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8/3/2019 20100913 OS205 Cardiac Imaging
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OOSS 220055:: TThhoorraaxxExam2TTooppiicc::CCAARRDDIIAACC IIMMAAGGIINNGG
[29 June 2010] Lecturer: Dr. Rogelio I. de Jesus
David, Lionel, Paul UPCM 2015 Page 1 of 7
Outline:
I. Introduction: Chest RadiographsII. Plain Film Anatomy
A. PA ViewB. Lateral ViewC. CT Scan
III. Congenital Heart DiseasesIV. Valvular Heart Diseases
I. INTRODUCTION: CHEST RADIOGRAPHS Most commonly requested diagnostic tool
Least costly and frequently effectiveEssential part of cardiac evaluation
Information obtained:Heart size and silhouetteEnlargement of cardiac chambersPulmonary blood flow/markings
Evaluation involves sequential logical assessment andcorrelation of both anatomic and physiologic information
available on PA and lateral radiographs
Patient with fever and cough. Infiltration in R lung based onx-ray. This is probably pneumonia.
Patient with chronic cough and weight loss. Both upperlobes of lungs with cavitations. This is probably tuberculosis.
Radiologists act as detectivesExtract as much info as you canCome up with a specific diagnosis that would fit all findings
II. PLAIN FILM ANATOMYA. PA View
Figure 1: Normal PA showing the borders and other visible structures.
Know relative positions of valves, atria, etc.
Know which structures are border-formingRIGHT BORDER LEFT BORDER
Superior vena cava
Right atrium
Inferior vena cava
Aortic knob
Main pulmonary artery segment
Left ventricle
Use the hila as a landmarkPulmonary arteries (PA) and bronchi are at the level of hilaPulmonary veins are below hila
Contrast study:WHITE Arteries and veins
BLACK Air-filled structures (e.g. bronchi, trachea)
B. Lateral ViewBORDERS
Left atrium (posterosuperior)
Left ventricle (posteroinferior)
Right ventricle (anteroinferior)
VISIBLE SHADOWS
Aorta
Main pulmonary trunk
Inferior vena cava
Note: Right atrium is not border-forming in the lateral view!
Note: Pulmonary arteries (left and right) and veins may bemistaken for enlarged lymph nodes in children
Figure 2: Normal lateral view showing borders and other visible structures.
C. CT Scan Axial (most requested)
Transverse cuts, as if viewed from the patients feet Your right hand side is the left side of the patient, your
left hand side is the right side of the patient
Contrast study:WHITE Bones
BLACK Air-filled structures (e.g. lungs, trachea)
GRAY Soft tissues (e.g. skeletal muscles, cardiac muscles)
Pulmonary arteries branching from main trunkMore superior on left side than right
L Pulmo.
Artery
Main Pulmo.
Trunk
R Pulmo.
Artery
LV
Aortic knob
IVC
RA
SVC
Main
Pulmo.Artery
aorta
IVC
RVLV
LA
L.Brachiocephalic v.
meeting with R.BCv
aorta
R Pulmo. Artery L Pulmo. Artery
esophagus
trachea
SVC
13 September 2010
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David, Lionel, Paul UPCM 2015 Page 2 of 7
III. PLAIN FILM INTERPRETATIONSystemic Approach
1. OVERVIEW OR OVERALL GLANCE AT THE FILM Is it adequate or optimal for cardiac evaluation?
Erroneous data can lead to misdiagnosis.Position
Slight degrees of rotation or obliquity will substantiallyaffect the cardiac contour and may alter the apparent
size as well
Obliquity can be deceiving and may be seen as a falseenlargement
Inspiration Should be in full inspiration
Diaphragm is at the level of the 9th-10th posterioraspect or the 5
th-6
thanterior aspect of the ribs
In suboptimal inspiration or supine chest radiographs,the lower lobe markings are crowded and may obscure
the possibility of early pulmonary edema
Film should not be taken during exhalation orsuboptimal inhalation because then the superoinferior
diameter decreases and the heart is squeezed
The vessels are crowded, which could simulatepulmonary edema
Exposure Underexposure appears whiter
May simulate pulmonary congestion Overexposure appears blacker (remember:
OVERcooked rice is black, nasunog!)
