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CARDIOVASCULAR

imaging
dr. Hari Soekersi, Sp.Rad(K)
Radiology Department of Hasan Sadikin
Hospital
Medical Faculty of Padjadjaran University
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Heart Anatomy

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Heart Conduction System

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Heart Conduction System 4 .

Cardiac Contraction 5 .

Circulation 6 .

POSITIONING 7 .

CHEST X-RAY POSITION • • • • POSTEROANTERIOR RIGHT/LEFT LATERAL RIGHT ANTERIOR OBLIQUE LEFT ANTERIOR OBLIQUE 8 .

POSTEROANTERIOR PROJECTION 9 .

POSTEROANTERIOR PROJECTION 10 .

POSTEROANTERIOR PROJECTION Superio r vena cava Right Atrium Aorta Pulmona ry artery Appendag e of the left atrium Left Ventricl e 11 .

Superior vena cava 2. Right atrium 5.LATERAL PROJECTION 1. Main pulmonary artery 4. Right ventricle 7. Tricuspid valve 6. Ascending aorta 3. Aortic arch 12 .

LATERAL PROJECTION 13 .

LATERAL PROJECTION 14 .

their margin may be indistinct .LATERAL PROJECTION Root of the main pulmonary artery Right Ventricl e Left Atrium Left Ventricl e Because these structures are in contact with 15 mediastinal fat.

Mitral valve 17.Main stem of the pulmonary artery 14.RIGHT ANTERIOR OBLIQUE PROJECTION 1.Left innominate vein 11.Left main bronchus 15. Right main branch of the pulmonary artery 6. Thoracic aorta 7.Tricuspid valve 16. Left atrium 8.Arch of the aorta 12. Innominate vein 3. Anterior wall of the trachea 2.Right ventricle 18.Left main branch of the pulmonary artery 13. Superior vena cava 5. Anterior border of the superior vena cava 4.Left ventricle 16 . Right atrium 9. Inferior vena cava 10.

RIGHT ANTERIOR OBLIQUE PROJECTION 17 .

LEFT ANTERIOR OBLIQUE PROJECTION 1. Posterior border of the trachea 10.Mitral valve 14.Left main branch of the pulmonary artery 11. Right atrial appendage 6. Left subclavian artery 9. Main pulmonary artery 5. Ascending aorta 4.Left main bronchus 12. Tricuspid valve 7.Left ventricle 15. Right main branch of the pulmonary artery 3. Right ventricle 8.Inferior vena cava 18 .Left atrium 13. Superior vena cava 2.

LEFT ANTERIOR OBLIQUE PROJECTION 19 .

PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE Analyze each case with six steps: 1 2 6 3 4 5 20 .

PLAIN FILMS DIAGNOSIS OF
CARDIAC DISEASE

Analyze each case with
six steps:

EVALUATION OF THE THORACIC CAGE FOR
SIGN OF PREVIOUS SURGERY OR OTHER
ABNORMALITIES
IDENTIFICATION OF THE POSITION OF THE
STOMACH BUBBLE AND HEPATIC SHADOW TO
DETERMINE BODY SITE
EVALUATION OF GREAT VESSELS FOR SIZE AND
POSITION
EVALUATION OF SPECIFIC CHAMBER
ENLARGEMENT
EVALUATION OF CARDIAC SIZE AND CONTOUR
EVALUATION OF PULMONARY VASCULARITY
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EVALUATION OF THE THORACIC
CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER
ABNORMALITIES

Signs of previous surgery
- periosteal elevation
- asymmetry thoracic cage
- smaller and slightly deformed rib
- resected rib in previous thoracotomy

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1

EVALUATION OF THE THORACIC
CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER
ABNORMALITIES

Congenital heart disease:
- premature fusion of sternum→ cyanotic
form
- hypersegmentation of sternum → Down’s
syndrome
- bulging of sternum → enlarged right
ventricle
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COMPLETE FUSION OF STERNAL SEGMENTS 24 .

