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CARDIOVASCULAR

IMAGING
LEVEL V MBCHB
BY DR ONYAMBU
LECTURER DDIRM

Objectives
Know the different imaging modalities
used in imaging the CVS
Understand the clinical application of
each modality
Understand the best imaging modality for
each clinical indication

IMAGING MODALITIES
Plain CXR-PA,LAT
Echocardiography
Isotope scanning
Cardiac catheterisation
Angiocardiography
CT
MRI

PLAIN X-RAYS

Plain radiographs are important as the


first imaging investigation in cases of
heart disease. It gives vital information
concerning:
Size of the heart
Enlargement of individual chambers
Pulmonary vasculature
Condition of the lung fields
Presence or absence of pleural effusion

SIZE OF THE HEART


Measured by the cardio-thoracic ratio
(CTR)
The maximum transverse diameter of the
heart is compared to the maximum
transverse diameter of the chest.
In normal adults this is <_ 50%
In children it is <_ 60%

CT OF THE HEART

Chamber orientation

RA-lies on the right and forms the RT heart


border

RV-lies to the LT and anterior to RA forms

anterior heart border


LA-lies posteriorly and forms the
posterior heart border
LV-forms the bulk of the left heart border

THE SHAPE OF THE HEART


The cardiac contour has characteristic
appearance in specific conditions
depending on the chambers mainly
enlarged.
LV enlargement is seen in HTN, and
aortic valve disease

The apex enlarges downward and to the left

LV ENLARGEMENT

THE LEFT ATRIUM

LA enlargement is seen in mitral valve


disease,
Enlarges backwards and to the right
Double density of the heart
Projects backwards and slightly upwards in
the lateral film .
Makes an impression on the barium filled
oesophagus.

MR

Severe MR disease
.Left atrial appendage
is large , producing a
convex bulge (arrow).
The heart is
considerably enlarged

VSD

RIGHT VENTRICULAR
ENLARGEMENT
May also be seen in mitral disease due
to increased pulmonary resistance
secondary to pulmonary congestion
Also seen in congenital cardiac lesions
associated with pulmonary stenosis or LR shunts.
Pulmonary disease with chronic airway
obstruction

RV
Lifting and rounding of the apex
Filling of the retrosternal airspace

Rt Ventricle enlargement

Mitral valve disease

1) Mitral stenosis(ms)
Almost always rheumatic in origin.
In the elderly, heavy calcification of the valve
apparatus can cause ms.
A rare congenital form of ms is also
recognized.
In rheumatic ms the valve orifice is slowly
diminished by progressive fibrosis,
calcification of valve leaflets, and fusion of the
cusps and subvalvular apparatus.

Ms cont

Flow of blood from left atrium to left ventricle


is restricted and left atrial pressure rises
leading to pulmonary venous congestion and
breathlessness.
There is dilatation and hypertrophy of the left
atrium and left ventricular filling becomes
more dependent on left atrial contraction.
mitral orifice is about 5cm sq and may be
reduced to 1cm sq or less in severe ms.

Investigations
ECG: features of rt ventricular
hypertrophy, left atrial hypertrophy and
fibrillations.
CXR: enlargement of left atrium and its
appendage.
-enlargement of main pulm artery.
-features of pulmonary venous
congestion.

MS

MS

MR

LUNG FIELDS
CONGESTION-due to pulmonary
venous hypertension following left heart
lesions resulting in back pressure on the
lung. Causes include; LV failure and
mitral valve disease.
CXR

Diversion of blood from the lower to the


upper zones of the lung in an erect PA film
of the chest

Cont
Pulmonary oedema with interstitial or
alveolar involvement
Septal lines- Kelly A,B and C
Lamellar effusions
Alveolar oedema is often perihilar with
blurring of the central lung areas (bats
wing appearance)
Pleural effusions may be seen.

PULMONARY PLETHORA

Seen in conditions of high pulmonary flow


mainly due to congenital L-R shunts.
Both arteries and veins become prominent
with end on vessels close to the hilum being
particularly well seen, and distal vessels
extending to the lung periphery
PAH (pulmonary arterial hypertension) may
develop in long standing ASD, increased
resistance caused by severe pulmonary
venous HTN

Cont..
PAH may develop acutely following
massive pulmonary embolus or from
chronic multiple pulmonary emboli.
PAH also occurs in chronic pulmonary
disease with chronic airways obstruction

X-Ray Findings-ASD

Enlarged
pulmonary
vessels
Normal-sized
left atrium
Normal to
small aorta.

ASD

PULMONARY OLIGAEMIA
Occurs when there is obstruction to the
pulmonary outflow at or below the
pulmonary valves.
It may be seen in R-L shunt as in
tetralogy of Fallot

PERICARDIAL EFFUSION
May be classified as
1.Inflammatory
-TB
-Supprative
-Rheumatic
-Viral
2.Non-inflammatory
-heart failure
-myocardial infarction
-Uraemia
-Haemopericardium
3.Malignant

Pericardial effusion
The radiological diagnosis can be difficult
unless the fluid is more than 200 mls.
R.F

Enlarged globular heart


Masking of the hilar
U/S is diagnostic
CT or MRI may show the effusion

CXR-pericardial effusion

Congestive cardiac failure

Heart failure occurs when a patient with


significant heart disease develops signs
and symptoms of low cardiac output,
pulmonary congestion, or systemic
venous congestion

CCF-CAN BE
LT sided
RT sided
Biventicular

Radiological features
Cardiomegaly
Enlarged hilar vessels
Prominence of upper lobe vessels
Septal or Kerley B lines
Ground glass appearance of alveolar
oedema
Pleural effusion

Upper lobe diversion of blood

CCF

Kerley A & B lines

CXR

LA myxoma. Large
heart with all chambers
involved . There is
interstitial pulmonary
oedema.

LT ATRIAL MYXOMA

Ischaemic heart disease


Almost always due to atheroma and its
complications particularly thrombosis.
Risk factors:-age
-male sex -family history
-smoking
-hypertension
-diabetes mellitus
-obesity
-sedentary life style -diet

Myocardial Ischaemia

IMAGING FEATURES

Plain radiographs:- normal


Myocardial perfusion studies:scintiscans of the heart are taken at
rest and after exercise.
Thallium 201 is taken up by viable
perfused myocardium.
Thallium 201 is injected during exercise
test with immediate exercise images and
perfusion images 3 hrs later, after resting

Myocardial perfusion
study.
Thallium scan
showing reversible
anterior myocardium
ischaemia.
Images are crosssectional tomograms
of the left ventricle.

CORONARY CT ANGIOGRAPHY
Indications
Recent onset chest pain
High cholesterol levels
High blood pressure
Family history of coronary artery disease
Smoking
Diabetes mellitus

CCTA

THE
END