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Cardiovascular system

Cardiovascular system
  • Introduction

  • Anatomy and pathology

  • Summary

Introduction

Introduction 1. History : anatomy of cardiovascular Cardiovascular -- 16 th century -- autopsy, ECG 2.

1. History : anatomy of cardiovascular

Cardiovascular -- 16 th century -- autopsy, ECG

2. Modalities

Without x ray ECG MRI Radiopharmacy Nuclear medicine Tc 99 m th 204

Introduction

Introduction With X - rays Without contrast media : chest X rays, fluoroscopy, EBCT With contrast

With X - rays

Without contrast media : chest X rays, fluoroscopy, EBCT

With contrast media: Esophagography,

interventional cardiography EBCT

3. Indication : Suspect abnormalities of CV and

lung disease based on clinical diagnosis

ANATOMY AND PATHOLOGY

ANATOMY AND PATHOLOGY 1. Chest X Ray Standard projections and technical consideration : high Kv 120-145,

1. Chest X Ray

Standard projections and technical consideration :

high Kv 120-145, lov KV 60-80

Position : postero-anterior, lateral, oblique

Deep inspiration, suspended breath Distance : 72 inches/ 180-200 cm

2. Mediastinum

2. Mediastinum The heart and great vessels occupy the mid thorax, within the mediastinum The anatomic

The heart and great vessels occupy the mid thorax,

within the mediastinum The anatomic borders of the mediastinum :

  • 1. Anteriorly : the sternum and its adjacent ribs

  • 2. Posteriorly : the vertebral column and its ribs

  • 3. Laterally : the medial aspects of the parietal pleuras

  • 4. Superiorly : the plane of the 1st rib

  • 5. Inferiorly : the diaphragm

3. Heart image on chest X-ray

3. Heart image on chest X-ray - Opaque silhoutte - Mostly located in left hemithorax -
  • - Opaque silhoutte

  • - Mostly located in left hemithorax

  • - Aortic arch

  • - Diaphragm

4. Influence factor of the heart contour

4. Influence factor of the heart contour 1. The age : infant / newborn : more
  • 1. The age : infant / newborn : more rounded and transversal

Childhood

2.

Adult

Respiration

Deep inspiration

Expiration

Chest X Rays of normal neonatus

Chest X Rays of normal neonatus
  • 1. Focus - film distance

  • 2. Habitus - pycknicus and asthenicus

  • 3. Abnormalities of the spine, sternum, the lungs --rotation of the heart

  • 4. Position of the patient, erect, supine

Adult chest X Rays

Adult chest X Rays

5. Evaluation of the chest X-ray

Technical aspect : KV, mAs, Artifact,
Technical aspect :
KV,
mAs,
Artifact,

blurring, distance

Object

aspect

:

deep

inspiration,

symmetrical, supine, erect

6. Cardiothoracic

ratio

M = midline A = 1/3 C1 B = ½ C1 D + E = 4 cm

6. Cardiothoracic ratio M = midline A = 1/3 C1 B = ½ C1 D +

F = height of the aorta, 2 cm form the edge of the manubrium

CTR =

A + B

C1 + C2

X 100%

7. Visualisation of the heart structures

7. Visualisation of the heart structures Postero-anterior projection : RA, RV, LV Lateral projection : RV,

Postero-anterior projection : RA, RV, LV

Lateral projection : RV, LV, LA -- PA, AA Right anterior oblique projection : LA,RA, RV--AA

Left anterior oblique

RAA, LV-LA, PA

projection : RV --

  • 8. Imaging of the lungs vascular

8. Imaging of the lungs vascular  Close relation between the lungs vascular and abnormalities of
  • Close relation between the lungs vascular and abnormalities of the heart, vice versa

  • Pulmonary arteries

  • Pulmonary veins

  • Aorta

Pulmonary artery/veins

Pulmonary artery/veins  Normally : Blood (RV) --> thru PA --> Right and Left Lungs 
  • Normally : Blood (RV) --> thru PA --> Right and Left Lungs

