FRCR 2A Cardiovascular Radiology SBA

Findings: The radiograph demonstrates enlarged central pulmonary arteries compatible with pulmonary arterial hypertension. The central pulmonary arteries also have calcified walls. In addition, there is deformity of the left upper ribs compatible with a prior thoracotomy. The MR confirms the presence of enlarged central pulmonary arteries and decreased signal in the central branches suggesting slow flow from elevated resistance. There is also an anastomosis between the left pulmonary artery and the descending aorta.

Findings: The CT scan demonstrates a large mass that fills part of the anterior mediastinum in front of the pulmonary outflow tract (A). This mass contains calcification. Image (B. obtained at a lower level shows that the mass is in continuity with the left ventricle. In addition, the left ventricular wall is thin in the anteroseptal portion with subendocardial mural thrombus formation and peripheral calcification. All of these findings in combination are diagnostic of a large left ventricular aneurysm that extends superiorly into the anterior mediastinum.

Findings: Both sequences demonstrate an enlarged aortic root that measures approximately 4.5 cm in diameter. In addition, there is thickening of the walls of the ascending aorta and pulmonary arteries. The gradient echo image demonstrates a mild degree of aortic valvular insufficiency. The findings are consistent with an arteritis, such as Takayasu's arteritis.

Findings: Contrast-enhanced CT images through the heart demonstrate the presence of diffuse thickening of the interatrial septum with thinning at the level of the fossa ovalis as seen on Figure 4C. The septal thickening is characterized by very low attenuation tissue characteristic of fat.

A. Lipomatous hypertrophy of the interatrial septum is characterized by deposition of non-encapsulated fat in the interatrial septum, sparing the fossa ovalis, a characteristic feature. It can be associated with arrhythmias.
B. Atrial lipoma can occur in any portion of the atria including the atrial septum. However, they do not spare the fossa ovalis as this case illustrates. Lipomas consist of encapsulated mature adipose cells, can grow to significant size, and are considered distinct from lipomatous hypertrophy of the interatrial septum.
C. Atrial myxomas are soft tissue benign tumors of the heart that can be found in any chamber, but are most commonly seen in the left atrium, attached to the interatrial septum. The fatty nature of this case excludes the diagnosis of myxoma.
D. The fatty appearance of the atrial infiltration excludes the diagnosis of bland thrombus of the right atrium.
E. Liposarcoma of the heart is extremely rare, and as liposarcomas at other sites is characterized by strands of soft tissue within the fatty tumoral mass. Again, the pure fatty nature of the tumor and sparing of the fossa ovalis excludes liposarcoma as a diagnosis.

Findings: Two contrast-enhanced CT images of the chest demonstrate the presence of high attenuation collection within the pericardial cavity producing mass-effect and displacement of the heart to the right. In addition, Figure 3B demonstrates a brightly enhancing structure on the inferior surface of the heart next to a metallic surgical clip near the distal portion of the posterior descending coronary artery.

A. Although the heart is displaced to the right inside the pericardial sac, there is no volvulus effect thus excluding the diagnosis.
B. Pericardial cysts are usually located in the right cardiophrenic angle and are usually filled with clear fluid. Although they can attain significant size, they do not displace the heart.
C. Constrictive pericarditis can be excluded based on a normal thickness pericardium in this case. Pericardial constriction would in addition be very unusual to present clinically several days after surgery, as is the case with this patient. The fluid filled pericardial cavity and heart displacement of this case are atypical for constrictive pericarditis.
D. The presence of high attenuation material in the pericardial sac is characteristic of hemopericardium. Pericardial hemorrhage was a result of a pseudoaneurysm formation at the distal graft anastomosis to the posterior descending branch, which explains the finding on Figure 3B. Associated bilateral pleural effusions and heterogeneity of the liver are the result of associated congestive changes from cardiac tamponade physiology.
E. In the post-pericardiotomy syndrome, clinical findings of chest pain and fever develops several days or weeks after cardiac or pericardial injury of all kinds including trauma, catheter perforation, or surgery. Treatment usually consists of aspirin or other non-steroidal anti-inflammatory drugs.

Findings: This contrast-enhanced CT demonstrates the ascending aorta anterior and to the left of the pulmonary artery.

A. D-Transposition of the great arteries is a cyanotic condition in which the atrioventricular connections are concordant (right atrium connected to right ventricle and left atrium connected to the left ventricle), but there is ventriculoarterial discordance (right ventricle connected to aorta, left ventricle connected to the pulmonary artery). As a result, the ascending aorta arises anteriorly and to the right of the main pulmonary artery.
B. In L-transposition of the great arteries there is atrioventricular discordance (right atrium connected to left ventricle, left atrium connected to the right ventricle) and ventriculoarterial discordance (right ventricle connected to aorta, left ventricle connected to the pulmonary artery). The hallmark of this congenital defect is the ascending aorta arising anteriorly and to the left of the pulmonary artery as this case illustrates. These patients also frequently present with heart block.
C. Truncus arteriosus is a cyanotic heart condition characterized by lack of septation of the aortic root and main pulmonary artery thus resulting in a common arterial trunk arising from the heart. Invariably a ventricular septal defect allows mixing of blood from both ventricular chambers. Unless totally repaired in infancy, adult survival is extremely unusual. In truncus arteriosus, the great vessels are not transposed.
D. In coarctation of the aorta there is a stenosis of the aorta (usually near the origin of the left subclavian artery) that produces variable obstruction to blood flow and if severe enough heart failure particularly in newborns. In adult patients, collateral vessels around the obstruction can lead to the formation of rib notching. This case demonstrates a normal diameter of the aorta with no collaterals.
E. Pseudocoarctation of the aorta refers to a condition in which the aortic arch is elongated producing a characteristic S-shaped deformity of the aortic arch. The relationship of the aorta and the pulmonary artery is otherwise preserved.

Findings: This standard chest radiograph of a 36-year-old female demonstrates the presence of moderate cardiomegaly. Further inspection reveals that there is left atrial and specifically left atrial appendage enlargement as evidence by a bulge along the left side of the heart just below the main pulmonary artery. There is increase in the subcarinal angle because of left atrial dilatation. In addition, there is pulmonary vascular redistribution indicating pulmonary venous hypertension.

