RADIOLOGICAL EXAMINATION OF THE CARDIOVASCULAR SYSTEM

1
RADIOLOGICAL EXAMINATION OF THE CARDIOVASCULAR
SYSTEM

• DEPARTMENT OF ONCOLOGY AND RADIOLOGY
• PREPARED BY I.M.LESKIV

2
METODS OF EXAMINATION

• Echocardiography, radionuclide examinations and
  plain films are the standard non-invasive imaging
  investigations used in cardiac disease.
  Echocardiography has now become a particularly
  important imaging technique that provides
  morphological as well as functional information.
  It is excellent for looking at the heart valves,
  assessing chamber morphology and volume,
  determining the thickness of the ventricular wall
  and diagnosing intraluminal masses. Doppler
  ultrasound is an extremely useful tool for
  determining the velocity and direction of blood
  flow through the heart valves and within cardiac
  chambers. Radionuclide examinations reflect
  physiological parameters such as myocardial blood
  flow and ventricular contractility but provide
  little anatomical detail, whereas plain
  radiographs are useful for looking at the effects
  of cardiac disease on the lungs and pleural
  cavities, but provide only limited information
  about the heart itself. MRI provides both
  functional and anatomical information but is only
  available in specialized centres and is used only
  for specific reasons.

3
ROENTGENOGRAPHY

• A complete roentgen study of the heart usually
  requires a minimum of four projections
  posteroanterior, left anterior oblique at
  approximately 60, right anterior oblique at
  approximately 45, and lateral. The films are
  exposed at a 6-foot distance, with the patient in
  the upright position and in moderately deep
  inspiration. Magnification resulting from
  divergent distortion is minimized by obtaining
  posteroanterior and anterior oblique views to
  place the heart closer to the film (the anterior
  chest is adjacent to film). A left lateral view
  (with the left side adjacent to film) also tends
  to minimize magnification. To outline the
  esophagus, we use a barium suspension as an aid
  in determining position and size of the aortic
  arch. In addition, alteration in esophageal
  contour may reflect changes in the left-sided
  chambers. The use of ultrasound in determining
  cardiac chamber size has decreased the use of the
  oblique projections, so that frequently the
  cardiac examination is restricted to PA and
  lateral projections, usually without barium in
  the esophagus.

4
Plain Radiography

• The standard plain films for evaluation of
  cardiac diseases are the PA view Lateral chest
  film, the PA view must be sufficiently penetrated
  to see the shadow within the heart, eg. The
  double contour of the Lt. atrium valve
  pericardial calcification.
• It provides limited information's about the
  Heart.
• It provides limited information's about the
  effect of the cardiac diseases on the lungs
  pleural cavities.
• We should assess the following points
• a- Heart (shape size).
• b- Great vessels (size, shape), Aortic arch
  (normally located to the Lt. of the Trachea, we
  should exclude the signs of coarctation of
  aorta).
• c- If there is any calcification.
• d- The main point is the examination of the
  Lung field for altered blood flow if there is
  any evidence of heart failure.

5
Normal CXR in PA view
6
Normal CXR in Lateral view
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FLUOROSCOPY

• Cardiovascular fluoroscopy no longer has
  widespread use and in our institution is largely
  limited to the evaluation of specific questions
  i.e., the presence of large pericardial effusions
  and the evaluation of aortic arch anomalies.
  Generally, calcium is better seen on fluoroscopy
  then on plain films and these observations may be
  made at the time of cardiac catheterization.
  Minor amounts of calcification are best seen on
  CT. The use of fluoroscopy has virtually
  disappeared in the study of congenital heart
  disease because in general the patients require
  more definitive studies such as cardiac
  catheterization, angiocardiography,
  ultrasonography, and MRI.
• There are several disadvantages in cardiac
  fluoroscopy, one of the most important of which
  is the amount of radiation to which the patient
  is exposed.
• The second disadvantage is distortion. Because
  the distance between the target of the x-ray tube
  and the patient is short, there is considerable
  enlargement of the cardiac silhouette and
  distortion of other thoracic structures. This can
  be decreased by using longer distances between
  target and the patient, and by using a small
  shutter opening, producing the central beam
  effect. The third disadvantage is lack of
  permanent record. This is obviated to a certain
  extent by the use of cine or videotape recording
  and by roentgenograms obtained before the
  procedure.

