CARDIAVASCULAR RADIOLOGY

Part I: Plain Film Anatomy Part II: Plain Film Interpretation Part III: Congenital Heart Disease Part IV: Valvular Heart Disease CHEST RADIOGRAPHS Most commonly requested diagnostic tool in radiology Least costly and frequently effective An essential part of cardiac evaluation Information o Heart size and silhoutte o Enlargement of cardiac chambers o Pulmonary blood flow/ markings The evaluation of the chest film in the cardiac patient involves sequential logical assesment and correlation of both anatomic and physiologic information on the posteroanterior view (PA) and lateral radiographs. PART I: PLAIN FILM ANATOMY Blood Flow: SVC and IVC Right atrium thru Tricuspid valve Right ventricle thru Pulmonic valve Pulmonary arteries LUNGS Pulmonic veins Left atrium thru Mitral valve Left ventricle thru aortic valve aorta Right cardio-mediastinal border SVC Right atrium Right chamber margin IVC Left cardio-mediastinal border Aortic knob Main pulmonary trunk Left atrial appendage Left ventricle Left cardiac border Posterior border on lateral view Left atrium Left ventricle IVC Anterior border on lateral view Right ventricle Posteroanterior (PA) View

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Right Border

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Lateral View

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Lateral View

Lateral View

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VISCEROATRIAL SITUS Situs: refers to the pattern of anatomic arrangement Atrial situs is usually concordant with veisceral situs; hence these two are described together Situs Solitus o The morphologic RA is to the RIGHT of the morphologic RA o The gastric air bubble is on the LEFT side and liver is on the RIGHT Situs Inversus o The morphologic RA is to the LEFT of the morphologic LA o The gastric air bubble is on the RIGHT side, and the liver is on the LEFT Situs ambiguous o Used when identification of visceroatrial situs is not possible due to paucity of anatomic markers

PART II: PLAIN FILM INTERPRETATION Systemic Approach 1. Overview or overall glance at the film 2. Check cardiac position and situs 3. Cardiac Size 4. Chamber Enlargement 5. Great Vessels 6. Lungs 7. Ancillary Findings 1. OVERVIEW OR OVERALL GLANCE AT THE FILM Is it adequate or optimal for cardiac evaluation? Things to consider: Position o Slight degrees of rotation or obliquity will substantially affect the cardiac contour and may alter the apparent size as well Inspiration o Should be in full inspiration o In suboptimal inspiration or supine chest radiographs, the lower lobe markings are crowded and may obscure the possibility of early pulmonary edema Exposure o Underexposure may simulate the appearance of pulmonary congestion o Overexposure may simuate diminished pulmonary blood flow CHECK CARDIAC POSITION AND SITUS

Dextrocardia Situs solitus

Dextrocardia Situs inversus

2.

CARDIAC POSITIONS LEVOCARDIA o The heart is predominantly in the LEFT CHEST and the cardiac apex points LEFTWARD DEXTROCARDIA o The heart si predominantly in the RIGHT CHEST, and the cadiac apex points RIGHTWARD MESOCARDIA o The heart is positioned in the MIDLINE and the cardiac apex points directly INFERIORLY DEXTROPOSITION (DEXTROVERSION) o Cardiac apex points LEFTWARD but the heart is located predominantly in the RIGHT CHEST (typically due to extrinsic force)

Situs ambiguous

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3.

CARDIAC SIZE

Lateral view: o Retrosternal fullness (contact of anterior cardiac border greater than 1/3 of the sternal length)

CARDIO THORACIC RATIO (CTR) Divide the widest dm of the heart by the widest diameter of the thorax taken at the inner side of the rib cage. Normal CTR: o Adults: 0.5 or < in an adequately taken PE film o Newborn: 0.65 4. CHAMBER ENLARGEMENT

LEFT ATRIAL ENLARGEMENT (LAE) PA view: o Double density o Enlargement of LA appendage o Upliftment of left mainstem bronchus o Widening of carinal angle

RIGHT ATRIAL ENLARGEMENT (RAE) Lateral bulging of the right heart border Elongation of the right heart border (length exceeds 50% of the mediastinal cardiovascular shadow)

RIGHT VENTRICULAR ENLARGEMENT (RVE) PA view: o Rounding and upliftment of cardiac apex

Lateral view: o Prominent posterosuperior cardiac border o Posterior displacement and upliftment of left mainstem bronchus Page 6 of 17

5. LEFT VENTRICULAR ENLARGEMENT (LVE) PA view: o Lateral and downward displacement of the cardiac apex

Great Vessels

PULMONARY VASCULAR PATTERN Normal o Bronchus with bigger dm than artery at suprahilar or perihilar area (if reversed, it is called monocle sign) o Pulmonary blood flow in the normal upright patient is much greater at the bases of the lung than it is at the apex

Lateral view: o Posterior displacement of the posterior inferior border of the heart o Hoffman-Rigler Sign: measured 2 cm above the intersection of the diaphragm and IVC: (+) if posterior border extends more than 1.8 cm of IVC

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Decreased o e.g. CHD (TOF), COPD, emphysema

Increased o May be seen in cardiac (left to right shunts such as in ASD, VSD, PDA) and non-cardiac conditions (A-V fistula) o There is increased prominence of both the upper and lower lobes centrally, in the midlung and at the perphery

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THE GREAT ARTERIES Are they in normal position? Are they of normal size? Aorta o

Main Pulmonary Artery o Normal

Normal

Prominent

Prominent

Concave

Diminutive 6. 7. Lungs Ancillary Findings

CALCIFICATIONS/ PROSTHESIS Pulmonary artery severe pulmonary arterial HPN Percardial restrictive percarditis Pleural Cardiac valves Coronary artery disease BONE DEFORMITIES Subtle like erosions Retarded overall bonegrowth Widened medullary bone space due to marrow hypertrophy Pectus carinatum which is commonly associated with congenital heart disease Page 9 of 17