A. The right ventricular outflow tract is normally located anterior to the aortic root, as is shown in this case.
B. There is no evidence of a coronary artery fistula.
C. The right coronary artery arises normally from the right sinus of Valsalva. The left coronary artery also arises from the right sinus of Valsalva and travels between the right ventricular outflow track and the aorta, a malignant course that may result in sudden death.  
D. The heart is located normally in the left hemithorax.

A. A coronary artery aneurysm is defined as an increase in diameter by 50%, not 100%.
B. Most coronary aneurysms are secondary to atherosclerosis.
C. Correct. Kawasaki disease has multiple manifestations in the heart, including coronary aneurysm formation. Large aneurysms (> 8mm) are frequently complicated by thrombosis and subsequent myocardial infarction. They may also rupture. Small aneurysms tend to regress to normal caliber over time.
D. Rupture of atherosclerotic coronary aneurysms is rare.

A. The pericardium normally measures 2 mm in thickness or less.
B. Most cases of constrictive pericarditis are secondary to idiopathic pericarditis or pericarditis following cardiac surgery and radiation therapy.
C. Although calcification is associated with constriction, the observation of calcification does not imply constriction. In order to make the diagnosis of constrictive pericarditis, the patient must have physiologic changes in association with pericardial thickening or calcification. This includes impaired diastolic filling and equalization of diastolic pressures in the right and left ventricles. The most common causes of calcific pericarditis include infection (tuberculosis), uremia and trauma.
D. Pericardial thickening or calcification may be present without physiologic impairment, although constrictive physiology is usually present when there is extensive pericardial calcification.

A. Correct. Most patients are right dominant with the right coronary artery giving rise to the posterior descending artery and posterior left ventricular branches.
B. Right dominant circulation is seen in 85% of individuals. The coronary circulation is left dominant in only 8% of individuals. In left dominant circulation, the posterior descending artery and posterior left ventricular branches arise from the left circumflex artery. In the remaining 7% there is a co-dominant system in which the posterior descending artery arises from the right coronary artery and the posterior left ventricular branches arise from the left circumflex coronary artery.
C. The right coronary artery supplies the sinoatrial node in 60% of individuals. The sinus node artery arises from the proximal right coronary artery. In 40% of individuals, the sinus node artery arises from the proximal left circumflex artery.
D. The diagonal branches arise from the left anterior descending coronary artery and supply the anterior free wall of the left ventricle. The acute marginal branch arises from the right coronary artery and supplies the right ventricle. The obtuse marginal branches arise from the circumflex coronary artery and supply the lateral left ventricle.

A. Correct. Myxoma accounts for half of all primary cardiac tumors.
B. Metastases to the pericardium and epicardium are most commonly from lung cancer. This is in part related to proximity to the heart and in part because of the prevalence of lung cancer. Metastases to the myocardium are most commonly from melanoma and the mode of spread is thought to be hematogenous. Myocardial metastases are less frequent than pericardial or epicardial metastases.
C. Primary cardiac malignancies are rare. Metastases to the heart are 20 to 40 times more common than primary tumors.
D. Only 25% of primary cardiac tumors are malignant.

A. Correct. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Follow-up studies have shown interval growth of the aortic valve graft in children and infants.
B. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Because a homograft is used, anticoagulation is not necessary.
C. The Ross procedure replaces the aortic valve with the patient’s pulmonary valve and replaces the pulmonary valve with a cryopreserved pulmonary valve homograft. Because both the pulmonary and aortic valves are replaced, the Ross procedure is a more extensive operation compared to conventional aortic valve replacement.
D. The Ross procedure is performed to correct aortic valve disease.

"A. The oblique sinus is separated from the transverse sinus by a pericardial reflection.
B. The postcaval recess arises from the pericardial cavity proper and is separated from the transverse sinus by a pericardial reflection.
C. Correct. The superior aortic recess arises from the transverse sinus and extends superiorly to surround the posterior, right lateral and anterior aspect of the ascending aorta.
D. The posterior pericardial recess is a superior extension of the oblique sinus, which does not communicate directly with the transverse sinus.

A. The calcifications are located in the wall of the left atrium.
B. Calcification of the pulmonary arteries may occur in patients with longstanding, severe pulmonary arterial hypertension. The calcifications in this case are located in the wall of the left atrium.
C. Correct. The calcifications are secondary to endocarditis from rheumatic heart disease. Other causes of endocarditis can also cause calcification of the left atrial wall.
D. The areas of calcification do not correspond with the anatomic location of the coronary arteries.

A. Rheumatic heart disease is the most common etiology of mitral stenosis.
A. Rheumatic valvular heart disease affects the mitral valve in almost all cases and concomitantly affects the aortic valve in approximately 50% of cases. Rheumatic heart disease rarely destroys only the aortic valve. Isolated aortic valve disease is typical of a bicuspid aortic valve.
B. Valvular calcification typically reflects valvular stenosis. A primarily insufficient valve rarely calcifies.
D. Correct. The congenitally deformed bicuspid aortic valve faces abnormal stress and pressure, which cause fibrosis, calcification, and stenosis.

A. Correct. Turbulent flow is usually a better indicator of restenosis than is isolated narrowing.
B. Spin-echo images may underestimate the amount of stenosis, which may be quite thin and difficult to detect.
C. Gradient-echo images are subject to significant artifacts from surgical clips and may overestimate the degree of narrowing.
D. Not all patients with significant coarctation have detectable collateral vessels, and residual collateral vessels may persist following successful repair.

Findings: The left lower lobe consolidation and mild volume loss has heterogeneous attenuation with associated loss of adjacent mediastinal tissue planes. A contiguous filling defect in the left inferior pulmonary vein extends into the left atrium. Left atrial size is normal.

A. In autopsy series, myocardial bridging, an intramuscular course of the coronary artery, occurs in 30% of specimens.
B. Correct. Because multiplanar reformatted images can be obtained from the CT dataset, CT is better able to detect the intramuscular course of the coronary artery.
C. In most cases, myocardial bridges are clinically silent.
D. Myocardial bridges are most frequently seen with the left anterior descending artery.

A. Outflow obstruction in the setting of hypertrophic cardiomyopathy occurs in a subvalvular location. While the aortic valve may close prematurely during mid-systole, aortic valve stenosis is not characteristic of hypertrophic cardiomyopathy.
B. Although mitral valve regurgitation may coexist with hypertrophic cardiomyopathy, it is not a characteristic of hypertrophic cardiomyopathy.
C. Correct. The increased flow velocity occurring through the narrowed subvalvular left ventricular outflow tract draws the anterior leaflet of the mitral valve anteriorly due to the Venturi effect. This results in further obstruction of the left ventricular outflow tract.
D. The mitral valve is typically drawn anteriorly during systole in the setting of hypertrophic cardiomyopathy. Prolapse posteriorly into the left atrium is not a characteristic of hypertrophic cardiomyopathy.