HYPERSEGMENTATION OF THE STERNUM 25 .

ATRIAL SEPTAL DEFECT WITH ENLARGED RIGHT VENTRICLE AND ANTERIOR BULGING OF THE STERNUM 26 .

2 IDENTIFICATION OF THE POSITION OF THE STOMACH BUBBLE AND HEPATIC SHADOW TO DETERMINE BODY SITE Abnormal hepatic and stomach position show abnormalities in position of the viscera  congenital cardiac disease 27 .

SITUS SOLITUS WITH DEXTROCARDIA Stomach bubble is under the left diaphragm Liver is on the right Heart is on the right with cardiac axis directed to the right 28 .

SITUS INVERSUS WITH DEXTROCARDIA Stomach bubble is under the right diaphragm Liver is on the left Heart is on the right with cardiac axis directed to the right 29 .

ISOLATED LEVOCARDIA OR SITUS AMBIGUS Stomach bubble is under the right diaphragm Liver is on the left Normal heart position 30 .

the apex pointing to the right Dextroversion : Location of the heart in the right chest. the left ventricle remaining in the normal position on the left with the apex pointing the the left 31 .? ? DEXTROCAR DIA DEXTROVERSIO N Dextrocardia : ? Location of the heart in the right side of the thorax.

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EVALUATION OF GREAT VESSELS
FOR SIZE AND POSITION

Enlargement of the pulmonary artery segment
Prominent pulmonary arterial segment along the left
upper cardiac border
In TGV and truncus arteriosusabnormal position
(concave)
Enlargement of the aorta
Three portions of the aorta can be evaluated:
ascending aorta, aortic arch dan descending aorta.

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ENLARGEMENT OF PULMONARY
ARTERY SEGMENT

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TRANSPOSITION OF GREAT VESSELS

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TRANSPOSITION OF GREAT VESSELS 35 .

4 EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT Signs of left atrial enlargement Signs of left ventricular enlargement Signs of right atrial enlargement Signs of right ventricular enlargement 36 .

Posterior displacement of both walls of the barium-filled esophagus 37 . A double density along the right cardiac border 4. Prominent bulge along the mid-left cardiac border 3. Widening of the angle of the carina >900 Lateral projection 1.SIGNS OF LEFT ATRIAL ENLARGEMENT Posteroanterior projection 1. Displace the barium-filled esophagus below the carina to the right 2.

SIGNS OF LEFT ATRIAL ENLARGEMENT Left anterior oblique projection Elevate the left mainstem bronchus and obliterates the spaces between the posterior cardicac margin and the left mainstem bronchus 38 .

LEFT ATRIAL ENLARGEMENT 39 .

SIGNS OF LEFT VENTRICULAR ENLARGEMENT Posteroanterior projection 1. Left ventricular dilatation produces downward displacement of the apex toward diaphragm. 2. Left ventricular hypertrophy produces a round left cardiac border Left anterior oblique projection Posterior cardiac margin to overlap the vertebral column 40 .

LEFT VENTRICULAR DILATATION 41 .

SIGNS OF RIGHT ATRIAL ENLARGEMENT Posteroanterior projection Difficult  increased convexity of the lower right heart border on PA projection 42 .

RIGHT ATRIAL ENLARGEMENT 43 .

SIGNS OF RIGHT VENTRICULAR ENLARGEMENT Posteroanterior projection Rounding and elevation of the cardiac apex Lateral projection Retrosternal space is obliterated Left anterior oblique projection Increased convexity of the anterior cardiac border 44 .

RIGHT VENTRICULAR ENLARGEMENT 45 .

5 EVALUATION OF CARDIAC SIZE AND CONTOUR Index of cardiac enlargement is the cardiothoracic ratio. In infants: >55% In adults : > 50% The lateral and oblique views must be considered 46 .

