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Introduction to Imaging

of the Cardiovascular
System

The heart is a vital organ and it weighs approximately


200-400 gms. It is usually in the size of a fist.
The heart consists of 4 chambers, 2 ventricles and 2
atria.

Methods of Investigations :

).

1234-

Plain ( conventional ) X ray.


Computed Tomography ( CT/ CTA ).
Echocardiography / Color Doppler .
Magnetic Resonance Imaging ( MRI

5- Catheter Angiography.
6- Cardiovascular nuclear medicine.

Plain Chest X Ray


Standard views for chest radiography :
PA ( postero-anterior ) view
Left Lateral view

Patients chest placed


against the film
cassette .
Patient in erect
position.
Patient well
centralized.
X rays penetrate the
patient posteriorly .

Patient placed with


the left side against
the film.

X ray enter the


patient through the
right axilla.

Viewing a chest film


1-Cardiac size and configuration.
2-Lung fields and broncho-vascular
markings.
3-Hilar shadows.
4-Diaphragm and costo-phrenic angles.
5-Ribs & soft tissues.

1-Cardiac size
What is the cardiothoracic ratio ?

Cardio thoracic ratio is the


maximum transverse diameter of
the heart on an x ray film in
relation to the thoracic cage
diameter.
Normally it is 50-55% or less.

1- Cardiac configuration
Cardiac boundaries on a
chest X ray

On a PA view, the right heart border is


formed by the right atrium, and the left
heart border is formed by the appendage of
the left atrium superiorly and the left
ventricle inferiorly.
On the lateral view, the anterior cardiac
border is formed by the right ventricle and
the posterior heart border by the left atrium
superiorly (just below the carina) and left
ventricle inferiorly.

CARDIAC ABNORMALITIES

Cardiomegaly
An enlarged heart is indicative of
cardiac disease, but a "normal sized
heart does not imply normality.
For example, significant hypertrophy
does not cause dilatation and
enlargement may not be appreciated
without comparison films.

Ventricular hypertrophy

Enlarged
Left Ventricle

Enlarged
Left Ventricle

IVC

Enlarged
Right Ventricle

Enlarged
Right Ventricle
(lateral CXR)

Right ventricular
enlargement.
Common cause is
cor pulmonale.
Obliterates retro
sternal space.

Fallot tetralogy

Enlarged
Left Atrium

Enlarged
Left Atrium

calcified
mitral
annulus

Left Atrial
enlargement.
Common cause is
mitral valve
disease.
Prominent left
atrial appendage.
Double density
over the right
cardiac border.
Widening of the
carina

Enlarged
Right Atrium

Right atrial
enlargement.
Causes include
lung diseases,
cardiac valve
disease and
pulmonary
embolism.
Bulge at right
cardiac border

Generalized
cardiac
enlargement.
- Usually due
to pericardial
effusion or
cardiomyopath
y.
- Flask shape
heart.

RADIOGRAPHIC FEATURES OF
CONSTRICTIVE PERICARDITIS

Pulmonary venous
hypertension

Normal heart size or


mild cardiomegally.

Calcification of the
cardiac margin.

Coronary Angiography
The Gold Standard technique for
evaluation of coronary arteries,
especially if intervention is planned,
e.g. balloon angioplasty, stenting.

Coronary
Angio

MDCT
A recent technology that uses X-rays to
image slices of patients bodies.
For cardiac imaging, we need a 64-slice
machine or higher.

aortic arch

Superior Vena Cava

Tracheal
bifurcation

left pulmonary artery

right pulmonary artery

pulmonary trunk

thoracic aorta

left atrium

left ventricle

pericardial sac

CT AORTIC ANGIOGRAPHY

CT CORONARY ANGIO

ADVANTAGES Vs DISADVANTAGES
Clear definition
and calcium
scoring.
Fast .
Less invasive.
Improved intra
vascular
visualization.

Ionizing radiation
Contrast risk :
allergy and
induced
nephropathy.
Technical errors .

Pulmonary
Angiography
Used for :
- Diagnosing pulmonary
emboli.
- Demonstration of
congenital
anomalies.

Pulmonary Embolism
Very common in patients
confined to bed .
Originating in leg and pelvic
veins or patients with heart
disease .

Appearances
Usually no evident findings on plain films
however in some patients :
Infarct appears as an area of consolidation,
pleural based, indistinguishable from
pneumonia.
On CT a filling defect is seen inside the
lumen of the pulmonary artery.

CARDIAC IMAGING QUIZ

Increased cardio
thoracic ratio means:
Cardiomegaly
Pericardial effusion
Cardiomyopathy
Non centralised patient
Supine patient

Double density at right


side of heart can indicate :
Right atrium enlargement
Left atrium enlargement
Right ventricle enlargement
Left ventricle enlargement

Obliterated retro sternal


space on lateral chest x ray
indicate :

Right atrium enlargement


Left atrium enlargement
Right ventricle enlargement
Left ventricle enlargement

Flask Shaped heart


indicate

Dilated Cardiomyopathy
Pericardiac effusion
All of the above
Non of the above

Calcium scoring can be


done by:
Plain X ray
Plain MDCT
Conventional angiography
CT coronary angiography