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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.

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

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Cadiovascular Anatomy

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heart

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<ul><li>多层螺旋心脏大血管 CTA </li></ul><ul><li>（三维重建图） </li></ul>

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多层螺旋心脏大血管 CTA （三维重建图）

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Methods <ul><li>X-ray </li></ul><ul><ul><li>Fluoroscopy </li></ul></ul><ul><ul><li>Plain radiography ? </li></ul></ul><ul><li>Angiocardiography & DSA </li></ul><ul><li>CT & CTA </li></ul><ul><li>MRI & MRA </li></ul><ul><li>Echocardiography (US) </li></ul><ul><li>Nuclear medicine </li></ul>

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X-ray---- PA view ----high KV, 2M /231 X-ray methods normal abnormities diseases

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X-ray---- Lat view /231 <ul><li>left lateral </li></ul>X-ray methods normal abnormities diseases

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Observing the chest plain film <ul><li>The size, shape, and position of the heart </li></ul><ul><li>The state of the lungs and pulmonary vessels </li></ul><ul><li>Aorta and cardiac calcifications </li></ul>methods normal abnormities diseases

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Normal appearance <ul><li>right ventricle, atrium : front </li></ul><ul><li>left ventricle, atrium : behind </li></ul>/231 <ul><li>Location of the heart ： </li></ul><ul><ul><li>2 / 3 on the left side of midline ， 1/ 3 on the right side </li></ul></ul><ul><ul><li>apex of heart point to left bottom ， oblique axis </li></ul></ul>methods normal abnormities diseases

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Normal appearance ----PA View <ul><li>Composition ： </li></ul><ul><ul><li>Right border of heart ： </li></ul></ul><ul><ul><ul><li>aorta （ old ）、 superior vena cava （ youth ） </li></ul></ul></ul><ul><ul><ul><li>right atrium </li></ul></ul></ul><ul><ul><li>Left border of heart ： </li></ul></ul><ul><ul><ul><li>aortic bulb ： aortic arch </li></ul></ul></ul><ul><ul><ul><li>pulmonary artery segment （ cardiac waist ）： main pulmonary artery </li></ul></ul></ul><ul><ul><ul><li>left ventricle ： </li></ul></ul></ul>/231 Upper 1/2 Lower 1/2 midline methods normal abnormities diseases 70 20

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<ul><li>Aorta arch below the clavicle, 2.0±1.0cm </li></ul><ul><li>aorta arch wider and higher –eldly, high BP </li></ul><ul><li>no aorta knob -- right aorta arch – variation </li></ul><ul><li>aorticopulmonary window – small indentation of the lung into the mediastinum, between the arch and left PA </li></ul>

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PA view /231 Left atrium PV PA methods normal abnormities diseases

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Normal appearance ---- Lat. view <ul><li>Composition: </li></ul><ul><ul><li>Anterior border of heart </li></ul></ul><ul><ul><ul><li>Ascending aorta </li></ul></ul></ul><ul><ul><ul><li>The infundibular of the right ventricle, pulmonary trunk </li></ul></ul></ul><ul><ul><ul><li>Anterior border of right ventricle </li></ul></ul></ul><ul><ul><li>Posterior border of heart </li></ul></ul><ul><ul><ul><li>Left atrium </li></ul></ul></ul><ul><ul><ul><li>Left ventricle </li></ul></ul></ul>/231 The normal R. atrium is not border-forming in this projection methods normal abnormities diseases

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Normal appearance ---- Lat. view /231 <ul><ul><li>Retrocardiac </li></ul></ul><ul><ul><li>esophageal space </li></ul></ul>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

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Normal appearance ---- Lat. view /231 <ul><li>normal L. atrium don’t displace the esophagus </li></ul>Barium-filled esophagus methods normal abnormities diseases

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Size of the heart and great vessels /231 <ul><ul><li>Normal ： C / T ≤0.5 </li></ul></ul><ul><ul><li>Slightly enlarged ： 0.51- 0.55 </li></ul></ul><ul><ul><li>Moderately enlarged ： 0.56- 0.60 </li></ul></ul><ul><ul><li>Massively enlarged ：＞ 0.60 </li></ul></ul>methods normal abnormities diseases