CARDIOTHORACIC RATIO (Cardiac width / Thoracic cage width) x 100% 47 .

The vessels in the right hillum is larger than in the left 48 .6 EVALUATION OF PULMONARY VASCULARITY In normal  the pulmonary vascular marking taper gradually toward the periphery of the lung fields. and more prominent in the lower lung fields.

49 . VSD.the peripheral arteries are sharply outlined and dilated and distributed equally to both the upper and lower lobes.ex. PDA. Increased pulmonary vascularity due to increased pulmonary blood flow. transposition of the great vessels.SIX DIFFERENT VASCULAR PATTERNS ARE RECOGNIZED 1. . . Normal pulmonary vascularity 2. truncus arteriosus.

Decreased pulmonary vascularity due to right-to-left shunts. Tetralogy of Fallot.small pulmonary arterial segment .3.reduced diameter of the hilar pulmonary arteries . .ex. tricuspid atresia. pulmonary stenosis 50 .

Pulmonary venous congestion .occurs in condition that causes increased resistance distal to pulmonary capillaries .ex. Mitral stenosis. 51 .4.fluid accumulates in the interstitial tissues and Kerley B lines . acute left ventricular failure are common causes.

different vascular pattern in each lung 52 .5. A bizarre pattern of pulmonary vascularity . Bronchial collateral 6.

PATHOLOGY 53 .

ACQUIRED HEART DISEASE • Radiology features of Left & Right Heart Failure • Acquired Valvular Heart Disease • Pericardial Disease • Acquired Vascular Disease 54 .

RADIOLOGY FEATURES OF LEFT & RIGHT HEART FAILURE • Many cardiac disease will eventually develop left or right heart failure • Understanding the radiology features of left & right heart failure  fundamental 55 .

• In left-sided cardiac failure. pulmonary arterial and pulmonary venous pressures. • Interstitial osmotic and alveolar pressures remain constant throughout the lung • Hydrostatic. the increased pulmonary venous pressure resulting from the elevated left ventricular end-diastolic pressure 56 .LEFT HEART FAILURE • Five factors influence the distribution of pulmonary blood flow. diminish from base to apex because of gravitational effects.

LEFT HEART FAILURE • The transudation of fluid into the pulmonary interstitium causes an increase in the interstitial pressure • The earliest radiographic manifestation on left-sided cardiac failure is: 1. 2. The hilar vessels become enlarged and indistinct. The increased interstitial fluid can be seen as ‘peribronchial cuffing’. An indistinctness of the vascular markings caused by the increased interstitial fluids. 3. 57 .

• Kerley B lines. 58 . The vascular markings are prominent in the upper lobes owing to the constriction of the lower lobe vessels and redistribution of flow to the upper lobes. This appears in a perihilar location (‘butterfly wings’ or ‘bat wings’).LEFT HEART FAILURE • Later. • Pleural effusion occurs late • Transudation of fluid into the alveoli leads to pulmonar edema. ‘cephalization’ occurs. due to fluid in the lobular septum.

& C • Kerley A : white arrow • Kerley B : white arrow head • Kerley C : black arrow head 59 . B.KERLEY A.

PULMONARY EDEMA • Classified into • Cardiogenic • Non-cardiogenic • Cardiogenic pulmonary edema  heart failure • Heart failure • Left heart failure  backward failure  pulmonary congestion  pulmonary edema • Right heart failure  backward failure  systemic congestion  doesn’t cause pulmonary edema 60 .

Cranialization / cephalization (PCWP 10-15 mmHg) 2.PULMONARY EDEMA • Chest x ray  screening tool • Left heart failure: • Heart enlargement with the apex downward to the diaphragm • Depend on the severity 1. Alveolar pulmonary edema (PCWP >25 mmHg) 61 . Interstitial pulmonary edema (PCWP 20-25 mmHg) 3.