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ANGIOCARDIOGRAPHY

• This method of contrast cardiac visualization has
  been used widely for examination of patients with
  all types of cardiac and pulmonary diseases. The
  method is used in the diagnosis of congenital and
  acquired cardiac disease. Selective
  angiocardiography in which a small amount of
  opaque medium (an organic iodide) is injected
  into a specific chamber or vessel during cardiac
  catheterization is used almost exclusively.

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CORONARY ARTERIOGRAPHYAORTOGRAPHY

• CORONARY ARTERIOGRAPHY
• Selective catheterization of the coronary
  arteries followed by injection of a contrast
  medium (one of the organic iodides) is used in
  combination with cineradiography rapid serial
  filming or videotaping to study the coronary
  arteries. Details of technique are beyond the
  scope of this discussion.
• AORTOGRAPHY
• This examination consists of the injection of one
  of the organic iodides into the aorta through a
  catheter introduced into one of its major
  branches and placed into a desired position in
  the aorta. The examination has a place in the
  investigation of patients with congenital and
  acquired problems of the aortic arch. It is used
  in infants with congestive heart failure in whom
  there is evidence of a left to right shunt and in
  whom patent ductus arteriosus is suspected.
  Coarctation of the aorta in infants may also
  cause congestive heart failure. The lesion can be
  defined by aortography. In adults, aortography is
  used to define anomalies of the aortic arch and
  its branches as well as in the study of the
  aortic valve and the coronary arteries. It is
  also useful in patients with masses adjacent to
  the aorta in whom aneurysm is a possibility and
  in patients suspected of having dissecting
  hematoma, and traumatic or other aneurysms.

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ULTRASONIC INVESTIGATION OF THE HEART

• The use of ultrasound in examination of the heart
  has increased greatly in the past 20 years, and
  it is now well established and a widely used
  diagnostic tool. Ultrasonic investigation is a
  noninvasive, safe, and comfortable study that
  will demonstrate valve and chamber motion wall
  thickness and size. Doppler examination allows
  determination of the cross sectional area of a
  valve as well as quantification of gradients that
  may be present. It is of value in the study of
  the hypertrophic cardiomyopathies both with and
  without associated subaortic stenosis and in the
  study of the congestive type in which there is
  chamber dilatation. With ultrasound, left
  ventricular diameter and outflow configuration
  can be determined qualitative assessment of
  right and left ventricular size is possible,
  also. The size of the left atrium can be measured
  accurately and left atrial myxomas or other
  intraatrial tumors can be detected. Ultrasound is
  also useful in the investigation of congenital
  heart disease, particularly in patients with
  hypoplastic left-heart syndrome, double-outlet
  right ventricle, and right ventricular volume
  overload. In addition, it is the most sensitive
  method for determining the presence of
  pericardial effusion.

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Echocardiography(Cardiac US)

• It is the major or basic imaging technique used
  in cardiology.
• It gives important informations about the
  Morphology
• Function of the heart.
• It is an excellent technique to look for
• a- Heart valves.
• b- Chamber morphology volume.
• c- Determining the ventricular wall
  thickness.
• d- Any intra-luminal mass.
• 3 basic techniques are used in Echocardiography,
  they are
• M-mode
• Two-dimensional sector scanning (Real time echo.)
• Doppler echocardiography (Color, Pulse wave)

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Echocardiography M-mode

• It is a continuous scan over a period of time
  (5-10 seconds), with pencil beam of sound
  directed to the site of interest.
• It can demonstrate chamber dimensions, wall
  thickness, valve movement (mainly for Lt.
  ventricular dimension in systole diastole).

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M-mode
14
Two-dimensional sector scanning (Real time echo.)

