4.other acquired heart disease

6/19/2013 1
CHAÅN ÑOAÙN HÌNH AÛNH
BEÄNH TIM MAÉC PHAÛI KHAÙC
BS.NGUYEÃN QUYÙ KHOAÙNG
BS.NGUYEÃN QUANG TROÏNG

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DAØN BAØI
Beänh ñoäng maïch chuû.
Beänh tim do cao huyeát aùp.
Phình ÑMC.
Hoäi chöùng Marfan.
Beänh Takayasu.
Beänh cô tim.
Beänh cô tim giaõn nôû.
Beänh cô tim phì ñaïi.
Beänh cô tim haïn cheá.

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DAØN BAØI
Nhoài maùu cô tim vaø caùc bieán chöùng.
Thieáu maùu cô tim.
Nhoài maùu cô tim.
Caùc bieán chöùng cuûa Nhoài maùu cô tim:
Thoâng lieân thaát.
Hoäi chöùng Dressler.
Phình thaát.
Ñöùt nhuù cô.

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DAØN BAØI
Beänh maøng tim.
Traøn dòch maøng tim.
Vieâm maøng tim co thaét.
Nang maøng tim.
Môõ ngoaøi maøng tim.

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BEÄNH TIM DO CAO HUYEÁT AÙP
Thaát (T) daøy ñoàng taâm Bôø (T) baøu sau
ñoù bôø (T) traûi daøi,moûm tim nhö chuùc
xuoáng döôùi voøm hoaønh (T).
ÑMC leân cong qua (P) vaø bung roäng
(>6cm)(Deùroulement aortique).
Chaån ñoaùn phaân bieät:Heïp van ÑMC
vaø Xô vöõa ñoäng maïch ôû ngöôøi giaø.

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ÑMC coù theå ñoùng voâi.
Tuaàn hoaøn phoåi bình thöôøng.
Khi coù Suy tim coù Taùi phaân phoái
tuaàn hoaøn phoåi,Phuø phoåi caáp.

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DEROULEMENT AORTIQUE (a>6cm)

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PHÌNH ÑOÄNG MAÏCH CHUÛ
ÑMC ñöôïc chia ra ÑMC ngöïc vaø ÑMC
buïng:
ÑMC ngöïc goàm ÑMC leân,Quai ÑMC
vaø ÑMC xuoáng.
ÑMC buïng goàm ÑMC treân thaän vaø
ÑMC döôùi thaän.
Bình thöôøng khaåu kính ÑMC leân lôùn
nhaát:3,3cm.

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Ñöôïc xem laø phình ÑMC khi ñöôøng kính
ÑMC>4cm;hình thoi, troøn,baùn nguyeät.
Ñoaïn leân:Giang mai,Xô vöõa ñoäng maïch,
Hoäi chöùng Marfan.
Ñoaïn ngang:Xô vöõa ñoäng maïch,Chaán
thöông.
Ñoaïn xuoáng:Xô vöõa ñoäng maïch.

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-Vaùch ñoäng maïch chuû goàm 3 lôùp:
I intima,M media,A adventitia.
-Khi lôùp Intima bò raùch,maùu seõ
traøn vaøo lôùp Media ñeå taïo thaønh
loøng giaû (false lumen).
-Treân X quang quy öôùc,neáu coù
ñoùng voâi quai ÑMC,thì Daáu hieäu
Calcium (Calcium sign) gôïi yù ñeán
Phình ÑMC boùc taùch (khoaûng
caùch töø lôùp Intima ñoùng voâi ñeán
bôø ngoaøi quai ÑMC >10mm).

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AORTIC DISSECTION
DeBakey:type I,II,III.
STANFORD:
-Type A:Type I+Type II.
-Type B:Type III.

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MECHANISMS OF AORTIC REGURGITATION IN PROXIMAL AORTIC DISSECTION

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AORTIC ANEURYSM

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AORTIC ANEURYSM

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ASCENDING AORTIC ANEURYSM

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-Saccular mass in the right mediastinum
(large arrows).
-Curvilinear calcification (small arrow).
-The trachea is displaced posteriorly
(double black arrows).
-Curvilinear calcification (small arrow).
SACCULAR ANEURYSM OF ASCENDING AORTA

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-The ascending aorta (large arrow).
-The trachea is displaced to the right side.
-A streak of calcium (small arrows) in the
intima denotes a thin aortic wall.
FUSIFORM ANEURYSM OF
THE ENTIRE THORACIC
AORTA

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-The lucency representing the
intima flap (arrows) extends from
the aortic root around the arch.
-The false lumen is less dense than
the true lumen.
-Aortic regurgitation.
AORTIC DISSECTION

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-The intima flap (arrows)
extending from the aortic
root distally into the
abdomen.
-Communication between
the false lumen and the
true lumen (curved
arrow).
AORTIC DISSECTION

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AORTIC DISSECTION:T:true lumen,F:false lumen,I:intimal
flap,LV:contrast in the LV Aortic insufficiency.

