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Cardiovascular

Dr. Yanto Budiman, Sp.Rad, M.Kes Bagian Radiologi RS/FK Atma Jaya Jakarta

ANATOMY AND PATHOLOGY


1. Chest X Ray Standard projections and technical consideration : high Kv 120-145, low KV 60-80

Position : postero-anterior, lateral, oblique


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

2. Mediastinum
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


- Opaque silhoutte
- Mostly located in left hemithorax

- Aortic arch
- Diaphragm

4. Influence factor of the heart contour


1. The age : infant / newborn : more rounded

and transversal
Childhood Adult

2. Respiration
Deep inspiration
Expiration

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

5. Evaluation of the chest X-ray


Technical aspect : KV, mAs, Artifact, blurring, distance Object aspect : deep inspiration,

symmetrical, supine, erect

6. Cardiothoracic ratio

M = midline A = 1/3 C1 B = C1 D + E = 4 cm F = height of the aorta, 2 cm form the edge of the manubrium A + B X 100% CTR = C1 + C2

7. Visualisation of the heart structures


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

8. Imaging of the lungs vascular


Close relation between the lungs vascular

and abnormalities of the heart, vice

versa
Pulmonary arteries Pulmonary veins Aorta

Pulmonary artery/veins
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

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

Pulmonary artery
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
ABNORMALITIES OF LUNG VASCULATURES Abnormalities of pulmonary vessels
Vascular widening
Vascular narrowing

Pathways irregularity

Vascular widening
Hilum enlargement > 16 mm, conform with trachea node enlargement - prominentmediastinal enlargement pulmonal artery widening(MPA)

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

small hilum, small and smooth periphery


vessels, more radio lucent

Abnormality of the aorta


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


Dextrocardia
Dextrocardia :heart, aorta and apex are in the right hemithorax

Enlargement of the heart


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,

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 ventricle enlargement


(hypertrophy & dilatation)
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

Left atrial enlargement


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 ventricle enlargement


PA : left extends laterally, left diaphragm is depressed
- 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 RAO : - heart intersects left leaf of diaphragm

Left ventricular hypertrophy & dilatation

CONGENITAL ANOMALY
Abnormality of the septum

Abnormality of the great arteries ---

shape and position


Abnormality of chamber of the heart
Abnormality of position

Congenital Heart Disease


I.

1.CHD with increased vasc Cyanotic marking


Acyanotic

TAPVR TAP TGP ASD VSD PDA ECD PAPVR

2.CHD with decreased vasc Cyanosis (+) marking T4F (PS, VSD, TA, RVH)
T3F (FS, ASD, RVH) PA TA Ebstein Anomali

Cyanosis (-)
PS (Valvuler, Infusidubuler, Supravalvuler) HP Primer

1. Congenital anomaly with increased pulmonary vascular markings


A. Without cyanosis 1. Atrial septal defect (ASD)

Septum primum Ostium primum closed Septum secundum Foramen ovale closed

Chest X ray
Depends on :
The severity of the defect Complication

L to R shunt
R to L shunt

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

ASD with Mitral Regurgitaion

With pulmonary hypertension


PA position

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
LV Enlargement

LA is normal/enlarged
RV Enlargement sternum Hilar enlargement Infero-posterior part of the heart overlapping with vertebral column close to upper

3. Ventricular septal defect (VSD)


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
Membranous septum Muscular septum Above the crista supra ventricular/ sub ulmonic

Ventricular septal defect

Radiological Imaging depends on defect size pulmonary vascular changes

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

Normal of pulmonary vascular


markings

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

VSD Moderate to large


RV dilatation and hypertrophy
LV hyperthropy RA is normal LA dilatation Aorta is small Widening of pulmonary arteries

VSD with pulmonary hypertension


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 premature infants Female : male = 3 : 1

A common problem in premature infants


It is a patency of a normal fetal structure between the left PA and the descending aorta (ductus arteriosus Botalli) L to R shunt

Chest X ray :
LA dilatation LV hypertrophy PA PV LA are enlarged LV AO RV dilatation (large defect)

Small PDA :
Heart Pulmonary vascularities N

Moderate PDA :
Ascending aorta N/slightly enlarged aorta arch PA : prominent next to AO Pulmonary vascular markings : increased Hila : wide R LA : enlarged LV are enlarged RV

PDA with pulmonary hypertension


RV dilatation (hypertrophy and dilatation) LA Asc aorta Aortic arch MPA Hila : normal : wide : prominent : prominent : wide

Periphery pulmonary vascularities : faint

Partial anomalous pulmonary venous return (PAPVR)


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 are enlarged

Similar to ASD 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

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


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 decrease pulmonary vascularity

with

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
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


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 - occasionally widening of ascending aorta

Lat

: anterior part of ascending


RV, LV N

Aorta : prominent (post stenotic dilatation)

5. Tricuspid insuficiency
Incidence
Etiology

: - 2% of all congenital disease in infancy


: - congenital - rheumatic

Chest X ray :
PA LAO RAO : - RA dilatation - pulmonary vascularity : decreased : auricle RA : more prominent : enlargement RA, protruded posteriorly, beneath LA most commonly congenital

6. Pulmonary stenosis
Etiology :

Aortic anomalies/abnormalities
Etiology : - inflammation process - degenerative process - traumatic factor - congenital Aortitis Aortasclerotic Aortaelongation Aortic aneurysm

Coarctatio aortae
Vascular ring

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