RADIOLOGICAL RADIOLOGICAL EXAMINATION OF THE EXAMINATION OF THE

CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM

DEPARTMENT OF ONCOLOGY AND DEPARTMENT OF ONCOLOGY AND RADIOLOGYRADIOLOGY

PREPARED BY I.M.LESKIVPREPARED BY I.M.LESKIV

METODS OF EXAMINATIONMETODS OF EXAMINATION Echocardiography, radionuclide examinations and plain films are the Echocardiography, radionuclide examinations and plain films are the

standard non-invasive imaging investigations used in cardiac disease. standard non-invasive imaging investigations used in cardiac disease. Echocardiography has now become a particularly important imaging Echocardiography has now become a particularly important imaging technique that provides morphological as well as functional information. It technique that provides morphological as well as functional information. It is excellent for looking at the heart valves, assessing chamber morphology is excellent for looking at the heart valves, assessing chamber morphology and volume, determining the thickness of the ventricular wall and and volume, determining the thickness of the ventricular wall and diagnosing intraluminal masses. Doppler ultrasound is an extremely useful diagnosing intraluminal masses. Doppler ultrasound is an extremely useful tool for determining the velocity and direction of blood flow through the tool for determining the velocity and direction of blood flow through the heart valves and within cardiac chambers. Radionuclide examinations heart valves and within cardiac chambers. Radionuclide examinations reflect physiological parameters such as myocardial blood flow and reflect physiological parameters such as myocardial blood flow and ventricular contractility but provide little anatomical detail, whereas plain ventricular contractility but provide little anatomical detail, whereas plain radiographs are useful for looking at the effects of cardiac disease on the radiographs are useful for looking at the effects of cardiac disease on the lungs and pleural cavities, but provide only limited information about the lungs and pleural cavities, but provide only limited information about the heart itself. MRI provides both functional and anatomical information but heart itself. MRI provides both functional and anatomical information but is only available in specialized centres and is used only for specific is only available in specialized centres and is used only for specific reasons.reasons.

ROENTGENOGRAPHYROENTGENOGRAPHY

A complete roentgen study of the heart usually requires a minimum of four A complete roentgen study of the heart usually requires a minimum of four projections: posteroanterior, left anterior oblique at approximately 60°, projections: posteroanterior, left anterior oblique at approximately 60°, right anterior oblique at approximately 45°, and lateral. The films are right anterior oblique at approximately 45°, and lateral. The films are exposed at a 6-foot distance, with the patient in the upright position and in exposed at a 6-foot distance, with the patient in the upright position and in moderately deep inspiration. Magnification resulting from divergent moderately deep inspiration. Magnification resulting from divergent distortion is minimized by obtaining posteroanterior and anterior oblique distortion is minimized by obtaining posteroanterior and anterior oblique views to place the heart closer to the film (the anterior chest is adjacent to views to place the heart closer to the film (the anterior chest is adjacent to film). A left lateral view (with the left side adjacent to film) also tends to film). A left lateral view (with the left side adjacent to film) also tends to minimize magnification. To outline the esophagus, we use a barium minimize magnification. To outline the esophagus, we use a barium suspension as an aid in determining position and size of the aortic arch. In suspension as an aid in determining position and size of the aortic arch. In addition, alteration inaddition, alteration in esophageal contour may reflect changes in the left-esophageal contour may reflect changes in the left-sided chambers. The use of ultrasound in determining cardiac chamber size sided chambers. The use of ultrasound in determining cardiac chamber size has decreased the use of the oblique projections, so that frequently the has decreased the use of the oblique projections, so that frequently the cardiac examination is restricted to PA and lateral projections, usually cardiac examination is restricted to PA and lateral projections, usually without barium in the esophagus.without barium in the esophagus.

Plain RadiographyPlain Radiography : :* The standard plain films for evaluation of cardiac diseases are * The standard plain films for evaluation of cardiac diseases are

the the PA viewPA view & & Lateral chest filmLateral chest film, the PA view must be , the PA view must be sufficiently penetrated to see the shadow within the heart, eg. sufficiently penetrated to see the shadow within the heart, eg. The double contour of the Lt. atrium & valve & pericardial The double contour of the Lt. atrium & valve & pericardial calcification.calcification.

* It provides limited information's about the Heart.* It provides limited information's about the Heart.* It provides limited information's about the effect of the cardiac * It provides limited information's about the effect of the cardiac

diseases on the lungs & pleural cavities.diseases on the lungs & pleural cavities.

We should assess the following points : a- Heart (shape & size). b- Great vessels (size, shape), Aortic arch (normally

located to the Lt. of the Trachea, we should exclude the signs of coarctation of aorta).

c- If there is any calcification. d- The main point is the examination of the Lung field

for altered blood flow & if there is any evidence of heart failure.

Normal CXR in PA view

Normal CXR in Lateral view

FLUOROSCOPYFLUOROSCOPY Cardiovascular fluoroscopy no longer has widespread use and in our Cardiovascular fluoroscopy no longer has widespread use and in our

institution is largely limited to the evaluation of specific questions: i.e., the institution is largely limited to the evaluation of specific questions: i.e., the presence of large pericardial effusions and the evaluation of aortic arch presence of large pericardial effusions and the evaluation of aortic arch anomalies. Generally, calcium is better seen on fluoroscopy then on plain anomalies. Generally, calcium is better seen on fluoroscopy then on plain films and these observations may be made at the time of cardiac films and these observations may be made at the time of cardiac catheterization. Minor amounts of calcification are best seen on CT. The catheterization. Minor amounts of calcification are best seen on CT. The use of fluoroscopy has virtually disappeared in the study of congenital use of fluoroscopy has virtually disappeared in the study of congenital heart disease because in general the patients require more definitive studies heart disease because in general the patients require more definitive studies such as cardiac catheterization, angiocardiography, ultrasonography, and such as cardiac catheterization, angiocardiography, ultrasonography, and MRI.MRI.

There are several disadvantages in cardiac fluoroscopy, one of the most There are several disadvantages in cardiac fluoroscopy, one of the most important of which is the amount of radiation to which the patient is important of which is the amount of radiation to which the patient is exposed.exposed.