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Lobular mass density (arrows)
on the left side of the heart.
LAO
FUSIFORM ANEURYSM OF DESCENDING AORTA

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ANEURYSM OF ABDOMINAL AORTA: EXTENSIVE CALCIFICATION

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3 YEARS PRIOR: Normal
appearing aorta.
Enlargement of the aortic
knob (arrow).
AORTIC DISSECTION

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Enlarged, elongated,
tortuous, descending aorta.
TWO WEEKS LATER
-Increase in the width of the
descending aorta (large arrows).
-Left pleural effusion (small arrows).
DISSECTING ANEURYSM

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ASYMPTOMATIC FIVE DAYS LATER:Left hemothorax,the aortic
outline has been obliterated by the blood
RUPTURE OF AORTIC ANEURYSM

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A:left hilar mass (arrow).
B:mass adjacent to the proximal descending aorta (arrow).
SACCULAR ANEURYSM

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TRUE CHANNEL:small arrows.
FALSE CHANNEL:double-headed arrows).
DISSECTING ANEURYSM

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A tumor or an aneurysm?
Opacification of the aorta
KINGKING OF AORTA

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A:Dilated aortic arch.
T:Displaced trachea.
B:Compressed left main
bronchus.
-All four cardiac chambers are
dilated.
AORTIC ANEURYSM /
IDIOPATHIC DILATED
CARDIOMYOPATHY

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FALSE ANEURYSM: The intima and media
are penetrated.False aneurysm typically has
a narrow neck.
(TRUE ANEURYSM: contain all three layers).

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FALSE ANEURYSM: narrow neck.

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-False aneurysm in the region of
the ligamentum arteriosum.
-The patient was involved in an
automobile accident 3 months
previously.
TRAUMATIC AORTIC ANEURYSM

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18-year-old involved in
motorcycle accident.
-Widening of the mediastinum.

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RUPTURE OF THE AORTA
WITH FALSE ANEURYSM.

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AORTIC DISSECTION

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AORTIC DISSECTION:T true lumen,F:false lumen,I:intima flap.

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AORTIC DISSECTION:AV:aortic valve,T true lumen,F:false lumen,I:intima flap.

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MRI-INFRARENAL ABDOMINAL AORTIC ANEURYSM

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As.Aorta PA
True lumen False lumen Thrombosis

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PENETRATING AORTIC
ATHEROSCLEROTIC ULCER
-Arrow:subintimal hematoma.
-Arrowhead:displaced intimal
calcification.

DẤU HIỆU MẢNG VÔI
(CALCIUM SIGN)
Mảng vữa xơ của ĐMC nằm ở lớp áo trong, nếu vôi hoá ta sẽ
thấy. Khi bị phình ĐMC bóc tách, máu len vào lớp áo giữa,
làm gia tăng khoảng cách giữa lớp intima và adventitia. Nghĩ
đến phình ĐMC bóc tách khi khoảng cách từ mảng vôi hoá
đến bờ ngoài quai ĐMC > 10 mm.

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AORTIC DISSECTION
-Arrows:displaced intimal
calcification.
-Small bilateral pleural
effusions.
-Mild bibasilar atelectasis.

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AORTIC DISSECTION
-Arrows:intimal flap.
-Small bilateral pleural
effusions.
-V:SVC.

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AORTIC DISSECTION
-t:true lumen.
-f:false lumen.

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AORTIC DISSECTION
WITH LEFT RENAL
ISCHEMIA
-Arrow:intimal flap.
-K:ischemia of the
posterior aspect of the
left kidney.

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RUPTURED AORTIC
DISSECTION
-Arrowheads:intimal flap.
-Arrow:nasogastric tube.
-Hemorrhage infiltrates
the soft tissues around the
descending aorta.

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MSCT-AORTIC DISSECTION

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MSCT-AORTIC DISSECTION
(3D-surface display)

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AORTIC ANEURYSM

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Click here for movie

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CT MRI

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MRA
AORTIC DISSECTION

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AORTIC DISSECTION

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AORTIC ANEURYSM
Thrombosis in
the aortic aneurysm

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The fusiform aneurysm
in the ascending aorta
does not involve the
aortic root.
LUETIC ANEURYSM

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CALCIFICATION IN THE ASCENDING
AORTA – SYPHILITIC AORTITIS

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LUETIC AORTITIS
-“Egg-shell” calcification
extends from the aortic
annulus through the entire
thoracic aorta.
-Calcification of the
ascending aorta is also seen
in pure atherosclerosis
and,rarely,in Takayasu’s
arteritis.

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Ascending aortic aneurysm with stenotic bicuspid aortic valve (arrows)
is domed in this systolic frame REITER’S SYNDROME

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Erosion of the vertebral bodies due
to pulsations of an aneurysm.
Aortography reveals the saccular
aneurysm (arrows).
Note:bulging of the intervertebral
cartilage (which resists erosion).

55 yo male patient with abdominal pain and
back pain

Ultrasound examinaton: Presence of “Ying Yan sign”: Aortic
aneurysm

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HOÄI CHÖÙNG MARFAN
Beänh lyù cuûa moâ lieân keát do thieáu huït
fibrillin coù yeáu toá gia ñình (chromosome
15q15-21).
Aûnh höôûng leân heä tim-maïch,heä xöông
vaø maét.Vôùi heä tim-maïch,toån thöông xaûy
ra >50% ngöôøi lôùn bò Hoäi chöùng Marfan.

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Söï thoaùi hoùa cuûa lôùp Media daãn tôùi giaõn
voøng van ÑMC vaø ÑMC leân.Tieáp ñeán laø
hôû van ÑMC Suy thaát (T).
Boùc taùch ÑMC laø bieán chöùng thöôøng
gaëp vaø thöôøng laø nguyeân nhaân gaây töû
vong.
Hôû van 2 laù thöôøng gaëp ôû treû em do coät
cô dö thöøa Sa van 2 laù.