May simulate emphysema, diminished pulmonaryblood flow or hypopulmovascularity
2. CARDIAC POSITION AND SITUSCARDIAC POSITION
Heart Predominantly in Apex Points Towards
Levocardia Left Left
Dextrocardia Right Right
Mesocardia Midline Down
Dextroposition
(dextroversion)
Right Left
Typically due to extrinsic forces, rotation of heart
Situs refers to the pattern of anatomic arrangement Atrial situs is usually concordant with visceral situs;
hence, these two are described together
VISCEROATRIAL SITUS
Atrium Viscera
Situs SolitusMorphologic RA is to the
right of the morphologic LA
Gastric air bubble
on left side
Liver is on the right
Situs InversusMorphologic RA is to the
left of the morphologic LA
Gastric air bubbleon right side
Liver is on the left
Situs
Ambiguous
Identification of situs not possible due to paucity of
anatomic markers (spleen and liver unidentifiable)
Note: Situs solitus is the normal condition.
Figure 3: Dextrocardia and situs solitus.
Figure 4:Dextrocardia and situs inversus.
Figure 5: Situs ambiguous.
3. Cardiac size Is heart enlarged or not?Cardio-Thoracic Ratio
Divide the widest transverse diameter of the heart bythe widest transverse diameter of the thorax taken at
the inner side of the rib cage
Figure 6: Cardio-thoracic ratio
Normal CT ratio in adults is usually 0.5 or less Normal CT ratio in the newborn is approximately 0.65 Normal CT ratio for children is between 0.5 and 0.65
(~0.6)
4. CHAMBER ENLARGEMENTRIGHT ATRIAL ENLARGEMENT
Right Heart
Border
Lateral bulging
Elongation (length exceeds 50% of the mediastinalcardiovascular shadow, midway between the
line at the root of the great vessels and the line
at the cardiophrenic sulcus)
LV
RARV
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David, Lionel, Paul UPCM 2015 Page 3 of 7
Figure 7: RA enlargement
RIGHT VENTRICULAR ENLARGEMENT (BUDDING BREAST)
PA ViewRounding
Upliftment and lateral discplacement of apex
Lateral View
Retrosternal fullness (contact of anterior cardiac
border greater than 1/3 of the sterna length),
which may lead to false positive of LV
enlargement since there is no more room for
growth of the RV
Figure 8: RV enlargement PA view (left) and lateral view (right)
LEFT ATRIAL ENLARGEMENT
PA View
Double density on right border due to
superposition of LA (denser) and RA
Enlargement of LA appendage seen inferior to the
left main bronchus (recall that the left border is
formed by only three bulges)
Upliftment of the left mainstem bronchus
Widening of the carinal angle (normal is 70-90)due to the left mainstem bronchus being pushed
upwards (sometimes not widened when the
right bronchus is very much vertically oriented)
Lateral View
Prominent posterosuperior cardiac border (recall
that the LA is most posterosuperior chamber)
Posterior displacement and upliftment of the left
mainstem bronchus
Note: Easiest to evaluate of all the chambers.
Figure 9: LA enlargement PA view (top) and lateral view (bottom).
LEFT VENTRICULAR ENLARGEMENT
(SAGGING BREAST ORHEAVY HEART)
PA ViewLateral and inferior displacement of the apex
(which is normally border-forming)
Lateral View
Posterior displacement of the posteroinferior
border of the heart
Hoffman-Rigler sign: measured 2cm above the
intersection of diaphragm and IVC; (+) if
posterior border extends >1.8 cm of IVC
Retrocardiac fullness
Note: RV enlargement may be confused to be LV enlargement because
heart is pushed back
Figure 10: LV enlargement PA view (top) and lateral view (bottom)
5.PULMONARY VASCULAR PATTERNStart with lungsit can help in assessment
NORMAL VASCULARITY
Tapering
From inner lung zones (medial) to outer lung
zones (peripheral)
Periphery must be relatively clearer/avascular
From lung base (inferior) to apex (superior)
Lower lobes are better perfused due to gravity
Vessels in lower lobes have greater caliber
Figure 11: Normal vascularity
Hypervascularity (increased vascularity) May be seen as an overall increase in vessel caliber However, medial to lateral and inferior to superior
taperings are maintained (e.g. in shunt anomalies)
Figure 12: Hypervascularity (lateral view in powerpoint)
Double density
Inc. carinal
angle
L bronchus
uplifted
LA
appen-
dage
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David, Lionel, Paul UPCM 2015 Page 4 of 7
Hypovascularity (decreased vascular pattern) Do not confuse with overexposed films, in which
everything is black. In hypovascularity, only the lungs
are black. (black is larger than white in relation to
pulmonary artery (white) and bronchus (black))
Found in cardiac patients of decreased pulmonaryblood flow (presence of obstruction)
Figure 13: Hypovascularity (lateral view in powerpoint)
Venous congestion Increased caliber of the vessels
Cephalization of pulmonary blood flow (vessels inupper lobes are thicker than in lower lobes)
Normal tapering from medial to lateral Do not confuse with increased arterial blood flow (e.g.
