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Anatomical variants and imaging artifacts on thoracic computed tomography (CT), when unrecognized as such, can lead to radiological misinterpretation and erroneous diagnosis. This is a concise review of 15 common CT diagnostic pitfalls due to anatomical variants and imaging artifacts which have potential to be misinterpreted as significant pathology, such as neoplasia, infection, traumatic injury, interstitial lung disease, pleural disease, or vascular lesions.

Background The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology’s central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the healthcare value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Background: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Purpose To evaluate the feasibility and accuracy of a combined magnetic resonance angiography (MRA) - magnetic resonance venography (MRV) protocol using contrast agents with blood pool properties, gadofosveset trisodium and gadobenate dimeglumine, in the evaluation of pulmonary embolus (PE) and deep venous thrombosis (DVT) as compared to the standard clinical reference imaging modalities; computed tomography pulmonary angiography (CTPA) and color-coded Duplex ultrasound (DUS). Materials and methods This prospective clinical study recruited patients presenting to the emergency department with clinical suspicion for PE and scheduled for a clinically indicated CTPA. We performed both MRA of the chest for the evaluation of PE as well as MRV of the pelvis and thighs to evaluate for DVT using a single contrast injection. MRA-MRV data was compared to the clinical reference standard CTPA and DUS, respectively. Results A total of 40 patients were recruited. The results on a per-patient basis comparing MRA to CTPA for pulmonary embolus yielded 100% sensitivity and 97% specificity. There was a small subset of patients that underwent clinical DUS to evaluate for DVT, which demonstrated a sensitivity and specificity of 100% for MRV. Conclusions This single-center, preliminary study using contrast agents with blood pool properties to perform a relatively rapid combined MRA-MRV exam to image for PE and above knee DVT shows potential as an alternative imaging choice to CTPA. Further large-scale, multicentre studies are warranted.

Histoplasmosis is primarily a pulmonary fungal infection with a vast array of radiological manifestations, which can mimic a number of thoracic diseases. This article reviews various presentations of histoplasmosis on chest imaging.

Pulmonary embolism is a common and potentially fatal pathological condition. Imaging plays a crucial role in the diagnosis and differentiation of the causes of pulmonary embolus. Here we present typical imaging findings associated with both thrombotic and nonthrombotic pulmonary emboli, as well as their potential mimickers.

BACKGROUND: Inflammation has a key role in the process of atherosclerosis. Production of leukotrienes by 5‐lipoxygenase has been linked to atherosclerotic plaques and cardiovascular events. HYPOTHESIS: In this study, a selective 5‐LO inhibitor will slow plaque progression using serial cardiac computed tomographic angiography (CCTA). METHODS: Patients with recent acute coronary syndrome (ACS) were prospectively assigned to one of 3 VIA‐2291 doses (25 mg, 50 mg, 100 mg) or placebo by oral administration. All groups underwent CCTA at baseline and at 6 months’ follow‐up. Plaque types such as low‐attenuation plaque (LAP), fibro‐fatty tissue (FF), fibro‐calcified plaque (FC), and dense calcium plaque (DC) were measured based upon predefined density threshold, and changes from baseline CCTA were analyzed. RESULTS: The final analysis included 54 patients (age, 56 ± 9 years; 85.1% male) with CCTA at baseline and 24 weeks. Evaluating on treatment VIA‐2291 (all 3 doses, n = 37) demonstrated significant reductions in plaque progression compared with placebo (n = 17). VIA‐2291 significantly reduced LAP (5.9 ± 20.7 mm(3) vs −9.7 ± 33.3 mm(3)), FF (11.1 mm(3) ± 13.3 mm(3) vs −0.9 ± 2.7 mm(3)), and FC (−0.1 ± 6.22 mm(3) vs −14.3 ± 6.2 mm(3); all P < 0.05) and retarded the progression of DC (3.9 ± 3.2 mm(3) vs 0.2 ± 0.4 mm(3)) compared with placebo. CONCLUSIONS: VIA‐2291 resulted in slowed plaque progression compared with placebo across different plaque subtypes in patients with recent ACS (http://ClinicalTrials.gov NCT00358826).

This article reviews the basic and clinical features of heart disease associated with carcinoid syndrome, with an emphasis on its principal imaging modalities.

