Imaging of cardiovascular system

Imaging technique Plain CXR :PA & lateral view Echocardio-study Radioisotop scan Computed tomography MRI Cardiac cartheritization & angiography.

What t observe Size & shape of the heart Pulmonary vessels Aorta. lungs

Cardiac enlargement Hear size usually measured on plain CXR by Cardiothoracic ration ,Normal ratio is less than 50%. On serial CXR more than 1.5cm changes in widest cardiac daim. indicated cardiomegaly.

Pulmonary vascular pattern Normal Increase pul. blood flow(pulmonary plethora). Due to Lt.-Rt shunt decrease pul. blood flow(pulmonary oligemia). Ex. TOF Pul. Venous hypertension . upper zone vessels equal or enlarge than lower zone vessels Pulmonary edema. 5. Pul. arterial hypertension” Causes: Core pulomale Pul. Embloi Mitral valve disease, or LT.-RT shunt. idiopathic Features: enlargement of pulmonary A.& hilar arteries

Global heart enlargements Pericarditis Cardiomyopathy Heart failure CXR PA view increase C/T ratio Lat. decrease in size of retrocardiac & retrosternal spaces , backward displacement of esophagus

Heart failure Cardiac enlargement+/- selective chamber enlargement Increased pulmonary venous pressure ( increase vasculairty in upper lung zones) Pulmonary edema pleural effusion. usually bilateral RT. Larger than LT. but if unilateral its s almost always Rt.side.

LEFT ATRIAL ENLARGEMENT Causes Mitral stenosis/ regurgitation LVF LA myxoma VSD PDA

PA CXR Double right heart border >75° splaying of carina with horizontal orientation of left main bronchus Enlarged left convex left atrial appendage Increased density of chamber >7 cm distance between left main stem bronchus and right lateral LA shadow

>7 cm distance between left main stem bronchus and right lateral LA shadow

>75° splaying of carina with horizontal orientation of left main bronchus

Doube right heart border

LAT. CXR Increased convexity of posterio-superior cardiac margin Posterior displacement of left main bronchus Posterior displacement of barium filled esophagus

RIGHT ATRIAL ENLARGEMENT Tricuspid stenosis/ regurgitation ASD AF Ebstein anomaly Pulmonary atresia

PA CXR Increase in curvature of RT heart border. Prominent round superior border at junction with SVC >5.5 cm from midline to most lateral RA margin >2.5 cm from right vertebral margin

LEFT VENTRICULAR ENLARGEMENT Pressure overload: Hypertension , AS Volume overload: VSD, AR, MR Aneurysm Cardiomyopathy

PA CXR Enlarges in post, inferior and leftward direction Increased Cardiothoracic ratio Larger radius of curvature of left heart border Downturned cardiac apex Depression of left hemidiaphragm

LAT. CXR Increased convexity of posteroinferior cardiac margin Hofman rigler rule: posterior cardiac margin projects >1.8 cm post to IVC measured at a point 2cm above intersection of IVC with right hemidiaphragm

RIGHT VENTRICULAR ENLARGEMENT PV stenosis Cor pulmonale ASD Tricuspid regurgitation Secondary to LVF

PA CXR Only extreme dilatation causes signs on frontal view Straightening/ convexity of left upper cardiac contour Upturned cardiac apex Left upper cardiac margin parallels left main stem bronchus as a long convex curvature Large appearance of MPA Occurs higher on the left heart border between left ventricular contour and pulmonary outflow tract

LAT CXR Prominent convexity of ant heart border >1/3 distance from anterior cardiophrenic sulcus to sternal angle Increased size prominent in retrosternal area

Valvular heart disease Mitral valve disease Mitral stenosis Radiological sign: 1.Lt atrial enlargement with normal cardiac size 2. Mitral valve calcification 3.Increase pulmonary venous pressure. 4.Pulmonary edema.

Mitral regurgitation Lt atrial &Lt.ventricular enlargement (increase cardiac size with LT ventricular configuration.. Pulmonary edema Increase pulmonary venous pressure.

Aortic valve disease Aortic stenosis: valve calcification Poststenotic dilation in ascending aorta LT ventricular enlargement Pul. venous hypertension. 3&4 are late features

Aortic regurgitation Dilated ascending aorta. Lt. ventricular enlargement (early)

Tricuspid valve Stenosis& regurgitation: Enlargment of Rt.atruim & SVC.

Congenital heart disease: Pulmonary stenosis Normal cardiac size Enlargement of main pul. A. Coarctaion of aorta: 1.Indentaion on aortic arch. 2.Dilation above coarctation due to Lt.subclavian A. enlargement 3.Dilation below coarctation due to poststenotic dilation of aorta. 4. Cardiac enlargmnt 50. Rib indentation : in long standing cases small cortical rib indentation due to enlargements of intercostal vessels.

Tetralogy of fallot : VSD Overriding of aorta Rt ventricular outflow obstruction RV hypertrophy. Radiological features: Normal CXR 50%. Boot shape heart Oligaemic lung Rt side aorta in 25%.

ASD, VSD, &PDA. Cardiac enlargement. Enlargement of Lt. main PA. pulmonary plethora.

Cardiac tumor Lt atrial myxoma Most common benign cardiac tumor .it may arise from intra-atrial septum or cardiac wal Radiological features: Best seen by cardiac MRI or echocradic study. Most patient have normal CXR. It may pedineculates floating within atrium to mitral valve causing MV dysfunction mimic MS or MR.

Pericardium pericardial effusion Marked increase in cardiac diam. With no specific chamber enlargements. Calcifications seen up o 50% of constrictive pericarditis. By echo study : As little as 25-50cc can be seen as echo-free fluid echogenisty between cardiac wall &pericarduim.

Pericarditis is defined as inflammation of the pericardium Pericarditis is defined as inflammation of the pericardium. It is normally found in association with cardiac, thoracic or wider systemic pathology and it is unusual to manifest on its own. It can be sub typed according to morphology. Acute forms serous pericarditis suppurative (purulent) pericarditis tuberculous (caseous) pericarditis : fibrinous pericarditis  haemorrhagic pericarditis Established forms constrictive pericarditis adhesive pericarditis Radiographic features CT / Carciac CT  At contrast-enhanced CT, enhancement of the thickened pericardium generally indicates inflammation 1. Cardiac MRI Usually T1, T2 and GRE cine sequences are performed.   The normal pericardial thickness is considered 2 mm while a thickness of over 4 mm suggests a pericarditis  The presence of an arrthymia may induce artefacts.

Aortic aneurysm Normal aortic daim Ascending=5cm Arch=4cm Descending=3cm Abdominal =2cm

false aneurysm (or pseudoaneurysm) Causes congenital atherosclerosis Aneurysms are focal abnormal dilatation of a blood vessel. They typically occur in arteries, venous aneurysms are rare. Aneurysms may also occur in the heart. Pathology Pathological types true aneurysm false aneurysm (or pseudoaneurysm) Causes congenital atherosclerosis hypertension vasculitis hereditary connective tissue disorders Marfan syndrome Ehlers-Danlos syndrome fibromuscular dysplasia infection: mycotic aneurysm, syphilis (luetic aneurysm) trauma iatrogenic myocardial infarction: may cause left ventricular aneurysm flow related (in cerebral AVM, contralateral ICA occlusion etc) Morphology: saccular aneurysm: eccentric, involving only a portion of the circumference of the vessel wall fusiform aneurysm: concentric, involving full circumference of the vessel wall Complications rupture distal thromboembolism pressure effects

Thanks