The second disadvantage is distortion. Because the distance between the The second disadvantage is distortion. Because the distance between the target of the x-ray tube and the patient is short, there is considerable target of the x-ray tube and the patient is short, there is considerable enlargement of the cardiac silhouette and distortion of other thoracic enlargement of the cardiac silhouette and distortion of other thoracic structures. This can be decreased by using longer distances between target structures. This can be decreased by using longer distances between target and the patient, and by using a small shutter opening, producing the central and the patient, and by using a small shutter opening, producing the central beam effect. The third disadvantage is lack of permanent record. This is beam effect. The third disadvantage is lack of permanent record. This is obviated to a certain extent by the use of cine or videotape recording and obviated to a certain extent by the use of cine or videotape recording and by roentgenograms obtained before the procedure.by roentgenograms obtained before the procedure.

ANGIOCARDIOGRAPHYANGIOCARDIOGRAPHY

This method of contrast cardiac This method of contrast cardiac visualization has been used widely for visualization has been used widely for examination of patients with all types of examination of patients with all types of cardiac and pulmonary diseases. The cardiac and pulmonary diseases. The method is used in the diagnosis of method is used in the diagnosis of congenital and acquired cardiac disease. congenital and acquired cardiac disease. Selective angiocardiography in which a Selective angiocardiography in which a small amount of opaque medium (an small amount of opaque medium (an organic iodide) is injected into a specific organic iodide) is injected into a specific chamber or vessel during cardiac chamber or vessel during cardiac catheterization is used almost exclusively. catheterization is used almost exclusively.

CORONARY ARTERIOGRAPHYCORONARY ARTERIOGRAPHYAORTOGRAPHYAORTOGRAPHY

CORONARY ARTERIOGRAPHYCORONARY ARTERIOGRAPHY Selective catheterization of the coronary arteries followed by injection of a Selective catheterization of the coronary arteries followed by injection of a

contrast medium (one of the organic iodides) is used in combination with contrast medium (one of the organic iodides) is used in combination with cineradiography rapid serial filming or videotaping to study the coronary cineradiography rapid serial filming or videotaping to study the coronary arteries. Details of technique are beyond the scope of this discussion.arteries. Details of technique are beyond the scope of this discussion.

AORTOGRAPHYAORTOGRAPHY This examination consists of the injection of one of the organic iodides into This examination consists of the injection of one of the organic iodides into

the aorta through a catheter introduced into one of its major branches and the aorta through a catheter introduced into one of its major branches and placed into a desired position in the aorta. The examination has a place in placed into a desired position in the aorta. The examination has a place in the investigation of patients with congenital and acquired problems of the the investigation of patients with congenital and acquired problems of the aortic arch. It is used in infants with congestive heart failure in whom there aortic arch. It is used in infants with congestive heart failure in whom there is evidence of a left to right shunt and in whom patent ductus arteriosus is is evidence of a left to right shunt and in whom patent ductus arteriosus is suspected. Coarctation of the aorta in infants may also cause congestive suspected. Coarctation of the aorta in infants may also cause congestive heart failure. The lesion can be defined by aortography. In adults, heart failure. The lesion can be defined by aortography. In adults, aortography is used to define anomalies of the aortic arch and its branches aortography is used to define anomalies of the aortic arch and its branches as well as in the study of the aortic valve and the coronary arteries. It is as well as in the study of the aortic valve and the coronary arteries. It is also useful in patients with masses adjacent to the aorta in whom aneurysm also useful in patients with masses adjacent to the aorta in whom aneurysm is a possibility and in patients suspected of having dissecting hematoma, is a possibility and in patients suspected of having dissecting hematoma, and traumatic or other aneurysms. and traumatic or other aneurysms.

ULTRASONIC INVESTIGATION ULTRASONIC INVESTIGATION OF THE HEARTOF THE HEART

The use of ultrasound in examination of the heart has increased greatly in The use of ultrasound in examination of the heart has increased greatly in the past 20 years, and it is now well established and a widely used the past 20 years, and it is now well established and a widely used diagnostic tool. Ultrasonic investigation is a noninvasive, safe, and diagnostic tool. Ultrasonic investigation is a noninvasive, safe, and comfortable study that will demonstrate valve and chamber motion wall comfortable study that will demonstrate valve and chamber motion wall thickness and size. Doppler examination allows determination of the cross thickness and size. Doppler examination allows determination of the cross sectional area of a valve as well as quantification of gradients that may be sectional area of a valve as well as quantification of gradients that may be present. It is of value in the study of the hypertrophic cardiomyopathies present. It is of value in the study of the hypertrophic cardiomyopathies both with and without associated subaortic stenosis and in the study of the both with and without associated subaortic stenosis and in the study of the congestive type in which there is chamber dilatation. With ultrasound, left congestive type in which there is chamber dilatation. With ultrasound, left ventricular diameter and outflow configuration can be determined; ventricular diameter and outflow configuration can be determined; qualitative assessment of right and left ventricular size is possible, also. qualitative assessment of right and left ventricular size is possible, also. The size of the left atrium can be measured accurately and left atrial The size of the left atrium can be measured accurately and left atrial myxomas or other intraatrial tumors can be detected. Ultrasound is also myxomas or other intraatrial tumors can be detected. Ultrasound is also useful in the investigation of congenital heart disease, particularly in useful in the investigation of congenital heart disease, particularly in patients with hypoplastic left-heart syndrome, double-outlet right ventricle, patients with hypoplastic left-heart syndrome, double-outlet right ventricle, and right ventricular volume overload. In addition, it is the most sensitive and right ventricular volume overload. In addition, it is the most sensitive method for determining the presence of pericardial effusion.method for determining the presence of pericardial effusion.

Echocardiography(Cardiac US)

* It is the major or basic imaging technique used in cardiology.

* It gives important informations about the Morphology & Function of the heart. * It is an excellent technique to look for : a- Heart valves. b- Chamber morphology & volume. c- Determining the ventricular wall thickness. d- Any intra-luminal mass.

