CARDIOVASCULAR

imaging
dr. Hari Soekersi, Sp.Rad(K)
Radiology Department of Hasan Sadikin
Hospital
Medical Faculty of Padjadjaran University
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Heart Anatomy

Heart Conduction System

Heart Conduction System

Cardiac Contraction

Circulation

POSITIONING

CHEST X-RAY POSITION

POSTEROANTERIOR
RIGHT/LEFT LATERAL
RIGHT ANTERIOR OBLIQUE
LEFT ANTERIOR OBLIQUE

POSTEROANTERIOR
PROJECTION

POSTEROANTERIOR
PROJECTION

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POSTEROANTERIOR
PROJECTION

Superio
r vena
cava
Right
Atrium

Aorta
Pulmona
ry artery
Appendag
e of the
left
atrium
Left
Ventricl
e

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LATERAL PROJECTION

1. Superior vena cava

2. Ascending aorta
3. Main pulmonary artery
4. Right atrium
5. Tricuspid valve
6. Right ventricle
7. Aortic arch

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LATERAL PROJECTION

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LATERAL PROJECTION

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LATERAL PROJECTION

Root of the
main
pulmonary
artery
Right
Ventricl
e

Left
Atrium
Left
Ventricl
e

Because these structures are in contact with

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mediastinal fat, their margin may be indistinct

RIGHT ANTERIOR OBLIQUE

PROJECTION

1. Anterior wall of the trachea

2. Innominate vein
3. Anterior border of the superior vena cava
4. Superior vena cava
5. Right main branch of the pulmonary artery
6. Thoracic aorta
7. Left atrium
8. Right atrium
9. Inferior vena cava
10.Left innominate vein
11.Arch of the aorta
12.Left main branch of the pulmonary artery
13.Main stem of the pulmonary artery
14.Left main bronchus
15.Tricuspid valve
16.Mitral valve
17.Right ventricle
18.Left ventricle

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RIGHT ANTERIOR OBLIQUE

PROJECTION

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LEFT ANTERIOR OBLIQUE

PROJECTION

1. Superior vena cava

2. Right main branch of the pulmonary artery
3. Ascending aorta
4. Main pulmonary artery
5. Right atrial appendage
6. Tricuspid valve
7. Right ventricle
8. Left subclavian artery
9. Posterior border of the trachea
10.Left main branch of the pulmonary artery
11.Left main bronchus
12.Left atrium
13.Mitral valve
14.Left ventricle
15.Inferior vena cava

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LEFT ANTERIOR OBLIQUE

PROJECTION

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PLAIN FILMS DIAGNOSIS OF

CARDIAC DISEASE

Analyze each case with

six steps:

6
3

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PLAIN FILMS DIAGNOSIS OF

CARDIAC DISEASE

Analyze each case with

six steps:

EVALUATION OF THE THORACIC CAGE FOR

SIGN OF PREVIOUS SURGERY OR OTHER
ABNORMALITIES
IDENTIFICATION OF THE POSITION OF THE
STOMACH BUBBLE AND HEPATIC SHADOW TO
DETERMINE BODY SITE
EVALUATION OF GREAT VESSELS FOR SIZE AND
POSITION
EVALUATION OF SPECIFIC CHAMBER
ENLARGEMENT
EVALUATION OF CARDIAC SIZE AND CONTOUR
EVALUATION OF PULMONARY VASCULARITY
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EVALUATION OF THE THORACIC

CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER
ABNORMALITIES

Signs of previous surgery

- periosteal elevation
- asymmetry thoracic cage
- smaller and slightly deformed rib
- resected rib in previous thoracotomy

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EVALUATION OF THE THORACIC

CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER
ABNORMALITIES

Congenital heart disease:

- premature fusion of sternum cyanotic
form
- hypersegmentation of sternum Downs
syndrome
- bulging of sternum enlarged right
ventricle
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COMPLETE FUSION OF
STERNAL SEGMENTS

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HYPERSEGMENTATION OF
THE STERNUM

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ATRIAL SEPTAL DEFECT WITH

ENLARGED RIGHT VENTRICLE AND
ANTERIOR BULGING OF THE STERNUM

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IDENTIFICATION OF THE
POSITION OF THE STOMACH
BUBBLE AND HEPATIC SHADOW
TO DETERMINE BODY SITE

Abnormal hepatic and stomach position

show abnormalities in position of the viscera
congenital cardiac disease

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SITUS SOLITUS WITH DEXTROCARDIA

