A 15 year old asymptomatic girl was followed by cardiology for a small perimembranous ventricular septal defect (VSD). A routine echocardiogram demonstrated spontaneous closure of the VSD, as well as right atrial and ventricular
enlargement. Significant volume loading from a VSD would cause left heart dilation which was not seen. The unexpected right heart dilation suggested a previously unnoticed atrial level shunt. She was referred for surgical closure of
a presumed secundum atrial septal defect (ASD). However, on review of imaging prior to surgery, an enlarged coronary sinus was noted.
CASES OF THE WEEK 2019
A 23-year-old migrant from Zimbabwe presented with a 10 day history of flu-like symptoms, myalgias, chest pain, palpitations, Troponin I of 1.8 mcg/L (normal <0.040) and peripheral eosinophilia of 3.42 x109/L (normal
<0.6 x109/L). He had been diagnosed with anti-neutrophil cytoplasmic antibody (ANCA) negative eosinophilic granulomatosis with polyangiitis (EGPA) with cardiac involvement 2 years prior, in 2015.
An asymptomatic 10-year-old male visited his pediatrician for his regular attention deficit and hyperactivity disorder (ADHD) follow-up. A new systolic ejection murmur was heard. Chest x-ray showed an abnormal aortopulmonary
window with enlargement of the left atrial shadow. ECG showed P-mitrale (M-shaped P-waves) in lead II and biphasic P-waves in lead V1, suggesting left atrial enlargement (Figure 1). These results prompted a referral
to pediatric cardiology.
A 56 year old male with a past medical history of antiphospholipid syndrome, chronic kidney disease stage III (resulting from a renal infarct from an embolic thrombus), and essential hypertension presented to the emergency department after a near syncopal
episode while he was uploading boxes. Upon EMS arrival, he was noted to be in monomorphic ventricular tachycardia (Figure 1) that needed immediate synchronized cardioversion with subsequent resolution of his symptoms.
A 30 year old gravida 2 para 1 female was referred for evaluation of a fetal intracardiac mass noted on routine obstetric ultrasound. Fetal echocardiogram at 26-weeks’ gestation revealed a single, large, homogenous, hyperechoic cardiac mass occupying
bi-atrial cavities with unobstructed intra-cardiac flows. There was normal biventricular systolic function and no pericardial effusion. Serial fetal echocardiograms showed the size of the mass increasing in proportion to
the rest of the cardiac size.
A 19-year-old woman presented with a 2-week history of painful atraumatic left ankle swelling associated with painful plantar-flexion and petechial rash on the left foot. Six weeks prior to presentation, she experienced
flu-like illness with headache, fevers and myalgias/athralgias. On examination, there was a non-blanching petechial rash over the dorsum of the left foot with associated edema and warmth but no erythema. Peripheral
pulses were normally palpable with normal capillary refill. Neurological exam of the foot was normal except for 4/5 power on plantar flexion due to pain. Ultrasound of the leg showed a thrombus in the lateral tarsal
artery raising a possibility of an embolus.
A 43-year-old male patient underwent left side radical nephrectomy four months ago for removal of biopsy proven clear renal cell carcinoma. The patient did not receive chemotherapy. The patient presented with complaints
of shortness of breath and hemoptysis. Echocardiogram revealed a left atrial mass with no right heart involvement detected. As renal cell carcinomas most commonly involve the heart by extension through the IVC and right-side
chambers, a left atrial thrombus was initially suspected in this case. The patient was referred for cardiac MRI to verify the diagnosis prior to starting anticoagulants.
A 46 year old woman presented with complaints of generalized abdominal pain. Initial work up with a Computerized Tomography (CT) scan of abdomen/pelvis revealed wedge shaped areas of low attenuation in her spleen and right
kidney which was consistent with infarction. She also had adynamic ileus secondary to bowel infarction along with findings suggestive of an embolus in her superior mesenteric artery (SMA). CT also revealed a possible
2 x 4.1 cm “mass” within the left ventricle of the heart.
A 54 year old woman was diagnosed with left-sided breast cancer in October 2015. She was treated with chemotherapeutic agents (CA) Adriamycin (cumulative dose of 400 mg/m2), cyclophosphamide and trastuzumab (Herceptin®).
She also received ADO–trastuzumab emtansine (Kadcyla®) for a history of metastatic breast cancer previously receiving treatment with Herceptin®. During her chemotherapy regimen an echocardiogram revealed lowered left
ventricular (LV) systolic function (LVEF 48%).
CASES OF THE WEEK 2018
A 6 year old male presented to the emergency department with a 2 week history of intermittent fever, fatigue, anorexia, and weight loss. His past medical history is significant for a history of refractory Kawasaki Disease
diagnosed 1 year prior to presentation.