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ECTOPIA LENTIS THUMB SIGN

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LONG EXTREMITIES AND DIGITS,TALL STATURE AND PECTUS CARINATUM

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-The aneurysm involves both the sinuses of Valsalva and the proximal
half of the ascending aorta.
ANNULOAORTIC ECTASIA

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-The aneurysm involves both the
sinuses of Valsalva and the
proximal half of the ascending
aorta.
ANNULOAORTIC ECTASIA

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A:aortic aneurysm of
ascending aorta.
Arrows:smaller aneurysm of
descending aorta.
MARFAN’S SYNDROME

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SPIN-ECHO MRI:
Dilated ascending aorta (5cm).
A 26-year-old woman with
MARFAN’S SYNDROME

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BEÄNH TAKAYASU
Vieâm ñoäng maïch Takayasu laø moät beänh
vieâm maïn tính maø nguyeân nhaân chöa
roõ,laøm toån thöông ÑMC vaø caùc nhaùnh
ñoäng maïch lôùn.
Beänh ñöôïc moâ taû laàn ñaàu tieân bôûi moät
nhaø Nhaõn khoa ngöôøi Nhaät:Takayasu
vaøo naêm 1908.

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BEÄNH TAKAYASU
Thöôøng gaëp ôû ngöôøi treû <40 tuoåi,
Nöõ/Nam=8/1.
Beänh laøm taêng saûn lôùp Intima,thoaùi hoùa
lôùp Media vaø xô hoùa lôùp Adventitia
Haäu quaû laø laøm heïp loøng ñoaïn ñoäng
maïch bò toån thöông 85% soá cas,laøm
giaõn loøng ñoäng maïch 2% soá cas vaø vöøa
heïp vöøa giaõn chieám 13% soá cas.

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BEÄNH TAKAYASU
THORACIC AORTOGRAM:No direct filling of any of the major arteries arising from
the aorta except the coronary arteries.
Delayed film (right):collateral channels faintly fill the carotid and vertebral systems.

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BEÄNH TAKAYASU
-Clinical features of coarctation.
-”rat-tail” angiographic appearance of
the descending aorta.

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BEÄNH TAKAYASU
Stenosis in a long segment of
the aorta (thoracoabdominal)
extending across the aortic
hiatus of the diaphragm.

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BEÄNH TAKAYASU
-Ascending aortic aneurysm.
-Stenosis of the proximal left common
carotid artery (arrowheads) and left
subclavian artery (open arrowheads).

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BEÄNH TAKAYASU
Extensive thin-line
calcification associated with
a diffusely dilated aorta in a
30-year-old woman.
TAKAYASU’S ARTERITIS

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BEÄNH CÔ TIM
ÑAÏI CÖÔNG
Nguyeân nhaân:
Theå tieân phaùt:Chöa roõ.
Theå thöù phaùt:Ngoä ñoäc,Nhieãm truøng,
Bieán döôõng.

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BEÄNH CÔ TIM
ÑAÏI CÖÔNG
Phaân loaïi:
Beänh cô tim giaõn nôû (Dilated
cardiomyopathy).
Beänh cô tim phì ñaïi (Hypertrophic
obstructive cardiomyopathy).
Beänh cô tim haïn cheá (Restrictive
cardiomyopathy).

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BEÄNH CÔ TIM
BEÄNH CÔ TIM GIAÕN NÔÛ
Coøn goïi laø Beänh cô tim sung huyeát.
Nguyeân nhaân:Phaàn lôùn khoâng tìm ra
nguyeân nhaân.
Di truyeàn:6,5%.
Dinh döôõng:Thieáu Vitamin B1.
Nghieän röôïu,Thuoác (Adriamycine).
Nhieãm truøng (Vi khuaån,virus).
Beänh collagen maïch maùu.
Sau sanh…

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BEÄNH CÔ TIM
Laâm saøng:Thöôøng thaàm laëng vaø töø töø.
Khôûi ñaàu thöôøng laø Suy tim.
Coù töøng ñôït Nhoài maùu phoåi.
Coù khi loaïn nhòp.
Coù theå ñoät töû.

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BEÄNH CÔ TIM
X quang:
Giaõn nôû caùc buoàng tim+Co boùp
keùm Tim to hình baàu,deã laàm vôùi
Traøn dòch maøng tim,Beänh Ebstein.
Hôû van 2 laù,Hôû van 3 laù.
Taùi phaân phoái tuaàn hoaøn phoåi.

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BEÄNH CÔ TIM
Sieâu aâm:
Giaõn roäng caùc buoàng tim.
EF giaûm roõ.
Thöôøng coù spontaneous contrast
(“smoke”) trong buoàng Thaát (T),coù theå
thaáy Huyeát khoái trong Thaát (T).
Hôû van 2 laù,3 laù.

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM
-Enlarged all chambers.
-Redistribution.
-Slight pulmonary edema.
-Small right pleural effusion.
AFTER FULL TREATMENT
-Normal heart size.
-Normal pulmonary vasculature.

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BEÄNH CÔ TIM
BEÄNH CÔ TIM PHÌ ÑAÏI
Ñaëc ñieåm laø phì ñaïi khoâng ñoái xöùng
Thaát (T) (Vaùch lieân thaát daøy hôn thaønh
sau thaát (T)) vaø buoàng tim khoâng giaõn.
Nguyeân nhaân:
Di truyeàn:50%.
Taêng Catecholamin.
Roái loaïn chuyeån hoùa Calci.