A. The pulmonary trunk may be either normal or enlarged on radiographs in patients with pulmonary valve stenosis. Isolated pulmonary trunk enlargement is more frequent with idiopathic dilatation of the pulmonary artery.
B. The right ventricle hypertrophies in response to the pressure overload caused by pulmonary valve stenosis. Ventricular dilatation only occurs if ventricular failure or tricuspid regurgitation is present.
C. Correct. Enlargement of the left main pulmonary artery, with or without pulmonary trunk enlargement, is the radiographic hallmark of pulmonary valve stenosis.
D. Enlargement of both main pulmonary arteries is characteristic of either overcirculation or pulmonary arterial hypertension. Enlargement of the right pulmonary artery is not a feature of pulmonary valve stenosis.

A. Correct. Chronic pulmonary venous hypertension in patients with mitral stenosis leads to elevated pulmonary arterial and right ventricular pressures. If severe, these will result in failure of the right ventricle, usually with tricuspid regurgitation.
B. The most frequent cause of pulmonary valve stenosis is a congenital valvular defect. Pulmonary valve stenosis secondary to rheumatic heart disease is very rare.
C. Rheumatic heart disease is the predominant cause of mitral stenosis. The tricuspid valve is primarily affected in only 5% of patients with rheumatic heart disease.
D. Tricuspid valve prolapse is associated with mitral valve prolapse and can result in tricuspid regurgitation and subsequent right atrial enlargement. Tricuspid valve prolapse is not associated with mitral stenosis.

A. Correct. On short axis images, the interventricular septum is curved with the convexity toward the right ventricle. This appearance is maintained during systole and diastole. Straightening, bowing with convexity toward the left ventricle and sinusoidal appearance of the interventricular septum are abnormal.

A. The chest radiograph shows normal heart size and vascularity. There is no evidence of pulmonary edema.
B. Correct. The chest radiograph shows normal heart size and vascularity. On the lateral view, there is calcification of the aortic valve, consistent with aortic stenosis. Identification of calcification of the aortic valve on a chest radiograph is usually associated with clinically significant aortic stenosis.
C. The chest radiograph shows normal heart size and vascularity. There is no evidence of left atrial enlargement or pulmonary venous hypertension.
D. The chest radiograph shows normal heart size and vascularity. There is no evidence of pericardial effusion.

"A. Acute intramural hematoma (IMH) exhibits high attenuation and is best identified on unenhanced CT.
B. Most penetrating atheromatous ulcers involve the descending thoracic aorta.
C. Correct. Penetrating atheromatous ulcer is a major cause of intramural hematoma.
D. Treatment is generally the same as for aortic dissection, and involvement of the ascending aorta typically mandates emergent surgical repair, while involvement of the descending aorta is treated medically to control hypertension.

Findings: On the chest radiograph, the main and central pulmonary arteries are markedly enlarged and rapidly taper in size in the lung periphery, compatible with pulmonary arterial hypertension. The heart size is upper normal, and left atrial size is normal. The lung perfusion scan, with images of the head and thorax, reveals 99mTc MAA activity within the lungs and brain.

A. Multiple pulmonary infarcts manifest as pulmonary perfusion defects, which are not present. Radiotracer should not normally accumulate in the brain.
B. Accidental injection of the radiotracer into an antecubital artery would cause most of the radiotracer to sequester initially in the distal small vessels of the hand. Those particles that entered the venous circulation would then be trapped in the lungs, without significant accumulation of radiotracer in the brain.
C. With mitral stenosis, no cardiac shunt is present. The heart size may be normal while the left atrium is typically enlarged. Long-standing pulmonary venous hypertension may induce pulmonary artery hypertension. Patients with mitral stenosis may have recurrent episodes of pulmonary hemorrhage and hemoptysis, which may then progress to pulmonary hemosiderosis and rarely ossification. In these instances, a calcium or bone-avid radiotracer may be deposited at the lung bases, the predominant site of hemosiderosis.
D. Correct. Occasionally, with a hemodynamically significant left-to-right cardiac shunt, the pulmonary artery hypertension and vascular resistance may become so high that right heart pressures exceed those of the left heart, and the direction of the cardiac shunt reverses. Thus, a left-to-right shunt becomes a right-to-left shunt, a phenomenon known as Eisenmenger’s physiology. In normal individuals, intravenous injection of appropriately labeled 99mTc MAA should only accumulate in the lungs. With a right-to-left cardiac shunt, the radiotracer will lodge not only in the lungs but also cross via the shunt to the organs supplies by the systemic circulation, such as the brain. Free pertechnetate is an occasional contaminant of 99mTc MAA preparation, is normally excreted by the kidneys, and should not localize in the brain.

Findings: The heart size is normal, and the main and left pulmonary arteries are enlarged. The right pulmonary artery and remainder of the pulmonary vascularity are normal.

A. In patients with aortic stenosis, the size of the heart and pulmonary arteries is typically normal. The size of the ascending aorta may be normal or exhibit post-stenotic dilatation.
B. Most cases of pulmonic stenosis occur at the valvular level, and the heart size is normal. In almost all cases, the main and left pulmonary arteries are dilated due to the post-stenotic jet that preferentially strikes these vessels.
C. A ventricular septal defect manifests radiographically as shunt vascularity with increase size of the main, central, and peripheral pulmonary arteries due to increased vascular flow through the lungs.
D. Partial absence of the pericardium is most common on the left and produces an unusual contour of the left cardiac border when a portion of the heart herniates through the pericardial defect. This contour abnormality does not conform to enlargement of the pulmonary artery segment or the left atrium.

Findings: The right ventricle, right atrium, and pulmonary trunk are enlarged. The interventricular septum is straightened rather than normally bowed to the right, which indicates elevated right ventricular pressure. The left ventricle is normal size but displaced posteriorly. The left lower lobe is atelectatic.