The patient is a 3-week-old male with a history of factor VII deficiency presented with new onset right shoulder swelling. He was brought to the ED after his mother noticed that his shirt was fitting differently and that
he was favoring use of his left arm. The mother further reported a hard lump on his left ribcage. She stated that it “just appeared”. She also reported labored breathing, with substernal retractions and tachypnea.
The patient is a 27-year-old male status post complete surgical repair of supra-cardiac total anomalous pulmonary venous return (TAPVR) in infancy. He was followed intermittently until 15 years old, with no concerning imaging findings, and was essentially asymptomatic. At 23 and 27 years of age, he presented to the emergency department with atrial fibrillation and atrial flutter, respectively, requiring cardioversion.
A 24 year old woman with a 3 year history of asthma presented with a disseminated dermatosis manifesting as erythematous, pruritic papules with pain in her metacarpophalangeal and interphalangeal joints. She received unspecified treatment with partial response. Six months later she presented again with erythematous, pruritic papules involving the back, both arms and hands, and right leg. She had edema of the ankles and feet and dyspnea.
A 6-year old boy with Kabuki syndrome and previously diagnosed bicuspid aortic valve was referred for elective cardiology follow-up after his family relocated to a new state. His past medical history was remarkable for developmental delay, bilateral sensorineural hearing loss, visual deficits (strabismus with esotropia, right hypertropia and latent bilateral nystagmus), ureteropelvic obstruction and moderate-severely pronated valgus flat feet. Kabuki syndrome was diagnosed on the basis of clinical features, and a chromosomal microarray was normal.
A 54-year-old male with a history of heart failure and coronary artery disease and recent LAD stenting presented with chest pain and shortness of breath. He was noted to have a fever to 101.5 ° F
and decreased breath sounds in the left lung base. On initial laboratory workup he was noted to have normal troponin levels but an elevated white count. His EKG demonstrated pathologic Q waves consistent
with a remote anteroseptal and inferior infarct.
A 59-year-old female with suspected dilated cardiomyopathy and no valvular pathology was referred for cardiac MRI. Resting EKG showed normal sinus rhythm, left ventricular hypertrophy, and non-specific T wave abnormalities.
A 39-year-old male with a history of obesity and poorly controlled essential hypertension presented to the emergency department with chest pain and shortness of breath. A CT angiogram demonstrated normal coronary anatomy.
However, a vascular structure was noted coursing from the innominate vein toward the left atrium (Image 1). This was interpreted as a persistent left superior vena cava (LSVC) with intact bridging vein. The patient
was referred to a cardiologist for further evaluation of his symptoms and management of his hypertension. 2-dimensional (2D) transesophageal echocardiogram (TEE) demonstrated a structurally normal heart, mild qualitative
dilation of the left atrium (LA), and no apparent atrial or ventricular septal defects. There was no significant atrioventricular valve insufficiency. The right ventricle (RV) and left ventricle (LV) were normal in
regards to size, global systolic function, and regional wall motion. A bubble contrast study was performed to exclude intracardiac shunting.
A four-year old patient with pulmonary atresia and ventricular septal defect (PA/VSD) after surgical repair with Contegra conduit (bovine jugular vein graft, Medtronic, Minneapolis, MN) at the age of 2 years underwent repeated
CMR scan under general anesthesia for evaluation of aortic regurgitation and assessment of left ventricular volumes. CMR showed significant aortic regurgitation through a perforation in the right coronary cusp with
mild left ventricular dilatation and mildly impaired left ventricular systolic function. Surprisingly, severe stenosis of the pulmonary conduit due to a mobile mass with severe dilatation and severe dysfunction of the
right ventricle was recognized. These findings were not seen on echocardiogram performed 2 months before and were suspicious of infectious endocarditis (IE).
A 71 year old female was seen at the outpatient clinic with complaints of exertional dyspnea. Her medical history noted an inferior myocardial infarction 2 years earlier, for which primary percutaneous coronary intervention
of the right coronary artery (RCA) was performed. This procedure had been compromised by cardiac tamponade, thought to have been caused by perforation of the RCA through wire exit. A subxyphoidal drainage was performed
removing 300ml of blood and thrombi, after which patient was treated conservatively.
Two months after this episode, the patient presented to the emergency department with dyspnea. A CT scan was performed under suspicion of pulmonary embolism, which proved not to be the case. A left ventricular
pseudoaneurysm was visible on this scan, but wasn’t reported and thus remained unrecognized.