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BEÄNH CÔ TIM
Cô cheá:
Thaønh thaát daøy do phì ñaïi caùc teá baøo
cô tim Caûn trôû söï höùng ñaày maùu.
Do söï daøy khoâng caân ñoái cuûa vaùch
lieân thaát Ngheõn buoàng toáng Thaát(T).
Do coät cô bò dòch chuyeån ra
tröôùc Chuyeån ñoäng ra tröôùc cuûa van
2 laù trong thì taâm thu Hôû van 2 laù.

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BEÄNH CÔ TIM
Laâm saøng:
Khoù thôû do RLCN taâm tröông Thaát (T).
Côn ñau thaét ngöïc:Thieáu maùu cô tim
do taêng khoái löôïng cô tim.
Ngaát khi gaéng söùc:do loaïn nhòp,coù theå
ñoät töû.

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BEÄNH CÔ TIM
X quang:
Tim to ít hoaëc vöøa.
Neáu coù Hôû van 2 laù thì Nhó (T) to.
Angiography:Loøng tim nhoû,hôû van 2 laù.
Chaån ñoaùn phaân bieät:
Heïp van ÑMC (Beänh cô tim phì ñaïi
khoâng coù phình ÑMC leân).
Hieän nay chaån ñoaùn nhôø Sieâu aâm,MRI.

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BEÄNH CÔ TIM
Sieâu aâm:
ASH (+):Asymmetric septal hypertrophy.
(Duøng TM mode ño ôû thì taâm tröông:
IVS/LVPW≥1,3).
SAM (+):Systolic anterior motion of MV.
Ngheõn buoàng toáng Thaát (T)(△P thay ñoåi
moãi ngaøy).
Hôû 2 laù vôùi ñoä naëng thay ñoåi moãi ngaøy.

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM
Extreme left ventricular hypertrophy

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BEÄNH CÔ TIM
End-diastolic RAO left
ventriculogram Normal
size and shape of the
left ventricle.
End-systolic RAO left ventriculogram
Small left ventricular cavity with mild mitral
regurgitation.Increased distance between the
ventricular cavity and the coronary arteries
Myocardium becomes thickened in systole
HCM (Hypertrophic cardiomyopathy).

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM
Asymmetric septal thickening (23mm) and a small left ventricular cavity.

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BEÄNH CÔ TIM
End-diastolic magnetic
resonance angiogram
Asymmetric hypertrophy
with septal thickening (S).
End-systolic magnetic
resonance angiogram
Myocardial thickening that
affects the entire myocardium.

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BEÄNH CÔ TIM
Oblique cine MRA (outfow 2-
chamber view) Prolapse
(arrow) of the posterior mitral
leaflet in early systole.
Oblique cine MRA (outfow 2-
chamber view) Prolapse of the
posterior mitral leaflet with a small
signal intensity loss due to
regurgitation (arrow) HCM.

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MRA
NORMAL HEART

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MRA
NORMAL HEART

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BEÄNH CÔ TIM
HYPERTROPHIC CARDIOMYOPATHY
Myocardial hypertrophy

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BEÄNH CÔ TIM
HYPERTROPHIC CARDIOMYOPATHY
Myocardial hypertrophy

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BEÄNH CÔ TIM
BEÄNH CÔ TIM HAÏN CHEÁ
Coøn goïi laø Beänh cô tim thaâm nhieãm,ñaëc
tröng bôûi baát thöôøng chöùc naêng taâm
tröông(Taêng ñoä cöùng vaùch tim Haïn
cheá ñoå ñaày thaát),trong khi chöùc naêng
taâm thu bình thöôøng hoaëc chæ giaûm nheï.
Bieåu hieän laâm saøng gioáng nhö Vieâm
maøng tim co thaét maïn tính.

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BEÄNH CÔ TIM
Nguyeân nhaân:
Amyloidosis.
Sarcoidosis.
Hemochromatosis.
Loeffler’s eosinophilic endocarditis.
Infiltration leuceùmique.
Fibrose endomyocardique.

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM
Trong ñoù hay gaëp nhaát laø Amyloidosis.
Do laéng ñoïng moät protein baát thöôøng
ôû nhieàu moâ,cô quan.
Thaâm nhieãm laøm daøy taát caû caùc thaønh
phaàn cuûa tim:cô,vaùch,van Hôû taát caû
caùc van tim.
TDMT töø ít ñeán vöøa.
20% beänh nhaân cheát vì Suy tim.

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BEÄNH CÔ TIM
-Amyloid infiltration in the
ventricular septum,left
ventricular free wall and
apex (arrows).
-Enlarged atria.

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BEÄNH CÔ TIM
Laâm saøng: Beänh lyù hieám.
Meät khi gaéng söùc.
Phuø chi.
Suy tim.
X quang:
Tim to ít.
Taêng aùp TM phoåi.
ÑM phoåi (P) & (T) to ít.

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BEÄNH CÔ TIM
Sieâu aâm:
Daøy ñoái xöùng Thaát (T).
Thaønh sau Thaát (T) vaø vaùch lieân thaát
coù hoài aâm laám taám (ground-glass).
Hôû van 2 laù,3 laù naëng hôn Hôû van
ÑMC,ÑMP.
TDMT (+) (++).

