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  1. 1. Cardiovascular Imaging M. J. McCowin, MD Clinical Professor of Radiology, UCSF G. Caputo, MD Professor of Radiology, UCD
  2. 2. Cardiac Imaging studies requested before Cardiology consult <ul><li>Chest x-ray (L. Antonietti, MD) </li></ul><ul><li>Nuclear Medicine </li></ul><ul><li>Echocardiography </li></ul><ul><li>?MRI </li></ul><ul><li>?CT </li></ul>
  3. 3. Chest x-ray <ul><li>Cardiac Contour size and shape </li></ul><ul><li>Poor for pericardial effusions </li></ul><ul><li>Left ventricular failure </li></ul><ul><li>Right ventricular failure </li></ul>
  4. 4. PA heart < ½ chest diameter
  5. 5. Chamber Enlargement LA LV RV RA LV RV la append LA
  6. 6. Cardiac Contours: enlarged RA, LA, and RV in mitral stenosis
  7. 7. New enlarged LV due to aneurysm
  8. 8. Aortic Valve calcified due to AS
  9. 9. 4 chamber enlargement due to MS/MI
  10. 10. PA and Lateral vs AP portable
  11. 11. Magnification of the heart with AP portable x-ray <ul><li>PA in </li></ul><ul><li>Radiology </li></ul><ul><li>AP as a </li></ul><ul><li>portable </li></ul>
  12. 13. Large Cardiac Contour
  13. 14. Large cardiac contour <ul><li>AP portable magnifies </li></ul><ul><li>Lordotic film magnif </li></ul><ul><li>Kyphotic film minim </li></ul><ul><li>Rotation changes </li></ul><ul><li>Pericardial effusion looks like cardiomegaly </li></ul>
  14. 15. Heart Failure <ul><li>RIGHT HEART </li></ul><ul><li>LE edema </li></ul><ul><li>Ascites </li></ul><ul><li>Cxr large rt heart </li></ul><ul><li>Cxr large azygous v </li></ul><ul><li>Often due to LHF or Pulmonary dx </li></ul><ul><li>LEFT HEART </li></ul><ul><li>Cardiomegaly </li></ul><ul><li>Pulmonary Edema </li></ul><ul><li>Pleural Fluid </li></ul>
  15. 16. Relationship of aortic arch,pa,azyg v. to trach carina
  16. 17. Heart Failure
  17. 18. Interstitial Edema <ul><li>Bronchovascular thickening and indistinctness </li></ul><ul><li>Vessels get bigger and busier </li></ul><ul><li>Vessels seen more to the periphery </li></ul><ul><li>Kerley lines (less common) </li></ul>
  18. 19. Which vessels are bigger, busier,more peripheral?
  19. 20. Dry Wet
  20. 21. Airspace Edema <ul><li>May be cardiogenic or non-cardiogenic </li></ul><ul><li>Very non-specific: aspiration, atypical pna, hemorrhage, etc. </li></ul><ul><li>ARDS will persist and become coarse over time </li></ul>
  21. 22. Air-space edema
  22. 23. Cardiac imaging requested prior to Cardiology consult <ul><li>Nuclear Medicine </li></ul><ul><ul><li>Perfusion </li></ul></ul><ul><ul><li>Wall motion </li></ul></ul><ul><ul><li>Viability </li></ul></ul><ul><ul><li>Shunts </li></ul></ul><ul><li>?MRI </li></ul><ul><ul><li>Pericard, chd, valv, shunts, perfusion, wm </li></ul></ul><ul><li>?CT </li></ul><ul><ul><li>Pericard calc, CA calc, cta for CA </li></ul></ul><ul><li>Echocardiography </li></ul><ul><ul><li>Pericardial fluid </li></ul></ul><ul><ul><li>Valve function, integrity/vegetations </li></ul></ul><ul><ul><li>Wall motion </li></ul></ul><ul><ul><li>Shunts </li></ul></ul><ul><ul><li>Congenital heart dx </li></ul></ul><ul><ul><li>?contrast agents </li></ul></ul>
  23. 24. Nuclear Med. Perfusion Studies: Thallium (potassium-like is extracted in K-ATPase pump), Sestamibi etc. <ul><li>Normal Stress Rest Perfusion </li></ul>stress rest stress rest
  24. 25. Cardiac anatomy as seen in SPECT nuclear imaging short axis, horiz. long., vert .long.