A 40-year-old man with pentalogy of Cantrell including omphalocele, epicordis with ventral herniation into the abdominal cavity, chest wall deformities, and congenital heart disease presented to our adult congenital heart
disease clinic with lower extremity swelling. His complex congenital heart disease consisted of double outlet right ventricle (DORV) with D-malposition of the great arteries, severe left pulmonary artery stenosis, severe
pulmonary insufficiency, cor triatrium sinister and ventricular herniation into the abdominal cavity.
A 32-year-old male patient with no relevant medical history presented with acute onset of chest pain. His initial ECG showed ST segment elevation in leads V1 to V3 with reciprocal ST segment depression in inferior leads
A 57 year old woman with a history of sinus venosus atrial septal defect and partial anomalous pulmonary venous return (PAPVR) repaired in childhood presented to the adult congenital heart disease clinic with junctional
rhythm and significant lower extremity swelling. She had three surgeries during childhood for congenital heart disease. She did not have consistent care for her heart disease and her surgical history was not clear at
presentation. In addition to her congenital heart disease she had known active hepatitis C infection. A month before presentation, she was evaluated for dizziness with bradycardia. She continued to have intermittent
bouts of dizziness without syncope.
A term male infant with a birth weight of 3,623 grams failed a routine pulse oximetry screening at approximately 36 hours of life. There were no pregnancy complications aside from maternal tobacco use. Pre-
and post-ductal saturations were 94% and 86-88%, respectively. An echocardiogram was notable for a large mass in the right pulmonary artery.
A 22-year old Caucasian gentleman was transferred as an emergency to our cardiac surgical center with a large unexplained right ventricular mass, with evidence of a large pulmonary embolus. He had a 6-week history of fevers
and rigors following a dental infection and had been admitted to another hospital 10 days previously for investigation. He was otherwise fit and well, with no previous medical history or medications. He had been treated
with a course of penicillin V at the time of initial dental infection, and had presented a number of times to his local emergency department in the preceding weeks with fevers, mouth ulcers, pleuritic chest pain and
had raised inflammatory markers (white cell count of 18 cells per cubic millimeter of blood with neutrophilia, C-reactive protein (standard assay) of 120 mg/mL, erythrocyte sedimentation rate of 80 mm/hr)
with negative blood cultures and no localizing signs of infection.
CASES OF THE WEEK 2017
A 71-year old male with a previous history of working-exposure to glass components was admitted to our hospital with persistent complaints of chest tightness, shortness of breath and edema in the lower limbs that started
3 months prior to his admission. An echocardiogram from a local hospital identified a nodule on the right-sided of the pericardium and large pericardial and pleural effusions. Percutaneous drainage was performed and
30 mL were obtained from the pericardium and 500 mL from the pleurae, both of hemorrhagic appearance. Biochemical analysis of pericardial and pleural fluids was not performed and cytological analysis was negative for
malignant cells. Medical treatment was initiated and the patient remained asymptomatic for the following 3 days. The patient’s symptoms recurred and rapidly worsened so he was admitted to our institution for further
examination and treatment.
A 64-year old Caucasian lady was seen at the rapid access chest pain clinic with a 6-month history of atypical chest pain. Her risk factors for cardiovascular disease were smoking, hypertension and familial risk. She was
referred for coronary angiography that revealed moderate right coronary artery/posterior descending artery stenosis while left ventriculography suggested an unusual cardiac orientation with a laterally displaced and
vertically oriented heart. She was referred to us for stress perfusion cardiovascular magnetic resonance (CMR) imaging.
A 64-year-old male with history of Acute Myelogenous Leukemia (AML) status post bone marrow transplant (BMT) in complete remission presented with dyspnea when laying on his right side which resolved when supine or in the
left lateral decubitus position. He also reported occasional shortness of breath with mild exertion. Only tachycardia was noted on clinical examination. There were no clinical signs of SVC syndrome.
A 59 year old male patient, diabetic, hypertensive presented with a non ST-segment elevation myocardial infarction (NSTEMI) (Image 1). The peak troponin I was 5.9 ng/ml (reference level up to 0.02 ng/ml). Coronary angiography,
performed within four hours from the onset of chest pain, showed a significant proximal left anterior descending (LAD) artery lesion for which two drug eluting stents were deployed. The right coronary artery (RCA) was
dominant with sluggish flow and an insignificant proximal lesion. No stents or angioplasty were performed on the RCA (Movie 1,2). ECG was recorded after catheterization (Image 2).
A 57-year-old female presented with atypical chest pain. Her past medical history was unremarkable. Initial ECG (Figure 1) revealed inferolateral T wave inversion without evidence of left ventricle hypertrophy by voltage
criteria; however, serial cardiac enzymes were negative.
Acute coronary syndrome was ruled out and the patient was referred for stress echocardiography. The stress echocardiogram revealed normal LV size and systolic function with no resting or inducible regional wall motion abnormality.