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Size of the heart and great vessels /231 a b C/T ratio = a+b / T = ≤ 0.5 T methods normal abnormities diseases

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Influencing factor of the normal heart shadow <ul><li>Body type ： oblique , transverse , vertical </li></ul><ul><li>Age ： with age grows ， globular — oblique — horizontal </li></ul><ul><li>Respiration ： </li></ul><ul><ul><li>inspiration ： dropping heart, normal heart shadow </li></ul></ul><ul><ul><li>expiration ： heart shadow horizontal </li></ul></ul><ul><li>Patient position ： </li></ul><ul><ul><li>erect position ： heart shadow elongated </li></ul></ul><ul><ul><li>lying position ： heart shadow enlargement </li></ul></ul>/231 methods normal abnormities diseases

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Influencing factor of normal heart shadow --- body type <ul><li>horizontal heart </li></ul><ul><li>oblique heart </li></ul><ul><li>dropping heart </li></ul>/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

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normal heart shadow /231 ＝ 45 ° oblique heart horizontal heart dropping heart ＝ 38° ＝ 52° methods normal abnormities diseases

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Influencing factor of normal heart shadow -- respiration <ul><li>inspiration expiration </li></ul>/231 methods normal abnormities diseases

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Influencing factor of normal heart shadow -- position <ul><li>erect position supine position </li></ul>/231 methods normal abnormities diseases

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Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial anomalies </li></ul>/231 methods normal abnormities diseases

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Basic X-ray features --- Heart dislocation <ul><li>Mirror image dextrocardias </li></ul>/231 methods normal abnormities diseases

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Basic X-ray features Heart dislocation /231 dextrocardia methods normal abnormities diseases

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/231 mirror image dextrocardias Basic X-ray features Heart dislocation methods normal abnormities diseases

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Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial abnormal </li></ul>/231 methods normal abnormities diseases

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<ul><li>Enlargement of the heart chambers </li></ul><ul><ul><li>Left ventricular enlargement </li></ul></ul><ul><ul><li>Right ventricular enlargement </li></ul></ul><ul><ul><li>Left atrium enlargement </li></ul></ul><ul><ul><li>Right atrium enlargement </li></ul></ul><ul><ul><li>General cardiac enlargement </li></ul></ul>/231 Basic X-ray features Heart enlargement methods normal abnormities diseases

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Left ventricular enlargement <ul><li>X-ray appearance ; </li></ul><ul><ul><li>cardiac apex extending to left and down </li></ul></ul><ul><ul><li>the point of opposite pulsation move down </li></ul></ul><ul><ul><li>left ventricle segment extended,rounded,expand to left </li></ul></ul><ul><ul><li>the aorta is prominent </li></ul></ul><ul><ul><li>Lat ： retrocardiac space become narrowed or disappeared, esophageal space disappeaered Common disease ： </li></ul></ul><ul><ul><li>high blood pressure </li></ul></ul><ul><ul><li>aortic incompetence 、 stenosis </li></ul></ul><ul><ul><li>mitral incompetence </li></ul></ul><ul><ul><li>congenital heart disease ： PDA </li></ul></ul>/231 methods normal abnormities diseases

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Left ventricular enlargement /231 methods normal abnormities diseases

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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

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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

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Right ventricular enlargement <ul><li>X-ray appearance ： </li></ul><ul><ul><li>MPA prominent </li></ul></ul><ul><ul><li>Lat ： contact between the front surface of heart and the sternum (anterior chest wall) >1/3 (narrow of the retrosternal space) </li></ul></ul><ul><li>Common disease ： </li></ul><ul><ul><li>Mitral valve stenosis </li></ul></ul><ul><ul><li>Chronic pulmonary heart disease </li></ul></ul><ul><ul><li>Pulmonary stenosis </li></ul></ul><ul><ul><li>Pulmonary hypertension </li></ul></ul><ul><ul><li>Fallot’s tetralogy </li></ul></ul><ul><ul><li>ASD , VSD </li></ul></ul>/231 methods normal abnormities diseases

