1.Diagnostic Radiology of Cardiovascular System Chen, Shaoqiong Acknowledgement : most of the slices are refer to the ppt provided by Dr. Biling Liang is gratefully acknowledged.

2. Diagnostic Radiology of Cardiovascular System /231 Imaging methods normal appearances abnormities diseases methods normal abnormities diseases 3. Cadiovascular Anatomy 4. heart 5.

CTA

6. CTA 7. Methods

X-ray

• Fluoroscopy

• Plain radiography?

Angiocardiography & DSA

CT & CTA

MRI & MRA

Echocardiography (US)

Nuclear medicine

8. X-ray---- PA view ----high KV, 2M /231 X-ray methods normal abnormities diseases 9. X-ray---- Lat view /231

left lateral

X-ray methods normal abnormities diseases 10. Observing the chest plain film

The size, shape, and position of theheart

The state of the lungs and pulmonary vessels

Aorta and cardiac calcifications

methods normal abnormities diseases 11. Normalappearance

right ventricle, atrium : front

left ventricle,atrium : behind

/231

Location of the heart

• 2 / 3 on the left side of midline 1/ 3 on the right side

• apex of heart point to left bottom oblique axis

methods normal abnormities diseases 12. Normalappearance----PA View

Composition

• Right border of heart

• • aorta old superior vena cava youth

• • right atrium

• Left border of heart

• • aortic bulb aortic arch

• • pulmonary artery segment cardiac waist main pulmonary artery

• • left ventricle

/231 Upper 1/2 Lower 1/2 midline methods normal abnormities diseases 70 20 13.

Aorta archbelow the clavicle, 2.01.0cm

aorta arch wider and higher eldly, high BP

no aorta knob -- right aorta arch variation

aorticopulmonary window small indentation of the lung into the mediastinum, betweenthe arch and left PA

14. PA view /231 Left atrium PV PA methods normal abnormities diseases 15. Normalappearance---- Lat. view

Composition:

• Anterior border of heart

• • Ascending aorta

• • The infundibular of the right ventricle, pulmonary trunk

• • Anterior border of right ventricle

• Posterior border of heart

• • Left atrium

• • Left ventricle

/231 The normal R. atrium is not border-forming in this projection methods normal abnormities diseases 16. Normalappearance ---- Lat. view /231

• Retrocardiac

• esophageal space

Retrosternal space the anterior heart bordertouchthe1/3 of the distance between the diaphagm and the suprasternal notchRV CT CT X-ray methods normal abnormities diseases 17. Normalappearance ---- Lat. view /231

normal L. atrium dont displace the esophagus

Barium-filled esophagus methods normal abnormities diseases 18. Size of the heart and great vessels /231

• Normal C / T 0.5

• Slightly enlarged 0.51- 0.55

• Moderately enlarged 0.56- 0.60

• Massively enlarged 0.60

methods normal abnormities diseases 19. Size of the heart and great vessels /231 a b C/T ratio = a+b / T =0.5 T methods normal abnormities diseases 20. Influencing factor ofthe normal heart shadow

Body type oblique , transverse , vertical

Age with age grows globular oblique horizontal

Respiration

• inspiration dropping heart, normal heart shadow

• expiration heart shadow horizontal

Patient position

• erect position heart shadow elongated

• lying position heart shadow enlargement

/231 methods normal abnormities diseases 21. Influencing factor ofnormal heart shadow --- body type

horizontal heart

oblique heart

dropping heart

/231 classification horizontal heartoblique heart dropping heart C/T R 0.50.5< 0.5 included angle of cardiac longitudinal 45 045 0 45 0 axis and horizontal Heart longest axis methods normal abnormities diseases 22. normal heart shadow /231 45 oblique heart horizontal heart dropping heart 38 52 methods normal abnormities diseases 23. Influencing factor ofnormal heart shadow--respiration

inspirationexpiration

/231 methods normal abnormities diseases 24. Influencing factor ofnormal heart shadow--position

erect positionsupine position

/231 methods normal abnormities diseases 25. Basic X-ray features

Heart dislocation

Heart enlargement

Abnormal pulmonary blood flow

Changes of aorta

Pericardial anomalies

/231 methods normal abnormities diseases 26. Basic X-ray features ---Heart dislocation

Mirror image dextrocardias

/231 methods normal abnormities diseases 27. Basic X-ray features Heart dislocation /231 dextrocardia methods normal abnormities diseases 28. /231 mirror image dextrocardias Basic X-ray features Heart dislocation methods normal abnormities diseases 29. Basic X-ray features

Heart dislocation

Heart enlargement

Abnormal pulmonary blood flow

Changes of aorta

Pericardial abnormal

/231 methods normal abnormities diseases 30.