However there was an incidental finding of asymmetric thickening of the distal inter-ventricular septum raising suspicion for atypical hypertrophic cardiomyopathy.
A 43 year old female with a past medical history significant for hypertension and mild rheumatoid arthritis and no known cardiac disease experienced the sudden onset of chest pain, malaise, and pre-syncope at an airport.
Paramedics were alerted and she was found to have inferior ST- segment elevations on an ECG (see Figure 1). The patient was immediately taken to the nearest cardiac catheterization laboratory and was found to have no
significant coronary artery lesions. Her peak CK-MB was in the 50s ng/mL and her peak Troponin was 15 ng/mL. A transthoracic echocardiogram demonstrated an inferior wall motion abnormality and a left ventricular ejection
fraction of 35-45% (see Figures 2-6). Her symptoms and inferior ST segment elevations subsequently resolved. She was diagnosed with coronary vasospasm and treated with diltiazem, carvedilol, aspirin, clopidogrel, nitroglycerin,
simvastatin, and lisinopril. After discharge, she participated in cardiac rehabilitation but reported low energy and fluid retention that was managed with low-dose diuretics.
A 60-year-old, obese woman with diabetes and hypertension presented with dyspnea on exertion and atypical chest pain for weeks. The physical examination was unremarkable. No ischemic changes were observed on the electrocardiogram.
The sensitive Troponin-T level was less than 50.0 ng/L (0.0-100.0).
A 71-year old woman, without relevant medical history, initially presented with progressive dyspnea and orthopnea due to new onset heart failure (New York Heart Association functional class III). Her blood pressure at admission
was 170/105 mmHg. A chest X-ray revealed cardiomegaly and pulmonary edema. A transthoracic echocardiogram was performed and moderately reduced left ventricular function and an echodense mass in the right atrium were
observed. For differentiation of various etiologies and diagnosis of the mass, cardiovascular magnetic resonance (CMR) imaging was the next step in the diagnostic strategy.
Early diagnosis of aortitis is crucial for proper management of the disease and prevention of future sequelae. Clinical presentation of aortitis is often nonspecific and patients with early stages of aortitis are often
asymptomatic. Traditionally, the diagnosis of aortitis is invasive often requiring arterial biopsy. However, advanced imaging can be an invaluable tool to assist clinicians in the evaluation of patients for possible
aortitis with high specificity, and sensitivity . In this case report, we present a patient with atypical presentation of aortitis, and describe how different imaging modalities can be used to assist in the diagnosis
A 43-year-old female with a history of asthma and uterine fibroids presented with shortness of breath. She reported chest tightness and was awakened from sleep with chest pain that radiated down her left arm. She had no
prior history of cardiac diseases. There was recent history of fever, and productive cough.
A 55-year-old Caucasian female presented with typical angina-like symptoms. Cardiovascular examination revealed a diastolic murmur, loudest at the left sternal edge. Her past medical history included mild hypercholesterolaemia
only. Electrocardiography showed sinus rhythm with no ischaemic changes. Coronary angiography showed unobstructed but markedly dilated high flow coronary arteries draining directly into the left ventricle (LV) through
a plexus of small vessels arising from both coronaries (coronary-cameral communications). This mimicked aortic regurgitation on aortography (Figure 2; prompt LV opacification but not through the valve). No epicardial
venous system enhanced.
A 34 year old female presented with a history of loss of appetite, unintended weight loss, and heart failure. Her past history was remarkable for a diagnosis of eosinophilic polyangiitis (EGPA). She also had a prior bout
of middle cerebral artery syndrome earlier in the year of uncertain etiology, although a coexisting PFO was found and thought to possibly represent a source of paradoxical embolism. A CT of the chest was performed to
evaluate suspected pulmonary involvement, and demonstrated left ventricular enlargement. A transthoracic echocardiogram depicted a thrombus in the left ventricle. A CMR exam was then performed to further evaluate this
finding, assess left ventricular function, and determine possible cardiac involvement by EGPA.
A 31 month old female was diagnosed with a large secundum atrial septal defect (ASD) following evaluation for a murmur as neonate. At that time, a separate “third chamber” was noted that appeared contiguous with the lateral
left atrium that was believed to represent a cor triatriatum membrane. One pulmonary vein was seen draining into the left atrium. The other pulmonary veins were thought to drain into the “third chamber” however transthoracic
echocardiography never definitively resolved this by color flow Doppler. She remained clinically asymptomatic although notably required three admissions for upper respiratory infections during the previous year. She
was scheduled for elective closure of the ASD and resection of the cor triatriatum membrane. An intraoperative transesophageal echocardiogram was performed, which demonstrated normal pulmonary venous return and concern
for a large extracardiac mass compressing the left atrium. The operative repair was delayed and the patient was transferred under anesthesia to the MRI suite to obtain a cardiac MRI for further evaluation of the mass
prior to same day resection.