Demonstrates fun-shaped slices of the heart in
motion. Standard examination consists of
combination of short long axis views 4
chamber view. Long short axis views
cross-section of the of the Lt. ventricle
mitral valve aortic valve, it is done by
placing the transducer in the intercostal space,
just to the Lt. of the sternum. 4 chamber view
both ventricles, both atria, mitral tricuspid
valves, it is done by placing the transducer
at the cardiac apex aiming upward medially.
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4 chamber view in 2 dimensional scan
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Para-sternal long axis
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Para-sternal short axis
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Apical 4 chamber view
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Para-sternal short axis (at Mitral valve level)
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Doppler echocardiography (Color, Pulse wave)
Changing in the frequency of the sound waves
are reflected from moving objects, this change
depends on the velocity of the reflecting
surface. RBCs are used as reflecting surface
the velocity of the blood flow can be measured.
21
Doppler flow measurements are used to
1- Measure cardiac output or Lt. to Rt.
shunt. 2- Detect quantify valvular
regurgitation. 3- Quantify pressure gradients
across stenotic valves. 4- Quantify flow.
22
Trans-Esophageal Echocardiography
By placing the U.S. probe in the esophagus
immediately behind the Lt. atrium, so it will
view the heart from behind.
(A normal descending thoracic aorta)
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DETERMINATION OF CARDIAC SIZE

• The most commonly used are (1) measurement of
  transverse diameters (2) measurement of surface
  area and (3) cardio-thoracic ratio. The
  transverse diameter of the heart is the sum of
  the maximum projections of the heart to the right
  and to the left of the midline the measurement
  should be made so as not to include epicardial
  fat or other noncardiac structures. The diameter
  can then be compared with the theoretic
  transverse diameter of the heart for various and
  weights. Surface area estimations based on
  artificial construction of the base of the heart
  and of the diaphragmatic contour of the heart.
  The cardiothoracic ratio is the ratio between the
  transverse cardiac diameter and the greatest
  internal diameter of the thorax, measured on the
  frontal teleroentgenogram. This is the easiest
  and quickest method of measurement of cardiac
  size an adult heart that measures more than one
  half of the internal diameter of the chest is
  considered enlarged. The method is gross, because
  the cardiothoracic ratio varies widely with
  variations in body habitus. It can be useful,
  however, as a rough estimate of cardiac size. The
  cardiothoracic ratio is most useful in assessing
  changes in heart size or monitoring progression
  of disease, or as a response to therapy.

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Heart Diseases
Evidence of heart diseases is given by
1- Size shape of the heart. 2-
Pulmonary vessels, which provide information
about the blood flow. 3- The
lungs, which may show pulmonary edema.
25

• Measurement of heart size. The transverse
  diameter of the heart is the distance between the
  two vertical tangents to the heart outline. When
  the cardiothoracic ratio (CTR) is calculated, the
  transverse diameter of the heart (B) is divided
  by the maximum internal diameter of the chest (A)

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Heart size
Cardio - Thoracic Ratio (CTR), is the maximum
thoracic diameter of the heart divided by the
maximum thoracic diameter, in adult CTR gt 50
while in children CTR gt 60.
27
Heart size
Comparing with previous films chest-x-ray films
is often more useful.
- The transverse cardiac diameter varies with the
phase of respiration with cardiac cycle, so if
the change in the cardiac size is lt 1.5 cm this
is negligible because the heart size is affected
by breathing cardiac cycle.
Overall increase in the heart size means
- Dilatation of more than one cardiac
chamber. - Pericardial effusion.
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Chamber hypertrophy and dilatation

• Pressure overload (as in Hypertension, Aortic
  Stenosis, Pulmonary Stenosis), this will lead to
• ventricular wall hypertrophy, such change will
  produce little change in the external contour of
  the heart, until the ventricle fails.
• Volume overload (as in Mitral Incompetence,
  Aortic Incompetence, Pulmonary Incompetence, Lt.
  to Rt. Shunt, Damage of the heart muscle), this
  will lead to dilatation of the relevant
  ventricle, this will cause an overall increase
  in the size of the heart (increase in the
  transverse cardiac diameter).
• Because enlargement of one ventricle affects
  the shape of the other, so it is only
  occasionally possible to get the classical
  feature Lt. or Rt. Ventricular enlargement.