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BEÄNH CÔ TIM
Heïp TM phoåi.
Myxome nhó (T).
Vieâm maøng ngoaøi tim co thaét.
Chaån ñoaùn xaùc ñònh:Giaûi phaãu beänh.

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BEÄNH CÔ TIM

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BEÄNH CÔ TIM
-Thickening of the LV due to
infiltration.
-Thickening of the valves
and biatrial enlargement.

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BEÄNH CÔ TIM
SPIN-ECHO MRI:
-Variable high density signal within
the myocardium.
-Dilated right atrium (closed curved
arrow).
-Enlarged IVC (open curved arrow).
-IVS has an abnormal contour
(straight arrow) High right
ventricular pressures.
RESTRICTIVE CARDIOMYOPATHY
(AMYLOID CARDIOMYOPATHY).

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LEFT VENTRICULAR ABNORMALITIES
IN THE CARDIOMYOPATHIES
DILATED RESTRICTIVE HYPERTROPHIC
1.LV cavity size
2.Free wall
thickness
3.Mitral
regurgitation
4.Wall motion
5.Mural thrombi
6.Systolic
function
7.Diastolic
function
8.Ejection
fraction
9.Cardiac output
-Increased
-Slightly increased,
normal,or decreased
-Mild to moderate
-Global hypokinesis
-Frequently
-Decreased
-Normal
-Decreased
-Decreased
-Normal to increased
-Slightly to
moderately increased
-Variable
-Normal to decreased
-Occasionally
-Normal
-Decreased
-Septal to free wall ratio
> 1.3
-Obstruction(-):none to mild
Obstruction(+):mild to severe
-Hyperkinetic
-None
-Decreased,normal,or
increased

6/19/2013 131
NHOÀI MAÙU CÔ TIM & BIEÁN CHÖÙNG
THIEÁU MAÙU CÔ TIM
Goïi laø Thieáu maùu cuïc boä cô tim hay Suy
ñoäng maïch vaønh maïn khi cô tim khoâng
ñöôïc töôùi maùu ñaày ñuû do beänh lyù cuûa
ñoäng maïch vaønh.
Coù nhieàu nguyeân nhaân,nhöng >90% laø
do Xô vöõa ñoäng maïch.

6/19/2013 132
Chaån ñoaùn döïa vào:Lâm sàng, ECG, các
men tim, Sieâu aâm,Chuïp ÑM vaønh,
MSCT,MRI,nhấp nháy đồ.
X quang qui öôùc:
Boùng tim bình thöôøng.
Ñoùng voâi ôû ÑM vaønh.

6/19/2013 133

6/19/2013 134
RIGHT CORONARY ARTERY
A.Plaque of atheroma (arrow).
B.Encircled lumen of the artery
(arrow-two years later).

6/19/2013 135
Calcification of the proximal branches of both anterior
descending and circumflex coronary arteries.

6/19/2013 136
Calcification in the left anterior
descending (LAD) and the left
circumflex arteries.

6/19/2013 137
Calcification in the left
main coronary artery

6/19/2013 138
COLORS ALL STRUCTURES WITH AN
ATTENUATION OF GREATER THAN
130HU PINK No calcium is present
in the LAD or diagonal branch.
Calcification in the LAD artery.

6/19/2013 139
Calcification in the LM, LAD
arteries.
Calcification in the circumflex
artery

6/19/2013 141

6/19/2013 142

Động mạch vành
xuống trước trái

6/19/2013 147
Normal perfusion
Myocardial ischemia:LAD and right
coronary artery territories.

6/19/2013 148
NHOÀI MAÙU CÔ TIM
Beänh coù taàn suaát töû vong cao #30%.
90% ôû beänh nhaân Xô vöõa ñoäng maïch.
Maûng xô vöõa bò nöùt,loeùt taïo laäp cuïc
maùu ñoâng laøm taéc ngheõn caáp tính ÑMV.

6/19/2013 149
Hoäi chöùng Suy ÑMV caáp (laâm saøng):
Taéc ngheõn ÑMV taïm thôøi<30 phuùt:
Côn ñau thaét ngöïc khoâng oån ñònh.
Taéc ngheõn ÑMV<60 phuùt:
Nhoài maùu cô tim khoâng soùng Q.
Taéc ngheõn ÑMV>60 phuùt:
Nhoài maùu cô tim coù soùng Q.

6/19/2013 150
X quang qui öôùc:
Boùng tim hôi to hoaëc to.
OAP khi vuøng nhoài maùu >25% khoái
thaát (T).

6/19/2013 151
-Enlarged heart size.
-Pulmonary edema due to left
heart failure.
ACUTE MYOCARDIAL INFARCTION

6/19/2013 152
BIEÁN CHÖÙNG
Thoâng lieân thaát:0,5-1% caùc tröôøng hôïp.
Xuaát hieän vaøi tuaàn vaøi thaùng sau NMCT.
2/3 naèm ôû phaàn tröôùc gaàn moûm.1/3 naèm
ôû phaàn sau.
Hoäi chöùng Dressler:<20%.
Xuaát hieän vaøi tuaàn vaøi thaùng sau NMCT.
Tim to do Traøn dòch maøng tim.
Traøn dòch maøng phoåi,Vieâm ñaùy phoåi.

