21 non ischaemic acquired Dr.Muhammad Bin Zulfiqar

DR. MUHAMMAD BIN ZULFIQARPGR IV FCPS SIMS/SHLradiombz@gmail.com

21 Non-ischaemic Acquired Heart Disease Grainger and Allison

• FIGURE 21-1 Summary of classification system proposed ■by American Heart Association. (Modified from Maron et al.1).

• FIGURE 21-2 M-mode (A) and B-mode (B, C) ■echocardiography in hypertrophic cardiomyopathy. M-mode allows measurements of left ventricle diastolic diameter (44 mm) and systolic diameter (28 mm), as well as thickened interventricular septum (28 mm). (B, C) Diastolic and systolic short-axis images, with clear evidence of hypertrophic septum.

• FIGURE 21-2 M-mode (A) and B-mode (B, C) ■echocardiography in hypertrophic cardiomyopathy. M-mode allows measurements of left ventricle diastolic diameter (44 mm) and systolic diameter (28 mm), as well as thickened interventricular septum (28 mm). (B, C) Diastolic and systolic short-axis images, with clear evidence of hypertrophic septum.

• FIGURE 21-3 B-mode (A, B) and Doppler ■echocardiography (C, D) horizontal long-axis views, in hypertrophic cardiomyopathy. (A, B) B-mode images show basal septal hypertrophy. (C) Doppler interrogation in outflow tract demonstrates a rest systolic gradient of 30 mmHg, while (D) transmitral flow evaluation shows an impairment of diastolic function, with reduced E wave equalised to A wave.

• FIGURE 21-3 B-mode (A, B) and Doppler ■echocardiography (C, D) horizontal long-axis views, in hypertrophic cardiomyopathy. (A, B) B-mode images show basal septal hypertrophy. (C) Doppler interrogation in outflow tract demonstrates a rest systolic gradient of 30 mmHg, while (D) transmitral flow evaluation shows an impairment of diastolic function, with reduced E wave equalised to A wave.

• FIGURE 21-4 Hypertrophic cardiomyopathy. ■(A) Cine-MRI frame showing typical localisation at basal septum. (B) Late gadolinium enhancement MRI short-axis image: thickened interventricular septum with large amount of fibrosis (hyperintense intramural foci).

• FIGURE 21-5 Cardiac CT in hypertrophic ■cardiomyopathy. Short axis mid ventricular image shows a diffuse left ventricle myocardial hypertrophy, with prevalent involvement of anterior wall.

• FIGURE 21-6 Gadolinium-enhanced MRI: ■short axis. (A) First-pass frame showing intramural perfusion defect in lateral wall (arrow); (B) late enhancement due to fibrosis is evident in the same segment.

• FIGURE 21-7 Different late gadolinium enhancement in ■hypertrophic phenotypes. First column, large septal intramural late enhancement in hypertrophic cardiomyopathy (HCM) (arrows). Second column: intramural lateral wall late enhancement in Fabry disease (arrow). Third column: subendocardial diffuse late enhancement in amyloidosis (arrow in left ventricle, white arrows in right ventricle). Fourth column: T2w image (top) showing intramural hyperintense foci and striae due to oedema; lower image shows late enhancement in the same areas.

• FIGURE 21-7 Different late gadolinium enhancement in ■hypertrophic phenotypes. First column, large septal intramural late enhancement in hypertrophic cardiomyopathy (HCM) (arrows). Second column: intramural lateral wall late enhancement in Fabry disease (arrow). Third column: subendocardial diffuse late enhancement in amyloidosis (arrow in left ventricle, white arrows in right ventricle). Fourth column: T2w image (top) showing intramural hyperintense foci and striae due to oedema; lower image shows late enhancement in the same areas.

• FIGURE 21-8 Primary dilative cardiomyopathy. ■(A) Frontal view and (B) lateral view show overall increased cardiac size, with signs of left atrial enlargement (black arrows in A, thin white arrows in B), and left ventricle enlargement (thick black arrows in A, thick white arrow in B).

• FIGURE 21-9 Dilative cardiomyopathy. ■Echocardiography shows enlarged left ventricle.