Stomach bubble is under the left diaphragm

Liver is on the right
Heart is on the right with cardiac axis directed to
the right
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SITUS INVERSUS WITH DEXTROCARDIA

Stomach bubble is under the right diaphragm

Liver is on the left
Heart is on the right with cardiac axis directed to the
right
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ISOLATED LEVOCARDIA OR SITUS

AMBIGUS

Stomach bubble is under the right

diaphragm
Liver is on the left
Normal heart position

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DEXTROCAR
DIA
DEXTROVERSIO
N
Dextrocardia :

Location of the heart in the right

side of the thorax, the apex
pointing to the right
Dextroversion :
Location of the heart in the right
chest, the left ventricle remaining
in the normal position on the left
with the apex pointing the the left
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EVALUATION OF GREAT VESSELS

FOR SIZE AND POSITION

Enlargement of the pulmonary artery segment

Prominent pulmonary arterial segment along the left
upper cardiac border
In TGV and truncus arteriosusabnormal position
(concave)
Enlargement of the aorta
Three portions of the aorta can be evaluated:
ascending aorta, aortic arch dan descending aorta.

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ENLARGEMENT OF PULMONARY
ARTERY SEGMENT

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TRANSPOSITION OF GREAT VESSELS

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TRANSPOSITION OF GREAT VESSELS

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EVALUATION OF SPECIFIC
CHAMBER ENLARGEMENT

Signs of left atrial

enlargement
Signs of left ventricular
enlargement
Signs of right atrial
enlargement
Signs of right ventricular
enlargement
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SIGNS OF LEFT ATRIAL ENLARGEMENT

Posteroanterior projection
1. Displace the barium-filled esophagus
below the carina to the right
2. Prominent bulge along the mid-left
cardiac border
3. A double density along the right cardiac
border
4. Widening of the angle of the carina >900

Lateral projection
1. Posterior displacement of both walls of
the barium-filled esophagus
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SIGNS OF LEFT ATRIAL ENLARGEMENT

Left anterior oblique projection

Elevate the left mainstem bronchus and
obliterates the spaces between the
posterior cardicac margin and the left
mainstem bronchus

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LEFT ATRIAL ENLARGEMENT

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SIGNS OF LEFT VENTRICULAR

ENLARGEMENT
Posteroanterior projection
1. Left ventricular dilatation produces
downward displacement of the apex
toward diaphragm.
2. Left ventricular hypertrophy produces a
round left cardiac border
Left anterior oblique projection
Posterior cardiac margin to overlap the
vertebral column

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LEFT VENTRICULAR DILATATION

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SIGNS OF RIGHT ATRIAL

ENLARGEMENT

Posteroanterior projection
Difficult increased convexity of the lower
right heart border on PA projection

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RIGHT ATRIAL ENLARGEMENT

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SIGNS OF RIGHT VENTRICULAR

ENLARGEMENT

Posteroanterior projection
Rounding and elevation of the cardiac
apex
Lateral projection

Retrosternal space is obliterated

Left anterior oblique projection

Increased convexity of the anterior cardiac

border

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RIGHT VENTRICULAR ENLARGEMENT

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EVALUATION OF CARDIAC SIZE

AND CONTOUR

Index of cardiac enlargement is the cardiothoracic

ratio.
In infants: >55%
In adults : > 50%
The lateral and oblique views must be considered

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CARDIOTHORACIC RATIO

(Cardiac width / Thoracic cage width) x 100%

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EVALUATION OF PULMONARY
VASCULARITY

In normal the pulmonary vascular marking

taper gradually toward the periphery of the lung
fields, and more prominent in the lower lung
fields.
The vessels in the right hillum is larger than in
the left

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SIX DIFFERENT VASCULAR

PATTERNS ARE RECOGNIZED
1. Normal pulmonary vascularity
2. Increased pulmonary vascularity due to increased
pulmonary blood flow.
- the peripheral arteries are sharply outlined and
dilated and distributed equally to both the upper
and lower lobes.
- ex. VSD, PDA, truncus arteriosus, transposition of
the great vessels.

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3. Decreased pulmonary vascularity due to

right-to-left shunts.
- small pulmonary arterial segment
- reduced diameter of the hilar pulmonary
arteries
- ex. Tetralogy of Fallot, tricuspid atresia,
pulmonary stenosis

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4. Pulmonary venous congestion

- occurs in condition that causes increased
resistance distal to pulmonary capillaries
- fluid accumulates in the interstitial tissues and
Kerley B lines
- ex. Mitral stenosis, acute left ventricular failure
are common causes.

