1349

Atypical

and Unusual

Vessels:

Imaging

S. Le&

Vivian

Edward

F. Patz,

Calcifications

and Great

Findings
Jr., James

T. T. Chen

Cardiovascular
calcifications
in the thorax
may be
clinically
significant
and may prove extremely
valuable
diagnostically.
The typical
appearance
and location
of
common
cardiovascular
calcifications
have been well
described
[1 2]. We present
a series of radiologic
findings In patients
with atypical
and unusual
cardiovascular calcificatlons
in the thorax.

Left Atrium
Calcification
of the entire left atrium is uncommon
(Fig. 1),
usually
resulting
from rheumatic
endocarditis
with mitral
stenosis. These patients are at increased
risk for atrial fibnillation and mural thrombi as a source for embolic complications.

Left

Cardiac

of the Heart

Myocandial
calcification
most commonly
occurs in association with left ventricular
aneurysm
after myocardial
infarction.
Aneurysms
usually occur in the antenolatenal on apical portion of
the left ventricle,
although
they may occasionally
arise in the
posterior,
inferior
(Fig. 2), on superior
(Fig. 3) portion
[1].

Calcification

Cardiac
calcification
can be classified
as
myocandial,
or penicandial,
although
radiographic
can be difficult.

Ventricle

endocandial,
distinction

Fig. 1.-Left
atrial calcification
in a 74year-old
man who underwent
mitral valve
replacement for severe mitral stenosis.
A and B, Posteroanterior
(A) and lateral (B)
radiographs
of chest show marked enlargement of the left atrium with nearly complete circumferential calcification of atrial wall.

Received
1 All

authors:

April 25, 1994;

Department

AJR 1994;163:1349.-1355

accepted

after revision

of Radiology,

Box 3808,

0361-803X/94/1636-1349

June
Duke

27, 1994.
University

American

Medical
Roentgen

Center,

Durham,

Ray Society

NC 27710.

Address

correspondence

to E. F. Patz.

1350

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1994

Fig. 2.-Left
ventricular
aneurysm
in a
57-year-old
man with intermittent
ventricular
tachycardia
and a distant history of myocardial
infarction.
Patient underwent
successful
aneurysmectomy
with intraoperative
electrophysiologic mapping.

A, Lateral radiograph
of a calcified

ventricular

shows inferior location

aneurysm

(arrowheads).

B, CT scan shows circumferential

tion of calcium

distribu-

in wall of this true aneurysm.

Fig.
3.-Left
ventricular
aneurysm
in a
43-year-old
woman
with atypical
chest pain and

fatigue.

ventriculography

and echocardiogra-

phy showed this 2-cm aneurysm,

thought to be
congenital,
as arising
from the anterior
surface
of the left ventricle immediately below the mitral

valve.

Also

note

tubular

impression

across

upper barium-filled
esophagus
(wavy arrow, A;
long arrow, B) which is pathognomonic
of an
aberrant
right subclavian
artery.

A, Posteroanterior
radiograph
of chest
shows a curvilinear rim of calcification
outlining a soft-tissue density projecting from left
lateral aspect of heart (short arrows).
B, Lateral radiograph shows calcific rim in
anterosuperior
heads).

Unusual locations suggest an uncommon

etiology, such as congenital on posttraumatic.
Congenital
aneurysms
and diverticula
are rare but have been reported in the submitnal location and in
the left ventricular
apex [3]. As many as one-third of all patients
with
ventricular
aneurysm
have
ventricular
anrhythmias.
Directed resections
based on electrophysiologic
guidance
may
help minimize
recurrent
annhythmias
[4]. Other complications
include thromboembolic
disease and heart failure.

portion

of left ventricle

(arrow-

Septum
Interventniculan
septal calcification
may be seen in patients
with severe mitral annulus or aortic valve calcification
(Fig. 5).
Spread
to the trigona
fibrosa
(the triangular
fibrous
area
between the mitral and tricuspid annuli) inevitably
involves the
bundle
of His. These
patients
are at risk for arnhythmias,
including
heart block [1].
Pericardium

Myocardium
Calcification
can result from causes
other than ischemic
disease,
such as rheumatic
heart disease
and other causes
of myocanditis.
Occasionally,
there may be calcification
of the
papillary
muscles
after trauma on rupture (Fig. 4).

Calcified
penicandial
cysts may be difficult to differentiate
from calcification
within a ventricular
aneurysm.
The pericandial cysts are usually found in the candiophnenic
angles, typically on the night side. Fluonoscopy
may help to diagnose
penicandial cysts in unusual
locations
(Fig. 6), although
CT on

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UNUSUAL

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CALCIFICATIONS

IN THE THORAX

1351

Fig. 4.-Calcification
of papillary muscle in a
72-year-old man with severe mitral valve insutficiency. Patient
had severe chest trauma 35
years before
this study, when a horse fell on
his chest. Angled opacity in region of left yentricie (curved
arrow)
corresponds to a calcified
posteromedial

papillary

muscle.

tour most likely represents

ruptured papillary muscle.