A 25 year old female with known neurofibromatosis type 1 with a large anterior mediastinal mass was investigated. F18-FDG PET-CT revealed a radiotracer avid anterior mediastinal mass with SUVmax of 4.3 and demonstrating a hypoactive center. The Iodine-123 MIBG SPECT-CT study performed subsequently did not demonstrate any uptake, thereby excluding for the most part the diagnoses of paraganglioma or neuroblastoma. At final pathology, a malignant peripheral nerve sheath tumour (MPNST) of the pericardium with areas of chondrosarcomatous and angiosarcomatous differentiation was diagnosed.

Atherosclerosis exacts a large toll on society in the form of cardiovascular morbidity, mortality, and resource use and is exacerbated by the epidemics of obesity and diabetes. Consequently, there is a critical need for more-effective methods of diagnosis, treatment, and prevention of the complications of atherosclerosis. Careful and well-conducted large population studies are needed in order to truly understand the natural history of the disease, its imaging biomarkers, and their links to patient outcomes. The Canadian Atherosclerosis Imaging Network (CAIN) is a unique research network funded by the Canadian Institutes of Health Research and the Canada Foundation for Innovation and designed to address these needs and to enable large population-based imaging studies. The central objective of CAIN is to move innovations in imaging toward their broad application in clinical research and clinical practice for the improved evaluation of cardiac and neurologic vascular disease. CAIN is established as an international resource for studying the natural history, progression, and regression of atherosclerosis, as well as novel therapeutic interventions aimed at atherosclerosis. The network represents Canada's leading atherosclerosis imaging experts, embodying both basic imaging science and clinical imaging research. The network is improving methods of detection and treatment of atherosclerosis and, through a better understanding of the underlying disease itself, improving strategies for disease prevention. The benefits are expected to appear in the next 2 to 3 years. CAIN will drive innovation in imaging technology within the field of cardiology and neurology and improve health outcomes in Canada and worldwide.

We report a case of an elderly male with significant comorbidities and a dominant aberrant left vertebral artery originating on an aneurysmal aortic arch. The patient underwent a successful staged hybrid procedure with aortic arch debranching and left vertebral artery transposition onto the left common carotid artery, followed by endovascular aneurysmal repair. doi: 10.1111/jocs.12053 (J Card Surg 2013;28:155–158)

Background— Psoriasis is a chronic inflammatory disease associated with increased risks of myocardial infarction and stroke. Systemic treatments for moderate to severe psoriasis can reduce skin and joint inflammation; however, their effects on vascular inflammation are unknown. Methods and Results— This randomized, controlled trial included 30 patients with moderate to severe psoriasis and a history, or multiple risk factors, of coronary atherosclerosis. Patients were randomized (2:1) to receive either adalimumab subcutaneously for 4 months or to control nonsystemic treatment (topical therapies or phototherapy). Vascular inflammation was measured in the carotid artery and ascending aorta at baseline and week 15, by 18 F-fluorodeoxyglucose uptake on positron emission tomography. The change in target:background ratio in the vessel with highest baseline target:background ratio (primary end point) was significant at week 15 compared with baseline for patients randomized to adalimumab (–0.23 [95% CI, –0.39 to –0.08]; P =0.004) but not for the control group (–0.10 [95% CI, –0.32 to 0.12]; P =0.35). The difference between study arms for this primary end point did not reach statistical significance (–0.13 [95% CI, –0.01 to 0.14]; P =0.32). The change in target:background ratio at week 15 improved with adalimumab compared with controls both in the ascending aorta (–0.26±0.11, P =0.021) and in carotid arteries (–0.32±0.15, P =0.037) when analyzed separately (secondary end points). Changes in other positron emission tomography indices also improved significantly with adalimumab compared with controls in the ascending aorta and carotids. High-sensitivity C-reactive protein decreased by 51% at week 16 with adalimumab compared with 5% in controls ( P =0·002). Conclusions— The study did not meet its primary end point because the change in target:background ratio in patients randomized to adalimumab was not different from controls. Although adalimumab may reduce vascular inflammation in patients with moderate to severe psoriasis, this effect is not large enough to be demonstrated in a study with a small sample size. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NTC00940862.