A. Myxoma is the most common primary benign cardiac mass in adults. These tumors most often arise in close proximity to the fossa ovalis. Nearly 75-85% originate in the left atrium; up to 25% occur in the right atrium and/or extend through the fossa ovalis and about 5% arise within the ventricles. On HASTE sequences, myxoma is heterogeneous with signal intensity slightly higher than normal myocardium. On T1WI, myxoma is isointense relative to the myocardium and on T2WI the signal intensity is greater than the myocardium. STIR sequences show no fat suppression. SSFP sequences often reveal increased signal (T2/T1 ratio) secondary to the gelatinous composition of the tumor with a high fluid-like content (relative T2-weighting). Perfusion images show no uptake of Gd-DTPA by the tumor but heterogeneous enhancement of the myxoma is possible on delayed Gd-DTPA imaging.

A. Obtaining more signal averages may increase signal, but will not eliminate aliasing artifact.

A. The radiograph does not demonstrate the presence of an IVC filter.

A. Although pulmonary vein stenosis is a reported complication following ablation procedures, there are no specific signs on this radiograph to definitively diagnose this condition.

A. Correct. The right ventricle is definitely larger than the left, and it should be smaller than, or the same size as, the left ventricle.

A. Hypertrophic cardiomyopathy is not associated with anomalous coronary origin. Causes of left ventricular hypertrophy include systemic hypertension, autosomal dominant mutation, and idiopathic.

A. The extensive transmural delayed enhancement indicates infarction and so the patient will not benefit from cardiac revascularization. This patient will be managed medically, including anticoagulation given the presence of a left ventricular thrombus.
B. The extensive transmural delayed enhancement indicates infarction and so the patient will not benefit from cardiac revascularization. This patient will be managed medically, including anticoagulation given the presence of a left ventricular thrombus.
C. The extensive transmural delayed enhancement indicates infarction and so the patient will not benefit from cardiac revascularization. This patient will be managed medically, including anticoagulation given the presence of a left ventricular thrombus.
D. Correct. Appropriate medical management is indicated to optimize cardiac function and improve survival while anticoagulation should be initiated in the absence of absolute contraindications to reduce the risk of thrombus progression or embolization.

A. Correct. The aberrant right subclavian artery, the most common embryologic abnormality of the aortic arch, is usually asymptomatic and found incidentally. 

A. Myxomas typically have soft tissue attenuation on CT imaging and may be heterogeneous. The most common location for myxoma is the left atrium with attachment of the tumor to the fossa ovale.

A. Correct.

C. Correct.

"C. Correct.

A. Anomalous pulmonary venous drainage on the left is usually from the left upper lobe to a left vertical vein. A persistent left superior vena cava typically drains into the coronary sinus.

A. Although hypoplastic left heart syndrome is the most common cause of congestive failure in the neonate, it only occasionally results in cyanosis.

A. Correct. Abnormal curvature of the ventricular septum toward the left ventricle indicates elevated right ventricular pressure.
B. Although the right ventricle will hypertrophy under the stress of a pressure overload, wall thickening may be difficult to identify on routine, non-gated CT scans.
C. Enlargement of right ventricle indicates a volume overload, such as tricuspid regurgitation or a left to right shunt, or the presence of right ventricular failure. Elevated right ventricular pressure alone will not generally enlarge the chamber.
D. Reflux of contrast into the IVC can be seen with either high right sided pressures (atrial or ventricular), or with tricuspid regurgitation.

A. Although tricuspid regurgitation frequently occurs in intravenous drug abusers with bacterial endocarditis, it is not as common as tricuspid regurgitation secondary to pulmonary hypertension.
B. Correct. The majority of cases of tricuspid regurgitation in adults result from high right sided pressures with or without right ventricular failure.
C. Ebstein’s anomaly may result in tricuspid regurgitation, but is a rare disease.
D. Although patients with rheumatic valvular heart disease frequently have tricuspid regurgitation, it almost always results from high right sided pressures related to mitral stenosis. Primary involvement of the tricuspid valve occurs in only about 5% of patients with rheumatic heart disease.

A. The diagonal artery is a branch of the left anterior descending coronary artery. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery.
B. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery.
C. Correct. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery.
D. The atrioventricular (AV) node artery, supplies the AV node. In 85-90 percent of patients, the AV node artery arises from the right coronary artery at the point where it gives off the posterior descending artery. A branch of the circumflex artery supplies the AV node in the remaining cases.

A. Incorrect.
B. Incorrect.
C. Incorrect.
D. Correct. Drainage of the pulmonary veins should be assessed in all patients with congenital anomalies. Nearly all patients with sinus venosus atrial septal defect have anomalous pulmonary venous drainage, most commonly drainage of the right upper lobe to the superior vena cava. Approximately 10 percent of patients with an ostium secundum atrial septal defect will have anomalous pulmonary venous drainage.

A. There is only a tiny strand of soft tissue density material connecting the proximal descending aorta and the left pulmonary artery. This represents the ligamentum arteriosum.
B. The bulge along the underside of the aorta is smooth and there is no evidence of any flap or periaortic hematoma. These findings make traumatic laceration highly unlikely.
C. Correct. The combination of a small, smooth bump along the bottom edge of the aorta along with the lack of any evidence of flap or mediastinal hematoma is typical of a ductus diverticulum. The soft tissue strand joining the bump to the pulmonary artery represents the ligamentum arteriosum, the remnant of the ductus arteriosus.
D. The bump has none of the hallmarks of penetrating atherosclerotic ulcer.

A. Ostium primum defects are the second most common atrial septal defects (ASD), accounting for about 15 percent of all ASDs. The primum portion of the atrial septum is located inferiorly at the level of the mitral and tricuspid valves. Ostium primum defects are often associated with atrioventricular defects. The abnormality on the image is not in this location.
B. Ostium secundum defects are the most common ASD, accounting for approximately 75 percent of all ASDs, and are located near the fossa ovalis, in the middle of the atrial septum. The abnormality on the image is not in this location.
C. Correct. Sinus venosus defects are the third most common ASD accounting for approximately 10 percent of all cases. The sinus venosus portion of the atrial septum separates the left atrium from the superior vena cava. The defect in this case is located in the superolateral aspect of the atrial septum at the junction of the superior vena cava and right atrium, near the insertion of the right pulmonary veins, consistent with a sinus venosus ASD.
D. Patent foramen ovale occurs in up to 25 percent of adults. The flap of tissue covering the foramen ovale typically closes the defect since the left atrial pressure is higher than the right atrial pressure. Normally, this flap of tissue fuses with the septum after the first year of life. The abnormality on the image is not in the location of the foramen ovale.

