The document discusses diagnostic radiology of the cardiovascular system. It provides details on basic X-ray features of heart conditions and describes common diseases including rheumatic heart disease, ischemic heart disease, congenital heart diseases like atrial septal defect and Tetralogy of Fallot. For specific conditions like mitral stenosis, it outlines the hemodynamics, typical X-ray appearances and key diagnostic features.

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. Basic X-ray features Heart dislocation Heart enlargement Abnormal pulmonary blood flow Changes of aorta Pericardial abnormal findings /231 methods normal abnormities diseases

3. Basic X-ray features Changes of pericardium Normal pericardium Pericardial anomalies Pericardial effusion Acute pericarditis Pericardial thickening 、 calcification Chronic pericarditis Constrictive pericarditis /231 methods normal abnormities diseases

4. Basic X-ray features Changes of pericardium Normal pericardium /231 methods normal abnormities diseases

5. Normal pericardium Inner serous layer is the epicardium Outer fibrous layer is pericardium Space between the two is pericardial space Normally contains about 20-50cc of fluid Fat covers outside of heart and outside of pericardium sandwiching pericardial space between the two layers Normal thickness of pericardium (parietal pericardium and fluid in space) is 2-4 mm Requires about 150-250cc before cardiac tamponade occurs

6. Basic X-ray features Changes of pericardium Normal pericardium Pericardial anomalies Pericardial effusion Acute pericarditis Pericardial thickening 、 calcification Chronic pericarditis Constrictive pericarditis /231 methods normal abnormities diseases

7. Pericardial effusion X-ray appearance ： Direct sign ： Heart shadow generally enlarge bilaterally “ water-bottle” or “flask” shape, globular Contour of cardiac border disappear Pulsation of the cardiac border weaken or disappear, but the aortal pulsation is normal Indirect sign ： Vena systemica return obstructed, right ventricle output decreased Superior vena cava widen Decreased lung markings Aortal shadow smaller Cardiac tamponade – impedes diastolic filling /231 Tuberculosis rheumatism uraemia virus neoplasm Fluid: Transudation exudation blood methods normal abnormities diseases

8. Pericardial effusion Pericardial effusion on both lateral chest radiograph and axial CT. Red arrow points to fat outside of pericardium. Green arrow points to pericardial space which is 8 mm in this patient (<4 mm is normal.) The yellow arrow points to fat outside of heart and the blue arrow to the myocardium.

9. Pericardial effusion

10. Pericardial effusion “ water-bottle” “flask” shape Globular shape methods normal abnormities diseases

11. Pericardial effusion general enlarge bilaterally Widened SVC methods normal abnormities diseases

12. Pericardial effusion /231 erect position supine position methods normal abnormities diseases

13. Pericardial thickening 、 calcification thickening ： Pericardium near the diaphragm (ventricular face) thicken obviously but the atrium aera and the root of the great vessels less thicken Epicardial fat pad ‘sign’ (+) Lat. / PA view: anterior pericardial stripe ＞ 2mm Hemodynamic change: Right ventricle compression ： venous return obstructed, vena cervicalis and vena cava dilatation Left ventricle compression ： left atrium and pulmonary venous pressure increased, so the left heart output decreased /231 methods normal abnormities diseases

14. Constrictive pericarditis X-ray ： Direct sign ： The heart shadow size is normal or little, midium enlarged A side or both sides of heart borders straighten, the demarcation among each arcus is undefined; contour: triangle , globular Heart pulsation weaken or disappear; the portion without thickened can bulge, and it’s pulsation enhanced Pericardial calcification ： eggshell, barred, patching, Pleural thickening, adhesion Indirect sign ： VP ↑ Superior vena cava dilatation Pulmonary venous hypertension /231 胸膜肥厚 methods normal abnormities diseases

15. Constrictive pericarditis /231 methods normal abnormities diseases

16. Pericardial calcification

17. Constrictive pericarditis - RA enlargement

18. Constrictive pericarditis - RA enlargement

19. Constrictive pericarditis - RA enlargement

20. Diagnostic Radiology of Cardiovascular System /231 Imaging methods normal appearances abnormities diseases methods normal abnormities diseases

