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Diagnostic radiology of cardiovascular 2009
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Diagnostic radiology of cardiovascular 2009

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  • 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.
    • 多层螺旋心脏大血管 CTA
    • (三维重建图)
  • 6. 多层螺旋心脏大血管 CTA (三维重建图)
  • 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 the heart
    • The state of the lungs and pulmonary vessels
    • Aorta and cardiac calcifications
    methods normal abnormities diseases
  • 11. Normal appearance
    • 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. Normal appearance ----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 arch below the clavicle, 2.0±1.0cm
    • 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, between the arch and left PA
  • 14. PA view /231 Left atrium PV PA methods normal abnormities diseases
  • 15. Normal appearance ---- 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. Normal appearance ---- Lat. view /231
      • Retrocardiac
      • esophageal space
    Retrosternal space the anterior heart border touch the1/3 of the distance between the diaphagm and the suprasternal notch RV CT CT X-ray methods normal abnormities diseases
  • 17. Normal appearance ---- Lat. view /231
    • normal L. atrium don’t 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 of the 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 of normal heart shadow --- body type
    • horizontal heart
    • oblique heart
    • dropping heart
    /231 classification : horizontal heart oblique heart dropping heart C/T R > 0.5 ≈0.5 < 0.5 included angle of cardiac longitudinal < 45 0 ≈45 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 of normal heart shadow -- respiration
    • inspiration expiration
    /231 methods normal abnormities diseases
  • 24. Influencing factor of normal heart shadow -- position
    • erect position supine 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 disappeaered Common 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 pulmonary artery ranges from 0 mm–15mm from 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
      • Fallot’s 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. General cardiac 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 We’re Going to Evaluate
    • Right Descending Pulmonary Artery
    • Distribution of flow in the lungs
      • Upper versus lower lobes
      • Central versus peripheral
  • 47. Venous Hypertension RDPA 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 normal Lower lobe vessels bigger than upper lobe Gradual tapering from central to peripheral
  • 52. PAH Increased Flow
  • 53. Unrecognizable most of the time Small 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 bend forward, 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 pain sudden ly, with tearing sensation , radiating to the neck and abdomen
    • Pathology : Hemorrhage in the media separate media from adventitia, and form pseudocoele 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.Marfan’s Ehlers-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

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