• FIGURE 21-10 Black-blood FSE T1w image ■of dilated cardiomyopathy. Left atrial and left ventricle enlargement is clearly evident

• FIGURE 21-12 Late gadolinium ■enhancement images in short-axis and four-chamber view, showing septal intramural contrast uptake in idiopathic dilated cardiomyopathy

• FIGURE 21-12 Late gadolinium ■enhancement images in short-axis and four-chamber view, showing septal intramural contrast uptake in idiopathic dilated cardiomyopathy

• FIGURE 21-11 Ischaemic versus non-ischaemic dilated ■cardiomyopathy. (A) Diastolic frame of two-chamber cine-MRI showing dilated left ventricle with inferoapical myocardial thinning. (B) Late enhancement in subendocardial layer of basal, mid and apical inferior segments, due to previous infarct in right coronary artery territory. (C) Diastolic frame of two-chamber cine-MRI showing dilated left Ventricle. (D) Short-axis late enhancement image, showing no gadolinium uptake.

• FIGURE 21-11 Ischaemic versus non-ischaemic dilated ■cardiomyopathy. (A) Diastolic frame of two-chamber cine-MRI showing dilated left ventricle with inferoapical myocardial thinning. (B) Late enhancement in subendocardial layer of basal, mid and apical inferior segments, due to previous infarct in right coronary artery territory. (C) Diastolic frame of two-chamber cine-MRI showing dilated left Ventricle. (D) Short-axis late enhancement image, showing no gadolinium uptake.

• FIGURE 21-13 MRI of dilated ■cardiomyopathy complication. Thrombi in left ventricle are evident in late enhancement four- (A) and two-chamber (B) views

• FIGURE 21-14 Cardiac CT in dilated cardiomyopathy. ■(A) Left ventricle dilation in four-chamber view. (B, C) MIP reformatted images of right coronary artery, common trunk and left descending coronary artery showing no atherosclerotic lesions.

• FIGURE 21-14 Cardiac CT in dilated ■cardiomyopathy. (A) Left ventricle dilation in four-chamber view. (B, C) MIP reformatted images of right coronary artery, common trunk and left descending coronary artery showing no atherosclerotic lesions.

• FIGURE 21-15 2D echocardiography in restrictive cardiomyopathy. ■End-diastolic frame on left, end-systolic frame on right. In both images an endocardial thickening with thrombotic layer and calcifications are evident. Thickening of mitral valve is also present

• FIGURE 21-16 Restrictive cardiomyopathy. (A) ■SE T1w image and (B) cine-MRI frame, both showing tubular shape of ventricles and enlarged atria. In (B) a flow void in the left atrium due to mitral regurgitation is evident.

• FIGURE 21-17 Restrictive cardiomyopathy ■due to fibroelastosis. (A) SE T1w image shows an apparent thickened myocardium; (B) STIR image shows a thickened hyperintense endocardium (arrows) with normal myocardium.

• FIGURE 21-18 Cardiac amyloidosis. (A, B) Contiguous ■T1w axial slices show marked myocardial thickening of both ventricles, with heterogeneous signal intensity; a small amount of pericardial effusion is present (arrows). (C) Late gadolinium enhancement shortaxis image shows no myocardial suppression due to increased extracellular space and interstitial amyloid accumulation.

• FIGURE 21-19 Iron overload in major ■thalassaemia. Multi-echo fast gradient-echo sequence for T2* quantification; from a short TE (1.1 ms, top left) to a long TE (18 ms, bottom right), a rapid decay of myocardium signal intensity

• FIGURE 21-20 Constrictive pericarditis. (A) This axial ■black-blood FSE image shows a diffuse pericardial thickening (5 mm), more evident anteriorly. Note also incomplete blood suppression in right atrium due to slow flow. (B) Axial unenhanced cardiac CT confirms pericardial thickening but also the presence of small calcifications

• FIGURE 21-21 European Society of Cardiology ■classification of primary cardiomyopathies. (Modified from Elliott et al.2).

• FIGURE 21-22 Arrhythmogenic right ventricular cardiomyopathy. ■Black-blood axial image shows a complete fatty substitution of right ventricle free wall (high signal intensity tissue); similar foci are evident in left ventricle apex and basal lateral wall (arrows).

• FIGURE 21-23 T1w axial image in a patient receiving ■intensive steroid treatment. An increased amount of fat is evident in the mediastinum, prepericardial and subepicardial spaces, but normal right ventricle myocardium is visible.