atrial septal defect), which is congenital. Venous
congestion is valvular or acquired (e.g. mitral stenosis)
Notes:
1.The terms hypervascular, hypovascular, and normovascular areused for congenital diseases.
a.Vessels/arteries/arterioles (white) and bronchioles (black) gotogether and are normally seen 1:1 in terms of size
b.In hypervascularity, the vessels are larger than the bronchiolesc. In hypovascularity, the vessels are smaller than the bronchioles2.The terms cephalization, congestion, and equalization are used for
valvular diseases.
Figure 14: Venous congestion
Kerleys B lines Horizontal lines seen in the periphery
Periphery should be relatively avascular (in normalpatients)
Indicative of fluid in the interlobular septa, as seen ininterstitial edema
Figure 15: Kerleys B-lines
Perihilar haziness
Fuzzy and blurred (as opposed to a normal radiographicimage, where vessels are distinct)
Figure 16: Perihilar haziness
Peribronchial cuffing Thick bronchioles (normal lining is hair strand-thick) Sign of pulmonary congestion
Figure 17: Peribronchial cuffing
REDISTRIBUTION
EqualizationCaliber of vessels in upper lobe is equal to that of
the lower lobe vessels
Cephalization
Caliber of vessels in the upper lobe is greater than
that of the lower lobe vessels
As seen in venous congestion
Interstitial edema Prominent horizontal lines (Kerleys B lines) Kerleys A lines: diagonal lines usually in upper lobes Kerleys C lines: tangled blood vessels with cobweb-like
appearance (facing you)
All Kerleys lines (A, B, and C) are indicative ofinterstitial edema
Alveolar edema Fluid or blood in alveoli Cotton-like appearance
Figure 18: Alveolar edema
6. THE GREAT ARTERIES/VESSELSAre they in normal position?Are they of normal size?
Aorta: normal, prominent, or diminutive (not seen)? Main pulmonary artery (seen above left main
bronchus): normal, prominent (dilated), or concave
(small, waistline is seen)?
The aorta and main pulmonary artery are for outflow. Thus,whatever is happening in the ventricle(s) is reflected in these
great vessels.
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David, Lionel, Paul UPCM 2015 Page 5 of 7
Figure 19: Prominent aorta
Figure 20: Concave main pulmonary artery
7. ANCILLARY FINDINGS (ribs, soft tissues, chest, etc.)Calcifications
Rib notching due to coarctation of the aorta Stenotic valves
Bone deformitiesOthers
IV.CONGENITAL HEART DISEASE(See appendix for diagram of congenital heart diseases.)