  25. 26. Diagram of short axis perfusion images: Would you pay full price for this donut? YES! the “ donut” is all there. (normal septal thinning)
  26. 27. 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
  27. 28. Circumferential data confirms reversible inferoseptal ischemia
  28. 29. Reversible ischemia ( ant/sept/apex) & stress-induced lv dilation Transient ischemic myocardial dysfunction S R R S R S
  29. 30. Fixed lateral perfusion deficit. ( fixed “bite out of donut”) stress rest stress rest
  30. 31. Cardiac Wall Motion with quantitative ejection fraction (chemo rx)
  31. 32. Regional wall motion
  32. 33. Imaging requests by Cardiology <ul><li>Nuclear Medicine Myocardial Viability FDG study </li></ul><ul><li>MR for perfusion, viability, myocardial function, CHD, evaluation of anatomy and flow, shunts, wm, pericardial dx </li></ul><ul><li>Cardiac angiography for coronary artery assessment, CHD, valve and shunt assess </li></ul><ul><li>Cardiac angio for RX! plasty, stent, ASD,chd </li></ul><ul><li>CT: CABG eval, CTA for coronary as. , contrast agents for ischemia </li></ul>
  33. 34. MRA cong double arch post-op ligation of left arch
  34. 35. Dilated LV and RA
  35. 36. Ao valv, pap muscle, rt pleural fluid, dilated lv
  36. 37. Coronal MRI shows aorta, av, lv (can eval for stenosis and regurg) Spin echo “black blood” anatomy Gradient echo “white blood” function & flow
  37. 61. CT coronary angiography
  38. 62. CT coronary angiography
  39. 63. CT coronary angiography
  40. 65. Vascular Imaging <ul><li>Non-Invasive </li></ul><ul><li>Ultrasound: carotid, AAA, pvd, venous </li></ul><ul><li>CTA: Aor Dissect, Aneurysm, PE, Trauma </li></ul><ul><li>MRA: Aor Dissect, Aneurysm, Veins </li></ul><ul><li>Invasive & RX </li></ul><ul><li>Angiography/Venogr </li></ul><ul><li>Balloon Dilatation </li></ul><ul><li>Stents </li></ul><ul><li>Embolization </li></ul><ul><li>Vascular shunts </li></ul>
  41. 66. Ultrasound <ul><li>Abdominal Aortic Aneurysm </li></ul><ul><li>Carotid Artery Disease (Atherosclerosis) </li></ul><ul><li>Peripheral artery disease </li></ul><ul><li>Vascular shunt evaluation </li></ul><ul><li>Venous disease: DVT etc. </li></ul>
  42. 67. Ultrasound of Carotid Artery CCA ICA ECA
  43. 68. Ultrasound of Carotid Artery note: brain, kidneys, heart must have both systolic & diastolic flow systole diastole
  44. 69. Atherosclerotic Plaque
  45. 70. Ultrasound for Venous Dx
  46. 71. CTA and MRA for Vascular Disease <ul><li>CTA </li></ul><ul><li>Aortic Dissection </li></ul><ul><li>Aortic Aneurysm </li></ul><ul><li>Peripheral Vascular Disease </li></ul><ul><li>Aortic Trauma </li></ul><ul><li>Pulmonary Emboli </li></ul><ul><li>MRA </li></ul><ul><li>Aortic Dissection </li></ul><ul><li>Aortic Aneurysm </li></ul><ul><li>Peripheral Vascular Disease </li></ul>
  47. 72. Abdominal Aortic Aneurysm
  48. 73. Abdominal Aortic Aneurysm MR
  49. 74. Abdominal Aortic Aneurysm CTA with 3D Rendering
  50. 75. R/o aortic dissection <ul><li>CTA </li></ul><ul><li>MRA </li></ul><ul><li>TEE </li></ul>
  51. 76. MRA for central and peripheral Arteries and veins
  52. 78. Aortic Trauma
  53. 79. Aortic Trauma
  54. 80. Intravenous Contrast <ul><li>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. </li></ul><ul><li>PICC lines and many other central lines cannot be used for this rapid power injection. </li></ul><ul><li>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). </li></ul><ul><li>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. </li></ul>
  55. 81. Pulmonary Artery Emboli Nuclear Medicine Perfusion Scan
  56. 82. CTAngiography for pulmonary artery emboli
  57. 83. Peripheral Vascular Disease
  58. 84. PVD after balloon Rx
  59. 85. Endovascular Stents
  60. 86. Endovascular repair of aneurysm
  61. 87. Endovascular repair of aneurysm
  62. 88. Acute Chest Pain: will CTA become the one stop shop?
  63. 89. CTAngiography for pulmonary artery emboli
  64. 90. Aortic dissection
  65. 91. CT coronary angiography
  66. 92. CTA: one stop shop for chest pain? <ul><li>Same CTA: </li></ul><ul><li>Rules out aortic dissection </li></ul><ul><li>Rules out pulmonary emboli </li></ul><ul><li>? Rules out coronary disease? Perhaps with 64 slice and up CT and image processing </li></ul><ul><li>Currently our Radiology Resident’s worst nightmare! </li></ul>
  67. 93. Cardiovascular Imaging <ul><li>NON-INVASIVE for DX </li></ul><ul><li>Ultrasound </li></ul><ul><li>Nuclear Medicine </li></ul><ul><li>CTA (inc. coronary) </li></ul><ul><li>MRA </li></ul><ul><li>Chest x-ray </li></ul><ul><li>INVASIVE for DX & TX </li></ul><ul><li>Coronary arteries </li></ul><ul><li>Fine detail of arteries </li></ul><ul><li>Lots of Therapeutic Possibilities ! </li></ul>