• Measure at equidistant from the hilar point.PULMONARY EDEMA • Cranialization / cephalization • Pulmonary veins at the superior part of the lung >3-5:1 than the pulmonary veins at the inferior part of the lung. • Mechanism: • Decreased vascular compliance at the lung base. • Vascular marking at the superior part of the lung is more crowded than the inferior part of the lung. • Hypoxic vasoconstriction phenomenon 62 .

PULMONARY EDEMA Cranialization / Cephalization 63 .

length 1-2cm. Length up to 6cm. oblique at the central part • Kerley C  reticular at the lung base (en face Kerley B) • Peribronchial thickening at both hila • Fluid in fissures • Pleural effusion (Bilateral especially the right side) 64 .PULMONARY EDEMA • Interstitial pulmonary edema • Interlobular septa thickening • Kerley B  lung base : thickness 1mm. horizontal • Kerley A  dilatation of channel that connect the peripheral lymphatic channel to central lymphatic channel.

PULMONARY EDEMA Kerley B lines 65 .

PULMONARY EDEMA 66 .

PULMONARY EDEMA Peribronchial thickening and fluid in 67 .

PULMONARY EDEMA Interstitial pulmonary edema 68 .

Bat’s wing appearance Butterfly appearance Usually no air bronchogram 69 .PULMONARY EDEMA • Alveolar pulmonary edema • • • • Infiltrates in the medial two third of the lung.

PULMONARY EDEMA Alveolar pulmonary edema 70 .

PULMONARY EDEMA Alveolar pulmonary edema 71 .

PULMONARY EDEMA • Non cardiogenic pulmonary edema • More peripherally • No cranialization/cephalization • Etiology: • • • • • Volume overload ARDS NSAID Neurogenic pulmonary edema (intracranial pressure>>) Drowned 72 .

PULMONARY EDEMA Non cardiogenic pulmonary edema 73 .

RIGHT HEART FAILURE • Usually caused by pulmonary hypertension • Reversed comma sign • RV hypertrophy • Prominent pulmonary artery segment • Compensated  RV hypertrophy • Decompensated  • RV dilatation • RA dilatation • Systemic congestion 74 .

RIGHT HEART FAILURE • Backward failure fromthe right heart failure  systemic congestion • Hepatomegaly • Increased jugular venous pressure • Dilated azygos vein • Ascites • Edema in the dependent part organ 75 .

RIGHT HEART FAILURE Mild PAH Severe PAH • Pulmonal artery segment dilatation • Right ventricular enlargement • Reduced bronchovascular marking 76 .

Pulmonary Hypertension • Increasing pressure of pulmonary artery   • May reflect an increase in left heart filling pressure in the presence of normal pulmonary vascular resistance. 77 . or a combination of these initiating factors.

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ACQUIRED VALVULAR HEART DISEASE • Cardiac valves  damage  stenosis or insufficiency • Aortic and mitral  most commonly affected • Principal hemodynamic effect: • Stenosis: Increased pressured in the proximal cardiac chamber Response  hypertrophy Dilatation  decompensation • Insufficiency: Enlargement of the cardiac chambers on both sides of the insufficient valve Response  dilatation 80 .

ACQUIRED VALVULAR HEART DISEASE • Mitral Valve • Mitral Stenosis • Mitral Insufficiency • Aortic Valve • Aortic Stenosis • Aortic Insufficiency • Tricuspid Insufficiency • Pulmonal Insufficiency 81 .