• FIGURE 21-24 Arrhythmogenic right ■ventricular cardiomyopathy. Cine-MRI axial (A) and short-axis (B) images show huge right ventricle dilation with small free-wall bulges (arrows in A).

• FIGURE 21-25 Echocardiography. Two-chamber view shows ■thickened endocardium and increased trabeculation of left ventricle apex (arrows

• FIGURE 21-26 Left ventricular non-compaction. (A) ■T1w black-blood vertical long-axis image shows increased number and thickness of myocardial trabeculae in mid and apical left ventricle regions. (B) Cine-MRI frame in horizontal long axis with measurement of non-compacted and compacted myocardium.

• FIGURE 21-27 Left ventricular non-compaction. Late ■enhancement images show contrast uptake in compacted myocardium (mostly at septal level), with subendocardial sparing, due to fibrotic changes. As an ancillary finding, multiple thrombi are visible.

• FIGURE 21-28 Takotsubo cardiomyopathy. (A) ■T2w image in vertical long axis shows diffuse hyperintensity of the myocardium, due to oedema (arrows); (B) late enhancement image in the same plane shows no contrast uptake, demonstrating absence of any irreversible lesion.

• FIGURE 21-29 Acute myocarditis. (A) T2w STIR short-axis ■image shows a subepicardial hyperintense area in inferior wall; (B) late enhancement image in corresponding plane shows contrast uptake with a non-ischaemic pattern. Patient presented 36 h before in emergency unit with chest pain and slight increase in cardiac enzymes; emergency coronary angiography was negative.

• FIGURE 21-30 Chronic myocarditis in patients ■presenting with new-onset severe tachyarrhythmia. (A) T2w STIR short-axis image shows no evidence of oedema; (B) late enhancement image in the same plane shows septal intramural contrast uptake. Septal endomyocardial biopsy demonstrated a lymphocytic infiltrate with interstitial fibrosis

• FIGURE 21-31 Chest X-ray, frontal view, in ■intensive care unit shows signs of alveolar pulmonary oedema without cardiac enlargement.

• FIGURE 21-32 Chest X-ray shows left atrial appendage ■enlargement (arrow) in mitral regurgitation; subcarinal opacity with slight dislocation of upper left main bronchus is also evident due to left atrium enlargement

• FIGURE 21-33 Mitral prolapse. ■Echocardiography (parasternal long axis) shows wide anterior leaflet prolapse of the mitral valve.

• FIGURE 21-34 Mitral regurgitation. Echo ■colour Doppler shows severe regurgitation in the left atrium and marked left ventricle enlargement (mitral annulus dilation).

• FIGURE 21-35 Mitral regurgitation. Echo ■colour Doppler shows severe mitral regurgitation (apical 4C). Mosaic effect is evident with complete occupation of the left atrium.

• FIGURE 21-36 Cine-MRI frame of functional ■mitral regurgitation (black jet directed from left ventricle to left atrium) in dilated cardiomyopathy

• FIGURE 21-37 Mitral stenosis. ■Echocardiography (parasternal long axis) shows marked thickening of mitral leaflets with restricted mitral valve orifice (doming anterior leaflet). Left atrial (LA) enlargement is evident.

• FIGURE 21-38 Cine-MRI frame of mitral ■stenosis. A small flow void directed from left atrium (LA) to left ventricle (LV) is visible (arrows), due to mild mitral stenosis. Left atrium is enlarged.

• FIGURE 21-39 Tricuspid regurgitation. Echo ■colour Doppler demonstrates severe tricuspid insufficiency with mosaic effect occupying entirely the right atrium.

• FIGURE 21-40 Cine-MRI frame of tricuspid ■regurgitation. A retrograde black jet directed from right ventricle to right atrium is evident (arrowheads).

• FIGURE 21-41 Chest X-ray of aortic stenosis shows rounded ■ profile of left ventricle (left third cardiac arch, white arrows), with slight enlargement of ascending aorta (right first cardiac arch, arrowheads).

• FIGURE 21-42 B-mode echocardiography, ■horizontal long axis, in aortic stenosis. Hyperechoic calcified aortic leaflets; mitral annulus calcification is also evident.

• FIGURE 21-43 Cardiac CT. Multiplanar short-axis reformation ■aortic valve shows leaflet calcification with reduced systolic orifice. Manual contouring of the orifice allows stenosis quantification (moderate to severe: 187 mm2).

