Chapter 5 Cardiac Computed Tomography

The clinical potential of computed tomography (CT) of the heart had always been limited by relatively long acquisition time and poor spatial resolution. The introduction of spiral multidetector CT scanning, and in particular, achievement of isotropic voxel acquisition, has shortened acquisition time, increased spatial and contrast resolution, and resulted in a dramatic expansion of the use of CT for evaluation of patients with acquired and congenital heart disease. Cardiac diagnosis by CT had always been limited to identification of abnormal calcification, or the observation of incidental findings, such as pleural or pericardial effusion. CT diagnosis and the characterization of pericardial, myocardial, and valvular disease, as well as the cause and sequelae of ischemic coronary heart disease, are now not only possible, but are rapidly becoming an imaging modality of choice in certain patient populations and clinical circumstances.

CURRENT TECHNOLOGY

CT scanners acquire a series of rotating thinly collimated x-ray beam projections obtained at different angles around the circumference of the patient (raw data). Individual axial images (slices) are formed from these projection data by the mathematical technique of back projection. The quality of an image formed by this technique improves with increasing the number of projections and by overlapping projection data. The number of x-ray projections obtained for image formation is limited by the ability of the scanner to rotate the x-ray source around the patient. That is, the faster the tube rotates around the patient, the shorter interval between individual projections, and thus, the more projections available for image formation per tube rotation. Use of a number of detectors (multidetector CT) and passing the patient through the bore of the scanner allows acquisition of a series of slices (a stack), a three-dimensional array of image data, which may be used for reconstruction of oblique sections and three-dimensional volume-rendered images.

Electrocardiogram (ECG) gated CT acquisition dramatically improves image quality. The ECG signal obtained from the patient provides a time code, indicating to the CT scanner where in the temporal progression of the cardiac cycle each of the projection data is obtained. That is, the scanner knows where in space projection data is obtained. The ECG signal assigns a time coordinate to the three-dimensional space coordinates of the image data, allowing the data to be parsed based on time and space (i.e., a series of stacks of image data, each obtained at one point in the cardiac cycle). This has two important advantages. First, it significantly decreases motion artifacts in cardiac imagery. Because image formation is performed using only projection data obtained at a particular phase of the cardiac cycle, imagery is coherent and appears sharper. Second, acquisition of a series of image stacks allows analysis of changes in cardiac morphology over the cardiac cycle, thus, providing a means of evaluating cardiac function.

APPROACH TO CARDIAC COMPUTED TOMOGRAPHY

Indications for Cardiac Computed Tomography

Indications for 64-detector cardiac CT are predominantly for evaluation of the epicardial coronary arteries in specific circumstances related to patient signs and symptoms and risk for coronary heart disease. Nevertheless, the value of CT in general, enhanced by the high temporal and spatial resolution of isotropic voxel acquisition (i.e., ECG gated 64-detector scanning) make use of this modality attractive in any patient in whom cardiac disease is being evaluated and especially if a CT is considered for evaluation of the heart or mediastinum.

Patient Preparation

Cardiac CT requires administration of intravenous iodinated contrast, necessitating prior evaluation of renal function and history of previous contrast administration complications. Of particular importance for performing cardiac CT is heart rate control. Slow, regular heart rate is essential for reliable data acquisition, image reconstruction, and accurate and confident interpretation. Thus, assessing the patients’ ability to receive rate control medications such as beta-blockers also needs to be considered. For example, patients with severe bronchospastic asthma should not receive beta-blockers, but they may receive other ratecontrol medications such as calcium channel blockers. Unless contraindicated, preexamination oral metoprolol may be adequate to achieve a target heart rate of 60 beats per minute. Intravenous administration of a series of 5-mg boluses of metoprolol immediately before examination, or while the patient is on the scanner table, may be necessary (or preferred, depending on the environment in which the examination is performed [i.e., inpatient versus outpatient facility]).

Examination is rapid enough to allow acquisition of all image data within a single breath hold. However, timing of the breath hold, and the depth of inspiration used is critical, and therefore, the patient must be informed of this, and better, allowed to practice before examination. Finally, cardiac CT examination is a fast procedure, and the patient undergoing the examination will experience a series of loud noises (gantry rotation) and unusual sensations (the flush of contrast administration) in rather rapid progression. Therefore, adequate explanation of what to expect during the examination will pay off in a more relaxed patient and more reliable imagery for interpretation.

Study Acquisition and Processing

A typical study commences with scout image acquisition to locate the cephalad and caudad limits (Fig. 5-1) of the examination (i.e., from above the aortic arch to the diaphragm if coronary artery bypass grafts are to be evaluated or from about the level of the tracheal carina to the diaphragm for evaluation of the epicardial coronary arteries). From the scout images, typically one identifies the aortic root or origin of the left main artery as the anatomic level for performing a contrast timing run to estimate time to maximum arterial opacification (Fig. 5-2). However, if, for example, the examination is being performed for evaluation of the cardiac veins (for placement of additional ventricular pacing leads, etc.) then timing may be based on maximum opacification of the coronary sinus, the confluence of the epicardial cardiac venous tributaries.