Angled

con-

misalignment

of a

Fig. 5.-interventrlcular
septal calcification
In a 57-year-old man with aortic stenosis. Lateral radiograph of chest shows marked calcification
(arrowheads)
of interventricular septum.
Although

patients

typically

have

heart

this patients course was complicated

tricular
fibrillation.

block,

by yen-

MRI should differentiate

penicardial
cysts from other lesions.
lt is important
to distinguish
penicandial
cysts from other
mediastinal
abnormalities
because,
if symptomatic,
penicardial cysts may be treated by percutaneous
aspiration.
Valvular

Calcification

The extent of calcification

within a valve is proportional
to
the severity of stenosis
[1]. Although
calcification
ofthe aortic
and mitral valves is relatively
common,
calcification
of the
pulmonary
valve is rare (Fig. 7). The most common
etiology
is thought to be congenital [1].
Coronary

Fig. 6.-Calcified
pericardial
cyst in a 58-year-old
man. Routine
chest radiograph shows mass surrounded by a rim of calcification In the left chest.
screening

Fig. 7.-Calcification
of puimonic valve In a
51-year-old man with progressive
right ventricular failure due to longstanding,
presumably
congenital, pulmonary stenosis.
A, Posteroantedor
radiograph
of chest shows
a markedly enlarged right ventricle and pulmonary trunk,

with

increased

blood

flow

to left lung.

Short curvilInear calcifications

(arrowheads)
correspond
to calcified valve cusps.
B, Lateral
view of pulmonary angiogram
confirms
marked
poetatenotic dilatation of puimonary
trunk,
with marked increase
in size of
left pulmonary artery compared
with right pulmonary

artery.

Arteries

Detection
of coronary
artery calcification
on chest radiographs
in symptomatic
patients
is 94% specific
for severe
coronary
artery disease
[5]. Among diagnostic
imaging techniques,
ultrafast
CT is most sensitive
for detection
of coronary artery calcification
[6]. Atherosclerotic
disease
can also
affect grafted vessels
with tubular calcifications
that may be
indistinguishable
from native disease
(Fig. 8).
Coronary
artery aneurysms
are rare (Fig. 9). They may
arise in association
with atherosclerotic
disease
on, rarely,
Kawasaki
disease.
Pseudoaneurysm
formation
after coronary artery bypass grafting has also been reported
[7].

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Fig. 8.-Calcification
graft (arrowheads)

December

1994

of saphenous
vein
in a 71-year-old
man 12

years after bypass grafting. These

were confirmed with angiography.

findings

Fig. 9.-Coronary
artery
aneurysms
in a
59-year-old
woman with a history of myocardial
infarction.
Lateral
radiograph
shows
calcified
dilatation
at origins
of left (solid arrow)
and
right (open arrow) coronary
arteries
and calcification
of entire right coronary
artery with a

second focal dilatation

Great

Vessels

Pu/mona,,

Art ety

The pulmonary
trunk and arteries
can develop
atherosclerotic
disease
and calcification
in patients
with longstanding
systemic
pressures
(Fig. 10). Pulmonary
artery
hypertension
may be idiopathic
on may be due to such entities as chronic
thromboembolic
disease
on shunting
with
Eisenmengen
physiology.

Ductus

Arteriosus

Closure of the ductus arteniosus

typically occurs
birth. Punctate
calcification
of the ductus arteniosus

soon after
in infants

distally (arrowhead).

is always associated
with a closed ductus arteniosus
[1]. In
adults, however,
curvilinear
calcification
of the ductus signifies patency
(Fig. 1 1 ). Chronic
left-to-night
shunting
can lead
to Eisenmengen
physiology.

Aorta
Atherosclerotic
disease
of the aorta is the most common
cause for calcification.
The location of the intimal rim of calcification
may be helpful
in distinguishing
aortic aneurysm
(peripheral
rim) from aortic dissection
(central
rim) in cases
of widened
mediastinum
(Fig. 12).
Less common
causes
of aortic calcifications
include
mycotic aneurysms
and vasculitides,
including Takayasus
arteni-

B
Fig. 10.-Pulmonary
artery hypertension
in a 67-year-old
A and B, Posteroanterior
(A) and lateral (B) radiographs

both pulmonary arteries and right heart. Right pulmonary

best on lateral view.

woman.

of chest show marked enlargement of

artery calcification (arrows) can be seen

Fig. 1 1 .-Calcification

of patent

ductus

arterlo-

sus in a 42-year-old
woman. Posteroanterior
radiograph
shows curvilinear calcification (arrow)
in region of aortopulmonary
lar cardiomegaly
is marked,

Eisenmenger
to-right

shunting.

physiology

window.
Biventricusuggesting
probable

after longstanding

left-

AJR:163,

December

Fig. 12.-Aortic

UNUSUAL

1994

dissection

in a 67-year-old

CALCIFICATIONS

IN THE

THORAX

1353

man with acute back pain.