21. Common disease of heart and great vessels Rheumatic heart disease Mitral stenosis Mitral regurgitation Ischemic heart disease Coronary artery disease Congenitial heart disease ASD Tetralogy of Fallot /231 method normal abnormities diseases

22. Rheumatic heart disease Involved valve ： Mitral valve 、 Aortic valve 、 Tricuspid valve Pathology ： Mitral valve stenosis : Valve ring cicatricle contraction Mitral valve insufficiency : /231 methods normal abnormities diseases

23. Mitral Stenosis Rheumatic Valvular Heart Disease Rheumatic heart disease causes mitral stenosis in 99.8% of cases

24. Right Ventricular Hypertrophy Stenotic mitral valve © Frank Netter, MD Novartis®

25. Mitral stenosis occurs Left atrial pressure  Left atrium enlarges Cephalization PIE PAH develops PVR increases RV enlarges Pulmonic regurg develops Tricuspid annulus dilates Tricuspid insufficiency RV failure Time course of MS in adult © Frank Netter, MD Novartis®

26.  Pulmonary venous and capillary pressure Effect of Mitral Stenosis On Lungs

27. Mitral stenosis hemodynamics /231 Mitral valve stenosis Left atrial output obstructed LV engorge insufficiently LA pressure increase & dilate Pulmonary venous hypertension, interstitial pulmonary edema RV burden increase & enlarge aortic knob shrink LV and aortic knob shrink methods normal abnormities diseases

28. Mitral stenosis X-ray appearance ： Cardiac type ：“ mitral configuration ” LA & RV enlarged ------- pulmonary artery segment Convexity LV shrink, Straightening of left heart border ------- Aortic knob shrink valvular calcification Pulmonary venous hypertension, interstitial pulmonary edema Hemosiderin deposited ： 1-2mm nodular shadow /231 LA enlargement PA – right border ： Double density of left atrial enlargement , double PA – left border ： left atrial appendage enlargement Lat & RAO ： esophagus compressed Elevation of left mainstem bronchus RV enlargement pulmonary artery segment Convexity Lat ： contact between the front surface of heart and the sternum (anterior chest wall) >1/3 methods normal abnormities diseases

29. Mitral stenosis /231 Four arus, diplopia, Pulmonary venous hypertension LA enlargement PA – right border ： double density PA – left border ： left atrial appendage enlargement Lat & RAO ： esophagus compressed methods normal abnormities diseases

30. Mitral stenosis LA LV RV LA LV LV LA Valve calcification Lat Cor

31. Mitral stenosis LA LV LA LV LA RV LV RA RV

32. Mitral stenosis LA LV LV LA RV RA

33. Mitral stenosis LA,RV enlarge, Hemosiderin pigmentation RV enlargement pulmonary artery segment Convexity Lat ： contact between the front surface of heart and the sternum (anterior chest wall) >1/3 methods normal abnormities diseases

34. Mitral stenosis /231 methods normal abnormities diseases

35. Mitral stenosis LA enlarge ： esophagus compression, diplopia RV enlarge: heart touch the anterior chest wall ＞ 1/3 LA enlargement PA – right border ： double density PA – left border ： left atrial appendage enlargement Lat & RAO ： esophagus compressed methods normal abnormities diseases

36. Mitral stenosis PV hypertension enlarged MPA Cephalization methods normal abnormities diseases

37. Mitral stenosis --- Hemosiderin deposited /231 methods normal abnormities diseases

38. Mitral stenosis—pulmonary interstitial edema-- Kerley’s B-line /231 Perpendicular to the chest wall methods normal abnormities diseases

39. Common disease of heart and great vessels Rheumatic heart disease Mitral stenosis Mitral regurgitation Ischemic heart disease Coronary artery disease Congenitial heart disease ASD Fallot 4 /231 method normal abnormities diseases

41. Coronary artery disease Myocardium O 2 supply insufficient Caused by severe coronary artery stenosis Atherosclerosis , spasm , thrombosis Myocardial infarction