3 basic techniques are used in Echocardiography, & they are :

M-mode : Two-dimensional sector scanning (Real time echo.) Doppler echocardiography (Color, Pulse wave)

Echocardiography M-mode

* It is a continuous scan over a period of time (5-10 seconds), with pencil – beam of sound directed to the site of interest.

* It can demonstrate chamber dimensions, wall thickness, & valve movement (mainly for Lt. ventricular dimension in systole & diastole).

M-mode

Two-dimensional sector scanning

(Real time echo.) : *Demonstrates fun-shaped slices of the heart in motion.

*Standard examination consists of combination of short & long axis views + 4 chamber view.

*Long & short – axis views : cross-section of the of the Lt. ventricle + mitral valve + aortic valve, & it is done by placing the transducer in the intercostal space, just to the Lt. of the sternum.

*4 chamber view : both ventricles, both atria, mitral & tricuspid valves, & it is done by placing the transducer at the cardiac apex & aiming upward & medially.

4 chamber view in 2 dimensional scan

Para-sternal long axis

Para-sternal short axis

Apical 4 chamber view

Para-sternal short axis(at Mitral valve level)

*Changing in the frequency of the sound waves are reflected from moving objects, this change depends on the velocity of the reflecting surface.

*RBCs are used as reflecting surface & the velocity of the blood flow can be measured.

Doppler echocardiography(Color, Pulse wave):

Doppler flow measurements are used to :

1 -Measure cardiac output or Lt. to Rt. shunt.

2 -Detect & quantify valvular regurgitation.

3 -Quantify pressure gradients across stenotic valves.

4 -Quantify flow.

Trans-Esophageal Echocardiography :

*By placing the U.S. probe in the esophagus immediately behind the Lt. atrium, so it will view the heart from behind.

(A = normal descending thoracic aorta)

DETERMINATION OF CARDIAC DETERMINATION OF CARDIAC SIZE SIZE

The most commonly used are (1) measurement of transverse diameters; (2) The most commonly used are (1) measurement of transverse diameters; (2) measurement of surface area; and (3) cardio-thoracic ratio. The transverse measurement of surface area; and (3) cardio-thoracic ratio. The transverse diameter of the heart is the sum of the maximum projections of the heart to diameter of the heart is the sum of the maximum projections of the heart to the right and to the left of the midline; the measurement should be made so the right and to the left of the midline; the measurement should be made so as not to include epicardial fat or other noncardiac structures. The diameter as not to include epicardial fat or other noncardiac structures. The diameter can then be compared with the theoretic transverse diameter of the heart can then be compared with the theoretic transverse diameter of the heart for various and weights. Surface area estimations based on artificial for various and weights. Surface area estimations based on artificial construction of the base of the heart and of the diaphragmatic contour of construction of the base of the heart and of the diaphragmatic contour of the heart. The cardiothoracic ratio is the ratio between the transverse the heart. The cardiothoracic ratio is the ratio between the transverse cardiac diameter and the greatest internal diameter of the thorax, measured cardiac diameter and the greatest internal diameter of the thorax, measured on the frontal teleroentgenogram. This is the easiest and quickest method on the frontal teleroentgenogram. This is the easiest and quickest method of measurement of cardiac size; an adult heart that measures more than one of measurement of cardiac size; an adult heart that measures more than one half of the internal diameter of the chest is considered enlarged. The half of the internal diameter of the chest is considered enlarged. The method is gross, because the cardiothoracic ratio varies widely with method is gross, because the cardiothoracic ratio varies widely with variations in body habitus. It can be useful, however, as a rough estimate variations in body habitus. It can be useful, however, as a rough estimate of cardiac size. The cardiothoracic ratio is most useful in assessing changes of cardiac size. The cardiothoracic ratio is most useful in assessing changes in heart size or monitoring progression of disease, or as a response to in heart size or monitoring progression of disease, or as a response to therapytherapy..

Heart Diseases

*Evidence of heart diseases is given by:

1 -Size & shape of the heart.

2 -Pulmonary vessels, which provide information about the blood flow.

3 -The lungs, which may show pulmonary edema.

Measurement of heart size. The transverse diameter of the heart is the distance Measurement of heart size. The transverse diameter of the heart is the distance between the two vertical tangents to the heart outline. When the cardiothoracic between the two vertical tangents to the heart outline. When the cardiothoracic ratio (CTR) is calculated, the transverse diameter of the heart (B) is divided by ratio (CTR) is calculated, the transverse diameter of the heart (B) is divided by the maximum internal diameter of the chest (A)the maximum internal diameter of the chest (A)

Heart size : *Cardio - Thoracic Ratio (CTR), is the maximum thoracic diameter of the heart divided by the maximum thoracic

diameter, in adult CTR > 50% while in children CTR > 60%.

*Comparing with previous films chest-x-ray films is often more useful.

-The transverse cardiac diameter varies with the phase of respiration & with cardiac cycle, so if the change in the cardiac size is < 1.5 cm; this is negligible because the heart size is affected by breathing & cardiac cycle.

*Overall increase in the heart size means: - Dilatation of more than one cardiac chamber.

- Pericardial effusion.

Heart size :

Chamber hypertrophy and dilatation:

*Pressure overload (as in : Hypertension, Aortic Stenosis, Pulmonary Stenosis), this will lead toventricular wall hypertrophy, & such change will produce little change in the external contour of the heart, until the ventricle fails.

•* Volume overload (as in : Mitral Incompetence, Aortic Incompetence, Pulmonary Incompetence, Lt. to Rt. Shunt, & Damage of the heart muscle), this will lead to dilatation of the relevant ventricle, & this will cause an overall increase in the size of the heart (increase in the transverse cardiac diameter).

* Because enlargement of one ventricle affects the shape of the other, so it is only occasionally possible to get the classical feature Lt. or Rt. Ventricular enlargement.

-Lt. Ventricular enlargement, the cardiac apex is displaced cardiac apex is displaced downwards and to the left. Note also that the ascending downwards and to the left. Note also that the ascending aorta causes a bulge of the right mediastinal border - a aorta causes a bulge of the right mediastinal border - a feature that is almost always seen in significant aortic valve feature that is almost always seen in significant aortic valve diseasedisease..