  • PA tributaries (small arteries) with bronchi to

the alveoli capillaries

  • PVs (capillary plexus) in alveoli septa --> to medial part of the lungs --> wider --> LA

  • PVs of the lungs basis --> to the lower part

of LA

  • PVs of the other part of the lungs --> to the upper part of LA

Pulmonary artery

• Hilum : consist of the pulmonary
• Hilum
:
consist
of
the
pulmonary

artery, pulmonary veins, bronchus and

nodes Right

hilum

:

in

the

middle

of right

lungs, apex and right diaphragm Left hilum : higher than the right hilum

Adult chest X Rays

Adult chest X Rays

Pulmonary artery

 Hilum : consist of the pulmonary
 Hilum
:
consist
of
the
pulmonary

artery, pulmonary veins, bronchus and

nodes

  • Right hilum

:

in

the

middle

of right

lungs, apex and right diaphragm

  • Left hilum : higher than the right hilum

PATHOLOGY

PATHOLOGY ABNORMALITIES OF LUNG VASCULATURES Abnormalities of pulmonary vessels  Vascular widening  Vascular narrowing 

ABNORMALITIES OF LUNG VASCULATURES

Abnormalities of pulmonary vessels

  • Vascular widening

  • Vascular narrowing

  • Pathways irregularity

Vascular widening

Vascular widening Hilum enlargement > 16 mm, conform with trachea  node enlargement -  prominent-

Hilum enlargement > 16 mm, conform with trachea

node enlargement -prominent- mediastinal enlargement

pulmonal artery widening(MPA)

volume increase--- L to R shunt, VSD, VSD,PDA

obstruction in periphery artery ASD,VSD,PDA Pulmonary art >------ capillaries

in lungs >, pulmonary veins>MPA at hilum >>

Pulmonary artery >> -fibrosis, emphysema,

atelectasis, and pulmonary veins congestion of lungs

Vascular narrowing

Vascular narrowing Vascular narrowing : pulmonary stenosis : decrease of blood volume in lungs, --- small

Vascular narrowing : pulmonary stenosis :

decrease of blood volume in lungs, --- small hilum, small and smooth periphery

vessels, more radio lucent

Abnormality of the aorta

Abnormality of the aorta Pitfalls : rotation of the heart, asymmetrical chest X ray  Widening

Pitfalls : rotation of the heart, asymmetrical chest X ray

Widening of the aorta :

of

Increase blood volume : leakage septal, R to L Obstruction of its tributaries at the periphery level :

Coarctatio aorta, stenosis Aorta--Takayashu

disease --- abdominal aorta

Abnormality of the aorta itself --widening in chronic hypertension

  • Narrowing of the aorta

Decrease of blood volume to the aorta --- septal leakage L to R, mitral stenosis

Malposition of the heart

Malposition of the heart  Dextrocardia  Dextroversion  Mesoversion  Levocardi

Dextrocardia

Dextroversion

Mesoversion

Levocardi

Malposition of the heart  Dextrocardia  Dextroversion  Mesoversion  Levocardi

Dextrocardia

: heart, aorta and apex are in the right hemithorax

Most often accompanied by situs inversus

Dextroversion : heart turns right Heart in right hemothorax Apex turned down LV at frontal side RV turns right-posteriorly

Mesoversion : heart in the middle of thoracal cavity

Levocardi : - heart in left hemithorax

- abdominal organ in right side

Enlargement of the heart

Enlargement of the heart 1. Enlargement of the heart image – pericardial disease : pericardial effusion

1. Enlargement of the heart image

pericardial disease : pericardial effusion

myocardial disease : enlargement of the cardiac chambers, cardiomyopathy

valvular disease : stenosis, insufficiency

2. Enlargement of the heart chambers :

hypertrophy, dilatation

Right atrial enlargement

PA : extension to right of right atrial border,
PA
: extension
to
right
of right
atrial border,

with increased convexity RAO : slight posteroinferior convexity

LAO : increases supero-inferior convexity (prominence of right atrial auricle)

LAT : right atrium protrudes behind esophagus

Right atrial enlargement

Right atrial enlargement
Right atrial enlargement
Right atrial enlargement
Right atrial enlargement