• FIGURE 21-44 Cine-MRI frame in aortic stenosis. ■In this threechamber view, a large flow void due to blood flow acceleration is evident in ascending aorta

• FIGURE 21-45 (A) Cardiac CT and (B) cine-■MRI of a bicuspid aortic valve. In both images only two semilunar leaflets are evident.

• FIGURE 21-46 Chest X-rays of aortic ■regurgitation. Frontal and lateral views demonstrate left ventricle enlargement, as left third cardiac arch widening in the frontal view, and second posterior arch in the lateral view (arrows).

• FIGURE 21-47 Aortic regurgitation. Echo colour Doppler ■shows aortic insufficiency, with a wide jet, while continuous Doppler interrogation shows a steep decay of the curve indicating severity of regurgitation (rapid pressure drop during diastole). Pressure half-time is <250 ms.

• FIGURE 21-48 Cine-MRI frames of aortic ■regurgitation. Retrograde jets in left ventricle are evident as flow voids, in (A) with normal aortic bulb, in (B) with annuloaortic ectasia.

• FIGURE 21-49 MRI velocity map of mild ■aortic regurgitation. Flow is measured in ascending (red line) and descending aorta (white line); area under the curve below zero (green line) represents regurgitant flow.

• FIGURE 21-50 Cardiac CT of aortic regurgitation. ■Multiplanar short-axis reformation of aortic valve demonstrates incomplete coaptation of leaflets, with central orifice.

• FIGURE 21-51 Examples of biological (A, B) ■and mechanical (C, D) valvular prostheses.

• FIGURE 21-51 Examples of biological (A, B) ■and mechanical (C, D) valvular prostheses.

• FIGURE 21-52 Chest X-rays, lateral views, ■of mechanical (A) and biological (B) mitral valve prostheses.

• FIGURE 21-53 Chest X-rays, lateral views, ■of mechanical (A) and biological (B) aortic valve prostheses.

• FIGURE 21-54 Chest X-rays, frontal views, ■demonstrate the different orientation of the left atrioventricular vector and the left ventriculoaortic vector (black lines), respectively, in (A) mitral and (B) aortic valve replacements

• FIGURE 21-55 Echocardiography of a ■monoleaflet mitral valve, four-chamber view. Right atrium (RA) enlargement with tricuspid leaflet thickening is also evident.

• FIGURE 21-56 Cardiac CT of mechanical ■valvular prosthesis. (A) Coronal reformatted image; (B) axial reformatted image of the valve; (C) corresponding image of the valve.

• FIGURE 21-56 Cardiac CT of mechanical valvular ■prosthesis. (A) Coronal reformatted image; (B) axial reformatted image of the valve; (C) corresponding image of the valve.

• FIGURE 21-56 Cardiac CT of mechanical ■valvular prosthesis. (A) Coronal reformatted image; (B) axial reformatted image of the valve; (C) corresponding image of the valve.

• FIGURE 21-57 Cine-MRI frames (A, short-■axis view; B, three-chamber view) show the typical susceptibility artefact generated by the mechanical aortic valve prostheses.

• FIGURE 21-58 Transoesophageal ■echocardiography in paravalvular aortic abscess. An anechoic rim anterior to a mechanical prosthesis is evident (arrows).

• FIGURE 21-59 Cardiac CT of paravalvular ■aortic leak. (A) Oblique coronal reformatted image of ascending aorta and (B) short-axis reformatted image of aortic valve demonstrate paravalvular extravasation of contrast medium around the prosthesis (arrows).

• FIGURE 21-60 MRI of huge paravalvular leak after aortic ■valve replacement. A large blood collection is evident, adjacent to aortic root, due to a paravalvular leak. (A, B) T1w axial and coronal oblique images show no signal in the collection because of flowing blood (the small amount of signal in the central part is due to slow turbulent flow). (C, D) Gadolinium enhanced gradient-echo images in the same planes demonstrate the passage of contrast medium in the collection; the susceptibility artefact of the mechanical valve is evident.

• FIGURE 21-60 MRI of huge paravalvular leak after aortic valve ■replacement. A large blood collection is evident, adjacent to aortic root, due to a paravalvular leak. (A, B) T1w axial and coronal oblique images show no signal in the collection because of flowing blood (the small amount of signal in the central part is due to slow turbulent flow). (C, D) Gadolinium enhanced gradient-echo images in the same planes demonstrate the passage of contrast medium in the collection; the susceptibility artefact of the mechanical valve is evident.