MITRAL VALVE
• Rheumatic fever  most frequent cause
• Acute: inflammatory process involve the
heart
• Chronic:
• thickening and fibrosis of the mitral valve
leaflets
• Fusion and shortening of the chordae
tendineae

• Female >> Male

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MITRAL STENOSIS
• Product of
• Fusion of the valve leaflet
• Fusion and shortening of the chordae
tendineae

• Etiology
• Rheumatic fever
• Bacterial endocarditis (vegetation)
• Thrombi
• Tumor
• Congenital
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MITRAL STENOSIS

• Hemodynamics
• Adult : Normal mitral valve area 4-6 cm2.
• Normal orifice  accomodate increased flow (during
exercise) without an increase in the left atrial
pressure (N:10mmHg)
• ↓ 1.5cm2  increase in left atrial pressure
(accentuated during excercise)
• 0.5cm2  left atrial pressure at rest 35 mmHg

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• PCWP ↑  pulmonary edema. 1. Cranialization / cephalization (PCWP 10-15 mmHg) 2. Interstitial pulmonary edema (PCWP 20-25 mmHg) 3. Protect the lungs from pulmonary edema 85 .MITRAL STENOSIS • Hemodynamics • Thus. the left atrium is hypertrophied and then enlarged. Alveolar pulmonary edema (PCWP >25-35 mmHg) • Pulmonary congestion  pulmonary hypertension • Pulmonary arterial hypertension  advantageous •. Limit pulmonary blood flow •.

MITRAL STENOSIS Mitral stenosis Pulmonary congestion edema Left atrial pressure Left atrium hypertrophied Diffuse hypoxic Diffuse vasoconstriction Left atrium dilatation (decompensation) Pulmonary congestion edema Pulmonary arterial hypertension Right ventricular hypertrophy – failure (decompensation) 86 .

MITRAL INSUFFICIENCY • Rheumatic fever  leading cause • Rheumatic process: • Fuses and shortens the chordae tendineae  limit movements  prevent complete closure • Usually associated with some degree of mitral stenosis That result from : • Other causes: Infarction • Rupture papillary muscle Bacterial endocarditis • Perforation of a valve cusp Marfan’s syndrome • Rupture of chordae tendineae • Dilatation of mitral valve ring from dilatation of the chamber • Tumor near the valve 87 .

88 .MITRAL INSUFFICIENCY • Posterior mitral valve prolapse • 7% of female • Minimal regurgitation • Rarely produce significant hemodynamic abnormalities.

MITRAL INSUFFICIENCY • Hemodynamics • Depends on • Extent of mitral valve that is not occluded during systole • Pressure difference between LV & LA during systole • Impedence to left ventricular outflow 89 .

MITRAL INSUFFICIENCY Mitral Regurgitation ↑ blood flow to LA Left ventricle dilatation Amount of Mitral Regurgitation ↑ Left atrium dilatation ↑ flow to LV during diastole Left ventricle dilatation Left Ventricle decompensation LA pressure ↑  pulmonary venous pressure ↑ RV systolic pressure ↑  right ventricular failure (rare) 90 .

MITRAL INSUFFICIENCY • Clinical Features • • • • Asymptomatic for a long time Fatigue and dyspnea Apical pansystolic murmur A mid diastolic murmur 91 .

pulmonary arterial hypertension 92 .MITRAL INSUFFICIENCY • Radiographic Features • Mild • Normal cardiac size and contour • Normal pulmonary vasculature • Moderate to severe • Cardiomegaly (LA and LV dilatation) • Pulmonary venous obstruction (cephalization. kerley. alveolar edema) • Eventually. interstitial.

MITRAL INSUFFICIENCY 93 .

MITRAL INSUFFICIENCY 94 .

PERICARDIAL DISEASE • Pericardial effusion • Pericardial cyst 95 .

PERICARDIAL EFFUSION • Fluid in the pericardial cavity • Caused by: • Pericarditis • Infection (bacterial. tb) • Rheumatic • Uraemia • Prolonged cardiac failure • Trauma • Fluid may be: • Serous • Purulent • Bloody 96 .

PERICARDIAL EFFUSION •Clinical features: • May be asymptomatic • Pericardial friction rub • Chest pain in pericarditis 97 .