A. The atrial lead is appropriately positioned in the right atrium. The right ventricular lead tip lies outside of the confines of the heart. If it were placed in the right ventricle, it would overlie the heart.

A. The distal coil should be located in the right ventricle. When an abnormal rhythm is detected, the device sends a defibrillation shock.

A. Angiosarcoma is the most common primary malignant cardiac tumor. However, it is not the most common primary malignant pericardial tumor.

A. Although pericardial cysts may measure higher than water attenuation if there is proteinaceous fluid or prior hemorrhage, the most common appearance is that of a simple cyst.

A. T2-weighted black-blood images are useful for morphologic assessment of the heart.

A. The mitral annulus is located at the atrioventricular groove. The calcification in this case involves the endocardial surface of the left ventricle.

A. Myxomas may occur in the ventricle, however they are much more common in the atria, especially the left atrium. The location of this abnormality adjacent to an area of myocardial infarction makes the diagnosis of thrombus much more likely.

A. The diagonal branches arise from the left anterior descending artery. The artery in this case arises at the trifurcation of the left main coronary artery.

A. The radiograph shows marked enlargement of the central pulmonary arteries with abrupt tapering, or pruning. This finding is consistent with pulmonary arterial hypertension. Although patients with atrial septal defect can develop pulmonary arterial hypertension, in this case, the lungs are markedly hyperinflated consistent with emphysema. In addition, the central pulmonary arteries are typically more markedly enlarged in patients with Eisenmenger physiology.

A. Correct. The papillary muscles are connected to the mitral valve leaflets by the chordae tendinae. When there is rupture of the chordae tendinae or the papillary muscle itself, the mitral valve is unable to function properly, resulting in mitral regurgitation. Because this is an acute process, accommodation does not occur, resulting in acute pulmonary edema. Edema predominantly affecting the right upper lobe can be seen if the jet of regurgitant blood is directed into the right superior pulmonary vein, which drains the right upper lobe. 

div>A. Correct. PA and lateral chest radiographs show dilated central pulmonary arteries and a relatively normal appearing cardiac silhouette. The images also show a percutaneous transvenous septal occlusive device overlying the atria, indicating this patient has undergone repair of an atrial septal defect (ASD). The presence of the septal occlusive device indicates that the likely etiology of the findings is an ASD. After correction of an ASD, central pulmonary artery enlargement may persist, although typically diminished when compared with presurgical radiographs. 

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A. In general it is recommended to wait six weeks after stent placement before performing MRI. This is to allow endothelialization which, in theory, prevents stent dislodgement. Stent migration is thought to allow increased exposure of the stent metal to platelets and increase the risk of thrombosis. However, there are many studies in the literature which demonstrate no adverse effects in patients who had MR imaging at a shorter interval after stent placement.

A. Acute marginal branches arise from the right coronary artery. Obtuse marginal branches arise from the left circumflex coronary artery.
B. In approximately 80% of individuals, the posterior descending coronary artery arises from the distal right coronary artery (right dominant circulation). Only about 10% of individuals have a posterior descending coronary artery supplied by the left circumflex coronary artery.
C. In approximately 60% of patients, the sinoatrial nodal artery arises from the right coronary artery.
D. A ramus intermedius arises between the left anterior descending and left circumflex coronary arteries from a trifurcation of the left main coronary artery.

"A. Regardless of the location of the infarction, the pattern of enhancement always spreads outward from the endocardium. Additionally, the infarct location can always be tracked back to the culprit artery.
B. While infarcts must have endocardial involvement, a patchy distribution is not characteristic of an ischemic event, as it would not follow the distribution of the culprit artery.
C. The pattern of enhancement of infarcts always spread outward from the endocardium.
D. The pattern of enhancement of infarcts always spread outward from the endocardium. Additionally, a patchy distribution is not characteristic of an ischemic event, as it would not follow the distribution of the culprit artery.

A. Sinus of Valsalva aneurysms are associated with aortic valvular insufficiency, particularly if the aneurysm has ruptured.
B. The majority of sinus of Valsalva aneurysms affect the right sinus, followed in frequency by the non-coronary sinus. Fewer than 5% of sinus of Valsalva aneurysms involve the left coronary sinus.
C. Sinus of Valsalva aneurysms are most commonly congenital in origin. Association with other congenital heart defects is common, including VSD, bicuspid aortic valve, and aortic insufficiency.
D. Most ruptures occur into the right atrium and ventricle, and cause heart failure. Intrapericardial rupture and tamponade, which can be fatal, is much less common than intracardiac rupture.

A. Myxoma is the most common PRIMARY benign cardiac neoplasm. They account for approximately 25% of all primary cardiac neoplasms.
B. Although patients with lymphoma may have involvement of the heart, primary cardiac lymphoma is uncommon.
C. Rhabdomyoma is the most common primary cardiac neoplasm in children.
D. Metastases occur far more frequently than primary cardiac neoplasms.

A. There is a bicuspid valve, the most common congenital heart defect. The anterior leaflet is larger than the posterior leaflet and has a raphe or seam-like ridge where the commissure should have formed.  
B. Although aortic stenosis may occur as a result of age-related valvular degeneration, the tricuspid appearance is maintained.
C. The late aortic valve sequelae of rheumatic heart disease include thickening of the leaflet edge, shortening of the cusps and fusion of the commissures. The commissures are sharply delineated in this case.
D. Bacterial endocarditis results in valvular vegetations. In advanced cases, there may be perforation of the cusps and resulting aortic regurgitation.

A. While Kawasaki disease is a cause of coronary artery aneurysm, atherosclerosis is the most common cause accounting for approximately 50% of all coronary artery aneurysms.
B. Infectious arteritis can result in coronary artery aneurysms (~10%) but is a much less common cause than atherosclerosis, congenital aneurysm, or Kawasaki disease.
C. Takayasu arteritis most commonly involves the aorta and its main branches. While involvement of the coronary arteries is not uncommon, coronary artery aneurysms or other significant coronary arterial abnormalities are infrequent manifestations of this disease.
D. Approximately 50% of all coronary artery aneurysm are caused by atherosclerosis. While the pathogenesis is somewhat unclear, a defect in the vessel media is thought to be an important feature in the development of coronary artery aneurysms.  

