Cardiac Imaging

Alaa Mohamed Reda

Lecturer of Radiology ,MD

what do you know about �x-ray ??

X-ray machine

X-ray tube

Different x-ray densities

�1-air

�2-fat

�3-soft tissue

�4-bone 

�5-metal 

X-ray image display

1- on film

2- on computer

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Objectives of our lecture:

• Methods of examination of the heart
• Normal radiological anatomy of the heart
• Common pathological diseases of the heart

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Objectives of our lecture:

• Methods of examination of the heart
• Normal radiological anatomy of the heart
• Common pathological diseases of the heart

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Methods of Examination of the heart

• Plain xray
• Angiography
• Echocardiography
• CT (multislice)
• MRI
• Radioisotopes (Nuclear medicine)

1-Plain xray: is the initial diagnostic modality in assessment of pathology, views include PA and lateral views.

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PA View

Lateral View

�����2-Echocardiography: is the study of the heart by Ultrasound and Doppler to assess cardiac chamber diseases and valve motion and function. �

3-CT (Multislice): recently CT scanners which

can acquire large body volume in very short time

, 3D images reconstruction

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4-MRI: also a recent modality in the imaging of the

cardiac chambers morphology and function.

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5-Nuclear medicine: imaging modalities that study the cardiac tissue viability as in Myocardial ischemia and infarction.

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6-Angiography: imaging cardiac chambers and coronary arteries using contrast material under real time fluoroscopic guidance which may be ….diagnostic or therapeutic as (coronary artery dilatation & stenting

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Objectives:

• Methods of examination of the heart
• Normal radiological anatomy of the heart
• Common pathological diseases of the heart

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Objectives:

• Methods of examination of the heart
• Normal radiological anatomy of the heart
• Common pathological diseases of the heart

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�Common pathological diseases of the heart �

• Pericardial effusion
• Cardiomegaly
• Cardiac chamber enlargement

LA Enlargement

Lt Atrial Appendage Enlargement

RA Enlargement

Rt Atrial Appendage Enlargement

LV Enlargement

RV Enlargement

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• Cardiomyopathy
• Valve lesions as mitral or aortic (stenosis or regurge) .
• Heart failure
• Pulmonary hypertension.

1-Cardiomegaly

• The cardiothoracic ratio should be less than 0.5.

A: Max. Transverse diameter of the heart

B: Max. Transverse diameter of the chest = 0.5

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• If cardiothoracic ratio is greater than 0.5 …suggests cardiomegaly

A

B

**Causes:

• Cardiomyopathy
• Pericardial effusion
• Valvular diseases
• Congenital heart diseases.
• Mass lesions

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2-Pericardial effusion�

• More than 250 ml are necessary to be detected in xray
• Symmetrical enlargement of cardiac shadow (Flask shaped heart)

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• DD is dilated cardiomyopathy / multiple valvular lesions.

Pericardial effusion

DD: Multiple valvular lesions

�3-Cardiomyopathy��

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water-bottle configuration +

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Dilatation of the azygos vein

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4-Chamber enlargement�

1- Left atrial enlargement:

Is the most posterior chamber in the heart

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*If enlarged:

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• Double density along right cardiac border
• Bulging of LA appendage
• Widening of the angle of the carina (> 60°)

• on Barium study: the esophagus is displaced posteriorly (lateral view)

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2- Left ventricular enlargement:

The LV forms the cardiac apex

If enlarged:

• Left downward displacement of the apex
• Round left cardiac border

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3- Right atrial enlargement:�

• Difficult to assess by plain x-ray
• Increased convexity of lower right heart border on PA view

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4- Right ventricular enlargement:�the most anterior chamber

• If enlarged:
• Rounding and elevation of cardiac apex
• On lateral vie: obliteration of retrosternal space.

5-Valvular lesions�

• Mitral and aortic valves ae the most commonly affected.
• Causes: congenital or acquired (rheumatic fever).

1-Mitral stenosis

Mitral stenosis

MS (loss of cardiac waist)

2-Mitral regurge

• “Big heart” (volume overload, cardiomegaly)
• Enlarged chambers: LA + LV
• Pulmonary Venous Hypertension (usually less severe than in mitral stenosis)
• Calcification of mitral valve

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NOTE:

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Mitral valve lesions usually occur in conjunction i.e. Mitral stenosis is usually associated with an element of mitral regurgitation and vice versa.

3-Aortic stenosis

• Degeneration (old age)
• Congenital (bicuspid valve)
• Rheumatic fever

• Congenital (membranous)
• IHSS

*Imaging features:

• Often difficult to detect abnormalities by plain film (usually no chamber enlargement).
• Enlargement of ascending aorta
• Calcification of aortic valve: if older than 40

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4-Aortic regurge

• Enlarged aorta and left ventricle.

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• Cardiomegaly

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6-heart failure �

*Definition:

• Means the heart fails to maintain sufficient circulation to provide adequate tissue oxygenation.

*Types:

• Right sided heart failure
• Left sided heart failure

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1-Right sided heart failure

* Right heart failure (this is usually due to chronic airways disease).

• Features of COPD (chronic obstructive pulmonary disease).
• Cardiomegaly, or normal sized with a prominent elevated apex due to right ventricular hypertrophy.
• Pulmonary hypertension : Pulmonary arterial enlargement and venous upper lobe diversion.
• +- pleural effusion .

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2-left heart failure & pulmonary edema .:�

* left heart failure & pulmonary edema (stages).:

• Stage I : upper lobe venous blood diversion
• Stage II: interstitial pulmonary edema

(interstitial thickening : kerly’s B lines)bilaterally in both lung bases.

• Stage III: alveolar edema (Bat wing appearance): perihilar opacities

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Stage I

Stage II

Stage III

7-pulmonary hypertension�

• Increased pulmonary arterial pressure

>25 mmHg.

• Imaging features: (central vessels enlarged and peripheral pruning)

- Enlargement of the main, right and left pulmonary arteries

- Rapid tapering of the peripheral pulmonary vasculature (‘peripheral pruning’).

- The heart size may be normal or enlarged.

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*Differential diagnosis:

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• Bilateral hilar lymph nodes enlargement.

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