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Background
With continued advancement in diagnostic imaging, congenital heart disease (CHD) can be detected and managed early in childhood; however, in some cases, CHD may be incidentally discovered in adulthood. Given that CHD may go undiscovered until a patient presents as an adult with either a related or unrelated indication for cardiac/thoracic imaging, it is important to recognize visual manifestation of these anomalies on diagnostic imaging of adults.

Educational Goals / Teaching Points
The goal of this exhibit is to provide education on a) identifying some types of CHD that can present in adulthood b) reviewing image findings characteristic of incidentally-found CHD in adults and c) understanding the clinical implications of identifying these anomalies.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
This exhibit covers the following disease processes and their corresponding image findings, including coarctation of the aorta, left-sided superior vena cava (SVC), atrial septal defects, partial anomalous pulmonary venous return, bicuspid aortic valves and associated aortopathy, anomalous coronary arteries, and L-transposition of the great arteries. Computed tomography angiography (CTA), magnetic resonance imaging (MRI), and echocardiogram are methods for further interrogation. For example, a 43-year-old man who underwent a noncontrast chest CT was incidentally found to have a focal narrowing of the aorta at the level of the aortic isthmus consistent with coarctation of the aorta. Additionally, chest radiography demonstrated the classic three sign suggestive of coarctation. Subsequent chest CTA was obtained for better demonstration and further evaluation. Discovery of coarctation warrants work up for hypertension and left ventricular hypertrophy. Additionally, there is a reported increase in prevalence of intracranial aneurysms in patients with coarctation of the aorta, which may warrant screening angiography. A second example of CHD incidentally discovered in adulthood is a 90 year-old woman who underwent a noncontrast CT and incidentally revealed a left-sided superior caval vein that drained into the coronary sinus. Although this anomaly poses a limited threat to patient safety (this is a normal variant occurring in approximately 1/200 individuals), this anomaly is an important consideration for any future intravascular procedures. For instance, chest radiographs of this particular patient demonstrated a dual-lead pacemaker by which the ventricular lead enters through the right SVC and the atrial lead enters through the left SVC. Knowledge of this variant indicates reassuring lead placement rather than alarming for procedural complications.

Conclusion
CHD has the potential to go undiscovered until adulthood. There is clinical value in radiologists being able to recognize its appearance on imaging as to avoid misdiagnosis. It is also important to recognize the clinical implications behind identified CHD, and thus guide providers to initiate proper work up.