A. Thrombus in the cardiac chambers can mimic tumor. However, thrombus is usually located in areas of slow flow such as the atrial appendages.
B. Although metastases are common, their presence often is not apparent on imaging. Given the location of this mass in the left atrium, arising from the region of the fossa ovalis, myxoma is more likely.
C. Approximately 85% of myxomas are located in the left atrium attached to the atrial septum, usually at the fossa ovalis. Myxomas that prolapse through the mitral valve can mimic symptoms associated with mitral stenosis.  
D. Lipomas show fat density on CT and fat signal characteristics on MR. The lesion in this case does not have imaging features of fat.

"A. Delayed-enhancement MR demonstrates hyperenhancement in the sub-epicardial region in patients with myocarditis.
B. There is subendocardial hyperenhancement in the inferoseptal region, consistent with myocardial infarction.
C. Coronary vasospasm is a clinical syndrome of chest pain at rest secondary to myocardial ischemia associated with ST-segment elevation. Delayed enhancement is seen in infarcted tissue and not in ischemic tissue.
D. This is also known as Takotsubo cardiomyopathy. MR imaging usually shows reversible left ventricular dysfunction with apical ballooning. MR may add to the diagnosis demonstrating regional wall motion abnormality with no evidence of delayed-enhancement.

"A. When the left pericardium is absent, as in this case, the heart shifts toward the left. Normally, the heart would not be in contact with the left chest wall.
B. The left ventricle is not dilated as would be expected in dilated cardiomyopathy.
C. The ventricles are normal in size and configuration but are displaced in the thorax due to the absence of the left pericardium.
D. Cardiac herniation and volvulus can occur in patients who undergo extrapleural pneumonectomy. The left lung is visible in this case.

Imaging Findings
Partial absence of left pericardium
Prominence of left atrial appendage
Complete absence
Levoposition of the heart
Flattening & elongation of left heart border

"A. The Coumadin ridge is located at the junction of the left atrial appendage and the left superior pulmonary vein and may cause the appearance of a filling defect.
B. The moderator band is located at the apex of the right ventricle and extends from the right ventricular free wall to the interventricular septum.
C. The crista supraventricularis is one of a series of muscular bands that separates the inflow and outflow portions of the right ventricle.
D. The crista terminalis is a muscular ridge of varying prominence that separates the trabeculated right atrial appendage from the smooth-walled right atrium.

Findings: There is a vascular structure connecting the inferior aspect of the posterior aortic arch and the main pulmonary artery consistent with a patent ductus arteriosus.

C. The image shows a connection between the aorta and main pulmonary artery consistent with patent ductus arteriosus.

Findings: Horizontal long axis MIP from a contrast-enhanced cardiac CT scan shows a defect high in the interatrial septum consistent with a sinus venosus atrial septal defect.

A. A small amount of fat is present in the interatrial septum and can be a normal finding. When lipomatous hypertrophy of the interatrial septum is present, there is sparing of the fossa ovalis. However, the fossa ovalis is more centrally located in the interatrial septum.
B. The image shows an abnormal connection between the superior aspect of the right atrium and the left atrium, consistent with sinus venosus atrial septal defect.
C. Septum primum defects are located close to the atrioventricular valve plane.
D. Septum secundum atrial septal defects are located at the foramen ovale.

A. Papillary fibroelastoma is a collection of avascular fronds of dense connective tissue lined by endothelium. Fibroelastomas account for approximately 10% of all primary cardiac tumors, with about 90% of them arising at valvular surfaces.

"A. The SA nodal branch arises from the proximal RCA in approximately 65% of the population coursing posteriorly toward the region of the SA node.

"A. Myocardial noncompaction is a rare disorder characterized by the failure of the myocardium to undergo appropriate compaction during embryogenesis. This compaction typically occurs during the fifth through eighth embryologic weeks, where the developing myocardium transitions from a loosely organized collection of myocardial fibers into a discrete muscular chamber. Failure of this mechanism results in a left ventricle comprised, in whole or in part, of noncompacted myocardial fibers, typically involving the inferior and lateral walls. This can result in heart failure, dysrhythmias, and thromboembolic disease. Imaging, either with MRI or echocardiography, reveals a ratio of noncompacted myocardium to normal myocardium of at least 2:1 in affected areas.

Terminology
Spongy myocardium
An arrest in the normal process of myocardial compaction, resulting in persistence of multiple prominent ventricular trabeculations and deep intertrabecular recesses
LVNC is being increasingly recognized as a distinct form of cardiomyopathy with a distinct underlying cause and prognosis

Imaging Findings
> 2:1 Ratio of non-compacted to compacted myocardium by echo criteria
Predominantly involves the mid to apical aspect of the left ventricle
Echocardiography has been traditionally utilized
Cardiac MR is playing an increasingly important role
> 2.3:1 ratio of non-compacted to compacted myocardium by MR criteria
May detect fibrosis on delayed enhanced imaging

Pathology
An arrest in endomyocardial morphogenesis, which normally occurs between weeks 5 to 8 of fetal life

Clinical Issues
Anticoagulation for the prevention of systemic embolism
Beta-blockers for the treatment of ventricular arrhythmias and heart failure
Cardioverter-defibrillator implantation

A. The acute marginal artery arises from the right coronary artery and does not determine dominance.
B. Although the posterior lateral artery is supplied by the circumflex coronary artery in a left dominant system, the circumflex must supply the posterior descending artery in order to be considered left dominant.
C. Dominance is determined by the artery that crosses the crux of the heart (the junction of the atrioventricular and the interventricular grooves) and gives rise to the posterior descending artery.
D. The conus artery supplies the conus and does not determine dominance.

A. The vertical long axis plane is obtained from the axial plane, using a line running from the apex through the atrioventricular valve (mitral valve).
B. The vertical long axis plane depicts the left atrium and ventricle and atrioventricular (mitral) valve. A line is drawn through the center of the mitral valve to the left ventricular apex to obtain the horizontal long axis plane.
C. The short axis plane is obtained by running a line perpendicular to the horizontal or vertical long axis and interventricular septum. The short axis view images are obtained orthogonal to the long axis of the left ventricle.
D. The four chamber views are orthogonal to the short axis views. From the short axis plane at the level of the mitral valve, the four chamber view is obtained by drawing a line from the anterior papillary muscle and the apex of the right ventricle.