Lt. Ventricular enlargement in a patient with Aortic Incompetence

Lt. Ventricular enlargement

-Rt. Ventricular enlargement, the cardiac apex is displaced upward (to the Lt. of diaphragm). Note also the features of Note also the features of

pulmonary arterial hypertension - enlargement of the main pulmonary arterial hypertension - enlargement of the main pulmonary artery and hilar arteries with normal vessels within the pulmonary artery and hilar arteries with normal vessels within the lungslungs..

Rt. Ventricular enlargement in a patient with Primary Pulmonary Hypertension

Rt. Ventricular enlargement

Lt. Atrial Enlargement:

*When it produces Double Contour, the Rt. border of the enlarged Lt. atrium is seen adjacent to the Rt. Cardiac

border within the main cardiac shadow.

Lt. Atrial Appendage : The enlarged LAA should The enlarged LAA should not be confused with dilatation of the main not be confused with dilatation of the main pulmonary artery. The main pulmonary artery is pulmonary artery. The main pulmonary artery is the segment immediately below the aortic the segment immediately below the aortic knuckle. The LAA is separated from the aortic knuckle. The LAA is separated from the aortic knuckle by the main pulmonary arteryknuckle by the main pulmonary artery

Lt. Atrial Enlargement in a patient with Mitral Valve Disease showing the “Double Contour Sign” (the left atrial (the left atrial border has been drawn in) and dilatation border has been drawn in) and dilatation of the left atrial appendage (LAA) of the left atrial appendage (LAA) (arrow)(arrow)..

Rt. Atrial Enlargement

*Will produce an increase of the Rt. cardiac border, & often accompanied by enlargement of Superior Vena Cava

( SVC.)

Valve movement deformity

&calcificationPlain X-ray films:

*Calcification is the only could be obtained directly related to the morphology of the valve.

*Calcification is better seen by fluoroscopy. *It occurs in mitral valve &/or aortic valve in rheumatic

heart diseases; & if it occurs in aortic valve alone( especially in adults )it is mainly congenital aortic stenosis.

*It is the easiest & the best to see calcification by the lateral view by drawing a line from the junction of the

diaphragm & the sternum to the Lt. main bronchus, so : -If the calcification is below & behind, means mitral valve. - If the calcification is above & in front, means aortic valve.

*If the line dissects the calcification, both valves (mitral& aortic) are calcified.

*Calcification of the mitral valve ring + elderly patient is occasionally seen in mitral regurgitation.

Valve calcifications

Mitral Valve Calcifications

Valve calcifications

Aortic Valve Calcifications

Ventricular Contractility

*General uniform decrease contractility in valvular disorder, congenital cardiomyopathy, & multi-vessel coronary artery

diseases.

*If there is focal decrease in contractility +/- dilatation in IHD.

*Increase contractility of the Lt. ventricle will cause hypertrophy as in aortic stenosis, HTN, & hypertrophic

obstructive cardiomyopathy (HOCM).

THE ADULT HEARTTHE ADULT HEART

Position of oesophagus (not opacified in this instance)

Pericardial diseasePericardial disease Echocardiography is ideally suited to detect pericardial fluid. Since patients are examined Echocardiography is ideally suited to detect pericardial fluid. Since patients are examined

supine, fluid in the pericardial space tends to flow behind the left ventricle and is recognized as supine, fluid in the pericardial space tends to flow behind the left ventricle and is recognized as an echo-free space between the wall of the left ventricle and the pericardium. A smaller amount an echo-free space between the wall of the left ventricle and the pericardium. A smaller amount of fluid can usually be seen anterior to the right ventricle. Even quantities as small as 20-50 ml of fluid can usually be seen anterior to the right ventricle. Even quantities as small as 20-50 ml of pericardial fluid can be diagnosed by ultrasound. The nature of the fluid cannot usually be of pericardial fluid can be diagnosed by ultrasound. The nature of the fluid cannot usually be ascertained, and needle aspiration of the fluid may be necessary; such aspiration is best ascertained, and needle aspiration of the fluid may be necessary; such aspiration is best performed under ultrasound control. Pericardial effusion can also be recognized at CT and performed under ultrasound control. Pericardial effusion can also be recognized at CT and MRI, although they are rarely performed primarily for this purpose. Computed tomography MRI, although they are rarely performed primarily for this purpose. Computed tomography and MRI are particularly useful for assessing thickening of the pericardium, whereas and MRI are particularly useful for assessing thickening of the pericardium, whereas echocardiography is poor in this regard.echocardiography is poor in this regard.

It is unusual to be able to diagnose a pericardial effusion from the plain chest radiograph. It is unusual to be able to diagnose a pericardial effusion from the plain chest radiograph. Indeed, a patient may have sufficient pericardial fluid to cause life-threatening tamponade, but Indeed, a patient may have sufficient pericardial fluid to cause life-threatening tamponade, but only have mild cardiac enlargement with an otherwise normal contour. A marked increase or only have mild cardiac enlargement with an otherwise normal contour. A marked increase or decrease in the transverse cardiac diameter within a week or two, particularly if no pulmonary decrease in the transverse cardiac diameter within a week or two, particularly if no pulmonary oedema occurs, is virtually diagnostic of the condition. Pericardial effusion should also be oedema occurs, is virtually diagnostic of the condition. Pericardial effusion should also be considered when the heart is greatly enlarged and there are no features to suggest specific considered when the heart is greatly enlarged and there are no features to suggest specific chamber enlargementchamber enlargement . . Pericardial calcification Pericardial calcification is seen in up to 50 % of patients with is seen in up to 50 % of patients with constrictive pericarditis. Calcific constrictive pericarditis is usually postinfective in aetiology, constrictive pericarditis. Calcific constrictive pericarditis is usually postinfective in aetiology, tuberculosis and Coxsackie infections being the common known causes. In many cases no tuberculosis and Coxsackie infections being the common known causes. In many cases no infecting agent can be identified. The calcification occurs patchily in the pericardium, even infecting agent can be identified. The calcification occurs patchily in the pericardium, even though the pericardium is thickened and rigid all over the heart. It may be difficult or even though the pericardium is thickened and rigid all over the heart. It may be difficult or even impossible to see the calcification on the frontal view. On the lateral film, it is usually maximal impossible to see the calcification on the frontal view. On the lateral film, it is usually maximal along the anterior and inferior pericardial borders. Widespread pericardial calcification is an along the anterior and inferior pericardial borders. Widespread pericardial calcification is an important sign, because it makes the diagnosis of constrictive pericarditis certain.important sign, because it makes the diagnosis of constrictive pericarditis certain.