Enlargement of the heart chambers

• Left ventricular enlargement

• Right ventricular enlargement

• Left atrium enlargement

• Right atrium enlargement

• General cardiac enlargement

/231 Basic X-ray features Heart enlargement methods normal abnormities diseases 31. Left ventricular enlargement

X-ray appearance ;

• cardiac apex extending to left and down

• the point of opposite pulsation move down

• left ventricle segment extended,rounded,expand to left

• the aorta is prominent

• Lat retrocardiac space become narrowed or disappeared, esophageal space disappeaeredCommon disease

• high blood pressure

• aortic incompetence stenosis

• mitral incompetence

• congenital heart disease PDA

/231 methods normal abnormities diseases 32. Left ventricular enlargement /231 methods normal abnormities diseases 33. If we draw a tangent line from the apex of the left ventricle to the aortic knob(red line)and measure along a perpendicular to that tangent line(yellow line) The distance between the tangent and the main pulmonary artery(between two small green arrows)falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away from the tangent line 34. 0 mm Main Pulmonary Artery Ao 15 mm Main Pulmonary Artery Ao LV LV Main pulmonaryartery ranges from0 mm15mmfrom tangent line 35. Right ventricular enlargement

X-ray appearance

• MPA prominent

• Lat contact between the front surface of heart and the sternum (anterior chest wall) >1/3 (narrow of the retrosternal space)

Common disease

• Mitral valve stenosis

• Chronic pulmonary heart disease

• Pulmonary stenosis

• Pulmonary hypertension

• Fallots tetralogy

• ASD , VSD

/231 methods normal abnormities diseases 36. Right ventricular enlargement /231 methods normal abnormities diseases 37. Left atrium enlargement

X-ray enlarged LA bulges to back & right

• PA right border double density of left atrial enlargement

• PA left border Indentation where the left atrium, when it enlarges, will appear on the left side of the heart

• Lat & RAO middle of esophagus compressed and displaced posteriorly

• LAO Elevation of left mainstem bronchus

• Common disease

• mitral lesion

• left ventricular failure

• congenital heart diseases

• • PDA

• • VSD

/231 methods normal abnormities diseases 38. Left atrium enlargement /231 methods normal abnormities diseases 39. Right atrium enlargement

X-ray appearance

• PA inferior segment of right border of heart extending to right , bulge, high bulge point

• LAO the right atrial curvature at least half as long as the anterior border of heart bulge

Common disease

• right heart failure

• ASD

• tricuspid disease

• pulmonary vein ectopy drainage

• atrial myxoma

/231 methods normal abnormities diseases 40. Right atrium enlargement /231 methods normal abnormities diseases 41. Generalcardiac enlargement

X-ray appearance

• PA The cardiac shadow is increased to both sides, the transverse diameter increased

• Lat and RAO narrowing of both retrosternal space and retrocardiac space, the oesophagus is displaced backward

• LAO the trachea bifurcation is sprayed, the trachea is displaced backward

Common disease

• Pericardial effusion

• Myocarditis

• Total cardiac failure

• Total cardiac failure, hyperthyroidism

/231 methods normal abnormities diseases 42. general cardiac enlargement -- Pericardial effusion/231 methods normal abnormities diseases 43. the five important cardiac contours are:

The ascending aorta

Indentation where double density of left atrial enlargement will appear

Aortic knob

Main pulmonary artery segment

Indentation where the left atrium, when it enlarges, will appear on the left side of the heart

The right atrium and left ventricle are less important because we evaluate ventricular enlargement by looking at the outflow tracts for each ventricle.