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Lt. Ventricular enlargement
- Lt. Ventricular enlargement, the cardiac apex
is displaced downwards and to the left. Note also
that the ascending aorta causes a bulge of the
right mediastinal border - a feature that is
almost always seen in significant aortic valve
disease.
Lt. Ventricular enlargement in a patient with
Aortic Incompetence
30
Rt. Ventricular enlargement
- Rt. Ventricular enlargement, the cardiac apex
is displaced upward (to the Lt. of diaphragm).
Note also the features of pulmonary arterial
hypertension - enlargement of the main pulmonary
artery and hilar arteries with normal vessels
within the lungs.
Rt. Ventricular enlargement in a patient with
Primary Pulmonary Hypertension
31
Lt. Atrial Enlargement
When it produces Double Contour, the Rt. border
of the enlarged Lt. atrium is seen adjacent to
the Rt. Cardiac border within the main cardiac
shadow.
Lt. Atrial Enlargement in a patient with Mitral
Valve Disease showing the Double Contour Sign
(the left atrial border has been drawn in) and
dilatation of the left atrial appendage (LAA)
(arrow).
Lt. Atrial Appendage The enlarged LAA should
not be confused with dilatation of the main
pulmonary artery. The main pulmonary artery is
the segment immediately below the aortic knuckle.
The LAA is separated from the aortic knuckle by
the main pulmonary artery
32
Rt. Atrial Enlargement
Will produce an increase of the Rt. cardiac
border, often accompanied by enlargement of
Superior Vena Cava (SVC).
33
Valve movement deformity calcification
Plain X-ray films
Calcification is the only could be obtained
directly related to the morphology of the
valve.
Calcification is better seen by fluoroscopy.
It occurs in mitral valve /or aortic valve in
rheumatic heart diseases if it occurs in
aortic valve alone (especially in adults) it
is mainly congenital aortic stenosis.
It is the easiest the best to see
calcification by the lateral view by drawing a
line from the junction of the diaphragm the
sternum to the Lt. main bronchus, so
- If the calcification is below behind, means
mitral valve. - If the calcification is
above in front, means aortic valve.
If the line dissects the calcification, both
valves (mitral aortic) are calcified.
Calcification of the mitral valve ring
elderly patient is occasionally seen in mitral
regurgitation.
34
Valve calcifications
Mitral Valve Calcifications
35
Valve calcifications
Aortic Valve Calcifications
36
Ventricular Contractility
General uniform decrease contractility in
valvular disorder, congenital cardiomyopathy,
multi-vessel coronary artery diseases.
If there is focal decrease in contractility /-
dilatation in IHD. Increase contractility
of the Lt. ventricle will cause hypertrophy as
in aortic stenosis, HTN, hypertrophic
obstructive cardiomyopathy (HOCM).
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THE ADULT HEART

Position of oesophagus (not opacified in this instance)
38
Pericardial disease

• Echocardiography is ideally suited to detect
  pericardial fluid. Since patients are examined
  supine, fluid in the pericardial space tends to
  flow behind the left ventricle and is recognized
  as an echo-free space between the wall of the
  left ventricle and the pericardium. A smaller
  amount of fluid can usually be seen anterior to
  the right ventricle. Even quantities as small as
  20-50 ml of pericardial fluid can be diagnosed by
  ultrasound. The nature of the fluid cannot
  usually be ascertained, and needle aspiration of
  the fluid may be necessary such aspiration is
  best performed under ultrasound control.
  Pericardial effusion can also be recognized at CT
  and MRI, although they are rarely performed
  primarily for this purpose. Computed tomography
  and MRI are particularly useful for assessing
  thickening of the pericardium, whereas
  echocardiography is poor in this regard.
• It is unusual to be able to diagnose a
  pericardial effusion from the plain chest
  radiograph. Indeed, a patient may have sufficient
  pericardial fluid to cause life-threatening
  tamponade, but only have mild cardiac enlargement
  with an otherwise normal contour. A marked
  increase or decrease in the transverse cardiac
  diameter within a week or two, particularly if no
  pulmonary oedema occurs, is virtually diagnostic
  of the condition. Pericardial effusion should
  also be considered when the heart is greatly
  enlarged and there are no features to suggest
  specific chamber enlargement . Pericardial
  calcification is seen in up to 50 of patients
  with constrictive pericarditis. Calcific
  constrictive pericarditis is usually
  postinfective in aetiology, tuberculosis and
  Coxsackie infections being the common known
  causes. In many cases no infecting agent can be
  identified. The calcification occurs patchily in
  the pericardium, even though the pericardium is
  thickened and rigid all over the heart. It may be
  difficult or even impossible to see the
  calcification on the frontal view. On the lateral
  film, it is usually maximal along the anterior
  and inferior pericardial borders. Widespread
  pericardial calcification is an important sign,
  because it makes the diagnosis of constrictive
  pericarditis certain.