CASES OF THE WEEK 2016
A 55 year old previously healthy woman was evaluated for progressive dyspnea on exertion with associated chest tightness. She denied fevers, chills, and night sweats. She underwent a 2D-Echocardiogram which showed a large
pericardial effusion with thickening of the right atrial wall and a mass just below the posterior tricuspid leaflet. Left and right ventricular systolic function was normal. Pericardiocentesis yielded 850 mL of
hemorrhagic fluid, analysis of which was nondiagnostic. A CT of the chest, abdomen, and pelvis demonstrated numerous lung nodules, ground glass lesions and diffuse mediastinal lymphadenopathy. In addition, the cardiac
mass was visualized. To define the probable etiology of the mass, cardiac MRI was performed for more precise localization and tissue characterization.
The case of a 85 year-old lady is presented who complain of atypical chest pain. After a markedly abnormal ECG showing high voltage R waves and deep, inverted T waves on precordial leads, an echocardiographic study
is performed, suggesting non-obstructive hypertrophic cardiomyopathy (HCM).
A CMR exam is requested to: 1) confirm the diagnosis; 2) precisely determine the extent of the process; 3) establish the presence or not of myocardial fibrosis; and 4) to rule out myocardial ischemia.
An 81-year-old male patient presented with sudden and intense chest pain. On the emergency ward, a transthoracic echocardiogram was performed showing an enlarged and wall-thickened thoracic aorta. Computed tomography angiography
confirmed the enlarged and wall-thickened thoracic aorta. In non-contrast images, a high-attenuation crescentic thickening of the aortic wall suggested an intramural hematoma or aortitis (Figure 1). 18F-FDG-PET suggested
that there was no overt inflammation but findings were equivocal (Figure 1). The patient was stable without pericardial effusion, periaortic hematoma, or large aortic aneurysm; therefore, a cardiac magnetic resonance
imaging study was performed in the next 12 hours to rule out aortitis (1).
A 57-year-old homeless man presented to the emergency room after a syncopal episode. He reported a two-day history of shortness of breath and upper back pain. He was noted to be hypotensive with a blood pressure of 92/69
mmHg. An electrocardiogram showed ST-segment elevations in the inferolateral leads. Emergent coronary angiography revealed diffuse obstructive disease in the left anterior descending coronary artery, occlusion of the
distal left circumflex coronary artery and complete total occlusion of the proximal right coronary artery. The left circumflex lesion was felt to be the culprit and it was treated with balloon angioplasty. Echocardiography
revealed a left ventricular ejection fraction (LVEF) of 15-20% with a contained rupture and pseudoaneurysm involving the lateral wall. He was recommended coronary artery bypass graft surgery and repair of the left ventricular
(LV) pseudoaneurysm, which he refused. He was discharged with medical treatment and presented with NYHA Class III heart failure symptoms 4 months later. He was agreeable to surgery at this time and for surgical planning,
he underwent a cardiovascular magnetic resonance (CMR) study.
A 20-year-old male with a history of hypertension presented to the emergency department because of a severe headache. On examination, the patient was confused and disoriented. His BP was 135/61 mmHg, temperature 35.6°C
(97.9°F), pulse 78, and respiratory rate 24. Cardiovascular exam showed a regular heart rhythm, a grade III/VI diastolic murmur heard best in the third left intercostal space, strong pulse, no edema, warm skin, and
capillary refill of < 3 seconds. No lower extremity blood pressures were obtained.
A 64 year old female presented with a long history of vague dyspnea on exertion and intermittent palpitations. She had a history of mild exercise intolerance for the last 50 years with difficulty keeping up with her peers
as early as high school. She had a normal physical exam with no murmur or gallop. A recent 24 hour Holter monitor was concerning for intermittent supraventricular tachycardia with possible atrial fibrillation. Her transthoracic
echocardiogram showed left atrial dilation and concern for possible cor triatriatum with a membrane across the mid left atrium. A nuclear stress test was negative with no evidence of infarct or ischemia. She had a transesophageal
echocardiogram that showed no evidence of cor triatriatum, severe left atrial dilation, dilated right coronary artery ostium, and continuous unidentified flow into the left atrium. A cardiac MRI and chest MRA was performed
to evaluate the etiology of left atrial dilation in the setting of a dilated coronary artery.
A 19-year old male with no previous cardiovascular history presented with NYHA Class III heart failure symptoms. Electrocardiogram on presentation showed normal sinus rhythm with Himalayan P waves (P waves > 5 mm and
peaked in lead II), right bundle branch block and right axis deviation.
