b.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Figure 23c.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Figure 23d.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Figure 23e.
Anomalous coronary artery in a 63-year-old woman who underwent TTE for a 2-month history of chest pain. (a) Parasternal short-axis TTE image at the level of the aortic valve shows that the origins of the coronary arteries can be difficult to identify at TTE. The remainder of the TTE was notable only for borderline concentric LV hypertrophy and mild LA enlargement. LC = left coronary cusp, NC = noncoronary cusp, RC = right coronary cusp. (b, c) Reconstructed axial oblique (b) and volume-rendered (c) images from cardiac CTA of the coronary arteries show anomalous origin of the right coronary artery (straight arrow in b, RCA in c) from the left coronary cusp with an interarterial course. AR = aortic root, curved arrow in b = left main coronary artery, arrowhead in b = pulmonary valve, LAD in c = left anterior descending coronary artery, LCx in c = left circumflex coronary artery. (d, e) Selected images from subsequent nongated CTA of the chest, abdomen, and pelvis show the anomalous origin of the right coronary artery (black arrow in e) from the left coronary cusp. AR = aortic root, * = RV outflow tract, arrow in d = left main coronary artery, white arrow in e = left circumflex coronary artery. This case highlights the fact that anomalous coronary arteries may not be detected at TTE and are occasionally discovered at nongated chest CT.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Figure 24a.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Figure 24b.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Figure 24c.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Figure 24d.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Figure 24e.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Figure 24f.
Anterior mediastinal mass. (a) Axial contrast-enhanced T1-weighted MR image shows a large avidly enhancing anterior mediastinal mass (arrow) with displacement of the heart secondary to mass effect. (b) Axial T2-weighted black-blood MR image shows the anterior mediastinal mass (arrow) with prominent internal hypointense flow voids. AR = aortic root, MPA = main pulmonary artery. (c, d) Axial (c) and sagittal (d) CTA images show the avidly enhancing anterior mediastinal mass (arrow) with an associated pericardial effusion (*). AR = aortic root, MPA in c = main pulmonary artery, RPA in d = right pulmonary artery. (e) Digital sub traction angiogram shows prominent contrast blush in the region of the mass (arrow) near the right coronary artery (arrowhead). (f) Parasternal long-axis TTE view retrospectively shows but incompletely characterizes the large anterior mediastinal mass (arrowhead), which is partially seen as a complex heterogeneous hypoechoic mass in the lateral aspect of the field of view. LVOT = LV outflow tract. Surgical biopsy yielded histologic findings consistent with a paraganglioma.
Extracardiac mass in an 81-year-old man who presented to the emergency department with acute chest pain and underwent CT pulmonary angiography (CTPA). (a) Axial CTPA image shows a large heterogeneous mass (*) in the left upper lobe that abuts and invades the pericardium, as well as a moderate-sized left-sided pleural effusion (arrowhead) and adjacent atelectasis. (b) Apical four-chamber view from TTE performed 2 weeks earlier shows the large hypoechoic mass (*) adjacent to the LV; the mass was seen only in retrospect. CT-guided biopsy demonstrated primary lung squamous cell carcinoma.
Figure 25a.
Extracardiac mass in an 81-year-old man who presented to the emergency department with acute chest pain and underwent CT pulmonary angiography (CTPA). (a) Axial CTPA image shows a large heterogeneous mass (*) in the left upper lobe that abuts and invades the pericardium, as well as a moderate-sized left-sided pleural effusion (arrowhead) and adjacent atelectasis. (b) Apical four-chamber view from TTE performed 2 weeks earlier shows the large hypoechoic mass (*) adjacent to the LV; the mass was seen only in retrospect. CT-guided biopsy demonstrated primary lung squamous cell carcinoma.
Extracardiac mass in an 81-year-old man who presented to the emergency department with acute chest pain and underwent CT pulmonary angiography (CTPA). (a) Axial CTPA image shows a large heterogeneous mass (*) in the left upper lobe that abuts and invades the pericardium, as well as a moderate-sized left-sided pleural effusion (arrowhead) and adjacent atelectasis. (b) Apical four-chamber view from TTE performed 2 weeks earlier shows the large hypoechoic mass (*) adjacent to the LV; the mass was seen only in retrospect. CT-guided biopsy demonstrated primary lung squamous cell carcinoma.
Figure 25b.
Extracardiac mass in an 81-year-old man who presented to the emergency department with acute chest pain and underwent CT pulmonary angiography (CTPA). (a) Axial CTPA image shows a large heterogeneous mass (*) in the left upper lobe that abuts and invades the pericardium, as well as a moderate-sized left-sided pleural effusion (arrowhead) and adjacent atelectasis. (b) Apical four-chamber view from TTE performed 2 weeks earlier shows the large hypoechoic mass (*) adjacent to the LV; the mass was seen only in retrospect. CT-guided biopsy demonstrated primary lung squamous cell carcinoma.
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References

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