CARDIOVASCULAR

IMAGING

LEVEL V MBCHB

BY DR ONYAMBU

LECTURER DDIRM

Objectives

Know the different imaging modalities

used in imaging the CVS

Understand the clinical application of

each modality

Understand the best imaging modality for

each clinical indication

IMAGING MODALITIES

Plain CXR-PA,LAT

Echocardiography

Isotope scanning

Cardiac catheterisation

Angiocardiography

CT

MRI

PLAIN X-RAYS

Plain radiographs are important as the first imaging investigation in cases of heart disease. It gives vital information concerning:

Size of the heart

Enlargement of individual chambers

Pulmonary vasculature

Condition of the lung fields

Presence or absence of pleural effusion

SIZE OF THE HEART

Measured by the cardio-thoracic ratio

(CTR)

The maximum transverse diameter of the

heart is compared to the maximum

transverse diameter of the chest.

In normal adults this is <_ 50%

In children it is <_ 60%

CT OF THE HEART

Chamber orientation

RA-lies on the right and forms the RT heart

border

RV-lies to the LT and anterior to RA forms

anterior heart border

LA-lies posteriorly and forms the

posterior heart border

LV-forms the bulk of the left heart border

THE SHAPE OF THE HEART

The cardiac contour has characteristic

appearance in specific conditions

depending on the chambers mainly

enlarged.

LV enlargement is seen in HTN, and

aortic valve disease

The apex enlarges downward and to the left

LV ENLARGEMENT

THE LEFT ATRIUM

LA enlargement is seen in mitral valve

disease,

Enlarges backwards and to the right

Double density of the heart

Projects backwards and slightly upwards in

the lateral film .

Makes an impression on the barium filled

oesophagus.

MR

Severe MR disease

.Left atrial appendage

is large , producing a

convex bulge (arrow).

The heart is

considerably enlarged

VSD

RIGHT VENTRICULAR

ENLARGEMENT

May also be seen in mitral disease due

to increased pulmonary resistance

secondary to pulmonary congestion

Also seen in congenital cardiac lesions

associated with pulmonary stenosis or L-

R shunts.

Pulmonary disease with chronic airway

obstruction

RV

Lifting and rounding of the apex

Filling of the retrosternal airspace

Rt Ventricle enlargement

Mitral valve disease

1) Mitral stenosis(ms)

Almost always rheumatic in origin.

In the elderly, heavy calcification of the valve

apparatus can cause ms.

A rare congenital form of ms is also

recognized.

In rheumatic ms the valve orifice is slowly

diminished by progressive fibrosis,

calcification of valve leaflets, and fusion of the

cusps and subvalvular apparatus.

Ms cont

Flow of blood from left atrium to left ventricle

is restricted and left atrial pressure rises

leading to pulmonary venous congestion and

breathlessness.

There is dilatation and hypertrophy of the left

atrium and left ventricular filling becomes

more dependent on left atrial contraction.

mitral orifice is about 5cm sq and may be

reduced to 1cm sq or less in severe ms.

Investigations

ECG: features of rt ventricular

hypertrophy, left atrial hypertrophy and

fibrillations.

CXR: enlargement of left atrium and its

appendage.

-enlargement of main pulm artery.

-features of pulmonary venous

congestion.

MS

MS

MR

LUNG FIELDS

CONGESTION-due to pulmonary venous hypertension following left heart lesions resulting in back pressure on the lung. Causes include; LV failure and mitral valve disease.

CXR

Diversion of blood from the lower to the upper zones of the lung in an erect PA film of the chest

Cont…

Pulmonary oedema with interstitial or

alveolar involvement

Septal lines- Kelly A,B and C

Lamellar effusions

Alveolar oedema is often perihilar with

blurring of the central lung areas (bat’s

wing appearance)

Pleural effusions may be seen.

PULMONARY PLETHORA

Seen in conditions of high pulmonary flow mainly due to congenital L-R shunts.

Both arteries and veins become prominent with end on vessels close to the hilum being particularly well seen, and distal vessels extending to the lung periphery

PAH (pulmonary arterial hypertension) may develop in long standing ASD, increased resistance caused by severe pulmonary venous HTN

Cont……..

PAH may develop acutely following

massive pulmonary embolus or from

chronic multiple pulmonary emboli.

PAH also occurs in chronic pulmonary

disease with chronic airways obstruction

X-Ray Findings-ASD

Enlarged

pulmonary

vessels

Normal-sized

left atrium

Normal to

small aorta.

ASD

PULMONARY OLIGAEMIA

Occurs when there is obstruction to the

pulmonary outflow at or below the

pulmonary valves.

It may be seen in R-L shunt as in

tetralogy of Fallot

PERICARDIAL EFFUSION

May be classified as

1.Inflammatory

-TB -Supprative

-Rheumatic -Viral

2.Non-inflammatory

-heart failure -myocardial infarction

-Uraemia -Haemopericardium

3.Malignant

Pericardial effusion

The radiological diagnosis can be difficult

unless the fluid is more than 200 mls.

R.F

Enlarged globular heart

Masking of the hilar

U/S is diagnostic

CT or MRI may show the effusion

CXR-pericardial effusion

Congestive cardiac failure

Heart failure occurs when a patient with

significant heart disease develops signs

and symptoms of low cardiac output,

pulmonary congestion, or systemic

venous congestion

CCF-CAN BE

LT sided

RT sided

Biventicular

Radiological features

Cardiomegaly

Enlarged hilar vessels

Prominence of upper lobe vessels

Septal or Kerley B lines

Ground glass appearance of alveolar

oedema

Pleural effusion

Upper lobe diversion of blood

CCF

Kerley A & B lines

CXR

LA myxoma. Large

heart with all chambers

involved . There is

interstitial pulmonary

oedema.

LT ATRIAL MYXOMA

Ischaemic heart disease

Almost always due to atheroma and its

complications particularly thrombosis.

Risk factors:-

-age -male sex -family history

-smoking -hypertension

-diabetes mellitus -obesity

-sedentary life style -diet

Plain radiographs:-

- normal

Myocardial perfusion studies:-

scintiscans of the heart are taken at

rest and after exercise.

Thallium 201 is taken up by viable

perfused myocardium.

Thallium 201 is injected during exercise

test with immediate exercise images and

perfusion images 3 hrs later, after resting

Myocardial Ischaemia

IMAGING FEATURES

Myocardial perfusion

study.

Thallium scan

showing reversible

anterior myocardium

ischaemia.

Images are cross-

sectional tomograms

of the left ventricle.

CORONARY CT ANGIOGRAPHY

Indications

Recent onset chest pain

High cholesterol levels

High blood pressure

Family history of coronary artery disease

Smoking

Diabetes mellitus

CCTA

THE

END