FIGURE 5-1 Scout acquisition image in a 68-year-old man referred for evaluation of chest pain. The clinical problem dictates the portion of the chest for evaluation. Evaluation of the aorta necessitates imaging from above the aortic arch (line A) to the diaphragmatic surface of the heart (line C). Evaluation of the heart or coronary arteries only requires evaluating from just above the origins of the coronary arteries (line B) to the diaphragmatic surface of the heart (line C).

FIGURE 5-2 Images from a timing run in a patient studied to exclude a left atrial myxoma. A, Image obtained before contrast administration through the aortic root (Ao), right ventricular outflow (RVO), left atrium (LA), left atrial appendage (arrow 4), and descending aorta (AoD). Pacing wires are seen in the right atrial appendage (arrow 1) and superior vena cava (arrow 2). A region of interest (ROI, o) has been placed over the left main coronary artery (arrow 3), faintly visualized embedded in the epicardial fat. B, Time-attenuation curve relative attenuation in Hounsfield units (HU) versus time, obtained from ROI placed in part A. Maximum opacification (arrow) obtained 12 seconds after contrast injection. C, Image obtained at 12 seconds after contrast administration, demonstrating opacification of the left main coronary artery (arrow 1), the ascending aorta (Ao), RVO, LA, left atrial appendage (arrow 2), and AoD.

The timing run is performed by rapid administration of a small bolus of intravenous contrast and obtaining a series of images over the target structure. Time to maximum opacification is measured, and the delays between contrast administration, institution of the breath hold, and image acquisition calculated, and the actual contrast-enhanced cardiac CT examination is performed. Generally speaking, this involves a large bolus of contrast administered by power injection into a proximal vein, with breath holding as the bolus of contrast passes through the central cardiac circulation with image acquisition commencing at the calculated delay after contrast injection.

Image Post-Processing

Intravenous contrast administration and radiation exposure are the two significant risk factors associated with performing cardiac CT. Thus, all examinations should be performed using the least intravenous contrast and radiation dose to assure a diagnostic study. The initial image data obtained from the CT scanner is axial images obtained at one particular phase of the cardiac cycle. In fact, using so-called snapshot acquisition, only one phase of the cardiac cycle is used for image acquisition, and thus only single phase data displayed. In principle, all the information in a volume of the chest obtained by CT examination is contained in the axial image data. The traditional approach to CT image interpretation is in the axial (acquisition) plane. However, the heart sits obliquely in the chest, oblique to all body planes (Fig. 5-3). Therefore, cardiac structure may not be visualized to best advantage in this section. Furthermore, many cardiac structures, most notably the epicardial coronary arteries, do not reside within only one isolated plane and are therefore best visualized using more advanced reconstruction methods. Unless obtained only at one phase of the cardiac cycle, image data obtained from a cardiac CT examination covers the entire cardiac cycle and can thus be best viewed not only in arbitrary tomographic section, but also serially in a cine loop mode, allowing qualitative and quantitative analysis of function. Comprehensive review of a case now involves a more integrated approach to the three- and four-dimensional data set (so-called volume visualization). The case is approached as a volume of information, using different means of data manipulation as needed to best view and elucidate a particular clinical problem. Most advanced image processing algorithms have been evaluated in the arterial bed. That is, the advantage of one technique over another for evaluation of the heart and heart disease has been restricted to date to the coronary arteries. Therefore, their value is limited to increasing lesion conspicuity, but not necessarily diagnostic precision. Nevertheless, if use of such techniques increases confidence in the diagnosis of an abnormality, then there exists at least a potential role in clinical cardiac imaging.

FIGURE 5-3 The heart in the chest. A, Surface-rendered three-dimensional display of a normal heart. The right ventricle (RV) is an anterior structure, bounded on the right by the right coronary artery (arrow 1), and on the left by the anterior descending artery (arrow 3). The left ventricular (cardiac) apex (arrow 4) lies inferior and to the left of the RV. The right atrial appendage (RAA), ascending aorta (Ao), main pulmonary artery (MP) and first diagonal branch of the anterior descending artery (arrow 2) are labeled. B, Coronal section cut through the posterior left (pl) and posterior right (pr) aortic sinuses of Valsalva. The left ventricular (LV) apex (arrow) points inferiorly and toward the left. The right atrium (RA), ascending aorta (AoA), MP, and LV papillary muscles (arrowheads) are labeled. C, Axial section cut through the interatrial (arrow 1) and interventricular septum (arrow 2). The LV apex (arrow 4) is directed toward the left, away from the coronal body plane. The left atrium (LA) and RA, crista terminalis (arrow 3), and RV are labeled.

