The Radiological Diagnostics of the Cardiovascular System

Dr. Lenchuk Tatyana, PhD

The methods of the cardiovascular system examination1. Fluoroscopy2. Roentgenography

These methods are performed in following positions:

- direct;- first oblique (rigth);- second oblique (left);- left lateral

3. Fluorography.4. Tomography.

5. Angiography of the peripheral vessels (arterio-, phlebo-, lymphography).

6. Angiocardiography.7. Computed tomography.8. Ultrasonography.9. Magnetic resonance imaging.

ULTRASOUND

ULTRASOUND

VCS

RPA LPA

PAAA

DA

RV

RA AA LV

LA

DA

Algorithm of the heart examination1. The evaluation of the thorax (its shape, ribs

location, distance between the ribs).2. The evaluation of the level and mobility of the

domes of diaphragm, sinuses (phreno-costal, phreno-cardiac).

3. The evaluation of the pulmonary vasculature (the symptoms of the arterial, venous hypertension, width and structure of the radices of the lungs).

4. The evaluation of the shape and position of the cardiovascular shadow, heart size and its chambers.

5. The evaluation of the cardiac and vascular function (amplitude, pulsation, rhythm, synchronism of the pulsation of the cardiac chambers, tonus of the miocardium).

Test Valsalva

The arcs of the heart in 3 positions

A. In direct anterior position the left contour is made by 4 arcs, which corresponds to the chambers and vessels.

- The first arc – arc of aorta, which is visible after 3 years old. Oftenly in that area thymus is visualized.

- The second arc – pulmonary trunc and the beginning of the left pulmonary artery.

- The third arc is made by the auricle of the left atrium and is clearly visible in case of its dilatation.

- The fourth arc – left ventricle.

The second and third arcs makes the weist of the heart.

The right contour is made by two arcs:

- The first arc - vena cava superior or ascending aorta;

- The second arc – contour of the right atrium.

The angle between these arcs is called atriovasal.

Б. Right (first) anterior oblique position.

There are anterior (retrosternal) and posterior (retrocardial) contour of the cardiac shadow. On anterior contour there are 3 arcs: ascending aorta, pulmonary trunk and left ventricle.

Posterior contour: aorta, left and right atriums.

B. Left (second) anterior oblique position.

In retrosternal area there are 3 arcs: ascending aorta, right atrium and right ventricle.

In retrocardial area – aorta, left atrium and left ventricle.

In this position ascending aorta, arc of aorta, descending aorta and left atrium are making aortic window, which normally has to be transparent.

The main radiological symptoms of the cardiovascular diseases

І. The syndrome of mitral shape of the heart with its asymmetric enlargement.

а) mitral shape with enlargment of its one chamber – right ventricle:

- in case of the pulmonary diseases and pulmonary artery disorders with the pulmonary hypertension;

- opened Botallo's duct (ductus arteriosus).

б) mitral shape with enlargment of its two chambers – right ventricle and left atrium:

- in case of mitral stenosis.

в) mitral shape with enlargment of its three chambers – right ventricle, left atrium and left ventricle:

- in case of mitral valve insufficiency;- combined mitral valvular

pathology;- mitral and aortic valvular

pathology with the domination of mitral.

Radiological symptoms of the mitral shape of the heart in

direct position1. The enlargement of the 2 and 3rd arcs (waist of the heart) on the left contour.2. the angle between these arcs is decreased.3. Dislocation of the right atriovasal angle upwards. 4. Inconstantly – enlargement of the 4th arc in the left.

ІІ. The syndrome of the aortic shape of the heart.

а) aortic shape of the heart with the enlargement of the left ventricle:

- miocardial diseases (primarily miocarditis);

- miocardial infarction.

б) aortic shape of the heart with the enlargement of left ventricle and aorta dilatation:

- arterial hypertension;- aortic valve insufficiency;- aortic stenosis;- combined aortic disease;- aortic and mitral valvular disease with

the domination of aortic.в) aortic shape of the heart with the

dilatation and elongation of aorta:- atherosclerosis of aorta.

Radiological symptoms of the aortic shape of the heart in direct

position

А) obligatory:1. deep incisura between 1st and

4th arc in the left.2. Clear waist of the heart.3. Elongation of the 4th arc in the

left.

B) optional:

1. Enlargement of the first arc in right side in case of the dilatation of the ascending aorta.

2. Enlargement of the first arc in left side in case of the dilatation of the arc of aorta;

3. Dislocation of the right atriovasal angle downwards.

ІІІ. The syndrome of the trapezoidal and round shapes of the heart.

- diffuse miocardial diseases;

- pericardial effusions.