• FIGURE 21-61 Pericardial involvement in mediastinal ■malignant thymoma. (A) T1w axial image demonstrates an oval-shaped mediastinal lesion adjacent to thickened pericardium; lateral left pericardium shows a plaque-thickening due to tumour diffusion (white arrow). (B) T2w image shows high and heterogeneous signal intensity of the mass. A left pleural effusion is also present.

• FIGURE 21-62 Cystic teratoma of the pericardium, with ■right atrium involvement. (A) T2w axial image shows a large right paracardiac cystic tumour with eccentric solid component; extracapsular tissue (black arrows) also invades epicardial fat and abuts superior vena cava (*), contacting the right coronary artery (white arrow). (B) Post-contrast T1w corresponding axial image demonstrates enhancement of the solid components of the tumour

• FIGURE 21-63 Two black-blood short-axis ■T1w MRI images of mediastinal NHL, with great vessel encasement, pericardial and myocardial infiltration (arrow) and inferior pericardial effusion (*).

• FIGURE 21-64 T1w axial image shows a rounded slightly ■hyperintense lesion in the left ventricle, arising from left lateral wall (white arrows). A small amount of pericardial effusion is evident (black arrow).

• FIGURE 21-65 Left ventricle lung cancer metastasis. (A) ■Contrast-enhanced CT image shows a heterogeneous mass in the left ventricle. (B, C) T1w and T2w horizontal long-axis MRI demonstrate the large implant of the lesion, involving the lateral wall of the left ventricle, with T2 high signal heterogeneity. (D) The left superior sulcus tumour is evident on the coronal T1w image

• FIGURE 21-65 Left ventricle lung cancer ■metastasis. (A) Contrast-enhanced CT image shows a heterogeneous mass in the left ventricle. (B, C) T1w and T2w horizontal long-axis MRI demonstrate the large implant of the lesion, involving the lateral wall of the left ventricle, with T2 high signal heterogeneity. (D) The left superior sulcus tumour is evident on the coronal T1w image

• FIGURE 21-66 2D echocardiography of ■neoplastic thrombus from renal cell carcinoma in inferior vena cava and right atrium

• FIGURE 21-67 Enhanced CT image shows ■direct invasion of left atrium from a left lower lobe bronchogenic carcinoma

• FIGURE 21-68 Echocardiography (2D and 3D) of ■atrial myxoma. On the left, systolic and diastolic frames show a large hyperechoic tumour of the left atrium passing through the mitral valve; on the right, a 3D short-axis image shows the tumour across the mitral valve.

• FIGURE 21-69 (A) FSE T1w horizontal long-axis view of left ■atrial myxoma: typical localisation in the area of fossa ovalis, with heterogeneous signal intensity; central hypointense area is due to calcifications. (B) FSE T2w fat-suppressed image, same plane: lesion shows heterogeneous hyperintensity with central dark area

• FIGURE 21-70 Same case as described in the caption ■to Fig. 21-45. (A) On SSFP image slight heterogeneous hyperintensity of the lesion compared with myocardium is evident; (B) late gadolinium enhancement image shows tiny foci of contrast uptake caused by fibrotic changes

• FIGURE 21-71 Atrial myxoma of fossa ■ovalis. (A, B) Axial T1 and T2 images show heterogeneity in signal intensity of the lesion. (C) and (D) are systolic and diastolic frames of cine-MRI: prolapse of the pedunculated myxoma through the mitral orifice is evident

• FIGURE 21-71 Atrial myxoma of fossa ovalis. ■(A, B) Axial T1 and T2 images show heterogeneity in signal intensity of the lesion. (C) and (D) are systolic and diastolic frames of cine-MRI: prolapse of the pedunculated myxoma through the mitral orifice is evident

• FIGURE 21-72 Atrial septum lipoma. (A) Cardiac CT shows a ■marked hypodense well-defined lesion; (B) T1w image demonstrates marked hyperintensity of the lesion, completely suppressed in STIR image (C). In (D) a frame from cine-SSFP shows high to intermediate signal intensity of the tumour, while post-contrast T1 GRE image does not demonstrate enhancement (E). Furthermore, in all the MR images, a subpleural lipoma is evident (*). (F) A different case of lipomatous infiltration of the interatrial septum is reported, just to show the classical sparing of the fossa ovalis (arrows).