A. The images demonstrate marked thickening of the basal aspect of the interventricular septum. This is the characteristic finding of hypertrophic cardiomyopathy with asymmetric septal hypertrophy (formerly known as idiopathic hypertrophic subaortic stenosis). In hypertrophic cardiomyopathy with asymmetric septal hypertrophy, the interventricular septum is at least 1.3 times thicker than the left ventricular free wall, and is accompanied by obstruction of the left ventricular outflow. This characteristically results in systolic anterior motion (SAM) of the mitral valve.
B. Hypertensive heart disease can result in ventricular hypertrophy, however it typically is concentric, without preferential involvement of the left ventricular septum.
C. Alcohol-related cardiomyopathy generally presents as a dilated cardiomyopathy.
D. Ischemic cardiomyopathy generally presents as a dilated cardiomyopathy.

"A. Diagonal branches arise from the left anterior descending coronary artery.
B. A ramus intermedius is an occasionally encountered vessel that arises at the crotch of the left anterior descending coronary artery and the left circumflex coronary artery.
C. Obtuse marginal branches represent the major branch vessels arising from the left circumflex coronary artery.
D. Acute marginal branches arise from the right coronary artery.

A. Correct. Several studies which used 4 and 16 detector row CT have shown consistently that at heart rates of greater than 70 beats a minute, cardiac motion degrades the images.
B. Asthma is a contraindication to beta blockers. This is because many beta blockers are not cardioselective and block both B1 and B2 receptors. B1 receptors are found in the heart and B2 receptors are found in the airways smooth muscle. Blocking of B2 receptors causes bronchospasm in asthmatics. Even cardioselective beta blockers (such as metoprolol or atenolol) are a relative contraindication in asthmatics and should be avoided.
C. Verapamil can be used as an alternative to beta blockers, such as in patients with asthma. It is usually given intravenously in cardiac CT.

"

A. Correct. Cardiac myxoma is the most common benign primary cardiac tumor. The majority of cardiac myxomas arise within the left atrium, typically arising from the fossa ovalis. Calcification within the tumor may be seen.
B. Cardiac fibromas are usually seen in children and may be detected in utero. Cardiac fibromas are almost always located in the ventricle, particularly the ventricular septum or free wall of the left ventricle. Calcification is often present.
C. Primary cardiac osteosarcomas may have areas of calcification or ossification. They are much less common than cardiac myxoma and typically arise from the posterior wall of the left atrium.
D. Left atrial thrombus is more common than cardiac myxoma. However, thrombus in the left atrium usually develops within the left atrial appendage or arises from the posterior or lateral atrial walls.

A. Left ventricular dilatation results in lateral displacement of the papillary muscles rendering them less efficient and resulting in mitral regurgitation.
B. Rheumatic endocarditis can cause fusion and shortening of the chordae tendinae leading to mitral regurgitation. Shortening and fusion of the chordae tendinae is not a feature of dilated car-diomyopathy.
C. Most patients with dilated cardiomyopathy are relatively well compensated and tend to have fairly normal LV end-diastolic and thus left atrial and pulmonary venous pressures.
D. Patients with dilated (congestive) cardiomyopathy by definition do not have myocardial ischemia as the cause of their dysfunction.

A. One cannot determine scarred myocardium from thickened pericardium containing a myocardial rupture with any imaging technique.
B. Although pseudoaneurysms of the left ventricle almost always occur in these locations, true ventricular aneurysms also may occur inferiorly or posteriorly.
C. Regardless of the imaging technique employed or the vascular structure involved, the sine qua non of a pseudoaneurysm is a narrow neck or mouth.
D. Clot may line the wall of either type of aneurysm.

A. Almost all patients with rheumatic aortic valve involvement also have mitral valve stenosis.
B. Congenital aortic stenosis implies that the valve is stenotic at birth. Congenital bicuspid aortic valves are usually not stenotic at birth. Due to increased turbulence, the valve becomes traumatized leading to fibrosis and calcification.
C. Although most adults with aortic valve stenosis who are under age 65 will have a bicuspid aortic valve, the cause is calcification of the valve, not the bicuspid nature per se. Furthermore, patients over the age of 65 years of age with aortic stenosis typically have a tricuspid valve.
D. Endocarditis results in aortic regurgitation, not stenosis.

A. Coronary artery calcification is almost always associated with coronary atherosclerosis.
B. On angiography, a significant stenosis is one in which there is obstruction of at least 50 percent of the diameter or 75 percent of the cross-sectional area of the vessel lumen.
C. On angiography, a severe stenosis is one in which there is obstruction of at least 75 percent of the diameter or 90 percent of the cross-sectional area of the vessel lumen.
D. Coronary artery calcification, when present, accounts for approximately 20 percent of the total plaque burden.

A. It is thought that atherosclerosis of saphenous vein bypass grafts results in decreased wall elasticity and resulting dilatation of the graft lumen over time.
B. Rupture of a sinus of Valsalva aneurysm typically involves the right sinus. Rupture of the left sinus is rare.
C. True aneurysms of the left ventricle most commonly occur in the anterolateral and apical wall. In contrast, false aneurysms are most commonly located in the posterolateral and diaphragmatic aspect of the left ventricle.
D. Left ventricular pseudoaneurysms typically have a narrow communication between the pseudoaneurysm and the left ventricular cavity. In contrast, the neck of a left ventricular true aneurysm is typically broad.

"D. The left superior vena cava (SVC) drains into the right atrium via the coronary sinus. A left-sided SVC, a normal anatomic variant, is found in 0.3% of normal individuals. 80% of such individuals also have a right-sided SVC and 60% have a left BCV connecting to the right and left SVCs.

A. Annuloaortic ectasia is characteristic of Marfan’s aortitis and manifests as a thin-walled ascending aortic aneurysm, dilatation of the aortic annulus, and redundant and floppy (myxomatous) aortic valve leaflets.
B. Annuloaortic ectasia is characteristic of Marfan’s aortitis and manifests as a thin-walled ascending aortic aneurysm, dilatation of the aortic annulus, and redundant and floppy (myxomatous) aortic valve leaflets.
C. The aortic aneurysm rarely extends to or involves the origin of the brachiocephalic artery.
D. Correct. Due to the dilated aortic annulus and redundant aortic valve leaflets, affected patients almost always have severe aortic regurgitation. Aortic stenosis is not a feature.

Findings: An area of low signal that arises from the perimembranous septum in early and mid systole (Figure 5B and Figure 5C) is not present during diastole (Figure 5A) and is compatible with turbulent flow across a defect in this portion of the ventricular septum.