Axial and Oblique Tomograms

Axial tomograms are the most basic of CT imagery and are the mainstay of cardiac CT interpretation (Fig. 5-4). Images are viewed in their thinnest reconstruction (i.e., a 64-detector scanner produces isotropic voxels 0.6 mm on an edge, and these slices are 0.6 mm thick. Axial tomograms should be analyzed in an interactive way by scrolling up and down through the slices. An organized approach to cardiac analysis is less likely to produce errors of omission. Therefore, a rigorous approach to image analysis should be adopted. That is, there is no one way to interpret a series of CT images. Rather, by adopting a method and keeping to it, such errors may be avoided. For example, one may scroll back and forth, analyzing one structure at a time, such as the ascending aorta, then the superior vena cava, and then the pulmonary arteries. Alternatively, one may follow the flow of blood through the heart and analyze structures in that order (i.e., the superior and inferior vena cava, followed by the right atrium, followed by the right ventricle and pulmonary arteries, etc.). No one axial slice should be used alone without its neighboring slices for analysis. Furthermore, the robust data set acquired by cardiac CT examination lends itself to the rapid image processing software available on workstations designed for these scanners. Reconstruction of particular structures in oblique tomographic section is frequently helpful for elucidating a perplexing series of images and provides a great deal of information concerning the severity of an abnormality and the effect of a particular abnormality on adjacent cardiac structures. Oblique tomograms may be constructed in arbitrary plane, depending on the problem at hand, or in the so-called standard planes, parallel and orthogonal to the intrinsic cardiac axes (Fig. 5-5). These planes are useful for the assessment of cardiac volumes, ejection fraction, and for comparison of CT findings with imagery obtained by other modalities (namely nuclear cardiology, angiocardiography, and echocardiography).

FIGURE 5-4 Axial image obtained through the membranous interventricular septum (black arrowhead). When properly timed, most of the intravenous contrast has passed to the left side of the cardiac circulation, resulting in higher attenuation in the left atrium (LA) and left ventricle (LV) than in the right atrium (RA) and right ventricle (RV). Ideally, right heart opacification is adequate to allow visualization of thin structure, including the membranous interventricular (black arrowhead) and interatrial septum (arrow 1), as well as intracavitary structure, including myocardial trabeculation (arrows 2 and 3). Particularly thin structures, such as the anterior mitral leaflet (double white arrowheads), needs high attenuation (and thus contrast concentration) for adequate visualization. The opacified coronary arteries appear as high attenuation objects embedded in the low attenuation epicardial fat. Here, the mid right coronary artery (arrow 4) and the origin of a marginal branch (arrow 5), the distal left anterior descending (arrow 6) and circumflex (arrow 7) arteries are identified. Depending on the timing of the acquisition, the coronary arteries appear with higher attenuation than the cardiac veins. For example, compare the appearance of the circumflex artery (arrow 7) and great cardiac vein (arrow 8). The right lower lobe pulmonary vein (arrow 9) and descending aorta (AoD) are labeled.

FIGURE 5-5 Constructing the standard cardiac planes. A, Axial acquisition image obtained through the atrioventricular septum (arrowhead), left ventricle (LV) and left atrium (LA). The plane containing the long axis of the left ventricle is constructed by drawing a line (AB) passing through the center of the mitral valve, connecting the posterior wall of the LA and the LV apex. Notice leftward tipping of the cardiac apex. The right (arrow 1) and left anterior descending (arrow 2) coronary arteries are seen in cross section. The crista terminalis (arrow 3) appears as a filling defect along the lateral right atrial (RA) wall. A LV papillary muscle extends from the lateral wall. B, Right anterior oblique sagittal reconstruction in plane defined in part A. Note the inferior tipping of the cardiac apex. The long axis of the LV is defined as the line (CD) passing through the mitral valve, connecting the posterior wall of the LA and the LV apex. The line (EF) orthogonal to CD defines the cardiac short axis. A chordae (black arrow 3) connects the mitral valve with a papillary muscle (black arrow 4). The main pulmonary artery (MP), trachea (T), left upper lobe pulmonary vein (arrow 1), and anterior descending coronary artery (arrow 2) are labeled. C, Short-axis reconstruction through the papillary muscles (arrowheads). The plane of the fourchamber view is constructed from the line (GH) drawn through the center of the LV and the apex of the right ventricle (RV). The anterior descending artery (arrow 1) and a diagonal branch (arrow 2) and the posterior descending artery (arrow 3) are viewed in cross section. D, Reconstruction in the four-chamber view, displaying the RV and LV, and RA and LA. A papillary muscle (pm) is attached to the fine filling defect (white arrowheads) of a mitral valve chord and valve leaflets (black arrowheads). The right coronary artery (arrow 1), right (arrow 2) and left (arrow 3) lower lobe pulmonary veins, and liver (Li) are labeled.

Maximum Intensity Projections

A maximum intensity projection (MIP) is produced by selecting the highest attenuation voxels along lines projected through the volume data set, that is, the line of sight of the observer (Fig. 5-6). The subset of these high attenuation voxels is used to produce a two-dimensional image. MIP imagery is more accurate for evaluating arteries than is volume rendering. However, the presence of other (nonvascular, namely, calcified) voxels confound the appearance of a structure. Furthermore, MIPs are twodimensional representations (projections) that do not accurately depict the actual three-dimensional relationships of nonadjacent structures.