Pericardial Diseases•20 – 50 ml of pericardial fluid is diagnosed by echo.

•Needle aspiration is needed to insure the nature of the fluid.

•CT scan & MRI can show the pericardial effusion; but more important is to measure the thickness of the pericardium where thickness of the pericardium where echo. is poor.

*Unusual to diagnose pericardial effusion by plain-X-ray because the patient may have pericardial effusion to cause a life-threatening tamponade; but only mild heart enlargement with otherwise normal contour.

•Marked increase or decrease in the transverse diameter of the cardiac shadow within on or two weeks + No pulmonary edema is virtually diagnostic of pericardial effusion.

•Marked increase in the cardiac size + no specific chamber + normal pulmonary vasculature (flask shape) (& the outline of the heart become very sharp) is diagnostic of pericardial effusion.

•Pericardial calcification is seen in 50% of patient within constrictive pericarditis, which is usually due to TB or Coxsackie's virus infection.

•Best seen on lateral CXR, along the anterior & inferior surface, because it may possible on frontal CXR.

*Usually the calcification is an important sign for constrictive pericarditis.

Pericardial Effusion

Pericardial Effusion due to Viral Pericarditis

Pericardial Effusion

Congestive Cardiomyopathy, this appearance usually confused with Pericardial Effusion

Pericardial effusion. The heart is greatly enlarged. (Three weeks before, the heart had been normal in shape and size.) The outline is well defined and the shape globular. The lungs are normal. The cause in this case was a viral pericarditis. This appearance of the heart, though highly suggestive of, is not specific to pericardial effusion. (Compare with (b).) (b) Congestive cardiomyopathy causing generalized cardiac dilatation. This appearance can easily be confused radiologically with a pericardial effusion.

Pericardial calcification in a patient with severe constrictive pericarditis. The distribution of the calcification is typical. It follows the contour of the heart and is maximal anteriorly and inferiorly. As always, it is more difficult to see the calcification on the PA film. (This patient also had pneumonia in the right lower lobe.)

A

B

Pericardial Effusion

Large Pericardial Effusion on an apical 4-chamber view echocardiogram

Large pericardial effusion on an apical four-chamber view echocardiogram. (b). CT scan showing fluid density (arrows) in pericardium. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

CT-scan shows fluid density (arrows) in the Pericardium

Pericardial Effusion

Pericardial Calcifications

Pericardial Calcification in a patient with Severe Constrictive Pericarditis

Pericardial Calcifications

Pericardial Calcification in a patient with Severe Constrictive Pericarditis

Pulmonary vesselsPulmonary vessels The plain chest film provides a simple method of assessing the pulmonary The plain chest film provides a simple method of assessing the pulmonary

vasculature. Even though it is not possible to measure the true diameter of vasculature. Even though it is not possible to measure the true diameter of the main pulmonary artery on plain film, there are degrees of bulging that the main pulmonary artery on plain film, there are degrees of bulging that permit one to say that it is indeed enlarged. Conversely, the pulmonary permit one to say that it is indeed enlarged. Conversely, the pulmonary artery may be recognizably small. The assessment of the hilar vessels can artery may be recognizably small. The assessment of the hilar vessels can be more objective since the diameter of the right lower lobe artery can be be more objective since the diameter of the right lower lobe artery can be measured: the diameter at its midpoint is normally between 9 and 16 mm. measured: the diameter at its midpoint is normally between 9 and 16 mm. The size of the vessels within the lungs reflects pulmonary blood flow.The size of the vessels within the lungs reflects pulmonary blood flow. There are no generally accepted measurements of normality, so the There are no generally accepted measurements of normality, so the diagnosis is based on experience with normal films. By observing the size diagnosis is based on experience with normal films. By observing the size of these various vessels it may be possible to diagnose one of the following of these various vessels it may be possible to diagnose one of the following haemodynamic patterns. haemodynamic patterns.

Increased pulmonary blood flow:Increased pulmonary blood flow: Atrial septal defect, ventricular septal Atrial septal defect, ventricular septal defect and patent ductus arteriosus are the common anomalies in which defect and patent ductus arteriosus are the common anomalies in which there is shunting of blood from the systemic to the pulmonary circuits (so-there is shunting of blood from the systemic to the pulmonary circuits (so-called left to right shunts), thereby increasing pulmonary blood flow. The called left to right shunts), thereby increasing pulmonary blood flow. The severity of the shunt varies greatly. In patients with a haemodynamically severity of the shunt varies greatly. In patients with a haemodynamically significant left to right shunt (2:1 or more), all the vessels from the main significant left to right shunt (2:1 or more), all the vessels from the main pulmonary artery to the periphery of the lungs are large. This radiographic pulmonary artery to the periphery of the lungs are large. This radiographic appearance is sometimes called appearance is sometimes called pulmonary plethora. pulmonary plethora. There is reasonably There is reasonably good correlation between the size of the vessels on the chest film and the good correlation between the size of the vessels on the chest film and the degree of shunting.degree of shunting.

Pulmonary Vessels

*It is not possible to measure the diameter of the MPA from the plain film (usually subjective); but if there are variable

degrees of bulging, means enlarged MPA.

*Assessment of the hilar pulmonary arteries is more objective & the diameter of the Rt. lower lobe artery at its

mid-point (normally 9 – 16 mm).

*The size of pulmonary vessels with the lung reflects the pulmonary blood flow.