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Right ventricular enlargement /231 methods normal abnormities diseases

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Left atrium enlargement <ul><li>X-ray ： enlarged LA bulges to back & right </li></ul><ul><ul><li>PA – right border ： double density of left atrial enlargement </li></ul></ul><ul><ul><li>PA – left border ： Indentation where the left atrium, when it enlarges, will appear on the left side of the heart </li></ul></ul><ul><ul><li>Lat & RAO ： middle of esophagus compressed and displaced posteriorly </li></ul></ul><ul><ul><li>LAO ： Elevation of left mainstem bronchus </li></ul></ul><ul><ul><li>Common disease ： </li></ul></ul><ul><ul><li>mitral lesion </li></ul></ul><ul><ul><li>left ventricular failure </li></ul></ul><ul><ul><li>congenital heart diseases ： </li></ul></ul><ul><ul><ul><li>PDA </li></ul></ul></ul><ul><ul><ul><li>VSD </li></ul></ul></ul>/231 methods normal abnormities diseases

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Left atrium enlargement /231 methods normal abnormities diseases

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Right atrium enlargement <ul><li>X-ray appearance ： </li></ul><ul><ul><li>PA ： inferior segment of right border of heart extending to right , bulge, high bulge point </li></ul></ul><ul><ul><li>LAO ： the right atrial curvature at least half as long as the anterior border of heart ， bulge </li></ul></ul><ul><li>Common disease ： </li></ul><ul><ul><li>right heart failure </li></ul></ul><ul><ul><li>ASD </li></ul></ul><ul><ul><li>tricuspid disease </li></ul></ul><ul><ul><li>pulmonary vein ectopy drainage </li></ul></ul><ul><ul><li>atrial myxoma </li></ul></ul>/231 methods normal abnormities diseases

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Right atrium enlargement /231 methods normal abnormities diseases

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General cardiac enlargement <ul><li>X-ray appearance ： </li></ul><ul><ul><li>PA ： The cardiac shadow is increased to both sides, the transverse diameter increased </li></ul></ul><ul><ul><li>Lat and RAO ： narrowing of both retrosternal space and retrocardiac space, the oesophagus is displaced backward </li></ul></ul><ul><ul><li>LAO ： the trachea bifurcation is sprayed, the trachea is displaced backward </li></ul></ul><ul><li>Common disease ： </li></ul><ul><ul><li>Pericardial effusion </li></ul></ul><ul><ul><li>Myocarditis </li></ul></ul><ul><ul><li>Total cardiac failure </li></ul></ul><ul><ul><li>Total cardiac failure, hyperthyroidism </li></ul></ul>/231 methods normal abnormities diseases

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general cardiac enlargement -- Pericardial effusion /231 methods normal abnormities diseases

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the five important cardiac contours are: <ul><li> The ascending aorta </li></ul><ul><li>Indentation where double density of left atrial enlargement will appear </li></ul><ul><li> Aortic knob </li></ul><ul><li> Main pulmonary artery segment </li></ul><ul><li> Indentation where the left atrium, when it enlarges, will appear on the left side of the heart </li></ul><ul><li>The right atrium and left ventricle are less important because we evaluate ventricular enlargement by looking at the outflow tracts for each ventricle. </li></ul>

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Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial abnormal </li></ul>/231 methods normal abnormities diseases

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Five States of the Pulmonary Vasculature <ul><li>Normal </li></ul><ul><li>Pulmonary venous hypertension </li></ul><ul><li>Pulmonary arterial hypertension </li></ul><ul><li>Increased flow </li></ul><ul><li>Decreased flow </li></ul>

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What We’re Going to Evaluate <ul><li>Right Descending Pulmonary Artery </li></ul><ul><li>Distribution of flow in the lungs </li></ul><ul><ul><li>Upper versus lower lobes </li></ul></ul><ul><ul><li>Central versus peripheral </li></ul></ul>