The purpose of this study was to investigate the prevalence of incidental deep venous thrombosis (DVT) in patients with clinically suspected peripheral arterial occlusive disease (PAOD) using contrast-enhanced MR angiography (MRA) with a blood pool contrast agent.Two hundred fifty-nine MRA examinations with blood pool contrast agent in 245 consecutive patients (161 men; age range, 36-92 years), yielding a total of 4102 assessable arterial and venous vessel segments, were assessed with regard to the rate of incidentally observed acute and organized DVT and arterial stenosis grades. Incidental DVT was confirmed using duplex ultrasound. Contralateral nondiseased veins served as internal controls. The relationship between PAOD stages and acute and organized DVT was investigated using chi-square tests and a Mann-Whitney U test.Arterial stenosis grading using MRA with blood pool contrast agent revealed less than 50% luminal stenosis in 78% of segments (3199/4102), 50% or greater stenosis in 8% of segments (317/4102), and occlusion in 14% of segments (586/4102). Incidental DVT was observed in 26 of 245 patients (11%) (acute DVT was seen in 10 patients and 26 segments; organized DVT was seen in 17 patients and 35 segments; and one patient had both acute and organized DVT). All incidentally diagnosed cases of DVT were confirmed by duplex ultrasound. Internal controls revealed no false-positive or -negative findings (26 patients and 172 segments). Incidental acute DVT was significantly more common among patients without arterial stenosis greater than 50% (p0.05). Otherwise, there was no significant relationship between Fontaine PAOD stages and the occurrence of acute (p = 0.688) or organized (p = 0.995) DVT.Incidental DVT was prevalent in 11% of patients with clinically suspected PAOD. MRA with blood pool contrast agent has a potential role in the simultaneous assessment of arteries and veins and can detect concomitant venous disease affecting therapeutic management.

Atherosclerosis and its thrombotic complications are the leading cause of morbidity and mortality in developed countries, and the burden of atherosclerotic disease is expected to increase even further in the coming decades due to soaring obesity rates that feed the diabetes epidemic. There is, therefore, a clear need for new drugs targeting atherosclerosis to add to our current therapeutic armamentarium. Drug approval currently is based on multicenter, randomized, placebo-controlled trials with long-term follow-up in thousands of patients to demonstrate clear benefits in mortality and cardiovascular events and to allow adequate assessment of safety. Cardiovascular drug development has become a hostage to its own success. New drugs must be compared to placebo but on the background of highly effective standard therapy that lowers event rates and necessitates huge sample sizes and long follow-up. Failures of promising new cardiovascular drugs in large clinical trials1 have had catastrophic consequences for the sponsoring pharmaceutical and biotechnological companies. These conditions are inhibiting new drug development and are stimulating a search for alternate methods to assess new compounds. Cardiovascular imaging techniques have been used to fill this need.2 Cardiovascular imaging trials are shorter and require only a fraction of the patients needed for a large events trial because all patients who complete an imaging trial contribute to the end point. Thus, imaging trials are less expensive. By themselves, they are not sufficient for drug approval by regulatory agencies partly because of the limited safety data that can be generated with the study drug given the number of patients involved and duration of exposure. Nevertheless, imaging studies can provide evidence to inform the decision about whether a large outcome trial should proceed. They are therefore currently best suited in phase 2 of drug development. Ideally, imaging studies also should provide useful data regarding the mechanism …

Background—Production of leukotrienes by 5-lipoxygenase (5-LO) has been linked to unstable atherosclerotic plaques and cardiovascular events. VIA-2291 is a potent 5-LO inhibitor.Methods and Results—In a double-blinded study, 191 patients were randomly assigned 3 weeks after an acute coronary syndrome to receive 25, 50, or 100 mg VIA-2291 or placebo daily for 12 weeks. The primary study end point, whole blood stimulated leukotriene LTB4 at trough drug level, was reduced in all VIA-2291 groups (P90% of patients in the 100-mg group. A significant reduction of urine leukotriene LTE4 was obtained in all dose groups. No serious adverse events were considered related to study drug. A subset of 93 patients who had undergone a 64-slice coronary CT examination at baseline continued on study medication for a total of 24 weeks and underwent a repeat scan. Five of these patients withdrew or were noncompliant and 28 had nonevaluable scans. Among the 60 remaining patients, new coronary plaques were observed in 5 of 18 (27.8%) placebo-treated patients and in 2 of 42 (4.8%) VIA-2291–treated patients (P=0.01). A reduction in noncalcified plaque volume at 24 weeks versus placebo was observed in VIA-2291–treated groups in the 34 of these 60 patients in whom this end point was analyzable (PConclusions—VIA-2291 reduces leukotriene production at 12 weeks after an acute coronary syndrome. Preliminary data from the CT substudy suggest that such a reduction in leukotriene production may influence atherosclerosis; however, this requires confirmation in a larger study.Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00358826.

