Imaging of the Heart

Imaging Modalities
CXR CT MRI Doppler Echocardiography TOE Nuclear Imaging incl. PET Angiography

What to assess
heart size relative ventricular wall thickness atrial dilatation coronary vessels heart function valve patency / insufficiency anatomical variants congenital anomalies (ASD, VSD, AVSD, PDA, etc) presence of thrombi in heart / vessels great vessel anomalies / injury/ disease viable vs death muscle tissue

Chest X Ray

Chest X Ray

The Cardio Thoracic Ratio

Assess only on PA view AP projection leads to magnification and a falsely high CTR Is a measure of the cardiac silhouette (not the heart itself) Good inspiratory effort necessary

Heart Failure

Right atrial enlargement

Left ventricle enlargement

Left atrial enlargement

Pericardial Effusion

Dextrocardia

CT
Cardiac CT with ECG triggering offers good image quality of the heart Analyze the heart using cardiac axes These axes are also used in cardiac CT/MR and must be reconstructed in order to assess the heart properly Axial slices are useful for a global assessment of the morphology of the heart and its relation to the pericardium

4-chamber view
Achieved by rotating upwards from the apex of the heart on the axial slices. In this axis the right ventricle is projected next to the right atrium the left ventricle next to the left atrium. The mitral valve comes into view and - depending on the contrast protocol - the tricuspid valve may also be visible. Apex of the heart is well demarcated (note that the apex is formed by the left ventricle)

3-chamber view
border between the mitral and aortic valves is localized on the axial slices - images are rotated from this point On this image left atrium left ventricle mitral valve aortic valve proximal ascending aorta are visible.

5-chamber view
similar to the 4-chamber view additionally displays the aortic valve and left ventricular outflow tract view achieved by rotating the 4-chamber view more cranially.

2-chamber view
the 2-chamber view is achieved by rotating the images perpendicularly to the mitral valve and parallel to the cardiac septum gives an overview of the left atrium ventricle and mitral valve.

Cardiac anatomy from right to left

Right atrium
right atrium has an anterolateral position in the heart lies inferior to the left atrium. superior vena cava enters through the roof of the right atrium. inferior vena cava enters the right atrium from below near the cardiac septum. coronary sinus (venous return of the coronaries) enters anterior to, and just to the left of the inferior vena cava (arrow)

Coronary sinus
main draining vein of the myocardium. runs in the atrioventricular groove on the posterior surface of the heart and enters the right atrium in the vicinity of the tricuspid valve.

Right ventricle
blood leaves the right atrium and enters the right ventricle via the tricuspid valve. shaped differently to the left ventricle left ventricle is cylindrical in shape and the cavity of the right ventricle is effectively wrapped around it. has a thinner wall which is more trabecularized, especially towards the apex. moderator band runs from the septum to the lateral wall of the right ventricle plays a key role in the electrophysiological conduction of the right ventricle (blue arrows).

Pulmonary veins
Oxygen-rich blood enters the left atrium via the pulmonary veins. In most cases two pulmonary veins on the left and two on the right middle pulmonary veins usually drain into the superior pulmonary vein

Left ventricle
blood enters the left ventricle via the mitral valve then enters the aortic valve via the left ventricular outflow tract.

Aortic Valve
cusps of the aortic valves are named according to their relationship with the coronary arteries the right coronary left coronary non-coronary cusp (R, L and N)

Coronary Arteries on Angiography

Coronary arteries in the anterior projection. Left Main or left coronary artery (LCA) Left anterior descending (LAD) diagonal branches (D1, D2) septal branches Circumflex (Cx) Marginal branches (M1,M2) Right coronary artery Acute marginal branch (AM) AV node branch Posterior descending artery (PDA)

PA 0 Caud 30

Coronary Arteries
Coronary arteries in the right anterior oblique projection. Left Main or left coronary artery (LCA) Left anterior descending (LAD) diagonal branches (D1, D2) septal branches Circumflex (Cx) Marginal branches (M1,M2) Right coronary artery Acute marginal branch (AM) AV node branch Posterior descending artery (PDA)

RAO 20 Caud 20

Coronary Arteries
Coronary arteries in the lateral projection. Left Main or left coronary artery (LCA) Left anterior descending (LAD) diagonal branches (D1, D2) septal branches Circumflex (Cx) Marginal branches (M1,M2) Right coronary artery Acute marginal branch (AM) AV node branch Posterior descending artery (PDA)

Echocardiography

Long axis view provides a reliable picture of the function of the basilar portions of the anterior septum and posterior walls. motion of the mitral valve opening aortic leaflets shows their rapid systolic opening and a diastolic closed position arising from a position at the base of the anterior mitral leaflet.

Apical two chamber view permits evaluation of the motion of the anterior and inferior left ventricular myocardial segments mid-portion of the mitral valve motion is also evident

Short axis view myocardial segments presented anterior wall and antero-septum presented superiorly and the posterior and inferior walls in the lower portion of the wedge view. contractile motion should be symmetric toward the mid-portion of the myocardial cavity

Short axis view aortic valve three leaflets of the aortic valve are seen left atrium behind the aortic root

Apical four chamber view symmetric display of the two large atrio-ventricular valves left ventricle is displayed to the viewer's right interventricular septum and interatrial septum form column of tissue in the middle of the image

Subcostal view provides nearly a perpendicular view of the interatrial septum permits it to use doppler to interrogate potential shunts between those chambers

TOE
1. 2. 3. 4. an invasive echo test It evaluates heart chamber size pumping action valve appearance and function blood flow through the heart

images taken from the oesophagus provides superior picture quality less interference to sound wave travel from the oesophagus into the heart compared to chest wall and lungs

MRI
Full 3D capabilities Excellent soft-tissue contrast Tradeoff: high spatial resolution/short acquisition time

Two main configurations: 1. 2. Spin-echo entire change in magnetization used to create the image high spatial resolution (0.5mm) very slow (13s for one slice) Gradient-echo only a part of the change in magnetization used to create the image lower spatial resolution (1mm) very fast ( 2s, real time)

MRI
Pulse sequences:
1. Cardiac Gated T1WI (axial views): anatomical assessment

1.
1. 1.

Gradient Echo (GRE) cine in short axis: assesses ventricular function, ejection fraction
Phase contrast MRA: estimates ventricular function, regurgitation Gadolinium MRA: to define the anatomy

Nuclear Imaging
Nuclear imagine evaluates how organs function, unlike other imaging methods that assess how organs appear Small amounts of a radioactive solution is introduced into the body Gamma detector detects the solution in different parts of the body and a computer generates a series of images of the areas of interest

Cardiac SPECT
Single Photon Emission Computed Tomography scans - also called myocardial perfusion imaging - non-invasive - used to assess the heart's structure and function measure blood flow through the heart detect areas of abnormal heart muscle Information obtained from SPECT scans can be used to: Identify blockages in the coronary arteries Determine whether someone has had an MI Predict those at high risk for MI Assess a patient's condition after bypass surgery or angioplasty

Cardiac PET
Positron Emission Tomography used to: look for coronary artery disease by examining how blood flows through the heart evaluate damage to heart tissue after an MI

MUGA
Multiple Gated Acquisition Scan (radionuclide angiography) (RNA) used to

evaluate heart function by measuring ejection fraction