Right ventricle enlargement

(hypertrophy & dilatation)

Right ventricle enlargement (hypertrophy & dilatation) PA : enlargement heart to left side enlargement dilatation of

PA

: enlargement heart to left side

enlargement dilatation of pulmonary arteries

increased convexing of heart waist, pushing pulmonary arteries to upper side

RAO : increased prominence of pulmonary sector

(bulguing of MPA) LAO : bulging on anterior aspect of RV

LAT : right ventricle “clumbs” upward, close to the sternum

Right ventricular hyperthropy & dilatation

Right ventricular hyperthropy & dilatation
Right ventricular hyperthropy & dilatation
Right ventricular hyperthropy & dilatation
Right ventricular hyperthropy & dilatation

Left atrial enlargement

Left atrial enlargement PA : enlargement heart to left & right side - prominence of left

PA : enlargement heart to left & right side

  • - prominence of left auricle

  • - double contour at right side

  • - left main bronchus displaced upward

RAO/LAT :

  • - enlargement heart to postero-interal (displaced esophagus to right)

  • - bulging of left atrial auricle/(appendage) displaces esophagus posteriorly

Left atrial enlargement

Left atrial enlargement
Left atrial enlargement
Left atrial enlargement

Left ventricle enlargement

Left ventricle enlargement PA : left extends laterally, left diaphragm is depressed RAO : - heart

PA : left extends laterally, left diaphragm is depressed RAO : - heart intersects left leaf of diaphragm - anterior apical position of heart extends further anteriorly - heart is displaced posteriorly, close to spinal LAO : LV extends beyond retrocardiac space, and cannot clear the spine LAT : LV displaced posteriorly, close to spine

Left ventricular hypertrophy & dilatation

Left ventricular hypertrophy & dilatation
Left ventricular hypertrophy & dilatation
Left ventricular hypertrophy & dilatation

3. Rotation of the heart

3. Rotation of the heart Rotation to left side , cause of RVE, aortic arch 

Rotation to left side , cause of RVE, aortic arch small and rounded, LV

To latero - posterior

Rotation to right side, cause of great LVE,

RV

dextro-lateral, RA dextro-

posterior,

aortic

arch

descending

aorta

on

the

left

side

of

vertebral

column

CONGENITAL ANOMALY

CONGENITAL ANOMALY  Abnormality of the septum  Abnormality of the great arteries --- shape and
  • Abnormality of the septum

  • Abnormality of the great arteries --- shape and position

  • Abnormality of chamber of the heart

  • Abnormality of position

1. Congenital anomaly with increased pulmonary vascular markings

1. Congenital anomaly with increased pulmonary vascular markings A. Without cyanosis 1. Atrial septal defect (ASD)

A. Without cyanosis

1. Atrial septal defect (ASD)

  • Septum primum

  • Ostium primum closed

  • Septum secundum

  • Foramen ovale closed

ASD secundum > ASD primum

Chest X ray

  • Depends on :

The severity of the defect Complication

  • L to R shunt

  • R to L shunt

Chest X ray

Chest X ray Without pulmonary hypertension PA position - Heart enlargement to left side - Apex

Without pulmonary hypertension

PA position

  • - Heart enlargement to left side

  • - Apex is rounded & upward

  • - Widening of the hila

  • - Widening of pulmonary artery and its tributaries

  • - Widening of pulmonary veins at supra and perihilar

  • - Periphery pulmonary vascular are clear

  • - Prominence of MPA

  • - Aortic arch is small

Increased pulmonary vascular marking

Chest X ray

Chest X ray Lat Position  No enlargement of LA & LV  Enlargement of RV

Lat Position

  • No enlargement of LA & LV

  • Enlargement of RV

ASD with Mitral Regurgitaion

ASD with Mitral Regurgitaion

With pulmonary hypertension

PA position

 Enlargement of the heart on both
 Enlargement
of
the
heart
on
both

sides

  • Extremely wide of central hila and became smaller to periphery

  • MPA is very prominent

  • Small aorta

  • Pulmonary veins are faint

  • Periphery area is more radio lucent

  • Barrel chest

Lateral position

Lateral position • LV Enlargement • LA is normal/enlarged • RV Enlargement close to upper sternum