6/19/2013 153
BIEÁN CHÖÙNG
6 weeks after myocardial infarction:
-Pericardial effusion.
-Bilateral pleural effusions.
-Consolidation of the left lung base. DRESSLER’S SYNDROME

6/19/2013 154
BIEÁN CHÖÙNG
4 weeks after myocardial
infarction:
-Pericardial effusion.
-Left pleural effusion.
-Consolidation of the left
lung base.
6 weeks later.
-Decreased heart size.
-Decreased
pleuropneumonic process.
3 months later.
-Normal heart size.
-Normal lung fields.
DRESSLER’S SYNDROME

6/19/2013 155
BIEÁN CHÖÙNG
Phình thaát:12-15% caùc tröôøng hôïp.
True aneurysm: NMCT Phình thaát.
Thöôøng ôû vuøng moûm phía tröôùc.
False aneurysm: Leõ ra vôõ tim nhöng
nhôø maøng ngoaøi tim bao boïc Phình
to ra.Thöôøng ôû vuøng sau beân hoaëc
maët döôùi.
X quang:Bôø tim phình ra,coù theå ñoùng
voâi.

6/19/2013 156
BIEÁN CHÖÙNG

6/19/2013 157
BIEÁN CHÖÙNG

6/19/2013 158
BIEÁN CHÖÙNG
VENTRICULAR ANEURYSM

6/19/2013 159
BIEÁN CHÖÙNG
CALCIFICATION IN THE LEFT VENTRICULAR ANEURYSM

6/19/2013 160
BIEÁN CHÖÙNG
CALCIFIED RIGHT VENTRICULAR ANEURYSM

6/19/2013 161
BIEÁN CHÖÙNG
VENTRICULAR ANEURYSM

6/19/2013 162
BIEÁN CHÖÙNG

6/19/2013 163
BIEÁN CHÖÙNG
Thinning of the myocardial wall (arrow).
OLD SEPTAL INFARCTION

6/19/2013 164
BIEÁN CHÖÙNG
FALSE ANEURYSM

6/19/2013 165
BIEÁN CHÖÙNG
FALSE ANEURYSM

6/19/2013 166
BIEÁN CHÖÙNG
Nang maøng tim:Thöôøng ôû goùc taâm
hoaønh (P).
U tuyeán öùc:ÔÛ treân vaø tröôùc.
False aneurysm: Thöôøng vôõ,hieám
khi coøn soáng soùt (Trong vaùch khoâng
coù maïch maùu).

6/19/2013 167
BIEÁN CHÖÙNG
Ñöùt nhuù cô:1% sau NMCT.
X quang boùng tim gaàn nhö bình
thöôøng,ñoâi khi tim to do giaõn Thaát
(T),Nhó (T) tuøy möùc ñoä.
Chuïp buoàng tim,SA tim:Sa van 2
laù,van 2 laù phaát phôùi.

6/19/2013 168
BEÄNH MAØNG TIM
TRAØN DÒCH MAØNG TIM
Nguyeân nhaân:Coù raát nhieàu nguyeân nhaân.
X quang TDMT:Muoán coù thay ñoåi treân X
quang,löôïng dòch phaûi>200ml.
Bình thöôøng giöõa laù thaønh vaø laù taïng coù
# 20ml dòch giuùp maøng tim tröôït leân
nhau.

6/19/2013 169
BEÄNH MAØNG TIM
Neáu TDMT<100ml Löôïng ít.
Neáu TDMT100-500ml Löôïng vöøa.
Neáu TDMT>500ml Löôïng nhieàu.

6/19/2013 170
BEÄNH MAØNG TIM
Chæ soá T/N>0,5.Khi Traøn dòch quaù nhieàu
cho hình aûnh baàu röôïu.
Ñaëc ñieåm cuûa boùng tim to laø thay ñoåi
nhanh theo thôøi gian.
Tuaàn hoaøn phoåi giaûm haún ñi (tröôøng phoåi
saùng).
Xoùa goùc taâm hoaønh (P) khoâng ñaëc hieäu.

6/19/2013 171
BEÄNH MAØNG TIM
Phim nghieâng Epicardial fat pat sign:
Khoang maøng tim ñöôïc giôùi haïn phía
tröôùc bôûi lôùp môõ trung thaát (mediastinal
fat) vaø phía sau bôûi lôùp môõ epicardial
(epicardial fat),khi khoang naøy daøy treân
2mm Hoaëc laø daøy maøng tim,hoaëc laø
TDMT.

6/19/2013 172
BEÄNH MAØNG TIM

6/19/2013 173
BEÄNH MAØNG TIM

6/19/2013 174
BEÄNH MAØNG TIM
NORMAL PERICARDIUM
-The pericardial cavity is seen
as a high-attenuation stripe
(arrows) flanked by
mediastinal and epicardial fat.
-CS:coronary sinus.

6/19/2013 175
BEÄNH MAØNG TIM
NORMAL PERICARDIUM
-The pericardial cavity is seen
as thin band of low signal
(arrows) flanked by
mediastinal and epicardial fat.

6/19/2013 176
BEÄNH MAØNG TIM
Fluoroscopy (coù gía trò):Tim khoâng ñaäp
hoaëc giaûm ñaäp.
Phim naèm ngöûa:Dòch doàn leân treân Tim
to troøn hôn vaø cuoáng tim ngaén.
Choïc doø dòch vaø bôm hôi vaøo ta thaáy
ñöôïc möïc thuûy-khí ôû khoang maøng tim.