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5. Bronchial collateral
6. A bizarre pattern of pulmonary vascularity
- different vascular pattern in each lung

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PATHOLOGY

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ACQUIRED HEART DISEASE

Radiology features of Left & Right Heart Failure
Acquired Valvular Heart Disease
Pericardial Disease
Acquired Vascular Disease

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RADIOLOGY FEATURES OF
LEFT & RIGHT HEART FAILURE
Many cardiac disease will eventually develop left or right heart
failure
Understanding the radiology features of left & right heart
failure fundamental

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LEFT HEART FAILURE

Five factors influence the distribution of pulmonary

blood flow.
Interstitial osmotic and alveolar pressures remain
constant throughout the lung
Hydrostatic, pulmonary arterial and pulmonary
venous pressures, diminish from base to apex
because of gravitational effects.
In left-sided cardiac failure, the increased pulmonary
venous pressure resulting from the elevated left
ventricular end-diastolic pressure
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LEFT HEART FAILURE

The transudation of fluid into the pulmonary
interstitium causes an increase in the interstitial
pressure
The earliest radiographic manifestation on left-sided
cardiac failure is:
1. An indistinctness of the vascular markings
caused by the increased interstitial fluids.
2. The hilar vessels become enlarged and
indistinct.
3. The increased interstitial fluid can be seen as
peribronchial cuffing.
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LEFT HEART FAILURE

Later, cephalization occurs. The vascular markings
are prominent in the upper lobes owing to the
constriction of the lower lobe vessels and
redistribution of flow to the upper lobes.
Pleural effusion occurs late
Transudation of fluid into the alveoli leads to
pulmonar edema. This appears in a perihilar location
(butterfly wings or bat wings).
Kerley B lines, due to fluid in the lobular septum.

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KERLEY A, B, & C

Kerley A : white arrow

Kerley B : white arrow head
Kerley C : black arrow head
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PULMONARY EDEMA
Classified into
Cardiogenic
Non-cardiogenic

Cardiogenic pulmonary edema heart failure

Heart failure
Left heart failure backward failure pulmonary congestion
pulmonary edema
Right heart failure backward failure systemic congestion doesnt
cause pulmonary edema

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PULMONARY EDEMA
Chest x ray screening tool
Left heart failure:

Heart enlargement with the apex downward to

the diaphragm
Depend on the severity
1. Cranialization / cephalization (PCWP 10-15
mmHg)
2. Interstitial pulmonary edema (PCWP 20-25
mmHg)
3. Alveolar pulmonary edema (PCWP >25
mmHg)
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PULMONARY EDEMA
Cranialization / cephalization
Pulmonary veins at the superior part of the lung >3-5:1 than the
pulmonary veins at the inferior part of the lung.
Vascular marking at the superior part of the lung is more crowded than
the inferior part of the lung.
Measure at equidistant from the hilar point.

Mechanism:
Decreased vascular compliance at the lung base.

Hypoxic vasoconstriction phenomenon

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PULMONARY EDEMA

Cranialization / Cephalization

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PULMONARY EDEMA
Interstitial pulmonary edema
Interlobular septa thickening

Kerley B lung base : thickness 1mm, length 1-2cm,

horizontal
Kerley A dilatation of channel that connect the peripheral
lymphatic channel to central lymphatic channel. Length up to
6cm, oblique at the central part
Kerley C reticular at the lung base (en face Kerley B)
Peribronchial thickening at both hila
Fluid in fissures
Pleural effusion (Bilateral especially the right side)

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PULMONARY EDEMA

Kerley B lines
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PULMONARY EDEMA

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PULMONARY EDEMA

Peribronchial thickening and fluid in

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PULMONARY EDEMA

Interstitial pulmonary edema

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PULMONARY EDEMA
Alveolar pulmonary edema

Infiltrates in the medial two third of the lung.

