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    Cardio Cardio Presentation Transcript

    • Cardiovascular Imaging M. J. McCowin, MD Clinical Professor of Radiology, UCSF G. Caputo, MD Professor of Radiology, UCD
    • Cardiac Imaging studies requested before Cardiology consult
      • Chest x-ray (L. Antonietti, MD)
      • Nuclear Medicine
      • Echocardiography
      • ?MRI
      • ?CT
    • Chest x-ray
      • Cardiac Contour size and shape
      • Poor for pericardial effusions
      • Left ventricular failure
      • Right ventricular failure
    • PA heart < ½ chest diameter
    • Chamber Enlargement LA LV RV RA LV RV la append LA
    • Cardiac Contours: enlarged RA, LA, and RV in mitral stenosis
    • New enlarged LV due to aneurysm
    • Aortic Valve calcified due to AS
    • 4 chamber enlargement due to MS/MI
    • PA and Lateral vs AP portable
    • Magnification of the heart with AP portable x-ray
      • PA in
      • Radiology
      • AP as a
      • portable
    • Large Cardiac Contour
    • Large cardiac contour
      • AP portable magnifies
      • Lordotic film magnif
      • Kyphotic film minim
      • Rotation changes
      • Pericardial effusion looks like cardiomegaly
    • Heart Failure
      • LE edema
      • Ascites
      • Cxr large rt heart
      • Cxr large azygous v
      • Often due to LHF or Pulmonary dx
      • LEFT HEART
      • Cardiomegaly
      • Pulmonary Edema
      • Pleural Fluid
    • Relationship of aortic arch,pa,azyg v. to trach carina
    • Heart Failure
    • Interstitial Edema
      • Bronchovascular thickening and indistinctness
      • Vessels get bigger and busier
      • Vessels seen more to the periphery
      • Kerley lines (less common)
    • Which vessels are bigger, busier,more peripheral?
    • Dry Wet
    • Airspace Edema
      • May be cardiogenic or non-cardiogenic
      • Very non-specific: aspiration, atypical pna, hemorrhage, etc.
      • ARDS will persist and become coarse over time
    • Air-space edema
    • Cardiac imaging requested prior to Cardiology consult
      • Nuclear Medicine
        • Perfusion
        • Wall motion
        • Viability
        • Shunts
      • ?MRI
        • Pericard, chd, valv, shunts, perfusion, wm
      • ?CT
        • Pericard calc, CA calc, cta for CA
      • Echocardiography
        • Pericardial fluid
        • Valve function, integrity/vegetations
        • Wall motion
        • Shunts
        • Congenital heart dx
        • ?contrast agents
    • Nuclear Med. Perfusion Studies: Thallium (potassium-like is extracted in K-ATPase pump), Sestamibi etc.
      • Normal Stress Rest Perfusion
      stress rest stress rest
    • Cardiac anatomy as seen in SPECT nuclear imaging short axis, horiz. long., vert .long.