LV Enlargement

LA is normal/enlarged

RV

Enlargement

close

to

upper

sternum Hilar enlargement Infero-posterior

part

of

the

heart

overlapping with vertebral column

3. Ventricular septal defect (VSD)

3. Ventricular septal defect (VSD) Incidence : The most common form of CHD (20-25%) of all

Incidence :

The most common form of CHD (20-25%) of all CHD

Clinical manifestation

  • - Small VSD : N growth, development, symptoms

  • - Moderate to large VSD : Increase exercise tolerance

  • - Delayed growth and development

  • - CHF is relative common in infancy

  • - Cyanosis with long standing pulmonary hypertension

Localization of defect

Localization of defect  Membranous septum  Muscular septum  Above the crista supra ventricular/ sub
  • Membranous septum

  • Muscular septum

  • Above the crista supra ventricular/ sub ulmonic

Localization of defect  Membranous septum  Muscular septum  Above the crista supra ventricular/ sub

Ventricular septal defect

Ventricular septal defect Radiological Imaging depends on • defect size • pulmonary vascular changes

Radiological Imaging depends on defect size pulmonary vascular changes

Chest X ray

Chest X ray  Tiny defect (maladies de Roger )  No heart enlargement  Normal

Tiny defect (maladies de Roger ) No heart enlargement Normal of pulmonary vascular markings

Small defect

Small defect • Heart enlargement to left side (LVH) • Dilatation of LA • Dilatation of

Heart enlargement to left side (LVH) Dilatation of LA Dilatation of RV Increased pulmonary vascular markings Apex towards diaphragm

VSD Moderate to large

VSD Moderate to large  RV dilatation and hypertrophy  LV hyperthropy  RA is normal
  • RV dilatation and hypertrophy

  • LV hyperthropy

  • RA is normal

  • LA dilatation

  • Aorta is small

  • Widening of pulmonary arteries

VSD with pulmonary hypertension

VSD with pulmonary hypertension • RV is more dilated • LA is Normal • Aorta is

RV is more dilated LA is Normal Aorta is normal MPA is prominent

Pulmonary

artery

and

its

central

tributaries are wider Chest is more emphysematous

Patent Ductus Arteriousus (PDA)

 Incidence : 10 % of all CHD, excluding
 Incidence
:
10
%
of
all
CHD, excluding

premature infants

  • Female : male = 3 : 1

  • A common problem in premature infants

It

is

a patency

of

between the left

a normal fetal structure

PA

and

the descending

aorta (ductus arteriosus Botalli)

  • L to R shunt

Chest X ray :

  • LA dilatation

  • LV hypertrophy

  PA PV LA LV AO
 PA
PV
LA
LV
AO

are enlarged

  • RV dilatation (large defect)

Small PDA :

  • Heart

  • Pulmonary vascularities

Small PDA :  Heart  Pulmonary vascularities N Moderate PDA :  Ascending aorta aorta

N

Moderate PDA :

  • Ascending aorta aorta arch

Small PDA :  Heart  Pulmonary vascularities N Moderate PDA :  Ascending aorta aorta

N/slightly enlarged

  • PA : prominent next to AO

  • Pulmonary vascular markings : increased

  • Hila : wide R

  • LA : enlarged

 LV  RV
LV
RV

are enlarged

PDA with pulmonary hypertension

PDA with pulmonary hypertension  RV dilatation (hypertrophy and dilatation)  LA : normal  Asc
  • RV dilatation (hypertrophy and dilatation)

  • LA

: normal

  • Asc aorta

: wide

  • Aortic arch

: prominent

  • MPA

: prominent

  • Hila

: wide

  • Periphery pulmonary vascularities : faint

Partial anomalous pulmonary venous return (PAPVR)

Partial anomalous pulmonary venous return (PAPVR)  Incidence “ Less than 1 % of all CHD
  • Incidence Less than 1 % of all CHD