*Increase pulmonary blood flow is seen in ASD, VSD& , PDA, & all of these will lead to Systemic to Pulmonary (Lt.

to Rt. shunt) & these will to increase pulmonary blood flow.

Pulmonary Vessels *Hemodynamically significant Lt. to Rt. shunt is (2/1 ratio

or more) & this will produce CXR findings; if less ratio there will be no CXR findings & all the pulmonary vessels

will (from the MPA to the periphery of the lung) will be enlarged, & this is called "Pulmonary Plethora."

*There is good correlation between the size of the vessel on CXR & degree of the shunt.

*Decrease pulmonary blood flow, all the vessels are small

" Pulmonary Oligemia."

*The commonest cause of decrease pulmonary blood flow is TOF & pulmonary stenosis.

*Obstruction of the Rt. ventricle outflow + VSD will lead to Rt. to Lt. shunt.

*Pulmonary stenosis will cause oligemia only is severe cases & babies or very young children.

Decreased pulmonary blood flow: Decreased pulmonary blood flow: To be recognizable radiologically, the reduction in To be recognizable radiologically, the reduction in pulmonary blood flow must be substantial. The pulmonary vessels are all small, an pulmonary blood flow must be substantial. The pulmonary vessels are all small, an appearance known as appearance known as pulmonary oligaemia. pulmonary oligaemia. The commonest cause is the tetralogy of Fallot, The commonest cause is the tetralogy of Fallot, where there is obstruction to the right ventricular outflow and a ventricular septal defect where there is obstruction to the right ventricular outflow and a ventricular septal defect which allows right to left shunting of the blood. Pulmonary valve stenosis only causes which allows right to left shunting of the blood. Pulmonary valve stenosis only causes oligaemia in extremely severe cases in babies and very young children.oligaemia in extremely severe cases in babies and very young children.

Pulmonary arterial hypertension: Pulmonary arterial hypertension: The pressure in the pulmonary artery is dependent on The pressure in the pulmonary artery is dependent on cardiac output and pulmonary vascular resistance. The con ditions that cause cardiac output and pulmonary vascular resistance. The con ditions that cause significant pulmonary arterial hypertension all increase the resistance of blood flow significant pulmonary arterial hypertension all increase the resistance of blood flow through the lungs. There are many such conditions including:through the lungs. There are many such conditions including:

various lung diseases (cor pulmonale);various lung diseases (cor pulmonale); pulmonary emboli;pulmonary emboli; pulmonary arterial narrowing in response to mitral valve disease or left to right shunts;pulmonary arterial narrowing in response to mitral valve disease or left to right shunts; idiopathic pulmonary hypertension.idiopathic pulmonary hypertension. Pulmonary arterial hypertension has to be severe before it can be diagnosed on plain Pulmonary arterial hypertension has to be severe before it can be diagnosed on plain

films and it is difficult to quantify in most cases. The plain chest film features are films and it is difficult to quantify in most cases. The plain chest film features are enlargement of the pulmonary artery and hilar arteries, the vessels within the lung enlargement of the pulmonary artery and hilar arteries, the vessels within the lung being normal or small. When the pulmonary hypertension is part of Eisenmenger's being normal or small. When the pulmonary hypertension is part of Eisenmenger's syndrome (greatly raised pulmonary arterial resistance in association with atrial septal syndrome (greatly raised pulmonary arterial resistance in association with atrial septal defect, ventricular septal defect or patentdefect, ventricular septal defect or patent ductus arteriosus, leading to reversal of the ductus arteriosus, leading to reversal of the shunt so that it becomes right to left), the vessels within the lungs may also be large, but shunt so that it becomes right to left), the vessels within the lungs may also be large, but there is still disproportionate enlargement of the central vessels.The reason for there is still disproportionate enlargement of the central vessels.The reason for pulmonary arterial hypertension may be visible on the chest film; in cor pulmonale the pulmonary arterial hypertension may be visible on the chest film; in cor pulmonale the lung disease is often radiologically obvious, and in mitral valve disease and other.lung disease is often radiologically obvious, and in mitral valve disease and other.

Pulmonary Arterial Hypertension

*The pressure in the pulmonary artery depends on:

1 -Cardiac output.

2 -Pulmonary vascular resistance.

*Conditions that cause significant pulmonary arterial hypertension all increase the resistance of blood flow

through the lungs, examples:

1 -Various lung diseases (cor pulmonale). 2 -Pulmonary embolism.

3 -Pulmonary arterial narrowing in response to mitral valve diseases or Lt. to Rt. shunt.

4 -Idiopathic pulmonary hypertension.

Pulmonary Arterial Hypertension

*By CXR: There will be enlargement of the mean pulmonary artery + the hilar pulmonary artery, vessels within the lung tissue are normal or small.

*Eisenmenger's syndrome:

Greatly raised pulmonary artery resistance in associationwith ASD, VSD, & PDA leading to reverse shunt (i.e. : Rt. to Lt. shunt).

Pulmonary Arterial Hypertension

*The cause of pulmonary arterial hypertension may be visible on the CXR as cor pulmonale & mitral valve

diseases.

Pulmonary Arterial Hypertension due to ASD & Eisenmenger's

syndrome

Pulmonary Venous Hypertension

*The commonest causes of pulmonary venous hypertension are:

1 -Mitral valve diseases. 2 -Lt. ventricular failure.

*In normal upright person (by CXR) the lower zone vessels

are larger than the upper zone.

*In pulmonary venous hypertension the upper zone vessels are enlarged.

*In severe cases, the upper zone vessels become larger

than that of the lower zone, & eventually Pulmonary Edema will supervene & may obscure the blood vessels.