FIGURE 5-6 Maximum intensity projection from an examination obtained to evaluate shortness of breath in a 54-year-old woman. The left main (arrow 1), anterior descending (black arrowheads) artery, and diagonal branch (arrow 2) appear to be within the same plane as the left circumflex (arrow 3) and marginal branches (arrows 4 and 5), and right coronary (arrow 6) and posterior descending (arrow 7) arteries. The great cardiac vein (white arrowheads) and inferior interventricular vein (arrow 8) are labeled.

Mutiplanar (Curved) Reformats

Multiplanar reformats (MPRs) are generally used to “untangle” a complex three-dimensional structure (such as a blood vessel) by displaying a plane constructed by a reference in the object (such as a centerline) in a planar two-dimensional manner. By identifying the x and y coordinates of a point within the object in each of a series of a stack (volume) of axial-acquired data, the “three-dimensional course” of the object can be ascertained. Then, the resultant “curved plane” is mathematically flattened out and displayed as a two-dimensional object (Fig. 5-7). These images are often confusing because of the unusual apparent course of a structure and distribution of adjacent structures.

FIGURE 5-7 Multiplanar reformat of a normal left ventricle (LV) and aorta. The course of the aorta, from aortic valve (arrow 2) to ascending aorta (AoA) to aortic arch (Ar) to descending aorta (AoD) is clear. The papillary muscles (arrowheads) of the LV appear as intracavitary filling defects. The main pulmonary artery (MP), superior vena cava (arrow 3), trachea (T), right atrium (RA), and azygos vein (arrow 4) are labeled. The distribution of segmental and subsegmental pulmonary artery and veins, viewed in cross section, is meaningless.

Three-Dimensional Volume-Rendered Images

Surface-rendered images are displays of the surfaces of a particular object within a three-dimensional data set. The processing algorithm asks whether a voxel is within an object or not based on comparison of attenuation of the voxel with a “threshold” value. Thus, the outermost voxels of similar attenuation form the surface of the object; those voxels “outside” this surface are not part of the object and not displayed. The “surface” of the object is further modeled as a collection of small polygons and displayed with surface shading based on expected appearance to an observer (Figures 5-3A, 5-8). Reducing the large three-dimensional data set to a surface drastically reduces the amount of data processed per manipulation and thus allows real time interaction between observer and object. These images are excellent for the visualization of gross cardiac structure and the relationship of the heart to surrounding organs.

FIGURE 5-8 Volume-rendered images of a normal heart. A, Image viewed from below and the right (looking from the right hip toward the left shoulder). The right atrial appendage (RAA) and right ventricular outflow (RVO) are thrown superiorly and away from the viewer. The right coronary artery (arrow 1) passes within the anterior atrioventricular ring, separating the cavity of the right atrium (RA) from the inflow portion of the right ventricle (RV). The conus artery (arrow 2) passes along the anterior surface of the RVO. A large marginal branch of the right coronary artery (arrow 3) passes along the anterior aspect of the sinus of the RV. An anterior cardiac vein (arrowheads) is faintly seen running parallel with the right coronary marginal branch, crossing the anterior atrioventricular ring and draining into the RA (double arrowheads). The left border of the RV is the anterior interventricular groove, containing the distal left anterior descending artery (arrow 4). The left-to-right relationship of the superior vena cava (SV) to ascending aorta (AoA) is demonstrated. The right upper (RU) and right lower (RL) lobe pulmonary veins are labeled. B, Image viewed from above and the left (looking from the left shoulder toward the right hip). The anterior descending artery (arrow 1) runs in the anterior interventricular groove between the RV and left ventricle (LV). A large diagonal branch (arrow 2) is seen passing over the anterior LV wall. A high marginal branch (arrow 3) of the circumflex artery and the true circumflex artery in the posterior atrioventricular ring (arrow 4) are seen. A portion of the anterior interventricular vein (arrowheads) runs parallel to the anterior descending artery. The RVO lies immediately inferior to the sinuses of Valsalva (sv) of the main pulmonary artery (MP). The right pulmonary artery (RP) arises from the MP and passes posterior to the AoA. In this view, the left atrial appendage (LAA) and the tip of the right atrial appendage (arrow 5) are visualized.

NORMAL ANATOMY

CT scanners produce imagery in the axial section. When acquired in isotropic resolution with adequate heart rate control, the data sets are robust, allowing reconstruction in arbitrary tomographic planes. In the following section, we will briefly review tomographic cardiac anatomy, emphasizing landmark structures within (and around) the heart, correlating their appearance in the axial and oblique tomographic sections, most importantly planes orthogonal and parallel to the intrinsic cardiac axes.

The heart is enveloped in the pericardium. The visceral pericardium cannot be resolved on CT, but with contrast enhancement, the parietal pericardium appears as a thin, bright structure, sandwiched between the pericardial space (and epicardial fat) and the pericardial fat- or air-filled lungs (Fig. 5-9). The pericardium reflects over the top of the main pulmonary artery, the ascending aorta at about the level of the insertion of the azygos vein, and along the diaphragmatic surface of the heart. The pericardial sac contains potential spaces anterior to the aorta (preaortic recess), between the aorta, pulmonary artery and left atrium (superior pericardial recess), and behind the heart, between the insertions of the left and right pulmonary veins (lateral recesses), which become more apparent in face of pericardial effusion or hemorrhage (Fig. 5-10). The coronary arteries are epicardial and are identified as contrast-enhanced cross sections within the epicardial fat, subjacent to the pericardial space, parietal pericardium, and pericardial fat (see Figure 5-9). They arise from the aortic sinuses of Valsalva, immediately cephalad to the aortic annulus (Fig. 5-11).