A 55-year old female patient presented after an episode of syncope secondary to polymorphic ventricular tachycardia (pVT). Her medical history included impaired glucose tolerance and deep venous thrombosis 17 years ago.
She did not use any medication. On examination, vital signs were normal and only raccoon eyes were observed. CT-cerebrum excluded intracranial pathology. During the hospital stay she experienced six episodes of pVT
with minimal prolongation of the QT interval, which converted to sinus rhythm either spontaneously or with defibrillation.
An asymptomatic 4-month-old male infant was referred for assessment of a heart murmur. An echocardiogram demonstrated a large (19x11 mm) mass arising from the basal inter-ventricular septum, encroaching on the right ventricular
outflow tract (RVOT), producing mild RVOT obstruction.
A 50 year old mixed race man was admitted in Coronary Care Unit after an episode of syncope and sudden onset chest pain associated with palpitations.
A 52 year old man with a history of arterial hypertension was admitted because of sustained monomorphic ventricular tachycardia (Fig. A) reverted by amiodarone.
The patient's mother presented at 33 weeks gestation for a fetal echocardiogram secondary to a suspected cardiac abnormality on obstetrical ultrasound.
A 17 year old male with a history of autism presented to the emergency room with a three day history of subjective fever, otitis media and acute onset of chest pain for one day.
Cases of the Week 2015
A case of PE at early pregnancy evaluated by CMR. When radiation and contrast media really matters.
An 85 year old male veteran had an incidental discovery of a large aneurysm in the region of a ductus diverticulum on a CT chest 2 years prior.
A 64-year-old male, a diabetic and a smoker, with no relevant cardiovascular history presented with a syncope during sexual intercourse after using sildenafil, with complete recovery after 10 minutes.
A 70-year-old female residing in a remote, rural part of Pakistan presented with several days of chest pain and dyspnea concerning for acute coronary syndrome.
A 46 year old woman was referred to our hospital for investigation of vaginal blood loss.
A 64 year old male presented one year after cardiac transplant for routine follow up. A 2D transthoracic echocardiogram revealed a mobile, echogenic lesion along the inferior wall of the right atrium.
A symptomatic 50 year old woman previously diagnosed as congenitally corrected transposition of great arteries (L-TGA) was referred to our department.
An 8-year old girl presented with clinical signs of low cardiac output after symptoms of fever and emesis during a few days. ECG revealed a complete atrio-ventricular (AV) block with a ventricular rate of 35 bpm and wide QRS complexes
(120 ms) with variable axis deviation and bundle branch block morphology.
A teenager who collapsed during athletic activity, has T wave inversion on ECG.
A 23 year-old gentleman presented to the coronary care unit with “dull aching” central chest pain without pleuritic or pericarditic features.
An 84 year-old man presented after an out-of-hospital cardiac arrest and was successfully resuscitated.
A 63 year old healthy man was seen in consultation for chest pain and an abnormal electrocardiogram (EKG).
An asymptomatic 42 year-old male is submitted for a CMR study after an echo scan showing asymmetric hypertrophy involving the apical segment of the left ventricle. A noticeable highly echogenic signal is described at the endocardial border
of the thickened apical region.
49-year-old gentleman diagnosed with T3aN0M1 metastatic renal cell carcinoma in September 2010, underwent a right-sided nephrectomy the same month. He presented to our emergency department with complaints of constant chest pain, which
waxes and wanes in intensity and sharp in characteristic.
A 70 year-old male had presented approximately 6 months prior to another hospital with fatigue, weakness, chest pain and dyspnea. At that time, left heart catheterization showed non-obstructive coronary artery disease and elevated left
ventricular end-diastolic pressures with a restrictive filling pattern.
A 15-year-old boy presented with progressively worsening exertional dyspnea following balloon aortic valvotomy in infancy for congenital aortic stenosis.
A 16-year-old boy was found to have an abnormal ECG during his appendectomy surgery. His background was remarkable for a small muscular VSD which had undergone spontaneous closure on an echocardiogram performed two years prior.
An 8-year old girl with a structurally normal heart presented with acute symptoms of low cardiac output. ECG revealed complete atrio-ventricular block with a ventricular rate of 35 bpm and wide QRS complexes (120 ms) with variable axis
deviation and bundle branch block morphology.
Cases of the Week 2014
A 15 year old boy with Tetralogy of Fallot (TOF) status post a valve-sparing repair who was referred for a cardiac MRI due to pulmonary valve insufficiency.
A 17 year-old male with a history of d-transposition of the great arteries status post arterial switch operation at age 3 days presented with increasing exercise intolerance.
A 34 year-old female with a 2-month history of shortness of breath and new onset lower extremity edema presented to the emergency department for assessment.