44. Basic X-ray features

Heart dislocation

Heart enlargement

Abnormal pulmonary blood flow

Changes of aorta

Pericardial abnormal

/231 methods normal abnormities diseases 45. Five States of the Pulmonary Vasculature

Normal

Pulmonary venous hypertension

Pulmonary arterial hypertension

Increased flow

Decreased flow

46. What Were Going to Evaluate

Right Descending Pulmonary Artery

Distribution of flow in the lungs

• Upper versus lower lobes

• Central versus peripheral

47. Venous HypertensionRDPA usually> 17 mm Upper lobe vessels equal to or larger than size of lower lobe vessels =Cephalization 48. Rapid cutoff in size of peripheral vessels relative to size of central vessels Central vessels appear too large for size of peripheral vessels which come from them =Pruning Pulmonary Arterial Hypertension 31 49. Increased Flow RDPA usually> 17 mm All of blood vessels everywhere in lung are bigger than normal 50. Increased Flow Normal 51. Increased Flow Distribution of flow is maintained as in normalLower lobe vessels bigger than upper lobe Gradual tapering from central to peripheral 52. PAH Increased Flow 53. Unrecognizable most of the timeSmall hila Fewer than normal blood vessels Decreased Flow 54. Basic X-ray features

Heart dislocation

Heart enlargement

Abnormal pulmonary blood flow

Changes of aorta

Pericardial abnormal

/231 methods normal abnormities diseases 55. Changes of aortal shape and density

elongation, widening ,calcification

• PA

• • Aorta distortion: the ascending and descending aorta displacement exceeding the heart boundary , intruding the lung field

• • The demarcation between the ascending aorta and right atrium descend

• • Aorta elongation: aortic knob is high , above the clavicula sometimes

• Lat

• • Ascending and descending aorta bendforward, backward respectively

/231 methods normal abnormities diseases 56. Aorta distortion and elongation /231 methods normal abnormities diseases 57. Aorta calcification /231 methods normal abnormities diseases 58. Aorta calcification /231 methods normal abnormities diseases 59. Coronary artery calcification /231 methods normal abnormities diseases 60. Dissection of aorta

Symptom

• Severe chest-back painsudden ly, withtearingsensation , radiating to the neck and abdomen

Pathology Hemorrhage in the media separate media from adventitia, and formpseudocoele inside the aortal wall

/231 Medical emergency

Clue for diagnosis

intimal tear point

intimal flap

pseudocoele

methods normal abnormities diseases 61. Dissection of aorta

Types

DeBakey Type I

Involves entire aorta

DeBakey Type II

Ascending aorta only

DeBakey Type III

Descending aorta only

/231 methods normal abnormities diseases 62. Dissection of aorta

Types

Stanford Type A

Ascending aorta involved

Stanford Type B

Ascending aorta NOT involved

/231 methods normal abnormities diseases 63. Dissection of aorta Usually medically Hypertension Atherosclerosis Descending aorta only Stanford Type B DeBakey Type III (most common) Usually surgically* Cystic medial necrosis e.g.MarfansEhlers-Danlos Ascending aorta only Stanford Type A (ascending aorta involved) DeBakey Type II (least common) Usually surgically* Hypertension Atherosclerosis Involves entire aorta Stanford Type A (ascending aorta involved) DeBakey Type I RX Common causes Portion of Aorta Involved Stanford Classification DeBakey Classification 64. Dissection of aorta True lumen methods normal abnormities diseases 65. Dissection of aorta True versus false channel methods normal abnormities diseases 66. Dissection of aorta methods normal abnormities diseases 67. Aneurysm

ascending aorta > 5 cm

Descending aorta > 4 cm

abdominal aorta >3 cm

Normal size of abdominal aorta >50 years of age:

• About 2 cm

68. Abdominal aortic aneurysm /231 perianeurysmal fibrosis (10%)methods normal abnormities diseases 69. Aneurysm/231 methods normal abnormities diseases 70. Abdominal aortic aneurysm /231 methods normal abnormities diseases 71. CTA /231 angiocardiography CT MRI echocardiography X-ray methods normal abnormities diseases 72. Aneurysm of aorta syphilitic /231 methods normal abnormities diseases