FIGURE 5-9 Axial acquisitions from a 50-year-old man with chest pain. A, Image obtained through the posterior left (pl) aortic sinus of Valsalva. The parietal pericardium (arrowheads) is seen as a bright pencil thin line sandwiched between low attenuation epicardial (arrow 1) and pericardial (arrow 2) fat, anterior to the tip of the right atrial appendage (RAA) and right ventricular outflow (RVO) free wall. The left atrium (LA), left atrial appendage (LAA), left lower lobe pulmonary vein (arrow 3), descending aorta (AoD), and superior vena cava (arrow 4) are labeled. B, Image obtained through the atrioventricular septum (black arrowhead). At this level, the pericardium over the anterior atrioventricular ring (arrow 1) is thin. A physiologic amount of pericardial fluid gives the pericardium over the right ventricular (RV) sinus some thickness (white arrowheads). The right coronary artery (arrow 2) and a marginal branch (arrow 3) are viewed in cross section embedded in the epicardial fat of the anterior atrioventricular ring. The anterior descending artery (arrow 4) and anterior interventricular vein (arrow 5) are viewed in cross section in the fat of the anterior interventricular groove. The circumflex artery (arrow 6) and great cardiac vein (arrow 7) are viewed in cross section within the posterior atrioventricular ring. Notice how the interatrial septum (double black arrows) bows toward the right atrium (RA). C, Image obtained through the cardiac crux, the intersection of the atrioventricular rings and interventricular septum (S) and the dome of the diaphragm (Di). The pericardium (arrowheads) surrounds the RV free wall. The free wall myocardium cannot be visually separated from the low intensity epicardial fat beneath the pericardium. The distal right coronary artery (arrow 1) is seen in cross section embedded in the fat of the anterior atrioventricular ring. The posterior left ventricular (LV) branch (arrow 3) is embedded within the fat of the posterior atrioventricular ring along with a segment of the great cardiac vein (arrow 4) and the posterior interventricular vein (arrow 5). The distal anterior descending artery (arrow 2) is seen in cross section, embedded within fat and beneath the pericardium. The septomarginal trabeculation (black arrowheads) appears as a branching filling defect along the RV side of the septum. A LV papillary muscle (pm) appears as a round, branching filling defect. The RA, suprahepatic inferior vena cava (IVC), and collapsed esophagus (Es) are labeled.

FIGURE 5-10 Images obtained from the patient in Figure 5-9. A, Axial acquisition through the main (MP) and left (LP) pulmonary artery. The preaortic recess is a fluid attenuation collection (arrow 1) between the ascending aorta (AoA) and MP. Similarly, the superior pericardial recess (arrow 2) is the fluid attenuation space between the superior vena cava (SV), AoA, and proximal right pulmonary artery (RP). The right upper lobe pulmonary vein (arrow 3) lies anterior to the prehilar right pulmonary artery, and the left upper lobe pulmonary vein (arrow 4) lies anterior to the left upper lobe pulmonary artery (arrow 5). The left bronchus (LB) and right bronchus (RB) are labeled. B, Right anterior oblique sagittal reconstruction from the patient in Figure 5-9 through the right ventricular outflow (RVO) and the aortic root (Ao). The pericardium (arrowheads) is a thin line separating the epicardial and pericardial fat. A small amount of fluid (double white arrows) has accumulated over the right ventricular sinus, increasing the width of the pericardial space. The preaortic recess (arrow 1) is a homogeneous fluid density bounded by the Ao, the RVO, and the reflection of the pericardium over the pulmonary artery and onto the aorta. The distal right coronary artery (arrow 2) runs in the inferior aspect of the anterior atrioventricular ring. The proximal right coronary artery (arrow 3) and the proximal portion of the conus branch (arrow 4) run embedded in fat in the superior aspect of the anterior atrioventricular ring. The suprahepatic inferior vena cava (IVC) enters the right atrium (RA) from its posterolateral aspect.

FIGURE 5-11 The origins of the coronary arteries. A, Axial acquisition through the origin of the left main coronary artery (arrow 1) from the posterior left (pl) aortic sinus of Valsalva. The proximal left anterior descending artery (arrow 2) passes between the right ventricular outflow (RVO) and left atrial appendage (LAA), along the superior aspect of the interventricular septum. A small amount of fat is seen in the superior pericardial recess (arrow 3). The left atrium (LA), superior vena cava (SV), and right atrial appendage (arrow 4) are labeled. B, Axial acquisition just inferior to part A. The right coronary artery (arrow 1) arises from the anterior aortic sinus of Valsalva (a) and then turns toward the right within the low attenuation fat of the anterior atrioventricular ring. A small segment of the proximal circumflex artery (arrow 2) is seen in the posterior atrioventricular ring, immediately anterior to the LA. The right atrial appendage (RAA), and right upper (arrow 3) and lower (arrow 4) and left lower lobe (arrow 5) pulmonary veins are labeled. C, Surface-rendered volume rendering of the aortic root and origins of the coronary arteries, viewed from the left shoulder toward the right hip (analogous to a cranialized left anterior oblique view). The left main artery (arrow 1) arises from near the sinotubular junction between the pl aortic sinus and the ascending aorta (AoA). The left anterior descending artery (arrow 2) passes along the superior aspect of the interventricular septum, giving a large diagonal branch (arrow 3) along the anterior left ventricular wall. The origin of the circumflex artery is obscured. The more distal vessel (arrow 4) passes within the posterior atrioventricular ring. The right coronary artery (arrow 5) arises from the anterior aortic sinus (a), caudad to the origin of the left main artery.