39
Pericardial Diseases

• 20 50 ml of pericardial fluid is diagnosed by
  echo.
• Needle aspiration is needed to insure the nature
  of the fluid.
• CT scan MRI can show the pericardial effusion
  but more important is to measure the thickness
  of the pericardium where thickness of the
  pericardium where echo. is poor.
• Unusual to diagnose pericardial effusion by
  plain-X-ray because the patient may have
  pericardial effusion to cause a
  life-threatening tamponade but only mild heart
  enlargement with otherwise normal contour.

• Marked increase or decrease in the transverse
  diameter of the cardiac shadow within on or
  two weeks No pulmonary edema is virtually
  diagnostic of pericardial effusion.
• Marked increase in the cardiac size no specific
  chamber normal pulmonary vasculature (flask
  shape) ( the outline of the heart become very
  sharp) is diagnostic of pericardial effusion.
• Pericardial calcification is seen in 50 of
  patient within constrictive pericarditis, which
  is usually due to TB or Coxsackie's virus
  infection.
• Best seen on lateral CXR, along the anterior
  inferior surface, because it may possible on
  frontal CXR.
• Usually the calcification is an important sign
  for constrictive pericarditis.

40
Pericardial Effusion
Pericardial Effusion due to Viral Pericarditis
41
Pericardial Effusion
Congestive Cardiomyopathy, this appearance
usually confused with Pericardial Effusion
42
Pericardial effusion. The heart is greatly
enlarged. (Three weeks before, the heart had been
normal in shape and size.) The outline is well
defined and the shape globular. The lungs are
normal. The cause in this case was a viral
pericarditis. This appearance of the heart,
though highly suggestive of, is not specific to
pericardial effusion. (Compare with (b).) (b)
Congestive cardiomyopathy causing generalized
cardiac dilatation. This appearance can easily be
confused radiologically with a pericardial
effusion.
A
B
Pericardial calcification in a patient with
severe constrictive pericarditis. The
distribution of the calcification is typical. It
follows the contour of the heart and is maximal
anteriorly and inferiorly. As always, it is more
difficult to see the calcification on the PA
film. (This patient also had pneumonia in the
right lower lobe.)
43
Pericardial Effusion
Large Pericardial Effusion on an apical 4-chamber
view echocardiogram
44
Large pericardial effusion on an apical
four-chamber view echocardiogram. (b). CT scan
showing fluid density (arrows) in pericardium.
LA, left atrium LV, left ventricle RA, right
atrium RV, right ventricle.
45
Pericardial Effusion
CT-scan shows fluid density (arrows) in the
Pericardium
46
Pericardial Calcifications
Pericardial Calcification in a patient with
Severe Constrictive Pericarditis
47
Pericardial Calcifications
Pericardial Calcification in a patient with
Severe Constrictive Pericarditis
48
Pulmonary vessels

• The plain chest film provides a simple method of
  assessing the pulmonary vasculature. Even though
  it is not possible to measure the true diameter
  of the main pulmonary artery on plain film, there
  are degrees of bulging that permit one to say
  that it is indeed enlarged. Conversely, the
  pulmonary artery may be recognizably small. The
  assessment of the hilar vessels can be more
  objective since the diameter of the right lower
  lobe artery can be measured the diameter at its
  midpoint is normally between 9 and 16 mm. The
  size of the vessels within the lungs reflects
  pulmonary blood flow. There are no generally
  accepted measurements of normality, so the
  diagnosis is based on experience with normal
  films. By observing the size of these various
  vessels it may be possible to diagnose one of the
  following haemodynamic patterns.
• Increased pulmonary blood flow Atrial septal
  defect, ventricular septal defect and patent
  ductus arteriosus are the common anomalies in
  which there is shunting of blood from the
  systemic to the pulmonary circuits (so-called
  left to right shunts), thereby increasing
  pulmonary blood flow. The severity of the shunt
  varies greatly. In patients with a
  haemodynamically significant left to right shunt
  (21 or more), all the vessels from the main
  pulmonary artery to the periphery of the lungs
  are large. This radiographic appearance is
  sometimes called pulmonary plethora. There is
  reasonably good correlation between the size of
  the vessels on the chest film and the degree of
  shunting.