The radiological symptoms of the trapezoidal and round

shapes of the heart

1. The transverse diameter is larger than longitudinal;

2. The phreno-cardiac angles are blunt (miocarditis) or acute (exudative pericarditis);

3. The cardiac contractions are weak, but visible (miocarditis) or not visible (exudative pericarditis);

4. The arcs of heart are smoothed (miocarditis) or not visible (exudative pericarditis);

5. Cardiac shadow is changed with the change of the body position (exudative pericarditis).

IV. The syndrome of the limited vascular dilatation:

- atherosclerosis;- syphilis;- aneurism.

V. The syndrome of the limited vascular narrowing:

- coarctation of aorta;- aortic stenosis;- isolated stenosis of the

pulmonary artery;- obliterative endarteriitis;- obliterative atherosclerosis.

Methods of research of coronary vessels

Invasive:*Coronary angiography - the "gold standard"*Intravascular ultrasound

Not invasive:Stress ECGStress EchoScintigraphy,Perfusion MRIMSCT of the heartwith a quantitative evaluationthe degree of calcificationcoronary arteries andnon-invasivecoronary angiography

Indications for MSCT of the heart

- patients with symptomatic coronary artery disease ;

- no symptoms of coronary artery disease but with risk factors for coronary heart

disease for evaluation of the coronary vessels (with hypercholesterolemia , diabetes ,

hypertension , smoking) ;

- after stenting / bypass surgery to avoid restenosis in the stented segments;

- in the early post-MI to determine the location and area of myocardial damage , to

detect thrombotic masses in the chambers of the heart

- Post-MI to study the functional parameters of the left ventricle

MSCT: Methods «Smart Score»

Technique of MSCT coronary angiography

AcquisitionAcquisition

MSCT coronary angiography

Left Coronary Arteries

З-D реконструкция Поперечные КТ-срезы

Right Coronary Arteries

З-D реконструкция Поперечные КТ-срезы

Cardiac Veins

3-D reconstruction Transverse CT slices

Cardiac Arteries

MSCT imaging of the coronary arteries

MIP - Maximum Intensity Projection, VR-Volume Rendered image

A - with plaque and stenosis of the LAD about 50%;B - with calcification and soft tissue plaques, total stenosis of LAD and RCA.

a б

MSCT - coronary angiography, 3-D images:A-when coronary arteries are not changed;B-with signs of local calcification of left coronary artery;C-with signs of diffuse calcification of the left coronary artery of its branches.

а

b

c

COMPARISON OF DATA MSCT coronary angiography WITH DATA ICG

not changedcoronary arteries

COMPARISON OF DATA MSCT coronary angiographyWITH DATA ICG

A subtotal stenosis of LAD and the first diagonal artery due to soft tissue component

Classification:

differentiation type of atherosclerotic plaque

accordingMSCT coronary

angiography

A) + AA): calcified nodule; B) + BB): calcified plaque; C) +CC): soft plaque; D) + DD): mixed plaque.

Дифференциация атеросклеротической бляшки

Type VI atherosclerotic lesion with extensive lipid accumulation (Lc = lipid core) and small intra-plaque hemorrhage (Hb) within the atherosclerotic widened intima (I) and media (M) cell layer. (А) Corresponding multidetector-row CT (MDCT) image shows a soft tissue lesion with a mean density of 40 HU. (B) In contrast to lipid-rich plaques, purely fibrous (F) plaque (Type Vc) without calcium demonstrate significantly higher attenuation (90 HU) on MDCT. (C) “Calcified nodules” or “spotty” lesions contain little pieces of calcium (Ca) that was removed in the process of preparing the slides. On MDCT the calcification can be easily detected and partly covers the adjacent fibrous soft tissue (110 HU).

calcified plaque

Data analysis MSCT coronary angiography after interventional procedures (stenting)

MSCT myocardial infarctionAcute MI After 5 mon.

CardIQ Function

The advantages of MSCT coronary angiography:

- High information;- Less radiation and contrast load than the ICG; -Does not require hospitalization; -Lack of endovascular interventions ; -Psychologically easier tolerated.

Disadvantages of MSCT coronary angiography:

-For CT angiography requires multidetector CT devices with cardioversion;

-Long processing time and the large amount of data (from 1500- 2000tys. slices;

- Difficulties timber heating CT data in patients with heart rhythm disturbances (arrhythmias ,

tachycardia);

Congenital cardiac diseasesRadiologically there are three groups

of the diseases:1 group – diseases with the arterial

shunt into the venous blood stream at the level of the heart or main vessels; in this case the volume of the blood in small circulation is increasing. Defect of the interatrial septum and interventricular septum, opened arterial duct, aortopulmonary fistula.

2 group - diseases with the venous shunt into the arterial blood stream (Fallot's tetrad, transposition of the main vessels without the stenosis of the pulmonary artery).

3 group – diseases without the shunt, with normal small circulation haemodynamics, but with the barrier of the blood flow. Isolated pulmonary stenosis, aortic coarctation, valvular stenosis of aorta.