The aortic root lies nearly in the geographic center of the heart. In axial section, the normal relationship of the ascending aorta to main pulmonary artery is aorta to the right. The plane of the aortic valve lies inferior and to the right of the pulmonary valve. Thus, when the pulmonary valve and main pulmonary artery are visualized, the ascending aorta is in field to the right. When the aortic root and sinuses of Valsalva are in field, the free wall myocardium of the right ventricular outflow is in view (Fig. 5-12). Measurement of aortic or pulmonary caliber should be expected to be inaccurate on axial CT examination as a result of their oblique course from the heart. Nevertheless, recognition of arterial enlargement is conveniently based on comparison of great artery caliber. The superior vena cava is formed by the confluence of the left and right innominate veins, immediately inferior to the origins of the branches of the aortic arch. The superior cava courses to the right of the ascending aorta and passes anterior to the right pulmonary artery before entering into the right atrium at about the level of the ostium of the right atrial appendage (Figures 5-9A, 5-10A, 5-10B, 5-13). The azygos vein passes over the right hilum to enter the superior cava from behind.

FIGURE 5-12 The relationship between the aortic valve and pulmonary valve. A, Axial acquisition through the main (MP) and right (RP) pulmonary artery and the pulmonary sinuses of Valsalva (arrowheads). At this anatomic level, the ascending aorta (AoA) is seen as a nearly circular structure. The superior vena cava (SV), two segmental right upper lobe (1 arrows), and the left upper lobe (arrow 2) pulmonary veins are labeled. B, Coronal reconstruction through the pulmonary artery sinuses of Valsalva (s). The leaflets of the pulmonary valve (black arrowheads) separate the sinuses from the right ventricular outflow (RVO). In this plane, anterior to the aortic root, segments of the right coronary artery (white arrowheads) are visualized. Note that the sinus of the right ventricle (RV) lies to the right of the cavity of the left ventricle (LV), and that the RV side of the interventricular septum is markedly trabeculated. The LV side of the septum is smooth. The right atrial appendage (RAA), liver (Li) and stomach (St) are labeled. C, Axial acquisition inferior to part A, through the anterior (a) and posterior right (pr) aortic sinuses of Valsalva. At this anatomic level, the RV sinus lies anterior and to the left of the aortic root. Proximal segments of the right (arrow 1) and sinoatrial node (arrow 2) coronary arteries are viewed in cross section embedded in low attenuation fat of the anterior atrioventricular ring. The mid anterior descending (arrow 3) and a large diagonal branch (arrow 4) are viewed in cross section within the low attenuation of the epicardial fat along and just lateral to the anterior interventricular groove. The anterior interventricular vein (arrowhead) is oblong and of lower attenuation. The circumflex artery (arrow 5), a marginal branch of the circumflex artery (arrow 6), and the great cardiac vein (arrow 7) are viewed as cross sections within the posterior atrioventricular ring. Note the filling defects of trabecular myocardium (black arrowheads) extending across the RV sinus. The left atrium (LA) and RAA are labeled. D, Coronal reconstruction through the posterior left (pl) and pr aortic sinuses of Valsalva and atrioventricular septum (black arrowhead). In this plane, posterior to the pulmonary valve, the MP is viewed in cross section. The circumflex coronary artery (arrow 1) and distal anterior interventricular vein (arrow 2) pass beneath the left atrial appendage (LAA) toward the posterior atrioventricular ring. The distal right coronary artery (arrow 3) is viewed in cross section within the fat of the inferior aspect of the anterior atrioventricular ring. Immediately superior, the filling defect of the tricuspid valve leaflet (white arrowheads) separates the right atrium (RA) from the inflow portion of the RV. The posterior interventricular vein (arrow 4), proximal to its drainage into the great cardiac vein, is viewed beneath the interventricular septum.

FIGURE 5-13 Reconstruction in left anterior oblique sagittal section through the superior vena cava (SV), interatrial septum (short black arrows), transverse right pulmonary artery (RP), and right bronchus (RB). Note the thinning of the septum (white arrowheads) in the region of the foramen ovale. The right lower lobe pulmonary vein (long arrow), left atrium (LA), and right atrium (RA) are labeled.