6/19/2013 177
BEÄNH MAØNG TIM
Beänh nhaân naèm tö theá Left lateral
decubitus: Chích CO2 vaøo tónh maïch Ño
khoaûng caùch (a) töø boùng khí ñeán bôø (P)
tim,bình thöôøng a≤ 4mm.Khi a>4mm
Traøn dòch maøng tim hoaëc daøy maøng
tim..
Ngaøy nay:Sieâu aâm chaån ñoaùn TDMT toát
hôn nhieàu (hôn X quang vaø caû CT).

6/19/2013 178
BEÄNH MAØNG TIM
Cheïn tim (cardiac tamponade):Xaûy ra
khoâng tuøy thuoäc vaøo löôïng dòch,maø tuøy
thuoäc vaøo thôøi gian taïo dòch nhanh hay
chaäm.
Laâm saøng:Khi hít vaøo,HA taâm thu giaûm
10mmHg.

6/19/2013 179
BEÄNH MAØNG TIM
X quang:
Boùng tim to nhanh theo thôøi gian.
TMCT giaõn,quai TM azygos phoàng.
Fluoroscopy:Tim ñaäp giaûm.

6/19/2013 180
BEÄNH MAØNG TIM
PERICARDIAL EFFUSION (“water-bottle” configuration)
-Enlarged heart size with clear heart border.
-Normal pulmonary vasculature.

DẤU HIỆU BẦU NƯỚC
(WATER-BOTTLE SIGN)
Tràn dịch màng tim nhiều, khiến bóng tim bè ra như bầu nước.

6/19/2013 182
BEÄNH MAØNG TIM
PERICARDIAL EFFUSION
-Clear heart border.
-Normal pulmonary vascularity.
CARDIAC FAILURE
-No clear heart border (interstitiel
edema), Kerley’s line, pleural effusion.
-Redistribution.

6/19/2013 184
BEÄNH MAØNG TIM
-Symmetric enlargement of the
cardiac silhouette (arrowheads).
-Decreased pulmonary
vasculature.
-Obliteration of the right
cardiophrenic angle (large
arrow).

6/19/2013 185
BEÄNH MAØNG TIM
Following pericardial tap and air
injection air-fluid level (large
arrow),true cardiac border
(small arrows),note the normal
thickness of the pericardium.

Sau khi chọc hút dịch màng tim

187

6/19/2013 188
BEÄNH MAØNG TIM

6/19/2013 189
BEÄNH MAØNG TIM
Water-bottle configuration.
Note the distance between
the right heart border and
the Swan-ganz catheter as
it passes through right
atrium (arrows).
Increased density of the
fluid-filled pericardiac sac
(P) is bordered anteriorly
and posteriorly by the
lucencies of the
epicardial and the
medisatinal fat.
Notice the separation
between the right
heart border of
pericardium (arrows)
and the lateral extent
of the cavity of the
RA.

6/19/2013 190
BEÄNH MAØNG TIM

6/19/2013 191
BEÄNH MAØNG TIM
INTRAVENOUS CARBON DIOXIDE INJECTION (left lateral decubitus position)
Carbon dioxide in the RA and SVC (black arrows).
The pericardiac space is widened (between white arrows).(Normal ≤ 4mm).
Either pericardial effusion or a thickened pericardium.

6/19/2013 192
BEÄNH MAØNG TIM
INTRAVENOUS CARBON DIOXIDE
INJECTION (left lateral decubitus position)
Carbon dioxide in the RA and SVC (b,d).
The pericardiac space is widened (a,c).
(Normal ≤ 4mm).
Either pericardial effusion or a thickened
pericardium.

6/19/2013 193
BEÄNH MAØNG TIM
DIAGNOSTIC PNEUMOPERICARDIUM
After removal of 25ml of
pericardial fluid and replacement
with 25ml carbon dioxide (g).
Thickened parietal pericardium
TUBERCULOUS PERICARDITIS

6/19/2013 194
BEÄNH MAØNG TIM

6/19/2013 195
BEÄNH MAØNG TIM
A band of fluid attenuation
(arrows) surrounding the heart.
SPIN-ECHO MRI:Pericardial effusion is
seen as a homogeneous signal void
(arrows) surrounding the heart,
subjacent to the pericardial fat.

6/19/2013 196
BEÄNH MAØNG TIM

6/19/2013 197
BEÄNH MAØNG TIM
SPIN-ECHO MRI:The increased signal tissue surrounding in the space
between the visceral pericardium and the external cardiac contour
(long arrows) is the inflamed parietal pericardium
TUBERCULOUS PERICARDITIS.

6/19/2013 198
BEÄNH MAØNG TIM
STAB INJURY TO THE
EPIGASTRIUM
-Fibrosis of the right
upper lobe was an
incidental finding.
A FEW DAYS LATER
-Cardiac enlargement.
-Decreased pulmonary
vasculature.
CARDIAC TAMPONADE
Following evacuation of the
pericardial blood.
Normal heart size.
(free air under the right
diaphragm due to
abdominal surgery).