Pulmonary Venous Hypertension

Pulmonary Venous Hypertension in a patient with Mitral Valve

Disease

Pulmonary oedemaPulmonary oedema: The common cardiac conditions causing pulmonary oedema are left : The common cardiac conditions causing pulmonary oedema are left ventricular failure and mitral stenosis. Cardiogenic pulmonary oedema occurs when the pulmonary ventricular failure and mitral stenosis. Cardiogenic pulmonary oedema occurs when the pulmonary venous pressure rises above 24-25 mmHg (the osmoticvenous pressure rises above 24-25 mmHg (the osmotic pressure of plasma). Initially, the oedema is pressure of plasma). Initially, the oedema is

confined to the interstitial tissues of the lung, but if it becomes more severe fluid will also collect in the confined to the interstitial tissues of the lung, but if it becomes more severe fluid will also collect in the alveoli. Both interstitial and alveolar pulmonary oedema are recognizable on plain chest films.alveoli. Both interstitial and alveolar pulmonary oedema are recognizable on plain chest films.

Interstitial oedema: Interstitial oedema: There are many septa in the lungs There are many septa in the lungs which are invisible on the normal chest film because which are invisible on the normal chest film because they consist of little more than a sheet of connective they consist of little more than a sheet of connective tissue containing very small blood and lymph vessels. tissue containing very small blood and lymph vessels. When thickened by oedema, the peripherally located When thickened by oedema, the peripherally located septa may be seen as line shadows. These lines, septa may be seen as line shadows. These lines, known as Kerley known as Kerley В В lines, named after the radiologist lines, named after the radiologist who first described them, are horizontal lines never who first described them, are horizontal lines never more than 2 cm long seen laterally in the lower zones. more than 2 cm long seen laterally in the lower zones. They reach the lung edge and are therefore readily They reach the lung edge and are therefore readily distinguished from blood vessels, which never extend distinguished from blood vessels, which never extend into the outer centimetre of the lung. Other septa into the outer centimetre of the lung. Other septa radiate towards the hila in the mid and upper zones radiate towards the hila in the mid and upper zones (Kerley A lines). These are much thinner than the (Kerley A lines). These are much thinner than the adjacent blood vessels and are 3-1 cm in length. adjacent blood vessels and are 3-1 cm in length. Another sign of interstitial oedema is that the outline Another sign of interstitial oedema is that the outline of the blood vessels may become indistinct owing to of the blood vessels may become indistinct owing to oedema collecting around them. This loss of clarity is oedema collecting around them. This loss of clarity is a difficult sign to evaluate and it may only be a difficult sign to evaluate and it may only be recognized by looking at follow-up films after the recognized by looking at follow-up films after the oedema has cleared. Fissures may appear thickened oedema has cleared. Fissures may appear thickened because oedema may collect against them.because oedema may collect against them.

Alveolar oedema: Alveolar oedema: Alveolar Alveolar oedema is a more severe oedema is a more severe form of oedema in which form of oedema in which the fluid collects in the the fluid collects in the alveoli. It is almost always alveoli. It is almost always bilateral, involving all the bilateral, involving all the lobes. The pulmonary lobes. The pulmonary shadowing is usually shadowing is usually maximal close to the hila maximal close to the hila and fades out peripherally and fades out peripherally leaving a relatively clear leaving a relatively clear zone that may contain zone that may contain septal lines, around the septal lines, around the edge of the lobes. This edge of the lobes. This pattern of oedema is pattern of oedema is sometimes referred to as sometimes referred to as the 'butterfly' or 'bat's the 'butterfly' or 'bat's wing' pattern.wing' pattern.

Septal lines in interstitial pulmonary oedema, (a) Left upper zone showing the septal lines Septal lines in interstitial pulmonary oedema, (a) Left upper zone showing the septal lines known as Kerley A lines (arrowed) in a patient with acute left ventricular failure following a known as Kerley A lines (arrowed) in a patient with acute left ventricular failure following a

myocardial infarction. Note that these lines are narrower and sharper than the adjacent myocardial infarction. Note that these lines are narrower and sharper than the adjacent blood vessels, (b) Right costophrenic angle showing the septal lines known as Kerley blood vessels, (b) Right costophrenic angle showing the septal lines known as Kerley В В lines in lines in a patient with mitral stenosis. Note that these oedematous septa are horizontal non-branching a patient with mitral stenosis. Note that these oedematous septa are horizontal non-branching

lines which reach the pleura. One such line is arrowed.lines which reach the pleura. One such line is arrowed.

B

Bat-Wing Appearance Alveolar oedema in a patient with acute left ventricular failure Alveolar oedema in a patient with acute left ventricular failure

following a myocardial infarction. The oedema fluid is concentrated in the more central portion following a myocardial infarction. The oedema fluid is concentrated in the more central portion of the lungs leaving a relatively clear zone peripherally. Note that all the lobes are fairly equally of the lungs leaving a relatively clear zone peripherally. Note that all the lobes are fairly equally involved.involved.

AortaAorta With increasing age the aorta elongates. Elongation necessarily involves unfolding, With increasing age the aorta elongates. Elongation necessarily involves unfolding,

because the aorta is fixed at the aortic valve and at the diaphragm. This unfolding because the aorta is fixed at the aortic valve and at the diaphragm. This unfolding results in the ascending aorta deviating to the right and the descending aorta to the left. results in the ascending aorta deviating to the right and the descending aorta to the left. Aortic unfolding can easily be confused with aortic dilatation.Aortic unfolding can easily be confused with aortic dilatation.

True dilatation of the ascending aorta may be due to aneurysm formation or secondary True dilatation of the ascending aorta may be due to aneurysm formation or secondary to aortic regurgitation,to aortic regurgitation, aortic stenosis or systemic hypertension.aortic stenosis or systemic hypertension.