A. The turbulent flow across a small perimembranous defect during systole is compatible with a ventricular septal defect and a left-to-right shunt. Most ventricular defects occur in the perimembranous septum and can close spontaneously.
B. Myxomas are benign cardiac neoplasms that arise most commonly in the left atrium, usually attached to the atrial septum. With less frequency, myxomas arise from the right atrium and right ventricle and rarely in the left ventricle. The area of low signal in the right ventricle only during systole negates tumor as the cause.
C. Aortic insufficiency is excluded for two basic reasons: The area of turbulence is seen during ventricular systole, and it is located in the right ventricular cavity.
D. Vegetations of the heart are typically attached to the valves and should be detectible both in systole and diastole.
E. Fibroelastoma is a benign heart neoplasm that may arise in any of the cardiac chambers and should be detected in both systole and diastole.

Findings: There is a semilunar filling defect partly filling the left ventricular apex. The periphery of the defect shows rim calcification with soft tissue and fat attenuation in its inner aspect.

A. Left ventricular mural thrombus (LVT) is a common sequela of anterior myocardial infarction. LVT formation occurs early after anterior myocardial infarction, even when a thrombolytic agent has been administered. The highest rate of LVT formation among patients with anterior wall MI occurs in patients with an ejection fraction less than 40%. Most apical ventricular filling defects in adult patients represent mural thrombi due to myocardial ischemia. Therefore, in this elderly patient, this is the most likely diagnosis.
B. Lipomas are encapsulated fatty tumors that can occur anywhere in the heart. The peripheral calcification and the soft tissue component make this diagnosis unlikely.
C. Pericarditis can result from infection, trauma, and inflammation and may eventually lead to pericardial calcification, which is greatest at the base of the heart and the atrioventricular grooves and less common in the apical region. Even though myocardial calcification could resemble calcific pericarditis, the fatty and soft tissue components and apical location of this lesion make this diagnosis unlikely.
D. Extragonadal thoracic mature teratomas are rare and typically arise in the anterior mediastinum near the thymus. Mature teratomas are typically complex multicystic masses that may exhibit tumoral fat, chunky or stippled calcifications, or both. The left ventricular apical location and rim calcification are unusual for teratoma.
E. Arrhythmogenic ventricle, ventricular dysplasia, arrhythmogenic right ventricular dysplasia (ARVD) is a familial cardiomyopathy of unknown cause characterized by ventricular dysrrhymias, risk of sudden death, and replacement of right ventricular myocardium with fatty and fibrous tissue. Most cases affect the right ventricle (inflow, apex, outflow) and rarely the left ventricle. Fatty infiltration of the myocardium, with areas of outpouching, can be seen. Calcification is not a feature of this condition, thus excluding this diagnosis.

Findings: Sequential contrast-enhanced CT images starting from the top demonstrate coronary artery bypass surgery with saphenous vein grafts arising from the ascending aorta. The right coronary graft becomes aneurysmal with mural thrombus on images 3C and 3D.

A. The diffuse aneurysmal dilatation in the lower portion of the right coronary artery saphenous graft makes this the most likely diagnosis. Saphenous venous grafts, when subject to systemic arterial pressure, can develop intimal hyperplasia and atherosclerotic changes with stenosis and occlusion. Cumulative vein graft patency at 10 years is approximately 45%. Saphenous vein graft aneurysms are rare complications and can be true or false aneurysms. The distinction of true or false aneurysm does not impact treatment, although false aneurysms tend to be larger.
B. The native coronary arteries are not involved, and, therefore, Kawasaki arteritis should not be a consideration.
C. Syphilitic aortitis typically affects the ascending aorta and causes a thick-walled aneurysm. This aneurysm does not involve the aorta, and syphilis should not be included in the differential.
D. Incorrect.
E. The sinuses of Valsalva are normal (Figure 3D), and there is no connection between the abnormality and the sinuses.

Findings: Aneurysm of the proximal left anterior descending coronary artery with rim calcification.

A. Although atherosclerosis can produce coronary aneurysms with mural calcification, the young age of the patient makes this diagnosis unlikely.
B. Marfan syndrome, a generalized connective tissue disorder with characteristic annulo-aortic dilation, may also manifest with ectasia of the proximal coronary arteries. However, calcification is not typical of Marfan syndrome. In addition, the aortic root has a normal caliber in this patient, which makes the diagnosis less likely.
C. Correct. Kawasaki disease (mucocutaneous lymph node syndrome) is characterized by a generalized microvasculitis of the medium and large arteries, particularly the coronary arteries. Aneurysms of the proximal segments of the coronary arteries are typical and may regress with time. However, aneurysms that persist beyond 2 years frequently calcify. Associated coronary artery stenosis may induce angina pectoris or myocardial infarction.
D. Takayasu arteritis can affect various segments of the aorta and its major branches and the pulmonary arteries. It produces stenotic lesions and, less commonly, aneurysms. The coronary arteries are usually spared.
E. Ehlers-Danlos syndrome represents an autosomal dominant disease of the connective tissues and affects predominantly males. Aneurysmal dilatation and dissection of the aorta and major branches have been described. Coronary artery involvement and aneurysmal calcification are unusual, thus making the diagnosis less likely.

Findings: Cardiac cine images in diastole and systole demonstrate the presence of a focal area of dark “jetting” arising from the aortic valve during systole (Figure 5B). No other areas of signal abnormalities are seen.

A. Other than the systolic signal abnormality arising from the aortic valve during ventricular systole, the aorta has normal appearance without intimal flaps that are the hallmark of aortic dissection.
B. Syphilitic aortitis is a rare delayed sequela of tertiary syphilis frequently occurring 15-30 years after the primary infection. Most cases involve the aortic root or arch and calcifications are common. The aortic leaflets are usually spared, and aneurysms are common.
C. Aortic stenosis is usually a consequence of degeneration of a bicuspid aortic valve, a condition seen in about 2% of the population. The presence of turbulent jetting across the aortic valve during ventricular systole makes this the most plausible diagnosis.
D. Lack of signal below the aortic valve during diastole (Figure 5A. implies a competent aortic valve thus excluding regurgitation as an alternative.
E. The aorta does not show any aneurysm formation in this case thus excluding the diagnosis. In addition, atherosclerosis does not typically involve the aortic valve.