PERICARDIAL EFFUSION • Radiographic Features • Cardiomegaly • No demarcation of the chamber or great vessels • Cardiac contour  water bottle • Chronic (stretching of pericardial cavity) • Erect: wide based • Supine: wide centrally • Acute (not elastic) • Round • Not depend on position • Fluoroscopy : cardiac pulsation decreased • USG  for minimal pericardial effusion 98 .

PERICARDIAL EFFUSION 99 .

PERICARDIAL CYST • Benign congenital anomaly of anterior-middle mediastium • Clinical features: • Asymptomatic • Occasionally with chest pain and dyspnea • Radiological features: • Mass at the cardiophrenic sulcus 100 .

PERICARDIAL CYST 101 .

ACQUIRED VASCULAR DISEASE • Aortic aneurysm • Elongatio aorta 102 .

AORTIC ANEURYSM • Dilatation of aorta (diameter > 4cm) • Diameter >5-6 cm  risk of rupture • Diameter ↑ 1cm/year  risk of rupture 103 .

AORTIC ANEURYSM • True aneurysm • True dilatation of the aortic wall • E/ • • • • Atherosclerosis (most common) Hypertension Inflammatory (rheumatoid arthritis. Ehlers-Danlos • Pseudoaneursym • Rupture of the aortic wall  focal bulging • E/Infection (mycotic aneurysm). syphilis) Marfan’s syndrome. takayasu arterits. trauma 104 .

105 .AORTIC ANEURYSM • Radiographic features: • Ascending aorta becomes the right heart border • Aortic knob > 35mm from the left margin of the trachea • Descending aorta shift to the left.

AORTIC ANEURYSM 106 .

AORTIC ANEURYSM • Complication: • Rupture • Dissection 107 .

AORTIC ANEURYSM • Rupture • • • • • • • Widened mediastinum (>8cm) Blurred aorta margin Loss of aortic knob Pleural cap Hemothorax (usually left sided) Right deviation of the trachea NGT shift to the right 108 .

AORTIC ANEURYSM 109 .

forming a second blood-filled channel within the wall • Classified by • De Bakey • Stanford 110 .AORTIC ANEURYSM • Dissection • Blood enters the medial layer of aortic wall through a tear or penetrating ulcer in the intima and tracks along the media.

AORTIC ANEURYSM 111 .

AORTIC ANEURYSM • Dissection • Radiographic features: • Widened mediastinum • Double aortic contour • Irregular aortic contour • Calcium sign: inward displacement of atherosclerotic calcification 112 .

AORTIC ANEURYSM 113 .

AORTIC ANEURYSM 114 .

AORTIC ANEURYSM 115 .

• With or without dilatation • E/ hypertension (most common) 116 .ELONGATIO AORTA • Elderly • Length of ascending aorta. aortic arch and descending aorta ↑.

ELONGATIO AORTA • Radiographic features • Less than 1 cm to the medial end of the clavicle • The film should be symmetrically taken and with enough inspiration. 117 .

ELONGATIO AORTA 118 .

lung fibrosis. tension pneumothorax.COR PULMONALE  COR PULMONALE is a disorder of the heart. chronic bronchitis. pulmonary resection  Chronic: emphysema. compresseion atelectasis. Lung carcinoma 119 . TBC. esp right heart ( right ventricle ) due to abnormalities of the lungs which causes major obstacles to the circulation of the heart ETIOLOGY :  Acute : pulmonary emobolism.

PATOPHYSIOLOGY In normal circumstances there is a balance between the blood vessel with a volume of blood flowing. resulting restriction to the circulation  pulmonary hypertension and right heart (especially right ventricle) hypertrophy 120 . When the area of blood vessel is reduced.

Cor Pulmonale 121 .

not visible Pulmonary vein 122 . Increasing radiolucency  emphysema. Left atrium & Left ventricle normal in size. 4. 3. bronchovascular marking decreasing. Lung abnormality 2. hilar widening. protruding of pulmonary artery. normal aorta. Right ventricle hipertrophy.Chest X-Ray: 1.

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Thank You 124 .