A three year old child presents with hemitruncus. This case illustrates the importance of an XMR facility for clinical decision-making in pediatric cardiology.
A 58 year-old man was admitted to hospital with a short history of rapidly progressive breathlessness, haemoptysis, weight loss and fatigue.
An example of a false (pseudo) aneurysm and a true aneurysm in two different patients.
A 75-year-old Caucasian female, diagnosed with intestinal carcinoid tumor presented with a syncopal episode.
A 77-year-old man presented with a 2-week history of low-grade fever and dyspnea. Chest X-ray revealed large pleural effusions on the right side.
A 77-year-old immuno-competent man was referred to our emergency room for onset of dyspnea, orthopnea and paroxysmal nocturnal dyspnea.
A 16 year old male previously dilated from congenital post-ductal aortic coarctation (AoCo) through balloon angioplasty at age of 1 year-old, was referred to cardiovascular imaging to rule out any possible complications derived from high-performance and continuous physical activity as a professional soccer player.
A 70 year old man with hepatitis B, solitary kidney and remote coronary artery bypass grafting from 17 years prior presented with an inferior myocardial infarction.
A 62 year-old Caucasian man presented to the Cardiology Clinic for a routine perioperative evaluation prior to juxtarenal abdominal aortic aneurysm repair.
A 3 year old girl was evaluated in clinic with a history of a previously diagnosed right aortic arch and a patent ductus arteriosus.
A 22 year old female was seen for a routine follow up of her apical muscular ventricular septal defect (VSD).
An asymptomatic 3 year old was evaluated for a murmur. Physical examination was significant for a widely split second heart sound with an ejection systolic murmur in the left upper sternal border.
Cardiac aspergilloma is a very rare entity. The diagnosis is usually made by direct observation of the fungal mass during surgery, biopsy, or pathology. We report the CMR findings in a patient with cardiac aspergilloma.
A 44 year old male status-post repair of dextro-transposition of the great arteries presented with atypical chest pain in the context of hypertension and hypercholesterolaemia.
Cases of the Week 2013
A 33-year-old man was suspected of having a regurgitant quadricuspid aortic valve on the basis of transthoracic echocardiography following the incidental discovery of a diastolic murmur.
A 70-year male presented with gradual deterioration, breathlessness, and peripheral oedema as well as bilateral pleural effusions. He had previous CABGx4(LIMA LAD, VG to OM, Diagonal and RCA).
A 23 year-old morbidly obese female presented with dyspnea on exertion. Shw was born with Down Syndrome, double outlet right ventricle, complete atrioventricular septal defect and pulmonary stenosis and underwent surgical correction at age 5. She also has a reported history of myocarditis at age 19 with resultant systolic dysfunction (EF 35-40%).
Clinical History: A 40 year-old male with no significant past medical history was referred for a chest CT due to the discovery of an enlarged pulmonary artery on routine chest x-ray.
This case report describes a case of co-incidental coronary disease, Takotsubo cardiomyopathy and hypertrophic cardiomyopathy, where cardiac magnetic resonance imaging (MRI) was crucial in establishing the diagnoses.
19 year old asymptomatic male with an abnormal left ventricular finding and ectopy.
A six year old girl was referred to pediatric cardiology for evaluation of a heart murmur.
A fifteen years old girl with known bicuspid aortic valve was admitted with ineffective endocarditis due to Strept. Agalactiae and treated with antibiotic therapy.
A 53 year-old man with no significant past medical history presented to our hospital reporting severe substernal chest pressure with associated diaphoresis that woke him up from sleep. A standard 12-lead electrocardiogram (figure 1) showed marked ST-segment elevation in leads V1, V2, and V3 and in the inferior leads II, III, and aVF, with ST depression in leads I, L, with T wave inversion in V5 and V6.
Progressive aortic root dilatation after repair of tetralogy of Fallot is a rare but recognized complication.The cardiovascular magnetic resonance in this case report represented a key tool for the surgical approach before a tetralogy of Fallot reoperation.
An asymptomatic fifteen-year-old boy with dextrocardia and complete transposition of the great arteries (CTGA) who had arterial switch operation and closure of ventricular septal defect (VSD) during infancy.
A previously healthy 18-year-old woman presented to an outside medical facility with fever and left scapular pain and was found to have an elevated D-dimer.
A 52 year old asymptomatic male affected by hypertension and without other remarkable past medical history presented to the outpatients clinic for check-up.
74 year old gentleman was discharged after an uneventful recovery following four vessel coronary artery bypass grafting, which was done for worsening angina pectoris and triple vessel disease.
A 60-year-old man, originally from Sardinia, with diabetes and hypertension presented with sporadic, nonspecific precordial discomfort of short duration.