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Pulmonary Vessels
It is not possible to measure the diameter of
the MPA from the plain film (usually
subjective) but if there are variable degrees
of bulging, means enlarged MPA. Assessment of
the hilar pulmonary arteries is more objective
the diameter of the Rt. lower lobe artery at
its mid-point (normally 9 16 mm). The
size of pulmonary vessels with the lung reflects
the pulmonary blood flow. Increase
pulmonary blood flow is seen in ASD, VSD,
PDA, all of these will lead to Systemic to
Pulmonary (Lt. to Rt. shunt) these will to
increase pulmonary blood flow.
50
Pulmonary Vessels
Hemodynamically significant Lt. to Rt. shunt is
(2/1 ratio or more) this will produce CXR
findings if less ratio there will be no CXR
findings all the pulmonary vessels will
(from the MPA to the periphery of the lung) will
be enlarged, this is called "Pulmonary
Plethora". There is good correlation between
the size of the vessel on CXR degree of the
shunt. Decrease pulmonary blood flow, all
the vessels are small "Pulmonary Oligemia".
The commonest cause of decrease pulmonary
blood flow is TOF pulmonary stenosis.
Obstruction of the Rt. ventricle outflow VSD
will lead to Rt. to Lt. shunt. Pulmonary
stenosis will cause oligemia only is severe
cases babies or very young children.
51
Decreased pulmonary blood flow To be
recognizable radiologically, the reduction in
pulmonary blood flow must be substantial. The
pulmonary vessels are all small, an appearance
known as pulmonary oligaemia. The commonest cause
is the tetralogy of Fallot, where there is
obstruction to the right ventricular outflow and
a ventricular septal defect which allows right to
left shunting of the blood. Pulmonary valve
stenosis only causes oligaemia in extremely
severe cases in babies and very young children.

• Pulmonary arterial hypertension The pressure in
  the pulmonary artery is dependent on cardiac
  output and pulmonary vascular resistance. The con
  ditions that cause significant pulmonary arterial
  hypertension all increase the resistance of blood
  flow through the lungs. There are many such
  conditions including
• various lung diseases (cor pulmonale)
• pulmonary emboli
• pulmonary arterial narrowing in response to
  mitral valve disease or left to right shunts
• idiopathic pulmonary hypertension.
• Pulmonary arterial hypertension has to be severe
  before it can be diagnosed on plain films and it
  is difficult to quantify in most cases. The plain
  chest film features are enlargement of the
  pulmonary artery and hilar arteries, the vessels
  within the lung being normal or small. When the
  pulmonary hypertension is part of Eisenmenger's
  syndrome (greatly raised pulmonary arterial
  resistance in association with atrial septal
  defect, ventricular septal defect or patent
  ductus arteriosus, leading to reversal of the
  shunt so that it becomes right to left), the
  vessels within the lungs may also be large, but
  there is still disproportionate enlargement of
  the central vessels.The reason for pulmonary
  arterial hypertension may be visible on the chest
  film in cor pulmonale the lung disease is often
  radiologically obvious, and in mitral valve
  disease and other.