Anatomic malformation of the heart and or its vessels
Occurs during intrauterine development Incidence:
8/1000 live births (most common congenital malformation)13% will have more than one cardiac defect25% will have associated non-cardiac deformity
Etiology is unknown or is multifactorial:HereditaryChromosomal abnormalityMaternal infectionTeratogenic drugsMaternal factorsEnvironmental
RADIOLOGIC INTERPRETATION OF CONGENITAL HEART DISEASE
1. Cyanotic or Non-cyanotic?2. Vascularity (hypervascular, hypovascular, cephalic, congested)3. Specific chamber enlargement4. Great Vessels (know which vessels are enlarged)5. Ancillary findingsVENTRICULAR SEPTAL DEFECT (VSD)
There is abnormal communication between LV and RVSome of the blood flows from LV to RV oxygenated blood
mixes with deoxygenated blood lungs (oxygenation of
blood) left side of heart some go to systemic
circulation, some go to right side of heart
Left to right shunt going to pulmonary circulation results inextra burden of volume
Acyanotic (oxygenated blood supplies systemic circulation) Radiographic findings:
Increased vascularity due to increase in blood volumetowards the right side
Enlargement of main and central pulmonary arteriesEnlargement of left ventricle due to strain on LV(also in left
atrium, but less noticeable)
Enlargement of right ventricle, but only in a large defect(shunting of blood in both systole and diastole)
Aorta is small or normal
If uncorrected, leads to pulmonary hypertension as one agesLungs vasoconstrict to counter too much blood flowRV
hypertrophies (pressure overload)shunt is
reversedblood going into systemic circulation is mixed
cyanosis (EISENMENGERIZATION)
Figure 21: Diagram of VSD
Figure 22: Radiographic findings in VSD
TOTAL ANOMALOUS PULMONARY VENOUS RETURN (TAPVR)
FLOW OF OXYGENATED BLOOD
Normal
Circulation
lungs pulmonary veins LA LV aorta
systemic circulation
TAPVR
lungsright side of heart
(oxygenated blood does not drain into the left side
of the heartnot compatible with life)
ASD (obligatory shunt between atria) is needed to survive This condition leads to cyanosis Radiographic findings:
vascularity ( blood volume to right side of heart)CardiomegalyChamber prominence (right side of the heart)Enlarged systemic vein into which drainage occursPulmonary arteries dilated
Type I (Supracardiac)Connection above heart; tangle of vessels above heartLeft-sided vertical vein connects pulmonary venous
confluence to left innominate vein, right SVC or azygos vein
Snowman appearance
Chamberprominence
Inc. vascularity
Inc. vascularit
cardiome al
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David, Lionel, Paul UPCM 2015 Page 6 of 7
Figure 23: Supracardiac TAPVR
Type II (Cardiac)
Connections to the RA or coronary sinusRadiographic findings mimic ASD but cyanotic
Figure 24: Cardiac TAPVR
Type III (Infracardiac)
Connection is below the diaphragm, to the portal vein,ductus venosus or hepatic vein
Radiographic findings: Normal sized heart Prominence of the right atrium & less often the rightventricle (due to right side involvement) Dilated pulmonary artery Pulmonary edema (most prone to edema)
Figure 25: Infracardiac TAPVR. Radiographic findings on right.
Mixed type
Various connections to the right side of the heart
Figure 26: Mixed TAPVR
TETRALOGY OF FALLOT (TOF)
Pulmonary stenosisNarrowing of the right ventricular outflow tractBlood has difficulty going to the lungsBlood from RA goes to RV but has difficulty going through
the pulmonary valve chooses an alternate route
Ventricular septal defectAlternative route chosen since there is pulmonary stenosisPressure in RV increases and deoxygenated blood is shunted
from the RV to the LV, bypassing the lungs
Less blood goes into the pulmonary circulation, resulting indecreased vascularity
Right ventricular hypertrophyDue to difficulty in propelling the blood to the lungs
Overriding aortaProminent aorta overrides VSDBlood going into the aorta is mixed, leading to cyanosis
Radiologic findings: VascularityNormal or enlarged cardiac sizeRV prominenceConcave main pulmonary artery segmentProminent aorta (right sided aortic arch in 20-25%)Small pulmonary artery
Figure 27: TOF
Figure 28: TOF radiologic findings
Remember:
Volume overload leads to dilation Pressure overload leads to hypertrophy
RA prominence
RV
Dec. vascularity
Concave MPAOverriding aorta
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David, Lionel, Paul UPCM 2015 Page 7 of 7
V. VALVULAR HEART DISEASES May be congenital or acquired
Pathophysiology and clinical manifestations similar in bothAlmost all acquired valvular heart diseases are rheumatic in
origin
MITRAL VALVE STENOSIS (MITRAL STENOSIS)
Figure 29: Mitral valve stenosis.
Narrowing of the mitral valve, so it cannot open properly Blood flow to the left ventricle (and to the systemic circulation) is
obstructed
Radiologic findings:Normal to slightly enlarged heartChamber prominence: LA (due to pressure build-up), RV
(pulmonary vasculature congestion)
Equalization or cephalization of pulmonary blood flowProminent main pulmonary artery segmentSmall aortaRA wont be affected unless tricuspid valve has a problem
Figure 30: Mitral stenosis (PA view)
Figure 31: Mitral stenosis (lateral view)
Ria: Nakakapagod mag-aral. Mas gusto ko mag-edit ng trans, k. Dear USERS,
kung mabasa niyo to, kung ako maka Top 10 na score sa exam na to alam
niyo na. Hahahaha!
Prominent LA
equalization
Prominent MPA
Prominent RV
Prominent RV
Prominent LA