This document discusses various cardiovascular imaging modalities including their uses, strengths, and limitations. It covers modalities such as chest x-ray, echocardiography, nuclear medicine studies, MRI, CT, ultrasound, and invasive angiography. For each modality, it provides examples of what cardiovascular structures or conditions they can best evaluate such as valve function, wall motion, perfusion, coronary arteries, aneurysms, and more. It also notes some modalities may be used for both diagnostic and interventional purposes.

1. Cardiovascular Imaging M. J. McCowin, MD Clinical Professor of Radiology, UCSF G. Caputo, MD Professor of Radiology, UCD

2. Cardiac Imaging studies requested before Cardiology consult Chest x-ray (L. Antonietti, MD) Nuclear Medicine Echocardiography ?MRI ?CT

3. Chest x-ray Cardiac Contour size and shape Poor for pericardial effusions Left ventricular failure Right ventricular failure

4. PA heart < ½ chest diameter

5. Chamber Enlargement LA LV RV RA LV RV la append LA

6. Cardiac Contours: enlarged RA, LA, and RV in mitral stenosis

7. New enlarged LV due to aneurysm

8. Aortic Valve calcified due to AS

9. 4 chamber enlargement due to MS/MI

10. PA and Lateral vs AP portable

11. Magnification of the heart with AP portable x-ray PA in Radiology AP as a portable

13. Large Cardiac Contour

14. Large cardiac contour AP portable magnifies Lordotic film magnif Kyphotic film minim Rotation changes Pericardial effusion looks like cardiomegaly

15. Heart Failure RIGHT HEART 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

16. Relationship of aortic arch,pa,azyg v. to trach carina

17. Heart Failure

18. Interstitial Edema Bronchovascular thickening and indistinctness Vessels get bigger and busier Vessels seen more to the periphery Kerley lines (less common)

19. Which vessels are bigger, busier,more peripheral?

20. Dry Wet

21. Airspace Edema May be cardiogenic or non-cardiogenic Very non-specific: aspiration, atypical pna, hemorrhage, etc. ARDS will persist and become coarse over time

22. Air-space edema

23. 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

24. Nuclear Med. Perfusion Studies: Thallium (potassium-like is extracted in K-ATPase pump), Sestamibi etc. Normal Stress Rest Perfusion stress rest stress rest

25. Cardiac anatomy as seen in SPECT nuclear imaging short axis, horiz. long., vert .long.

26. Diagram of short axis perfusion images: Would you pay full price for this donut? YES! the “ donut” is all there. (normal septal thinning)

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

28. Circumferential data confirms reversible inferoseptal ischemia

29. Reversible ischemia ( ant/sept/apex) & stress-induced lv dilation Transient ischemic myocardial dysfunction S R R S R S

30. Fixed lateral perfusion deficit. ( fixed “bite out of donut”) stress rest stress rest

31. Cardiac Wall Motion with quantitative ejection fraction (chemo rx)

32. Regional wall motion

33. 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

34. MRA cong double arch post-op ligation of left arch

35. Dilated LV and RA

36. Ao valv, pap muscle, rt pleural fluid, dilated lv

37. Coronal MRI shows aorta, av, lv (can eval for stenosis and regurg) Spin echo “black blood” anatomy Gradient echo “white blood” function & flow

61. CT coronary angiography

62. CT coronary angiography

63. CT coronary angiography

65. 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

66. Ultrasound Abdominal Aortic Aneurysm Carotid Artery Disease (Atherosclerosis) Peripheral artery disease Vascular shunt evaluation Venous disease: DVT etc.

67. Ultrasound of Carotid Artery CCA ICA ECA

68. Ultrasound of Carotid Artery note: brain, kidneys, heart must have both systolic & diastolic flow systole diastole

69. Atherosclerotic Plaque

70. Ultrasound for Venous Dx

71. 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

72. Abdominal Aortic Aneurysm

73. Abdominal Aortic Aneurysm MR

74. Abdominal Aortic Aneurysm CTA with 3D Rendering

75. R/o aortic dissection CTA MRA TEE

76. MRA for central and peripheral Arteries and veins

78. Aortic Trauma

79. Aortic Trauma

80. 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.

81. Pulmonary Artery Emboli Nuclear Medicine Perfusion Scan

82. CTAngiography for pulmonary artery emboli

83. Peripheral Vascular Disease

84. PVD after balloon Rx

85. Endovascular Stents

86. Endovascular repair of aneurysm

87. Endovascular repair of aneurysm

88. Acute Chest Pain: will CTA become the one stop shop?

89. CTAngiography for pulmonary artery emboli

90. Aortic dissection

91. CT coronary angiography

92. 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!

93. 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 !