52
Pulmonary Arterial Hypertension
The pressure in the pulmonary artery depends on
1- Cardiac output. 2-
Pulmonary vascular resistance.
Conditions that cause significant pulmonary
arterial hypertension all increase the
resistance of blood flow through the lungs,
examples 1- Various lung diseases
(cor pulmonale). 2- Pulmonary embolism.
3- Pulmonary arterial narrowing in response to
mitral valve diseases or Lt. to Rt.
shunt. 4- Idiopathic pulmonary
hypertension.
53
Pulmonary Arterial Hypertension
By CXR
There will be enlargement of the mean pulmonary
artery the hilar pulmonary artery, vessels
within the lung tissue are normal or small.
Eisenmenger's syndrome
Greatly raised pulmonary artery resistance in
association with ASD, VSD, PDA leading to
reverse shunt (i.e. Rt. to Lt. shunt).
54
Pulmonary Arterial Hypertension
The cause of pulmonary arterial hypertension
may be visible on the CXR as cor pulmonale
mitral valve diseases.
Pulmonary Arterial Hypertension due to ASD
Eisenmenger's syndrome
55
Pulmonary Venous Hypertension
The commonest causes of pulmonary venous
hypertension are 1- Mitral valve
diseases. 2- Lt. ventricular failure.
In normal upright person (by CXR) the lower zone
vessels are larger than the upper zone.
In pulmonary venous hypertension the upper zone
vessels are enlarged. In severe cases,
the upper zone vessels become larger than that
of the lower zone, eventually Pulmonary
Edema will supervene may obscure the blood
vessels.
56
Pulmonary Venous Hypertension
Pulmonary Venous Hypertension in a patient with
Mitral Valve Disease
57
Pulmonary oedema The common cardiac conditions
causing pulmonary oedema are left ventricular
failure and mitral stenosis. Cardiogenic
pulmonary oedema occurs when the pulmonary venous
pressure rises above 24-25 mmHg (the osmotic
pressure of plasma). Initially, the oedema is
confined to the interstitial tissues of the lung,
but if it becomes more severe fluid will also
collect in the alveoli. Both interstitial and
alveolar pulmonary oedema are recognizable on
plain chest films.

• Interstitial oedema There are many septa in the
  lungs which are invisible on the normal chest
  film because they consist of little more than a
  sheet of connective tissue containing very small
  blood and lymph vessels. When thickened by
  oedema, the peripherally located septa may be
  seen as line shadows. These lines, known as
  Kerley ? lines, named after the radiologist who
  first described them, are horizontal lines never
  more than 2 cm long seen laterally in the lower
  zones. They reach the lung edge and are therefore
  readily distinguished from blood vessels, which
  never extend into the outer centimetre of the
  lung. Other septa radiate towards the hila in the
  mid and upper zones (Kerley A lines). These are
  much thinner than the adjacent blood vessels and
  are 3-1 cm in length. Another sign of
  interstitial oedema is that the outline of the
  blood vessels may become indistinct owing to
  oedema collecting around them. This loss of
  clarity is a difficult sign to evaluate and it
  may only be recognized by looking at follow-up
  films after the oedema has cleared. Fissures may
  appear thickened because oedema may collect
  against them.

• Alveolar oedema Alveolar oedema is a more severe
  form of oedema in which the fluid collects in the
  alveoli. It is almost always bilateral, involving
  all the lobes. The pulmonary shadowing is usually
  maximal close to the hila and fades out
  peripherally leaving a relatively clear zone that
  may contain septal lines, around the edge of the
  lobes. This pattern of oedema is sometimes
  referred to as the 'butterfly' or 'bat's wing'
  pattern.

58
Septal lines in interstitial pulmonary oedema,
(a) Left upper zone showing the septal lines
known as Kerley A lines (arrowed) in a patient
with acute left ventricular failure following a
myocardial infarction. Note that these lines are
narrower and sharper than the adjacent blood
vessels, (b) Right costophrenic angle showing the
septal lines known as Kerley ? lines in a patient
with mitral stenosis. Note that these oedematous
septa are horizontal non-branching lines which
reach the pleura. One such line is arrowed.
59
Bat-Wing Appearance Alveolar oedema in a patient
with acute left ventricular failure following a
myocardial infarction. The oedema fluid is
concentrated in the more central portion of the
lungs leaving a relatively clear zone
peripherally. Note that all the lobes are fairly
equally involved.
60
Aorta