Cardiac pseudoaneurysm is a rare but potentially lethal complication of myocardial infarction. Clinical manifestations may be nonspecific or, in some cases, may even be silent. Therefore, high clinical suspicion should be maintained when a patient becomes unstable after a myocardial event. Efficient use of imaging examinations is crucial in providing an accurate diagnosis and, thereafter, timely and appropriate treatment. The authors report a case involving a giant left ventricular pseudoaneurysm that required both transthoracic echocardiography and magnetic resonance imaging to reach the correct diagnosis. The pathology, clinical presentation, diagnostic work-up and treatments of cardiac pseudoaneurysms are reviewed.

A 52-year-old male underwent simultaneous replacement of a severely stenotic bicuspid aortic valve with a CarboMedics 25-mm prosthesis and replacement of the aneurysmal ascending aorta with a Vascutek 28-mm graft. Follow-up CT angiographies of the thoracic aorta revealed a progressively enlarging pseudoaneurysm along the entire length of the ascending aorta. On the last scan, the pseudoaneurysm measured 122×98×174 mm. The site of the leak could not be identified on any of the postoperative scans (Fig. 1). MRI angiography of the thoracic aorta was performed next. Intravenous Gadofosveset-enhanced first-pass 4D Trak MR angiography allowed identification of the site of contrast leak into the pseudoaneurysm at the proximal anastomosis, appearing as a discreet, progressively enlarging area of progressively increasing intensity (Fig. 2).

Background Aortic coarctation has been associated with generalized vascular disease, yet little is known about retinal vascular patterns and their changes over time. Objectives The aim of this study is to characterize the nature and extent of retinal vascular disease in adults with aortic coarctation, and explore age-related effects and associations with cardiovascular outcomes. Methods A prospective cross-sectional seroepidemiological study was conducted on 60 consecutive adults with repaired aortic coarctation, age 42.4±14.1years, 61.7% male. In addition to detailed questionnaires, imaging studies, and laboratory testing, high-quality retinal images were acquired by 45° nonmydriatic digital funduscopy. Results No patient had evidence of hypertensive retinopathy. A distinctive vascular pattern characterized by bilaterally symmetric tortuosity of retinal arteries and veins was observed. Arterial tortuosity was abnormal in 98.3% of patients and decreased with age ( P =0.0005). In patients ≥45years, a 1-point increase in the arterial tortuosity score was associated with a 1.5-fold higher risk of cardiovascular complications (i.e., acute coronary syndrome, stroke, cerebral aneurysm, aortic dissection/rupture) [odds ratio 1.50, 95% CI (1.01, 2.24), P =0.0496]. Abnormal venous tortuosity was present in 75.0% of patients and non-significantly correlated with higher levels of serum inflammatory markers (C-reactive protein, fibrinogen, interleukin-6, and tumor necrosis factor-alpha). A higher venous tortuosity score was likewise associated with an increased risk of cardiovascular complications [odds ratio 1.86, 95% CI (1.03, 3.35), P =0.0392]. Conclusions Adults with repaired aortic coarctation exhibit a unique retinal vascular pattern characterized by excessive arterial and venous tortuosity that regresses with age. Greater tortuosity is associated with adverse cardiovascular outcomes in patients ≥45years.

We report a case of an elderly male with significant comorbidities and a dominant aberrant left vertebral artery originating on an aneurysmal aortic arch. The patient underwent a successful staged hybrid procedure with aortic arch debranching and left vertebral artery transposition onto the left common carotid artery, followed by endovascular aneurysmal repair.