The left atrium is located high and posterior in the heart between the aortic root and the descending aorta and spine, nearly in the midline (see Figures 5-2A, 5-9A, 5-12C). The left atrial wall should be bald smooth and the cavity free of filling defects. The relationship between the left upper lobe pulmonary vein and orifice of the left atrial appendage is constant, and well-demonstrated on CT. The left upper lobe vein passes behind the orifice of the left atrial appendage to enter the posterior aspect of the atrial cavity. A redundant fold of endothelium (the “Q-tip sign”) separates their orifices (Fig. 5-14). The course of the right upper lobe pulmonary vein is nearly constant as well. As it passes medial and inferior from the right pulmonary parenchyma, it passes from anterior-to-posterior to the right pulmonary artery and superior vena cava to enter the superolateral aspect of the left atrium (Figures 5-10A, 5-11B, 5-12A, 5-15). The left lower lobe pulmonary vein often takes a horizontal course, passing between the anterior aspect of the descending aorta and the posterior wall of the left atrium (see Figures 5-5D, 5-9A, 5-11B). The right middle and right lower lobe pulmonary veins frequently form a confluent structure before draining into the left atrium. A common anatomic variant is for the middle lobe veins to drain independently (see Figure 5-15), and slightly superior to the drainage of the right lower lobe vein. Pulmonary vein stenosis, whether of primary or secondary origin, appears as focal narrowing of vessel at an arbitrary location. Juxtaorificial narrowing (see Figures 5-14B, 5-15B) secondary to radiofrequency ablation is, luckily, much less common than in the past.

FIGURE 5-14 The left upper lobe pulmonary vein. A, Reconstruction in right anterior oblique sagittal section through the body of the left atrial appendage (LAA). The entry of the left upper lobe pulmonary vein (LUL) is toward the posterior aspect of the left atrium (LA). It enters the LA just posterior to the orifice of the LAA. The “Q-tip” (short black arrow) separates their ostia. The distal anterior interventricular vein (arrow 1) and proximal circumflex artery (arrow 2) pass beneath the LAA to enter the posterior atrioventricular ring. Mitral leaflet tissue separates the LA from the left ventricle (LV). The trabeculated filling defect of a papillary muscle (pm) occupies the distal LV cavity. The coronary sinus (arrow 3) and distal circumflex artery (arrow 4) lie inferior to the LA. The left bronchus (LB) and proximal left pulmonary artery (LP) are also labeled. B, Reconstruction in oblique sagittal section through the aortic root (Ao), origin of the right coronary artery (arrow) and LA. The origin of the left upper lobe pulmonary vein (arrowheads) exhibits mild circumferential narrowing, secondary to previous radiofrequency ablation at this site. The main pulmonary artery (MPA), the right atrium (RA), and the inferior vena cava (IV) are also noted.

FIGURE 5-15 Reconstruction obtained by contrast-enhanced examination in two individuals. A, Left anterior oblique sagittal section through the posterior aspect of the left atrium (LA) and descending aorta (AoD). The right upper (arrow 1) and right middle lobe (arrow 2) pulmonary veins drain independently to the LA. Notice how the right upper lobe vein passes from anterior and superior-to-inferior to the right pulmonary artery (RP) immediately distal to the origin of the right upper lobe pulmonary artery (arrow 3). The collapsed esophagus (Es) and suprahepatic inferior vena cava (IVC) are labeled. B, Coronal section through the trachea (T) and left (LP) and right (RP) pulmonary arteries, and LA in a 45-year-old man who underwent radiofrequency ablation 3 weeks ago. There is mild narrowing of the proximalmost left upper lobe vein (LU) as it enters the LA. The aortic arch (Ao) is labeled.

The left atrium shares the interatrial septum with the inferior, anterior, and right-sided right atrium (the sinus venosus interatrial septum separates the inferior aspect of the superior vena cava from the left atrium; see Figures 5-9B, 5-13). The left atrium forms a posterior border of the heart. The esophagus is intimately related to the posterior wall of the left atrium. The left atrial appendage forms part of the left border of the heart, immediately inferior to the main pulmonary artery (see Figures 5-8B, 5-9A, 5-12D). The right atrium receives the superior vena cava and inferior vena cava. The inferior vena cava enters the inferior aspect of the atrium inferior and lateral to the drainage of the coronary sinus. The two structures share a redundant fold of endothelium, the eustachian valve (Figures 5-9C, 5-16). The coronary sinus is the confluence of the cardiac veins (Fig. 5-17). The anterior interventricular vein runs with the anterior descending artery along the anterior interventricular groove (see Figures 5-6, 5-8B, 5-9B, 5-12C, 5-17) and then passes along the base of the heart to the posterior atrioventricular ring to run with the circumflex coronary artery as the great cardiac vein. This vein receives a lateral ventricular vein from the lateral ventricular wall and then passes beneath the left atrium. It picks up the posterior interventricular vein (which runs with the posterior descending coronary artery) to become the coronary sinus and enter the right atrium. The right atrium is divided by a constant mural filling defect, the crista terminalis (see Figure 5-5A). This remnant of the vein of the sinus venosus divides the right atrium into a trabeculated anterior portion and a smooth walled posterior portion. The hepatic veins usually drain to the suprahepatic inferior vena cava before entering the right atrium (see Figures 5-10B, 5-16), but on occasion, they drain directly to the floor of the right atrium. The two atria share the interatrial septum. The plane of the interatrial septum is oblique to the coronal body plane and bows toward the right atrium (see Figures 5-3C, 5-4, 5-5D, 5-9B, 5-13, 5-16). From superior to inferior, the septum is divided into the lateral sinus venosus portion, the medially located secundum portion, and the inferior and medial primum septum. The primum septum is in fibrous continuity with the anterior mitral leaflet, the membranous and atrioventricular septum, and the septal tricuspid leaflet (see Figures 5-4, 5-12C). The interatrial septum is fat laden and thins in the region of the foramen ovale.