• With increasing age the aorta elongates.
  Elongation necessarily involves unfolding,
  because the aorta is fixed at the aortic valve
  and at the diaphragm. This unfolding results in
  the ascending aorta deviating to the right and
  the descending aorta to the left. Aortic
  unfolding can easily be confused with aortic
  dilatation.
• True dilatation of the ascending aorta may be due
  to aneurysm formation or secondary to aortic
  regurgitation, aortic stenosis or systemic
  hypertension.
• The two common causes of aneurysm of the
  descending aorta are atheroma and aortic
  dissection. A rarer cause is previous trauma,
  usually following a severe deceleration injury.
  The diagnosis of aortic aneurysm may be obvious
  on plain film but substantial dilatation is
  needed before a bulge of the right mediastinal
  border can be recognized. Atheromatous aneurysms
  invariably show calcification in their walls and
  this calcification is usually recognizable on
  plain film. Computed tomography with intravenous
  contrast enhancement is very useful when aortic
  aneurysms are assessed. It is important to know
  the extent of aortic dissections as those
  involving the ascending aorta are treated
  surgically while those confined to the descending
  aorta are usually treated conservatively with
  hypotensive drugs. Standard echocardiography
  shows dissection of the aortic root but
  transoesophageal echocardiography shows
  dissections distal to the aortic root and in the
  descending aorta as well. Dissecting aneurysms
  can also be shown with CT and MRI and these
  non-invasive techniques have largely replaced
  aortography, which is only performed in selected
  cases.
• Two congenital anomalies of the aorta may be
  visible on plain films of the chest coarctation
  and right-sided aortic arch, a condition that is
  sometimes seen in association with intracardiac
  malformations, notably tetralogy of Fallot,
  pulmonary atresia and truncus arteriosus. It can
  also be an isolated and clinically insignificant
  abnormality. In right aortic arch, the soft
  tissue shadow of the arch is seen to the right,
  instead of to the left, of the lower trachea.

61
Aortic dissection, (a) Transoesophageal
echocardiogram showing the true (T) and false (F)
lumina in the descending aorta. CT scan showing
the displaced intima (arrows) separating the true
and false lumina in the ascending and descending
aorta. MRI scan showing the displaced intima in
the ascending and descending aorta (arrows). AAo,
ascending aorta DAo, descending aorta PA,
pulmonary artery.
62
MSCT vs. references method of conventional
angiography

• 16 row MSCT Sensitivity 92-95
• Specificity 86-93
• positive predictive value 79-80
• negative predictive value 97
• K Nieman,Lancet ,2001
• Attention MSCT is exellent method in excluding
  coronary artery disease in patients with
  non-specyfic chest pain.(Ch.Becker)

63
MSCT EVALUATION OF STENTS

• Visualization and availability stents for
  analysis - 50-77
• Patency stents
• - sensitivity 75
• - specificity 96
• Occluded stents
• sensitivity 98-100

Schuijf JP, Am J Cardiol 2004,94(4),427
64
MSCT evaluation of aorto-coronary by-passes

• Closed aorto-coronary graft
• - specificity 97,
• - sensitivity 98
• Narrowing
• - specificity 75
• - sensitivity 92
• After 3 years from 20-to 30 by-passes are
  occluded

Silber S iwsp. Herz 2003, 2126-35
65
Coronary Artery Disease Diagnostic possibilities
of MSCT

• NONINVASIVE ANGIOGRAPHY OF CORONARY ARTERIES
• Evaluation of coronary anatomy, morphology and
  anomalies of the origin, calcium scoring (CS).
• Identification of soft and calcification plaques
  and their
• - location
• - range
• - length
• Assessment of myocardial function
• Thickness and wall motion
• Hemodynamic paramters
• Myocardial perfusion

66
MSCT coronary calcium score the relationship
to coronary artery disease.

• Studies using serial MSCT scans indicate that the
  annual progression of coronary calcium varies
  between 30 to 50 in symptomatic or asymptomatic
  nontreated high risk individuals.
• In patients treated effectively with
  lipid-lowering medication the progression of
  coronary calcium score varies between 0-20.

Schmermund A i wsp. Cardiol Clin 2003,21(4)
67
Coronary Calcium Scores according to Varying Age
and Sex (ECTB) (10377 asymptomatic pts)
During a mean follow-up of 5 years , the death
was - 2,4 Risk-adjusted relative risk values of
coronary calcium were 11-100 1,64 101-400 1,
74 401-1000 2,54 gt 1000 4,03 as comapred
with score of 10 or less (plt0,001 for all values)
Shaw LI i wsp. , Radiology 2003228,826
68
64 MSCT STENTS AND BY-PASS
Occluded by-pass for CX, implanted 3 stents in
CX, all patency