We describe a simple and reproducible technique permitting both effective left atrial reduction plasty and safe mitral annulus reconstruction, using a patch of left atrium tissue. In a 64-year-old patient undergoing redo mitral valve replacement for mechanical prosthesis disinsertion, a giant left atrium and extensive calcification of the mitral annulus were noted. This technique permitted a safe mechanical mitral prosthesis re-replacement and a significant reduction of left atrial volume by 70%.

This case report is a unique presentation of a new potential indication for Gadofosvest (Ablavar), a blood pool contrast agent for magnetic resonance angiography (MRA). Ablavar is an excellent MRA contrast agent because it provides optimal contrast opacification of both the arterial and venous system, unlike the conventional extracellular agents that are used for arterial imaging only. The present case report demonstrates the ability of Ablavar to demonstrate pulmonary arteriovenous malformation (AVM), showing both its arterial feeders as well as its venous drainage tract.

Echocardiography has been and remains an invaluable tool for cardiac evaluation, including characterisation of cardiac masses. Even if most cardiac masses are considered benign, significant morbidity related to obstruction, infiltration, thromboembolism, arrhythmias and even death may occur. Therefore, a rapid and precise diagnosis is mandatory. Echocardiography enables key questions regarding the mass to be answered, such as: location, size, mobility, haemodynamic consequences and differentiation with extra-cardiac disease, embryologic remnants or artefacts. Recent advances in computed tomography (CT) and cardiac magnetic resonance (CMR) may help in the further characterisation of cardiac masses. This article presents challenging cases encountered at the Montreal Heart Institute between 2005 and 2008; we discuss the differential diagnosis of each mass and the current role of echocardiography, cardiac CT, and cardiac MRI (table 1). View this table: Table 1 Evaluation of seven cardiac masses through transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac magnetic resonance imaging (CMR), and computed tomography (CT) scan A middle age person underwent an uneventful left atrial myxoma resection many years ago, without any residual mass on follow-up transthoracic echocardiography (TTE) performed 1 year after. A few months later' however, she complained of non-specific symptoms of fatigue, shortness of breath, and atypical chest pain. Symptoms such as fever, weight loss or neurological problems were denied. Physical examination, ECG and chest x-ray were normal. Repeat TTE (figure 1, video 1) depicted a sessile bi-lobar, non-obstructive and immobile mass in the left atrium, with suspected right atrium extension. A transoesophageal echocardiogram (TOE) confirmed the 11×9 mm slightly mobile mass attached posteriorly to the interatrial septum, on the left atrial side. A recurrent myxoma was suspected, but neither a thrombus nor a sarcoma could be excluded, given the rapid growth of this mass. CMR further delineated this left atrial irregular mass, originating from the interatrial septum, hypointense on T1 weighted and hyperintense …

Recent improvements in multidetector computed tomography (MDCT) with 64-slice scanners have allowed acquisition of a coronary study in 5 s to 6 s, with good temporal and spatial resolution. Previous studies have reported an underestimation of plaque burden by MDCT. Whether shorter scan times can allow correct assessment of plaque volume requires comparison with intravascular ultrasound (IVUS).Patients (n=30) scheduled for coronary angiography also underwent MDCT and IVUS examinations within 96 h. MDCT examination was performed with a 64-slice scanner. Nitroglycerin was administered before all imaging procedures. MDCT, quantitative coronary angiography (QCA) and IVUS analyses were performed by observers blinded to other results. Plaque volumes were determined by MDCT and IVUS in one vessel, and maximum percentage diameter stenosis was identified in each coronary segment by MDCT and QCA.The mean (+ or - SD) plaque volume was determined to be 179.1 + or - 78.9 mm(3) by MDCT and 176.1 + or - 87.9 mm(3) by IVUS. There was a strong positive correlation for plaque volume between MDCT and IVUS (r=0.84, P0.0001). Percentage diameter stenosis assessed by MDCT and QCA also correlated well (r=0.88 per patient and r=0.87 per vessel, P0.0001 for both). The maximum percentage diameter stenosis per vessel was 38.1 + or - 30.2% with MDCT and 34.1 + or - 27.6% with QCA. The sensitivity and specificity of MDCT in detecting stenoses above 50% per vessel were 100% and 91.0%, respectively.Plaque volumes measured by 64-slice MDCT and IVUS correlate well, without systematic underestimation. The sensitivity and specificity of MDCT to detect stenoses greater than 50% by QCA are excellent with the administration of nitroglycerin before imaging.