  • One or more (but not all) pulmonary veins drain into the RA or its tributaries, such as the SVC, IVC, left innominate vein

  • Important consideration The number of anomalous pulmonary vein The prescence and the size of ASD The pulmonary vascular resistance

Chest X ray

  • Important RA RV

PA

  • Similar to ASD

Chest X ray  Important RA RV PA  Similar to ASD are enlarged  Heart

are enlarged

  • Heart enlargement (RA, RV)

  • Widening of MPA

  • Widening of hila

  • Occasionally :

a

dilated PVC,

a crescent,

shaped, vertical shadow in the right lower

lung

B. Increased pulmonary markings with cyanosis

vascular

B. Increased pulmonary markings with cyanosis vascular  Total anomalous pulmonary venous return (TAPVR) Incidence :
  • Total anomalous pulmonary venous

return (TAPVR) Incidence : 1 % of all CHD

No direct communication between the pulmonary veins and LA

Depending

on

the

site

of

the

drainage of the pulmonary veins

  • Supracardiac SVC

  • Cardiac coronary smos

  • Infra cardiac PV, HV, IVC

  • Mixed type

2. Persistent truncus arteriosus

  • Incidence : less than 1 % of all CHD

  • VSD : is always present

  • Only a single trunk leaves the heart and gives rise to pulmonary, systemic and coronary circulations

  • Blood from RV & LV drain into the trunk cyanotic

Chest X rays

  • Heart enlargement, oval shaped (RV, LV, LA)

  • Increased pulmonary vascularity

  • A right aortic arch (50%)

Transposition of the great vessel

Transposition of the great vessel

• Incidence “ 5% of all CH defect More common in males M : F = 3 : 1 The aorta arises anteriorly from RV The pulmonary artery arises posteriorly from

LV

ASD, VSD, PDA are necessary for survival More common bidirectional shunt More common R to L shunt Chest X-ray

Heart enlargement, oval/egg shaped, with a narrow superior mediastinum

Increases pulmonary vascularity

Congenital heart anomalies with decrease pulmonary vascularity

Congenital heart anomalies with decrease pulmonary vascularity A. Without cyanosis 1. Pulmonary stenosis – Incidence 5%

A. Without cyanosis

1. Pulmonary stenosis

Incidence 5% - 8% of all congenital heart defects

Valvular stenosis Subvalvular stenosis (infundibulum) Supravalvular stenosis (mainstem of PA)

Chest X rays

  • Heart size is normal

  • RV enlargement : hyperthrophy dilatation

  • MPA is prominent

  • Pulmonary vascularity is normal decreased

  • Heart enlargement (CHF)

  • Lung : more lucency (small lung vessels)

  • Different vascularization between right and left lung on valvular stenosis

  • Post stenotic dilatation

B. With cyanosis

1. Tetralogy of Fallot

Incidence 10% of all congenital heart diseases The most common cyanotic cardiac defect beyond infancy Four abnormalities

VSD (R to L) Pulmonary stenosis infundibular/valvular Over riding aorta Right ventricular hypertrophy

The severity of RVH and defect of VSD depend on stenotic of pulmonary artery

Chest X ray

Chest X ray • RV : enlargement, extends heart to left • Apex : upturned •

RV : enlargement, extends heart to left Apex : upturned Concavity of heart waist/MPA Booth shaped/coeur en sabot Lungs vessels are smaller increased radiolucency Widening of the aortic arch Right sided aorta/aortic arch (25%)

2. Trilogy of Fallot

Similar to Tetralogy of Fallot excluded VSD/overriding

aorta

Abnormalities are :

Pulmonary stenosis RVH

Leakage

of

atrial septum thru ASD/persisten

foramen ovale Chest X ray Similar to PS imaging

RVH Apex : uptoward Decreased pulmonary vascularity

3. Pulmonary atresia Is a part of RV hypoplasie

RV : small

PA : absent

VSD : absent

Combination between ASD & PDA

Chest X ray Heart enlargement, oval shaped

LA enlargement

RA enlargement

LV enlargement

Concavity of heart waist

4. Tricuspid valve atresia Connection of LA & RA thru ASD

Connecting of LV & RV thru VSD 5. Ebstein anomaly

Chest X ray

Extreme cardiomegaly

Decreased pulmonary vascular markings

Acquired heart disease

Acquired heart disease 1. Mitral stenosis Incidence : - Rare in children - The most common
  • 1. Mitral stenosis Incidence : - Rare in children