• FIGURE 21-72 Atrial septum lipoma. (A) Cardiac CT shows a marked ■hypodense well-defined lesion; (B) T1w image demonstrates marked hyperintensity of the lesion, completely suppressed in STIR image (C). In (D) a frame from cine-SSFP shows high to intermediate signal intensity of the tumour, while post-contrast T1 GRE image does not demonstrate enhancement (E). Furthermore, in all the MR images, a subpleural lipoma is evident (*). (F) A different case of lipomatous infiltration of the interatrial septum is reported, just to show the classical sparing of the fossa ovalis (arrows).

• FIGURE 21-72 Atrial septum lipoma. (A) Cardiac CT shows a marked ■hypodense well-defined lesion; (B) T1w image demonstrates marked hyperintensity of the lesion, completely suppressed in STIR image (C). In (D) a frame from cine-SSFP shows high to intermediate signal intensity of the tumour, while post-contrast T1 GRE image does not demonstrate enhancement (E). Furthermore, in all the MR images, a subpleural lipoma is evident (*). (F) A different case of lipomatous infiltration of the interatrial septum is reported, just to show the classical sparing of the fossa ovalis (arrows).

• FIGURE 21-73 2D echocardiographic subcostal ■view shows a typical rhabdomyoma (hyperechoic rounded lesion) attached to the basal interventricular septum (calipers).

• FIGURE 21-74 B-mode echocardiography ■shows a small hyperechoic lesion (calipers) attached to valve leaflets. At surgery a fibroelastoma was found and resected.

• FIGURE 21-75 Angiosarcoma of right ventricle. (A) Axial T1w ■image shows a large tumour with irregular margins, involving free wall of right ventricle, right atrioventricular groove, tricuspid annulus and right atrium wall; furthermore, multiple nodules are visible in both lungs, with large consolidation in left inferior lobe; (B) T2w image demonstrates high signal intensity of the tumour. (C, D) Pre- and post-contrast T1w short-axis images show strong enhancement of the tumour and the lung metastasis. Biopsy confirmed the suspected angiosarcoma

• FIGURE 21-75 Angiosarcoma of right ventricle. (A) Axial T1w image ■shows a large tumour with irregular margins, involving free wall of right ventricle, right atrioventricular groove, tricuspid annulus and right atrium wall; furthermore, multiple nodules are visible in both lungs, with large consolidation in left inferior lobe; (B) T2w image demonstrates high signal intensity of the tumour. (C, D) Pre- and post-contrast T1w short-axis images show strong enhancement of the tumour and the lung metastasis. Biopsy confirmed the suspected angiosarcoma

• FIGURE 21-76 Interatrial mass, involving both atria. (A) ■T1w axial image shows an isointense lesion, while (B) the T2w image demonstrates a marked hyperintensity. (C) In post-contrast T1w image a strong and homogeneous enhancement of the mass is visible. Biopsy revealed an angiosarcoma; compared with the case shown and described in Fig. 21-49, this localisation is uncommon.

• FIGURE 21-76 Interatrial mass, involving both atria. (A) ■T1w axial image shows an isointense lesion, while (B) the T2w image demonstrates a marked hyperintensity. (C) In post-contrast T1w image a strong and homogeneous enhancement of the mass is visible. Biopsy revealed an angiosarcoma; compared with the case shown and described in Fig. 21-49, this localisation is uncommon.

• FIGURE 21-77 2D echocardiographic ■subcostal image in a case of rhabdomyosarcoma shows a hyperechoic mass infiltrating the right atrioventricular groove (white arrow). Pericardial effusion is also evident (black arrows

• FIGURE 21-78 T1w axial images show the ■dark line of the pericardium (with a small amount of fluid within) between the high signal intensity of the prepericardial and subepicardial fat.

• FIGURE 21-78 T1w axial images show the ■dark line of the pericardium (with a small amount of fluid within) between the high signal intensity of the prepericardial and subepicardial fat.

• FIGURE 21-78 T1w axial images show the ■dark line of the pericardium (with a small amount of fluid within) between the high signal intensity of the prepericardial and subepicardial fat.