Constrictive pericarditis is caused by adhesions between the visceral and parietal layers of the pericardium and progressive pericardial fibrosis that restricts diastolic filling of the heart. Later on, the thickened pericardium may calcify. Despite a better understanding of the pathophysiologic basis of the imaging findings in constrictive pericarditis and the recent advent of magnetic resonance imaging (MRI) technology, which has dramatically improved the visualization of the pericardium, the diagnosis of constrictive pericarditis remains a challenge in many cases. In patients with clinical suspicion of underlying constrictive pericarditis, the most important radiologic diagnostic feature is abnormal pericardial thickening, which can be shown readily by computed tomography (CT) and especially by MRI, and is highly suggestive of constrictive pericarditis. Nevertheless, a thickened pericardium does not always indicate constrictive pericarditis. Furthermore, constrictive pericarditis can occur without pericardial thickening.

A currently asymptomatic 31-year-old man was referred for recent atypical short stabbing chest discomfort occurring at rest. One month earlier, he had complained of a prolonged chest pain episode lasting ≈1 day, temporally related to the use of inhaled cocaine, for which he did not seek medical consultation. He had smoked half a pack of cigarettes a day for 15 years and suffered 2 remote episodes of blunt chest trauma. The first occurred at 12 years of age when he was in a low-velocity automobile accident as a …

Coronary artery aneurysms, stenoses, and thromboses are significant complications of Kawasaki disease (KD). While appearing in childhood, coronary complications are often left unrecognized until early and mid-adulthood. Along with the increasing capacity of noninvasive coronary artery imaging modalities, especially computed tomography and magnetic resonance, radiologists are more likely to face the diagnosis of KD in adults. This article will review the clinical aspects of KD for radiologists and will compare coronary imaging modalities in the diagnosis of KD.

Computed tomography (CT) of the abdomen was performed to evaluate the liver in a 19-year-old woman who had undergone treatment for β-thalassemia intermedia. CT revealed findings that prompted further investigation with cardiovascular magnetic resonance (MR) imaging. MR imaging was performed with a 1.5-T system (Signa Cvi; GE Medical Systems, Milwaukee, Wis). Selected CT and MR images are shown.

WEB This is a Web exclusive article. rteriovenous fistulas secondary to arteriovenous malformations, iatrogenic intervention, and blunt and penetrating trauma have been described as a cause of hyperkinetic heart failure [1]. Cardiac chamber enlargement, systolic–diastolic murmurs, and varicose veins may be the earliest findings. Late complications include thrombosis and pseudoaneurysm. We describe a rare and, to our knowledge, previously unreported arteriovenous malformation arising from the right renal artery, draining into the right hepatic vein, and causing right atrial enlargement.

A 29-year-old man presenting with syncopal ventricular tachycardia was diagnosed with arrhythmogenic right ventricular (RV) cardiomyopathy. Cardiac magnetic resonance imaging (MRI) revealed an unequivocal dyskinetic segment at the basal portion of the RV lateral free wall. Three-dimensional electroanatomic voltage mapping using the EnSite NavX™ system recorded a low voltage area corresponding to the diseased portion of the right ventricle identified by MRI. This report describes concordance between cardiac MRI and this novel mapping system in arrhythmogenic RV cardiomyopathy.

Cardiovascular complications are the second leading cause of late mortality in survivors of Hodgkin's lymphoma (HL) exposed to mediastinal radiotherapy. Symptomatic cardiac disease following classic thoracic irradiation for HL is reported in 10%-30% of patients at 5-10 years of follow-up. We present the case of a 44-year-old man with a history of left cervical nodular lymphocyte predominant HL treated at childhood with 40 Gy extended field thoracic irradiation (Mantle) who presented with mixed aortic and mitral valve disease, coronary artery stenosis, myocardial and aortic calcifications, and mediastinal fibrosis. Despite extensive cardiac surgery, the postoperative course was complicated and resulted in the patient's death. We review herein the typical cardiac involvement related to mediastinal radiotherapy and the controversies surrounding its surgical approach.