(A) and after (B) onset of symptoms

show marked widening of mediastinum and soft-tissue density

lateral to rim of aortic calcification
C, CT scan obtained before surgery shows calcified intimal flap and contrast material within true (straight arrow) and false (curved
arrow)
lumina.
A, Posteroanterior

radiographs

obtained
before
(arrowheads).

and syphilitic aortitis. Takayasus

arteritis commonly
affects
the aorta and its large branches.
Stenosis is the most common
angiographic
finding; dilatation is less common. Approximately
18% have aortic calcification
[8] (Fig. 13). Aortic calcifications
arising from untreated
syphilis are rare. Approximately
10% of
patients with untreated syphilis have cardiovascular
lesions 10tiS

25

years

later,

with

aortic

aneurysm

and

aortic

insufficiency

being the major complications

(Fig. 14) [9].
latrogenic
and posttraumatic
causes
of aortic aneurysms
have also been reported. These include false aneurysms
(Fig. 15)

and aortic dissections,

gery [7]. Clinical history

Other

which may develop

after aortic sunand location may aid in the diagnosis.

Vessels

Less commonly,
other large vessels in the thorax, such as
the subclavian
arteries,
may be affected by the diseases
just
described,
including
atherosclerosis
(Fig. 16), vasculitides,
infection,
and iatrogenic
and posttnaumatic
complications
(Fig. 17).

Fig. 13.-Takayasus
arteritis in a 24-year-old woman with no signs or symptoms in the
chest, who had chest radiography before abdominal surgery.
A, Posteroanterlor
radiograph of chest shows a markedly dilated aorta with an irregular
contour and fine curvilinear calcifications (arrowheads).
B, Lateral aortogram shows annuioaortic ectasia with marked narrowing and irregularity of
great vessels.

Fig. 14. -Syphilitic aortltis in a 63-year-old man with

a distant history of untreated syphilis. Chest radiograph
shows an unusually focal aneurysm in ascending aorta,
a typical location for syphilitic aneurysm.

1354

Fig.

LEE

1 5.-Aortic

pseudoaneurysm

in an asymptomatic

68-year-old

man

ET

who

AL.

underwent

AJR:163,

aortic

valve replacement 2 years before this examination.

A, Lateral radiograph shows a thin rim of calcification anterior to prosthetic valve (arrowheads).
B, CT scan shows thrombosed
pseudoaneurysm
(p5) anterior to ascending aorta (AA).

Fig.

December

1994

1 6.-Calcification
in right
subclavian
in an elderly
man with severe
meliitus and atherosclerotic
disease.

artery (arrows)
diabetes

Fig. 17.-Pseudoaneurysm
in right subclavian artery in a 35-year-old man who had a stab
wound to the chest approximately
10 years
before this study.
A, Chest radiograph
shows a soft-tissue
mass projecting over medial head of right clayide, which Is outlined
by a rim of calcification.
B, Digital subtraction
angiogram shows no
flow into a large pseudoaneurysm
arising at
origin of the right subclavian artery.

Fig. 18.-Calcified
aortic graft in a 50-year-old
man with aortic coarctation
repaired
at age 16 years.
A and B, Posteroanterior
(A) and lateral (B) radiographs
of chest show narrowing
of descending
aorta at level of graft, with diffuse calcification
(arrows).
A pressure gradient of approximately 15 mm Hg was recorded across the graft.
C, Lateral aortogram shows decreased caliber at the graft. Reflux of contrast material across plane of aortic valve was consistent with aortic insuf-

ficiency across a bicuspid

aortic valve.

AJR:163,

December

1994

UNUSUAL

CALCIFICATIONS

IN THE THORAX

1355

Fig. 19.-Rastelli
conduit (pulmonary artery
to ascending aorta) In a 53-year-old woman
with repaired
tetralogy
of Fallot.
A and B, Posteroanterior
(A) and lateral (B)
radiographs of chest show a diffusely calcified
Rastelli

Surgical

conduit.

Conduits

Most often placed for correction

on palliation
of congenital
disease,
vascular
conduits
may also be a source of unusual
thoracic calcification.
Atherosclerotic
degeneration
in vascular
conduits
may result in calcification
visible on chest radiographs (Figs. 18 and 19). Identifying
the location of the more
commonly
used cardiac conduits
in congenital
heart surgery
aids in their identification
when clinical history is not available.

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3. Hamaoka
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HA. Syphilitic
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