    • - The most common valvular involvement

in adult rheumatic patients Etiology : - Rheumatic fever

  • - Viral

  • - Streptococcus bacteria

Involved area :

  • - Valves

  • - Ring of valves

  • - Papillary muscles

  • - Myocardium

  • - Pericardium

Involved valves valves weakness 2 chorda tendinae weakness valves are insuficient narrowing of the valve

  • Valve narrowing LA dilatation (because of blood accumulation) increased LA pressure congestion of the pulmonary veins pulmonary hypertension increased resistancy in capillaries obstruction of blood from RV increased in RV pressure RVH

Chest X ray

  • Changing of : - heart shaped &

- pulmonary vascularity

PA

  • LA dilatation

  • Double contour in right side

  • Prominence of LAA, MPA

  • Elevation of main stein left bronchus

  • Small aorta

  • Heart enlargement to left with upright apex

  • Displaced esophagus to right side

Lateral

  • Without contrast

    • Holtzknecht space is clear

  • With contrast

    • Displaced esophagus posteriorly

  • 2. Mitral insuficiency Incidence

: - the most common valvular involvement

in children with RHD

- Males are more commonly affected than females

Etiology : Rheumatic fever

  • - Paralyzed of mitral valve, chorda hendriae

  • - Paralyzed of papillary muscls

  • - Prolaps of one valve leaflet

  • - Dilatation of ring valve

Blood few back into LA

Chest X rays

PA :

- Enlargement of LA & LV

  • - Pulmonary vascularity is usually within normal limits

  • - Double contour

  • - Auricle of LA prominent

  • - Elevation of the left mainstem bronchus

  • - Displacement esophagus to right Lat: - Displacement esophagus posteriorly

    • - LV protruded posteriorly

3. Aorta insuficiency

Incidence

: - More common in males than females

  • - Rheumatic endocarditis

  • - Aneurysma

  • - Aortasclerotic Regurgitation of blood into LV dilatation LVH + dilatation

Chest X ray :

PA : - apex turned down

  • - aortic arch : prominent wide

  • - concavity of pulmonal, auricle area

  • - aortic configuration

Lat : retrocardiac space is occupied (LV dilatation)

4. Aortic stenosis

Incidence

: - 5% of all congenital heart defect

- more common in males than females (4:1)

Chest X ray :

PA

:

- heart enlargement to left side

 
  • - apex turned down

Lat

:

  • - occasionally widening of ascending aorta anterior part of ascending

Aorta : prominent (post stenotic dilatation) RV, LV N

5. Tricuspid insuficiency

Incidence

Etiology

: - 2% of all congenital disease in infancy : - congenital - rheumatic

Chest X ray :

PA

: - RA dilatation - pulmonary vascularity : decreased

LAO

: auricle RA : more prominent

RAO

: enlargement RA, protruded posteriorly, beneath LA

6. Pulmonary stenosis

Etiology :

most commonly congenital

Aortic anomalies/abnormalities

Aortic anomalies/abnormalities Etiology : - inflammation process - degenerative process - traumatic factor - congenital 

Etiology : - inflammation process

  • - degenerative process

  • - traumatic factor

  • - congenital

  • Aortitis

  • Aortasclerotic

  • Aortaelongation

  • Aortic aneurysm

  • Coarctatio aortae

  • Vascular ring

Pericard abnormalities

Pericard abnormalities

Etiology : -infection -trauma 1. Cardiac tamponade

  • 2. Pericardial effusion

  • 3. Pericarditis

  • 4. Pericardial cyst

Cor pulmonale

Pericard abnormalities Etiology : -infection -trauma 1. Cardiac tamponade 2. Pericardial effusion 3. Pericarditis 4. Pericardial

Heart disturbances because of chronic pulmonary diseases