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Venous Hypertension RDPA usually > 17 mm Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization

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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

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Increased Flow RDPA usually > 17 mm All of blood vessels everywhere in lung are bigger than normal

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Increased Flow Normal

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Increased Flow Distribution of flow is maintained as in normal Lower lobe vessels bigger than upper lobe Gradual tapering from central to peripheral

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PAH Increased Flow

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Unrecognizable most of the time Small hila Fewer than normal blood vessels Decreased Flow

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Basic X-ray features <ul><li>Heart dislocation </li></ul><ul><li>Heart enlargement </li></ul><ul><li>Abnormal pulmonary blood flow </li></ul><ul><li>Changes of aorta </li></ul><ul><li>Pericardial abnormal </li></ul>/231 methods normal abnormities diseases

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Changes of aortal shape and density <ul><li>elongation, widening ,calcification </li></ul><ul><ul><li>PA ： </li></ul></ul><ul><ul><ul><li>Aorta distortion: the ascending and descending aorta displacement exceeding the heart boundary , intruding the lung field </li></ul></ul></ul><ul><ul><ul><li>The demarcation between the ascending aorta and right atrium descend </li></ul></ul></ul><ul><ul><ul><li>Aorta elongation: aortic knob is high , above the clavicula sometimes </li></ul></ul></ul><ul><ul><li>Lat ： </li></ul></ul><ul><ul><ul><li>Ascending and descending aorta bend forward, backward respectively ， </li></ul></ul></ul>/231 methods normal abnormities diseases

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Aorta distortion and elongation /231 methods normal abnormities diseases

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Aorta calcification /231 methods normal abnormities diseases

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Aorta calcification /231 methods normal abnormities diseases

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Coronary artery calcification /231 methods normal abnormities diseases

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Dissection of aorta <ul><li>Symptom ： </li></ul><ul><ul><li>Severe chest-back pain sudden ly, with tearing sensation , radiating to the neck and abdomen </li></ul></ul><ul><li>Pathology ： Hemorrhage in the media separate media from adventitia, and form pseudocoele inside the aortal wall </li></ul>/231 Medical emergency <ul><li>Clue for diagnosis </li></ul><ul><li>intimal tear point </li></ul><ul><li>intimal flap </li></ul><ul><li>pseudocoele </li></ul>methods normal abnormities diseases

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Dissection of aorta <ul><li>Types </li></ul><ul><li> DeBakey Type I </li></ul><ul><li> Involves entire aorta </li></ul><ul><li> DeBakey Type II </li></ul><ul><li> Ascending aorta only </li></ul><ul><li> DeBakey Type III </li></ul><ul><li> Descending aorta only </li></ul>/231 methods normal abnormities diseases

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Dissection of aorta <ul><li>Types </li></ul><ul><li> Stanford Type A </li></ul><ul><li> Ascending aorta involved </li></ul><ul><li> Stanford Type B </li></ul><ul><li>Ascending aorta NOT involved </li></ul>/231 methods normal abnormities diseases

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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

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Dissection of aorta True lumen methods normal abnormities diseases

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Dissection of aorta True versus false channel methods normal abnormities diseases

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Dissection of aorta methods normal abnormities diseases

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Aneurysm <ul><li>ascending aorta > 5 cm </li></ul><ul><li>Descending aorta > 4 cm </li></ul><ul><li>abdominal aorta >3 cm </li></ul><ul><li>Normal size of abdominal aorta >50 years of age: </li></ul><ul><ul><li>About 2 cm </li></ul></ul>

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Abdominal aortic aneurysm /231 perianeurysmal fibrosis (10%) methods normal abnormities diseases

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Aneurysm /231 methods normal abnormities diseases

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Abdominal aortic aneurysm /231 methods normal abnormities diseases

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CTA /231 angiocardiography CT MRI echocardiography X-ray methods normal abnormities diseases

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Aneurysm of aorta （ syphilitic ） /231 methods normal abnormities diseases