cardiovascular, kuliah atma

7/30/2019 Cardiovascular, Kuliah Atma

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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 60-80Position : postero-anterior, lateral, oblique

Deep inspiration, suspended breathDistance : 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

pleuras4. 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 = ½ C1

D + E = 4 cm

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

A + B

C1 + C2X 100%CTR =



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 , LV-LA, 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 --> Rightand Left Lungs

PA tributaries (small arteries) with bronchi tothe alveoli capillaries

PVs (capillary plexus) in alveoli septa --> tomedial 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 theupper 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, conformwith trachea

node enlargement - prominent-

mediastinal 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--Takayashudisease --- abdominal aorta

– Abnormality of the aorta itself --widening in chronichypertension

Narrowing of the aorta

– Decrease of blood volume to the aorta --- septalleakage 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 thecardiac 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

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



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 vascmarking

2.CHD with decreased vasc

marking

Cyanotic TAPVR

TAP

TGP

Acyanotic ASD

VSD

PDAECD

PAPVR

Cyanosis (+) – 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 hypertensionPA 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 bothsides

Extremely wide of central hila andbecame 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 close to uppersternum

• Hilar enlargement

• Infero-posterior part of the heart

overlapping with vertebral column



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 supraventricular/ 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, excludingpremature 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

PVLA are enlarged

LV

AO

RV dilatation (large defect)



Small PDA : Heart

Pulmonary vascularitiesModerate PDA : Ascending aorta

aorta arch PA : prominent next to AO

Pulmonary vascular markings : increased

Hila : wide R

LA : enlarged

LV

RV

N

N/slightly enlarged

are enlarged



PDA with pulmonary hypertension

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)

Incidence “ Less than 1 % of all CHD

One or more (but not all) pulmonary veinsdrain into the RA or its tributaries, such asthe 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 are enlarged

PA

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 lowerlung



B. Increased pulmonary vascular

markings with cyanosis 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 heartand gives rise to pulmonary,

systemic and coronary circulations

Blood from RV & LV drain into thetrunk cyanotic



Chest X rays Heart enlargement, oval shaped (RV,

LV, LA)

Increased pulmonary vascularity

A right aortic arch (50%)

T iti f th t l



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 fromLV

• 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

A. Without cyanosis

1. Pulmonary stenosis

– Incidence 5% - 8% of all congenital heartdefects

– 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 andleft 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 beyondinfancy

•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 increasedradiolucency

• Widening of the aortic arch

• Right sided aorta/aortic arch (25%)



2. Trilogy of Fallot

Similar to Tetralogy of Fallot excluded VSD/overridingaorta

Abnormalities are :

• Pulmonary stenosis

• RVH

• Leakage of atrial septum thru ASD/persistenforamen 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

A qui d h t dis s



Acquired heart disease

1. Mitral stenosis

Incidence : - Rare in children

- The most common valvular involvementin 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

Aorta : prominent (post stenotic dilatation)

RV, LV N

5 T i id i fi i



5. Tricuspid insuficiency

Incidence : - 2% of all congenital disease in infancy

Etiology : - 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

l / b l



Aortic anomalies/abnormalities

Etiology : - inflammation process

- degenerative process

- traumatic factor

- congenital

Aortitis

Aortasclerotic

Aortaelongation

Aortic aneurysm Coarctatio aortae

Vascular ring

cardiovascular, kuliah atma

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