Bats wing appearance
Butterfly appearance
Usually no air bronchogram

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PULMONARY EDEMA

Alveolar pulmonary edema

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PULMONARY EDEMA

Alveolar pulmonary edema

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PULMONARY EDEMA
Non cardiogenic pulmonary edema
More peripherally
No cranialization/cephalization
Etiology:

Volume overload
ARDS
NSAID
Neurogenic pulmonary edema (intracranial pressure>>)
Drowned

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PULMONARY EDEMA

Non cardiogenic pulmonary edema

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RIGHT HEART FAILURE

Usually caused by pulmonary hypertension
Reversed comma sign
RV hypertrophy
Prominent pulmonary artery segment
Compensated RV hypertrophy
Decompensated
RV dilatation
RA dilatation
Systemic congestion

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RIGHT HEART FAILURE

Backward failure fromthe right heart failure
systemic congestion
Hepatomegaly
Increased jugular venous pressure
Dilated azygos vein
Ascites
Edema in the dependent part organ

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RIGHT HEART FAILURE

Mild PAH

Severe PAH

Pulmonal artery segment dilatation

Right ventricular enlargement
Reduced bronchovascular marking
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Pulmonary Hypertension
Increasing pressure of pulmonary artery

May reflect an increase in left heart filling pressure

in the presence of normal pulmonary vascular
resistance, or a combination of these initiating
factors.

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ACQUIRED VALVULAR HEART

DISEASE
Cardiac valves damage stenosis or
insufficiency
Aortic and mitral most commonly affected
Principal hemodynamic effect:
Stenosis:
Increased pressured in the proximal cardiac
chamber
Response hypertrophy
Dilatation decompensation
Insufficiency:
Enlargement of the cardiac chambers on both
sides of the insufficient valve
Response dilatation
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ACQUIRED VALVULAR HEART

DISEASE
Mitral Valve
Mitral Stenosis
Mitral Insufficiency

Aortic Valve
Aortic Stenosis
Aortic Insufficiency

Tricuspid Insufficiency
Pulmonal Insufficiency

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MITRAL VALVE
Rheumatic fever most frequent cause
Acute: inflammatory process involve the
heart
Chronic:
thickening and fibrosis of the mitral valve
leaflets
Fusion and shortening of the chordae
tendineae

Female >> Male

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MITRAL STENOSIS
Product of
Fusion of the valve leaflet
Fusion and shortening of the chordae
tendineae

Etiology
Rheumatic fever
Bacterial endocarditis (vegetation)
Thrombi
Tumor
Congenital
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MITRAL STENOSIS

Hemodynamics
Adult : Normal mitral valve area 4-6 cm2.
Normal orifice accomodate increased flow (during
exercise) without an increase in the left atrial
pressure (N:10mmHg)
1.5cm2 increase in left atrial pressure
(accentuated during excercise)
0.5cm2 left atrial pressure at rest 35 mmHg

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MITRAL STENOSIS
Hemodynamics
Thus, the left atrium is hypertrophied and then
enlarged.
PCWP pulmonary edema.
1. Cranialization / cephalization (PCWP 10-15 mmHg)
2. Interstitial pulmonary edema (PCWP 20-25 mmHg)
3. Alveolar pulmonary edema (PCWP >25-35 mmHg)

Pulmonary congestion pulmonary hypertension

Pulmonary arterial hypertension advantageous
. Limit pulmonary blood flow
. Protect the lungs from pulmonary edema

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MITRAL STENOSIS

Mitral stenosis

Pulmonary congestion edema

Left atrial pressure

Left atrium
hypertrophied

Diffuse hypoxic

Diffuse vasoconstriction

Left atrium dilatation

(decompensation)
Pulmonary congestion edema

Pulmonary arterial
hypertension
Right ventricular
hypertrophy failure
(decompensation)
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MITRAL INSUFFICIENCY
Rheumatic fever leading cause
Rheumatic process:
Fuses and shortens the chordae tendineae limit
movements prevent complete closure
Usually associated with some degree of mitral
stenosis
That result from :
Other causes:
Infarction
Rupture papillary muscle
Bacterial endocarditis
Perforation of a valve cusp
Marfans syndrome
Rupture of chordae tendineae
Dilatation of mitral valve ring from dilatation of the chamber
Tumor near the valve
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MITRAL INSUFFICIENCY
Posterior mitral valve prolapse
7% of female
Minimal regurgitation
Rarely produce significant hemodynamic abnormalities.