The two common causes of The two common causes of aneurysm aneurysm of the descending aorta are atheroma and aortic of the descending aorta are atheroma and aortic dissection. A rarer cause is previous trauma, usually following a severe deceleration dissection. A rarer cause is previous trauma, usually following a severe deceleration injury. The diagnosis of aortic aneurysm may be obvious on plain film but substantial injury. The diagnosis of aortic aneurysm may be obvious on plain film but substantial dilatation is needed before a bulge of the right mediastinal border can be recognized. dilatation is needed before a bulge of the right mediastinal border can be recognized. Atheromatous aneurysms invariably show calcification in their walls and this Atheromatous aneurysms invariably show calcification in their walls and this calcification is usually recognizable on plain film. Computed tomography with calcification is usually recognizable on plain film. Computed tomography with intravenous contrast enhancement is very useful when aortic aneurysms are assessed. It intravenous contrast enhancement is very useful when aortic aneurysms are assessed. It is important to know the extent of aortic dissections as those involving the ascending is important to know the extent of aortic dissections as those involving the ascending aorta are treated surgically while those confined to the descending aorta are usually aorta are treated surgically while those confined to the descending aorta are usually treated conservatively with hypotensive drugs. Standard echocardiography shows treated conservatively with hypotensive drugs. Standard echocardiography shows dissection of the aortic root but transoesophageal echocardiography showsdissection of the aortic root but transoesophageal echocardiography shows dissections dissections distal to the aortic root and in the descending aorta as well. Dissecting aneurysms can distal to the aortic root and in the descending aorta as well. Dissecting aneurysms can also be shown with CT and MRI and these non-invasive techniques have largely also be shown with CT and MRI and these non-invasive techniques have largely replaced aortography, which is only performed in selected cases.replaced aortography, which is only performed in selected cases.

Two Two congenital anomalies congenital anomalies of the aorta may be visible on plain films of the chest: of the aorta may be visible on plain films of the chest: coarctation and right-sided aortic arch, a condition that is sometimes seen in association coarctation and right-sided aortic arch, a condition that is sometimes seen in association with intracardiac malformations, notably tetralogy of Fallot, pulmonary atresia and with intracardiac malformations, notably tetralogy of Fallot, pulmonary atresia and truncus arteriosus. It can also be an isolated and clinically insignificant abnormality. In truncus arteriosus. It can also be an isolated and clinically insignificant abnormality. In right aortic arch, the soft tissue shadow of the arch is seen to the right, instead of to the right aortic arch, the soft tissue shadow of the arch is seen to the right, instead of to the left, of the lower trachea.left, of the lower trachea.

Aortic dissection, (a) Transoesophageal echocardiogram Aortic dissection, (a) Transoesophageal echocardiogram showing the true (T) and false (F) lumina in the showing the true (T) and false (F) lumina in the

descending aorta. CT scan showing the displaced intima descending aorta. CT scan showing the displaced intima (arrows) separating the true and false lumina in the (arrows) separating the true and false lumina in the

ascending and descending aorta. MRI scan showing the ascending and descending aorta. MRI scan showing the displaced intima in the ascending and descending aorta displaced intima in the ascending and descending aorta (arrows). AAo, ascending aorta; DAo, descending aorta; (arrows). AAo, ascending aorta; DAo, descending aorta;

PA, pulmonary artery.PA, pulmonary artery.

•16 row MSCT : Sensitivity 92-95%

• Specificity 86-93%

• positive predictive value 79-80 %

• negative predictive value 97 %

* K Nieman,Lancet ,2001

Attention: MSCT is exellent method in excluding coronary artery disease in patients with non-specyfic chest pain.(Ch.Becker)

MSCT vs. references method of conventional MSCT vs. references method of conventional angiography*angiography*

MSCT – EVALUATION OF STEMSCT – EVALUATION OF STENNTSTS

Visualization and availability stents for analysis - Visualization and availability stents for analysis - 50-77%50-77%

Patency stentsPatency stents

- sensitivity 75% - sensitivity 75%

- specificity 96 %- specificity 96 % Occluded stentsOccluded stents

sensitivity 98-100%sensitivity 98-100%

Schuijf JP, Am J Cardiol 2004,94(4),427

MSCT – evaluation of aorto-MSCT – evaluation of aorto-coronary by-passescoronary by-passes

Closed aorto-coronary graft Closed aorto-coronary graft

- specificity 97%, - specificity 97%,

- sensitivity 98%- sensitivity 98%

NarrowingNarrowing

- specificity 75% - specificity 75%

- sensitivity 92%- sensitivity 92%

After 3 years from 20-to 30% by-passes are occludedAfter 3 years from 20-to 30% by-passes are occluded

Silber S iwsp. Herz 2003, 2;126-35

NONINVASIVE ANGIOGRAPHY OF CORONARY NONINVASIVE ANGIOGRAPHY OF CORONARY ARTERIESARTERIES

Evaluation of coronary anatomy, morphology and anomalies of the Evaluation of coronary anatomy, morphology and anomalies of the origin, calcium scoring (CS). origin, calcium scoring (CS).

Identification of soft and calcification plaques and their Identification of soft and calcification plaques and their

- location- location

- range- range

- length- length

Assessment of myocardial function Assessment of myocardial function Thickness and wall motionThickness and wall motion Hemodynamic paramters Hemodynamic paramters Myocardial perfusionMyocardial perfusion

Coronary Artery Disease Diagnostic possibilities of MSCT

MSCT – coronary calcium score – the MSCT – coronary calcium score – the relationship to coronary artery relationship to coronary artery

disease.disease.

Studies using serial MSCT scans indicate that the Studies using serial MSCT scans indicate that the annual progression of coronary calcium varies annual progression of coronary calcium varies between between 30% to 50%30% to 50% in symptomatic or in symptomatic or asymptomatic nontreated high –risk individuals. asymptomatic nontreated high –risk individuals.

In patients treated effectively with lipid-lowering In patients treated effectively with lipid-lowering medication the progression of coronary calcium score medication the progression of coronary calcium score varies between varies between 0-20%.0-20%.

Schmermund A i wsp. Cardiol Clin 2003,21(4)

Coronary Calcium Scores according to Coronary Calcium Scores according to Varying Age and Sex (ECTB) Varying Age and Sex (ECTB)

(10377 asymptomatic pts)(10377 asymptomatic pts)

Shaw LI i wsp. , Radiology 2003;228,826

During a mean follow-up of 5 years , the death was - 2,4%Risk-adjusted relative risk values of coronary calcium were: 11-100 1,64

101-400 1,74 401-1000 2,54 > 1000 4,03

as comapred with score of 10 or less (p<0,001 for all values)

64 MSCT – STENTS AND BY-PASS64 MSCT – STENTS AND BY-PASS

Occluded by-pass for CX, implanted 3 stents in CX, all patency