FIGURE 5-16 Reconstruction in right anterior oblique sagittal section through the interatrial septum (arrow 1) and the aortic (black arrowheads) and pulmonary (arrow 2) valves. Before draining to the right atrium (RA), the coronary sinus (cs), and suprahepatic inferior vena cava (IVC) are separated by a low attenuation (fat laden) tissue, the eustachian valve (white arrowheads). The posterior interventricular vein (arrow 3) runs along the inferior aspect of the interventricular septum and has not yet joined the great cardiac vein. In this section, the right upper lobe pulmonary vein (arrow 4) is now inferior to the right pulmonary artery (RP) and is entering the left atrium (LA). The ascending aorta (AoA) and left ventricle (LV), right (RLi) and left (LLi) lobes of the liver, and the intrahepatic inferior vena cava (Hivc) are labeled. The main pulmonary artery (MP) is also labeled.

FIGURE 5-17 Volume-rendered images of the cardiac veins from a normal heart. To help orient the images, the aorta (Ao) and coronary arteries were included. The arteries are coded yellow and the veins red. A, Reconstruction in anterior view from the front of the heart. The right coronary artery (arrow 1) arises from the anterior aortic sinus of Valsalva (a). The anterior interventricular vein (arrow 5) passes along the anterior left ventricular wall parallel with a diagonal branch of the anterior descending artery (arrow 4). The vein passes to the posterior atrioventricular ring where it becomes the great cardiac vein (arrow 2), running along with the circumflex artery (arrow 3). A large lateral ventricular vein (arrow 6) runs along the lateral left ventricular wall with a large circumflex marginal branch (arrow 7). The posterior interventricular vein (arrow 8) passes along the inferior aspect of the interventricular septum. It runs parallel with the posterior descending artery (arrow 9) and then joins the great cardiac vein to form the coronary sinus (cs). The cs drains to the right atrium (RA). B, Reconstruction in caudally angulated view, from the left hip (cardiac apex) to the right shoulder (the cardiac base). The continuous vein starts over the anterior left ventricular wall as the anterior descending vein (arrow 1). It moves toward the left, leaving the anterior interventricular groove to enter the posterior atrioventricular ring as the great cardiac vein (arrow 2). The vein and circumflex coronary artery (arrow 3) define the posterior atrioventricular ring. The posterior interventricular vein (arrow 4) defines the inferior interventricular septum and drains into the great cardiac vein. Notice how as the circumflex artery decreases in caliber, the great cardiac vein increases. The coronary sinus (arrow 5) drains into the right atrium.

The tricuspid valve lies within the anterior atrioventricular ring with the right coronary artery, protecting the inflow to the right ventricle (see Figure 5-17). The leaflets are usually poorly visualized in less-enhanced right ventricles. The mitral valve lies within the posterior atrioventricular ring, along with the circumflex coronary artery and the great cardiac vein, and protects the inflow to the left ventricle (see Figures 5-5B, D, 5-14, 5-17). The right ventricular inflow lies anterior, inferior, and to the right of the left ventricular inflow. Thus, the left ventricle lies slightly superior and posterior and to the left of the right ventricle (see Figures 5-3A, C, 5-5A, C, 5-8B). The two ventricles share the interventricular septum. The right ventricular side of the septum contains the septomarginal trabeculation and is therefore irregular and trabeculated (see Figures 5-9C, 5-12B). The basal aspect of the trabeculation contributes to the crista supraventricularis and right ventricular infundibulum (see Figures 5-8B, 5-10B, 5-12B). The right ventricle gives papillary muscles from both the septomarginal trabeculation along the interventricular septum and also from the free wall. These myocardial trabeculations appear as filling defects distributed within the right ventricular cavity. The left ventricle gives two large papillary muscles from the posterior (lateral) ventricular wall. Muscle bundles divide into heads and subheads, appearing as branching intracavitary filling defects (see Figures 5-3B, 5-5A, C, D, 5-9C, 5-14). Tricuspid valve chordae are generally not well visualized on CT. However, mitral chordae tendineae are frequently exquisitely visualized. They appear as stringlike filling defects connecting the papillary muscle heads and the mitral leaflets (see Figures 5-5B, D). Because the left ventricle gives no papillary muscles from the interventricular septum, the left ventricular side of the septum appears smoother than the right ventricular side. However, interconnected left ventricular myocardial trabeculations are commonly seen along the lateral wall and toward the ventricular apex.