6/19/2013 199
BEÄNH MAØNG TIM
SUPERIOR VENA CAVAGRAM
-Dilated SVC.
-Reflux into the azygos vein and IVC.
CARDIAC TAMPONADE

6/19/2013 200
BEÄNH MAØNG TIM
CARDIAC TAMPONADE WITH RIGHT VENTRICULAR COLLAPSE (ARROWHEADS)

6/19/2013 201
BEÄNH MAØNG TIM
VIEÂM MAØNG TIM CO THAÉT
Tuoåi 30-50,Nam/Nöõ=3/1.
Nguyeân nhaân:Sau Vieâm maøng ngoaøi tim
caáp,sau chaán thöông,sau phaãu thuaät
maøng ngoaøi tim,lao,Coxackie,
Histoplasmose, H.influenza type A,B
Autoimmune:RAA,Lupus…

6/19/2013 202
BEÄNH MAØNG TIM
X quang:
Tim khoâng to hoaëc to ít.
Nhó (T) to trong 20% tröôøng hôïp.Khi
Vieâm co thaét maùu trôû veà tim khoù khaên.
Ñoùng voâi (50%) ôû nhó (P),hieám khi ôû nhó
(T) vì maët sau khoâng coù pericarde,Thaát
(T) ít hôn thaát (P) do thaát (T) ñaäp maïnh
(Ngöôïc vôùi ñoùng voâi trong cô tim).

6/19/2013 203
BEÄNH MAØNG TIM
X quang:
TMCT giaõn do maùu khoù veà tim.
TDMP coù theå keøm theo (60%).
Chaån ñoaùn phaân bieät:Beänh cô tim haïn
cheá.
Maøng tim khoâng daøy,khoâng ñoùng voâi.
Cô tim daøy vaø söï co boùp giaûm trong 2
thì (taâm thu vaø taâm tröông).

6/19/2013 204
BEÄNH MAØNG TIM
CT vaø MRI raát coù ích trong chaån ñoaùn
Vieâm maøng ngoaøi tim co thaét.
50% beänh nhaân coù voâi hoùa maøng ngoaøi
tim,deã daøng nhaän thaáy treân CT.
Daøy maøng tim deã thaáy treân MRI.

6/19/2013 205
BEÄNH MAØNG TIM
-Normal heart size.
-Dilated SVC (arrows).
-Dilated azygos vein (arrowheads).
-Dilated HV.
-Dilated IVC.
CONSTRICTIVE PERICARDITIS

6/19/2013 206
BEÄNH MAØNG TIM
SPIN-ECHO MRI: Intermediate signal intensity band between the
epicardial fat and the pericardial fat (curved arrow and black arrows)
is thickened pericardium CONSTRICTIVE PERICARDITIS

6/19/2013 207
BEÄNH MAØNG TIM
The pericardium is irregularly thickened (arrows)
CONSTRICTIVE PERICARDITIS.

6/19/2013 208
BEÄNH MAØNG TIM
PERICARDIAL CALCIFICATION (RIGHT VENTRICLE)

6/19/2013 209
BEÄNH MAØNG TIM

6/19/2013 210
BEÄNH MAØNG TIM
Pericardial calcification (closed arrow).
Dilated IVC (open arrow). CONSTRICTIVE PERICARDITIS.

6/19/2013 211
BEÄNH MAØNG TIM
CONSTRICTIVE PERICARDITIS
Thickening of
the pericardium

6/19/2013 212
BEÄNH MAØNG TIM
NANG MAØNG TIM
3/4 naèm beân (P),1/4 naèm beân (T).
Hieám khi coù caû 2 beân,luùc ñoù seõ khoù
phaân bieät vôùi TDMT.
Hình nghieâng:Nang naèm phía tröôùc
döôùi.
Sieâu aâm:Hình aûnh echo troáng (Spring-
water cyst).
Chaån ñoaùn phaân bieät:Môõ ngoaøi maøng
tim (CT ño tyû troïng)

6/19/2013 213
BEÄNH MAØNG TIM
NANG MAØNG TIM
PERICARDIAL CYST

6/19/2013 214
BEÄNH MAØNG TIM
NANG MAØNG TIM
CALCIFIED PERICARDIAL CYST

6/19/2013 215
BEÄNH MAØNG TIM
NANG MAØNG TIM

6/19/2013 216
BEÄNH MAØNG TIM
NANG MAØNG TIM
PERICARDIAL CYST

6/19/2013 217
BEÄNH MAØNG TIM
NANG MAØNG TIM
PERICARDIAL CYST / ASBESTOSIS

6/19/2013 218
BEÄNH MAØNG TIM
NANG MAØNG TIM
PERICARDIAL CYST

6/19/2013 219
BEÄNH MAØNG TIM
MÔÕ NGOAØI MAØNG TIM
Thöôøng coù nhöng khoâng nhieàu.
Moät soá tröôøng hôïp lôùp môõ naøy to nhö
moät lipoma Boùng tim to ra.
Sieâu aâm:Echo keùm (khoù chaån ñoaùn
phaân bieät vôùi Xuaát huyeát).
CT:chaån ñoaùn chính xaùc nhôø ño tyû
troïng.

6/19/2013 220
BEÄNH MAØNG TIM

6/19/2013 221
BEÄNH MAØNG TIM

Chest X Ray of 54 y. old
male patient for heath
check up.

224
No dyspnea,no dysphagia
Normal ECG and cardiac US.

CT scan shows
low attenuation
structure around
the heart
Mediastinal
lipomatosis

226 June 19, 2013
CẢM ƠN QUÝ VỊ ĐÃ QUAN TÂM THEO DÕI

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