PART III: CONGENITAL HEART DISEASES Anatomic malformation of the heart and or its vessels, w/c occurs during the itrauterine development

Incidence: 8/1000 live births Most common congenital malformation 13% will have more than one cardiac defect 25% will have associated non cardiac deformity Etiology: Unknown Multifactorial o Hereditary o Chromosomal abnormality o Maternal infection o Teratogenic drugs o Maternal factors o Environmental

VENTRICIULAR SEPTAL DEFECT (VSD)

RADIOLOGIC INTERPRETATION OF CHD 1. Cyanotic or Non- cyanotic 2. Vascularity 3. Specific chamber enlargement 4. Great Vessels 5. Ancillary Findings

Increased vascularity Normal or enlarged cardiac size Chamber prominence o Either or both ventricles o Left atrium Enlarged main and central pulmonary arteries Normal or small aorta

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PATENT DUCTUS ARTERIOSUS (PDA)

ATRIAL SEPTAL DEFECT (ASD)

Increased vascularity Normal or enlarged cardiac size Chamber prominence: o Left ventricle o Left atrium Enlarged main and central pulmonary arteries Prominent aortic knob / dilated aorta

Increased vascularity Cardiomegaly Chamber prominence o Right atrium o Right ventricle Enlarged main and central pulmonary arteries Small aortic knob

TRANSPOSITION OF THE GREAT ARTERIES (D-TGA)

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Increased vascularity Cardiomegaly Cardiac silhoutte o Egg on its side o Apple on a stem Narrow vascular pedicle

TOTAL ANOMALOUS OF PULMONARY VENOUS RETURN (TAPVR)

PERSISTENT TRUNCUS ARTERIOSUS (PTA) There is common origin of the pulmonary artery and aorta, a common trunk, the truncus arteriosus

Increased vascularity Pulmonary venous congestion or edema is frequent in Type 1 Cardiomegaly Chamber prominence o Either or both ventricles o Left atrium Concave main pulmonary artery segment (prominent in Type 1) Wide mediastinum due to large aortic shadow Right aortic arch (35%)

Increased vascularity Cardimegaly Chamber prominence: o Right atrium o Right ventricle Enlarged systemic vein into which drainage occurs

TYPE I SUPRACARDIAC Left-sided vertical vein connects pulmonary venous confluence to the LEFT INNOMINATE VEIN, RIGHT SVC OR AZYGOUS VEIN Snowman appearance Page 12 of 17

MIXE TYPE With various connection to the right side of the heart

TYPE II- INTRACARDIAC Connects to the RIGHT ATRIUM OR CORONARY SINUS Radiograph findings: similar to ASD

TETRALOGY OF FALLOT (TOF)

TYPE III- INFRACARDIAC Connection is BELOW THE DIAPHRAGM, TO THE PORTAL VEIN, DUCTUS VENOSUS, OR HEPATIC VEIN Pulmonary edema Normal sized heart Prominence of the RIGT ATRIUM and less often th RIGHT VENTRICLE

Decreased vascularity Normal or enlarged cardiac size Right ventricular prominece Concave main pulmonary artery segment Prominent aorta Right aortic arch in 20-25%

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EBSTEINS ANOMALY Tricuspid valve incompetent)

displaced

into

RV

(severely

PULMONARY STENOSIS (PS) Decreased vascularity Marked cardiomegaly Right atrial prominence Balloon or box-shaped

Normal to decreased vascularity Normal or enlarged cardiac size Right ventricular prominence Post stenotic dilatation of the pulmonary artery AORTIC STENOSIS (AS)

Normal vascularity Cardiomegaly Left ventricular prominence Dilated ascending aorta

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COARCTATION OF AORTA (COA)

Normal vascularity Cardiomegaly Left ventricular prominence 3 sign Rib notching

PART IV: VALVULAR HEART DISEASE Congenital or acquired Pathophs and CM are similar in both entities Almost all acquired VHD are RHEUMATIC in origin

MITRA STENOSIS (MS)

Normal or slightly enlarged heart Chamber prominence: o Left atrium o Right Ventricle Equalization or cephalization of pulmonary blood flow Prominent main pulmonary artery segment Small aorta

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AORTIC STENOSIS (AS)

Normal sized heart or mild cardiomegaly LVH +/- PVH Dilated ascending aorta +/- calcification

MITRAL REGURGITATION (MR)

AORTIC REGURGITATION (AR) Cardiomegaly Chamber prominence: o Left atrium o Left Ventricle Pulmonary venous congestion (MR>MS) Small aorta

Cardiomegaly LVE Dilated ascending aorta and aortic arch Normal pulmonary vascularity Page 16 of 17

Cardiac silhoutte is symmetrically enlarged Lungs are quite clear; normovascular WATERBOTTLE CONFIGURATION

PERICARDIAL EFFUSION BY UTZ

TRICUSPID VALVE DISEASE

Anechoic fluid surrounding the heart 2D echo is the most sensitive method Dampened pulsations

PERCARDIAL EFFUSION IN CT SCAN

Right atrial enlargement +/- SVC or IVC prominence

Thick ring of fluid density around the heart

HEART IN FAILURE Cardiomegaly Increased Pulmonary Vascularity +/- Pleural Effusion

PERCARDIAL EFFUSION ON X-RAY

Dilated Aorta Aortic Stenosis Aortic Insufficiency Systemic HPN

Pulmonary arterial HPN Dilated pulmonary vein and arteries Constriction of peripheral branches

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