42. Coronary artery CTA MIP With Contrast Medium

43. VRT Recon. Normal Coronary artery CTA

44. 前降支和旋支 前降支和对角支 前降支和旋支 心底部冠脉供血 正常冠脉 MIP 重建

45. 正常冠状动脉 CT ： 119148

46. Ischemic heart disease LV enlargement PA – cardiac apex extending to left and down left ventricle segment extended,rounded,expand to left Lat ： retrocardiac space become narrowed or disappeared, esophageal space disappeaered Aorta enlarged methods normal abnormities diseases

47. Ischemic heart disease cardiomegaly methods normal abnormities diseases

48. Multi-slice spiral CT /231 Plain scan Calcification in the coronary A. wall methods normal abnormities diseases

49. Coronary artery CTA Negative prediction 100 ％ positive prediction 80 ～ 88 ％

50. Coronary artery calcification & soft plaque

51. Coronary artery soft plaque

52. Coronary artery stenosis DSA

53. Myocardial infarction /231 Real time : infarcted myocardium non-enhanced Delay enhancement in the infarcted myocardium methods normal abnormities diseases

55. Common disease of heart and great vessels Rheumatic heart disease Mitral stenosis Mitral regurgitation Ischemic heart disease Coronary artery disease Congenitial heart disease ASD Fallot 4 /231 method normal abnormities diseases

56. Congenital heart disease Classification ： Hemodynamics ： left to right shunt, right to left shunt, no shunt Clinic ： cyanotic, non- cyanotic X-ray: increased pulmonary blood flow , pulmonary oligemia, LBV no change pathological changes ： Atrial septal defect （ ASD ） Ventricualr septal defect （ VSD ） Tetralogy of Fallot （ F4 ） Patent ductus arteriosus （ PDA ） Pulmonary stenosis （ PS ） /231 method normal abnormities diseases

57. ASD Right atrium open looking into left atrium through ASD Normal © Frank Netter, MD Novartis® fossa ovalis

58. ASD----hemodynamics /231 Left -> right shunt But depend on the P. Vscular resistance RA LA RA flow ↑ RV flow ↑ PBF↑ RA hypertrophy dilatation RV hypertrophy dilatation pulmonary hypertension Right heart failure methods normal abnormities diseases

59. Discontinuity in the atrial septum with systolic signal void consistent with L->R shunt on atrial level Right atrium is mildly dilated; RV, LV and LA size are normal SCMR Auckland MRI

60. ASD Clinic mostly adult SM on the 2th-3rd intercostal of the left sternal border Change of hemodynamics X-ray appearance Cardiomegaly , “mitral configuration” RA & RV↑ , RA↑ ↑ obviously Pulmonary artery segment bulge ， hilum angiectasia, hilum dance pulmonary blood flow↑ ↑. PAH in later stage LA do not enlarge, LV and aorta shrink /231 4 type: Ostium primum , ostium secundum Sinus venosus , coronary sinus Fossa Ovalis defect 80~90% Atrial septal defect methods normal abnormities diseases

61. ASD RA RA

62. ASD aorta shrink RA & RV↑ , RA↑ ↑ obviously RA RV PA Aorta svc

63. ASD RA & RV↑ , RA↑ ↑ obviously

64. ASD /231 Enlargement of RA methods normal abnormities diseases RA RV PA Aorta svc

65. ASD /231 methods normal abnormities diseases

66. ASD /231 Preoperative Postoperative methods normal abnormities diseases

67. ASD /231 Pulmonary hypertension methods normal abnormities diseases RA RV PA Aorta svc

68. ASD Prominent pulmonary vessels Prominent MPA Normal left atrium

69. Tetralogy of Fallot Most common CHD with hematoasthenia and cyanosis Including four anomalies : Pulmonary stenosis Ventricular septal defect Aortic overriding Hypertrophy of the RV Radiologic findings Cardiac apex displaced upward “coer en sabot” PA segment concave Decreased vasculature R aortic arch in 25% /231 methods normal abnormities diseases

70. Fallot’s tetralogy /231 methods normal abnormities diseases

71. Tetralogy of Fallot

72. Tetralogy of Fallot

73. Tetralogy of Fallot /231 methods normal abnormities diseases

74. F4 Aortic overriding Pulmonary stenosis right->left shunt RV hypertrophy LA RV MR:41655

75. F4 MR:41655