• FIGURE 21-79 Pericardial cyst. Contiguous ■black-blood T1w axial images show a well-defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.

• FIGURE 21-79 Pericardial cyst. Contiguous ■black-blood T1w axial images show a well-defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.

• FIGURE 21-79 Pericardial cyst. Contiguous ■black-blood T1w axial images show a well-defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.

• FIGURE 21-79 Pericardial cyst. Contiguous ■black-blood T1w axial images show a well-defined lesion close to superior vena cava and right atrium, with intermediate signal intensity due to proteinaceous fluid content.

• FIGURE 21-80 Partial pericardial agenesis. (A) Chest ■X-ray, frontal view, shows prominent left second cardiac arch, with deep incisure between first and second left cardiac arch; main pulmonary trunk is deeply located in the lung. (B-D) Serial T1w axial MR images show pulmonary trunk (B, C) out of mediastinal margins (acute angle with anterior mediastinal fat) while the heart (D) is completely rotated towards the left, occupying the left hemithorax.

• FIGURE 21-80 Partial pericardial agenesis. (A) ■Chest X-ray, frontal view, shows prominent left second cardiac arch, with deep incisure between first and second left cardiac arch; main pulmonary trunk is deeply located in the lung. (B-D) Serial T1w axial MR images show pulmonary trunk (B, C) out of mediastinal margins (acute angle with anterior mediastinal fat) while the heart (D) is completely rotated towards the left, occupying the left hemithorax.

• FIGURE 21-81 Pericardial effusion, chest X-■rays. (A) Frontal view shows double contouring of left third cardiac arch (small arrows); (B) lateral view demonstrates a retrosternal opacity (arrows), contoured by fat radiolucency (prepericardial and epicardial).

• FIGURE 21-82 B-mode echocardiography ■shows anterior anechoic fluid collection (*).

• FIGURE 21-83 Pericardial effusion in ■pericarditis. (A) T1w short-axis image shows no signal in the effusion, with mild thickening of the pericardium. (B) Cine-MRI frame shows hyperintense signal of the effusion, due to its prolonged T2 (SSFP signal is T2/ T1-dependent

• FIGURE 21-84 Pericardial haematoma (post-■endomyocardial biopsy). (A) T1w horizontal long-axis image shows well-circumscribed high signal pericardial collection, abutting right atrium. (B) T2w fat-saturated short-axis image demonstrates the high signal of the collection due to acute bleeding.

• FIGURE 21-85 Pericarditis. (A) Cine-MRI ■frame, short-axis image demonstrates mild pericardial effusion (arrows). (B) Delayed postgadolinium enhancement, same plane, shows contrast uptake of pericardial layers, due to inflammation

• FIGURE 21-86 Constrictive pericarditis. (A) Chest X-ray, lateral view, ■shows thick pericardial calcifications. (B, C) CT images demonstrate the presence, site and thickness of pericardial calcifications in a patient with pleuro-pulmonary tuberculosis

• FIGURE 21-86 Constrictive pericarditis. (A) Chest X-ray, ■lateral view, shows thick pericardial calcifications. (B, C) CT images demonstrate the presence, site and thickness of pericardial calcifications in a patient with pleuro-pulmonary tuberculosis

• FIGURE 21-86 Constrictive pericarditis. (A) Chest X-ray, lateral view, shows thick ■pericardial calcifications. (B, C) CT images demonstrate the presence, site and thickness of pericardial calcifications in a patient with pleuro-pulmonary tuberculosis

• FIGURE 21-87 Constrictive pericarditis. Axial ■craniocaudal T1w images show a marked and diffuse pericardial thickening in patient with previous tuberculosis. Right atrial enlargement is evident in the images B and C.

• FIGURE 21-87 Constrictive pericarditis. Axial ■craniocaudal T1w images show a marked and diffuse pericardial thickening in patient with previous tuberculosis. Right atrial enlargement is evident in the images B and C.

• FIGURE 21-88 Cystic teratoma of the pericardium, with ■right atrium involvement. (A) T2w axial image shows a large right paracardiac cystic tumour with eccentric solid component; extracapsular tissue (black arrows) invades also epicardial fat and abuts superior vena cava (*), contacting the right coronary artery (white arrow). (B) Post-contrast T1w corresponding axial image demonstrates enhancement of the solid components of the tumour

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