    • Diagram of short axis perfusion images: Would you pay full price for this donut? YES! the “ donut” is all there. (normal septal thinning)
    • Thallium stress/rest: reversible ischemia inf/septum c/w RCA disease stress rest stress rest large “bite” out of donut! “ donut bite” fills in at rest
    • Circumferential data confirms reversible inferoseptal ischemia
    • Reversible ischemia ( ant/sept/apex) & stress-induced lv dilation Transient ischemic myocardial dysfunction S R R S R S
    • Fixed lateral perfusion deficit. ( fixed “bite out of donut”) stress rest stress rest
    • Cardiac Wall Motion with quantitative ejection fraction (chemo rx)
    • Regional wall motion
    • Imaging requests by Cardiology
      • Nuclear Medicine Myocardial Viability FDG study
      • MR for perfusion, viability, myocardial function, CHD, evaluation of anatomy and flow, shunts, wm, pericardial dx
      • Cardiac angiography for coronary artery assessment, CHD, valve and shunt assess
      • Cardiac angio for RX! plasty, stent, ASD,chd
      • CT: CABG eval, CTA for coronary as. , contrast agents for ischemia
    • MRA cong double arch post-op ligation of left arch
    • Dilated LV and RA
    • Ao valv, pap muscle, rt pleural fluid, dilated lv
    • Coronal MRI shows aorta, av, lv (can eval for stenosis and regurg) Spin echo “black blood” anatomy Gradient echo “white blood” function & flow
    • CT coronary angiography
    • CT coronary angiography
    • CT coronary angiography
    • Vascular Imaging
      • Non-Invasive
      • Ultrasound: carotid, AAA, pvd, venous
      • CTA: Aor Dissect, Aneurysm, PE, Trauma
      • MRA: Aor Dissect, Aneurysm, Veins
      • Invasive & RX
      • Angiography/Venogr
      • Balloon Dilatation
      • Stents
      • Embolization
      • Vascular shunts
    • Ultrasound
      • Abdominal Aortic Aneurysm
      • Carotid Artery Disease (Atherosclerosis)
      • Peripheral artery disease
      • Vascular shunt evaluation
      • Venous disease: DVT etc.
    • Ultrasound of Carotid Artery CCA ICA ECA
    • Ultrasound of Carotid Artery note: brain, kidneys, heart must have both systolic & diastolic flow systole diastole
    • Atherosclerotic Plaque
    • Ultrasound for Venous Dx
    • CTA and MRA for Vascular Disease
      • CTA
      • Aortic Dissection
      • Aortic Aneurysm
      • Peripheral Vascular Disease
      • Aortic Trauma
      • Pulmonary Emboli
      • MRA
      • Aortic Dissection
      • Aortic Aneurysm
      • Peripheral Vascular Disease
    • Abdominal Aortic Aneurysm
    • Abdominal Aortic Aneurysm MR
    • Abdominal Aortic Aneurysm CTA with 3D Rendering
    • R/o aortic dissection
      • CTA
      • MRA
      • TEE
    • MRA for central and peripheral Arteries and veins
    • Aortic Trauma
    • Aortic Trauma
    • Intravenous Contrast
      • A large-bore (>22g, preferably an 18g or >) peripheral IV is required and is best placed in the right arm because the venous drainage is closer to the heart than the left arm.
      • PICC lines and many other central lines cannot be used for this rapid power injection.
      • Note also that intravenous iodinated contrast may be contraindicated in some patients, particularly those with a history of contrast allergy and patients with renal insufficiency (creatinine > 1.5).
      • Additional caution regarding contrast is needed for patients in heart failure, a history of a serious allergy of any kind, multiple myeloma, diabetes particularly if on metformin (glucophage), or if a recent large contrast bolus has not yet been cleared from the body.
    • Pulmonary Artery Emboli Nuclear Medicine Perfusion Scan
    • CTAngiography for pulmonary artery emboli
    • Peripheral Vascular Disease
    • PVD after balloon Rx
    • Endovascular Stents
    • Endovascular repair of aneurysm
    • Endovascular repair of aneurysm
    • Acute Chest Pain: will CTA become the one stop shop?
    • CTAngiography for pulmonary artery emboli
    • Aortic dissection
    • CT coronary angiography
    • CTA: one stop shop for chest pain?
      • Same CTA:
      • Rules out aortic dissection
      • Rules out pulmonary emboli
      • ? Rules out coronary disease? Perhaps with 64 slice and up CT and image processing
      • Currently our Radiology Resident’s worst nightmare!
    • Cardiovascular Imaging
      • NON-INVASIVE for DX
      • Ultrasound
      • Nuclear Medicine
      • CTA (inc. coronary)
      • MRA
      • Chest x-ray
      • INVASIVE for DX & TX
      • Coronary arteries
      • Fine detail of arteries
      • Lots of Therapeutic Possibilities !