A 65 year old, non-diabetic, normotensive and obese female complained of exertional angina of four years’ duration. She had a transient ischemic attack 15 days ago. Physical examination was unremarkable.
Cases of the Week 2012
59 yo female two months post abdominal hysterectomy, bilateral salpingo-oophorectomy for a high grade endometrial leimyosarcoma.
A 61 year old gentleman presented with worsening breathlessness for 2 years. He had a past history of COPD and idiopathic pericardial constriction which had been treated many years earlier by pericardial stripping through a median sternotomy.
We present a case of a 27 year old Native American male with a past medical history of complex congenitally corrected transposition of great arteries (CCTGA) with associated double outlet right ventricle (DORV), dextrocardia, subpulmonary stenosis, subpulmonary VSD and PDA.
69 year-old male with history of endovascular abdominal aortic aneurysm repair, COPD, and metastatic lung cancer status post resection on radiation therapy was referred to a cardiothoracic surgeon for consideration of aortic valve replacement (AVR) after a routine transthoracic echocardiography (TTE) at an outside facility revealed evidence of severe aortic stenosis (AS) with a peak gradient of 105 mmHg and aortic valve area (AVA) of 0.78 cm2.
A four week old male infant was noted to be dysmorphic including hypertelorism, bilateral inguinal herniae, umbilical hernia and bilateral club feet. A right axillary mass was noted on examination; ultrasound revealed the mass to be a dilated and tortuous vessel but could not conclude definitively whether it was venous or arterial.
A 46-year-old man with history of Hodgkin’s lymphoma treated with radiation 20 years ago. Four years previously he had undergone pleurodesis for recurrent pleural effusions. He recently developed worsening dyspnea, lower extremity edema, and ascites. At another facility, he was treated initially for interstitial lung disease with bronchodilators without improvement of his symptoms. He was referred to our center for further evaluation.
The patient is a previously healthy 9 year old child who presented to her primary care doctor with complaints of her feet turning white.
Patient presenting with constitutional symptoms and right atrial mass. Several differential diagnosis and CMR helped to point the correct diagnosis and plan treatment
27 year-old male with the history of heterotaxy syndrome, Tetralogy of Fallot with pulmonary atresia, and right aortic arch.
A 51 year old man was referred for a CMR study. He had repair of Tetralogy of Fallot in childhood.
A 49 year-old male presented with a 10-day history of worsening shortness of breath, paroxysmal nocturnal dyspnea and orthopnea
68 year old female, smoker, with a history of hyperlipidemia, and type 2 diabetes mellitus. In 2007 she suffered from a myocardial infarction with incomplete revascularization.
Cases of the Week 2011
A 18 year old male with tuberous sclerosis presents for cardiac MR after an abnormal echogenic foci was identified on echocardiogram.
A 53 year old male with dyspnea and left atrial prolapsing sarcoma.
A 28 year old woman with history of Wolf-Parkinson-White syndrome status-post ablation of a right posterolateral bypass tract in four years earlier who was referred to us for evaluation of an abnormal transthoracic echocardiogram.
A 65 year old patient presented with symptoms of worsening right heart failure. Transthoracic echocardiography showed right heart dilatation and severe tricuspid regurgitation with grossly abnormal, thickened and retracted tricuspid valve leaflets.
A 63 year old male patient initially presented to the outpatient clinic with fatigue and progressive shortness of breath.
A 69-year-old male with a history of previous myocardial infarction developed increasing exertional dyspnoea and angina four years after initial presentation. CMR demonstrated a left ventricular aneurysm with thrombus.
A 43-year old man with no remarkable past medical history presented with progressive dyspnea and peripheral edema. ECG showed frequent polymorphic ventricular ectopic beats
Echocardiogram showed LV systolic dysfunction.
Myocardial contusion is a ubiquitous cause of hospitalization. The most common etiologies are auto-pedestrian accident, CPR, fall from heights>20’, and motor vehicle accidents.The majority of patients will have a troponin leak and may have EKG changes. Since the right ventricle is the most anterior portion of the heart it is commonly traumatized.
A 42 year old asymptomatic male underwent CMR for screening.
We describe two cases with known and previously documented mitral valve (MV)prolapse on transthoracic echocardiography.
Anterior Mitral Valve Cleft in the Presence of a Primum ASD.
A 38 year-old man without symptoms. His father was diagnosed with right ventricular arrythmogenic cardiomyopathy after heart transplant for ventricular arrhythmias and dilated cardiomyopathy.
72 year old female with susceptibility artifact from oral iron ingestion.
An 18-year-old African American male was admitted to our Emergency Department after developing sudden and severe chest pain.