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MITRAL INSUFFICIENCY
Hemodynamics
Depends on
Extent of mitral valve that is not occluded during systole
Pressure difference between LV & LA during systole
Impedence to left ventricular outflow

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MITRAL INSUFFICIENCY
Mitral Regurgitation

blood flow to LA

Left ventricle dilatation

Amount of Mitral
Regurgitation

Left atrium dilatation

flow to LV during
diastole
Left ventricle dilatation

Left Ventricle
decompensation
LA pressure
pulmonary venous
pressure
RV systolic pressure
right ventricular
failure (rare)
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MITRAL INSUFFICIENCY
Clinical Features

Asymptomatic for a long time

Fatigue and dyspnea
Apical pansystolic murmur
A mid diastolic murmur

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MITRAL INSUFFICIENCY
Radiographic Features
Mild
Normal cardiac size and contour
Normal pulmonary vasculature

Moderate to severe
Cardiomegaly (LA and LV dilatation)
Pulmonary venous obstruction (cephalization, interstitial, kerley,
alveolar edema)
Eventually, pulmonary arterial hypertension

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MITRAL INSUFFICIENCY

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MITRAL INSUFFICIENCY

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PERICARDIAL DISEASE

Pericardial effusion
Pericardial cyst

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PERICARDIAL EFFUSION
Fluid in the pericardial cavity
Caused by:
Pericarditis
Infection (bacterial, tb)
Rheumatic
Uraemia
Prolonged cardiac failure
Trauma
Fluid may be:
Serous
Purulent
Bloody

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PERICARDIAL EFFUSION

Clinical features:
May be asymptomatic
Pericardial friction rub
Chest pain in pericarditis

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PERICARDIAL EFFUSION
Radiographic Features

Cardiomegaly
No demarcation of the chamber or great
vessels
Cardiac contour water bottle
Chronic (stretching of pericardial cavity)
Erect: wide based
Supine: wide centrally

Acute (not elastic)

Round
Not depend on position

Fluoroscopy : cardiac pulsation decreased

USG for minimal pericardial effusion
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PERICARDIAL EFFUSION

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PERICARDIAL CYST
Benign congenital anomaly of anterior-middle
mediastium
Clinical features:
Asymptomatic
Occasionally with chest pain and dyspnea

Radiological features:
Mass at the cardiophrenic sulcus

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PERICARDIAL CYST

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ACQUIRED VASCULAR
DISEASE
Aortic aneurysm
Elongatio aorta

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AORTIC ANEURYSM

Dilatation of aorta (diameter > 4cm)

Diameter >5-6 cm risk of rupture
Diameter 1cm/year risk of rupture

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AORTIC ANEURYSM
True aneurysm
True dilatation of the aortic wall
E/

Atherosclerosis (most common)

Hypertension
Inflammatory (rheumatoid arthritis, takayasu arterits, syphilis)
Marfans syndrome, Ehlers-Danlos

Pseudoaneursym
Rupture of the aortic wall focal bulging
E/Infection (mycotic aneurysm), trauma

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AORTIC ANEURYSM
Radiographic features:
Ascending aorta becomes the right heart border
Aortic knob > 35mm from the left margin of the trachea
Descending aorta shift to the left.

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AORTIC ANEURYSM

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AORTIC ANEURYSM
Complication:
Rupture
Dissection

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AORTIC ANEURYSM
Rupture

Widened mediastinum (>8cm)

Blurred aorta margin
Loss of aortic knob
Pleural cap
Hemothorax (usually left sided)
Right deviation of the trachea
NGT shift to the right

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AORTIC ANEURYSM

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AORTIC ANEURYSM
Dissection
Blood enters the medial layer of aortic wall through a tear or
penetrating ulcer in the intima and tracks along the media,
forming a second blood-filled channel within the wall
Classified by

De Bakey
Stanford

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AORTIC ANEURYSM

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AORTIC ANEURYSM
Dissection
Radiographic features:

Widened mediastinum
Double aortic contour

Irregular aortic contour

Calcium sign: inward displacement of atherosclerotic calcification

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AORTIC ANEURYSM

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AORTIC ANEURYSM

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AORTIC ANEURYSM

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ELONGATIO AORTA

Elderly
Length of ascending aorta, aortic arch and descending
aorta .
With or without dilatation
E/ hypertension (most common)

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ELONGATIO AORTA

Radiographic features
Less than 1 cm to the medial end of the clavicle
The film should be symmetrically taken and with enough
inspiration.

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ELONGATIO AORTA

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COR PULMONALE
COR PULMONALE is a disorder of the heart, esp right heart
( right ventricle ) due to abnormalities of the lungs which
causes major obstacles to the circulation of the heart
ETIOLOGY :
Acute : pulmonary emobolism, compresseion atelectasis, tension
pneumothorax, pulmonary resection
Chronic: emphysema, chronic bronchitis, lung fibrosis, TBC, Lung
carcinoma

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PATOPHYSIOLOGY
In normal circumstances there is a balance between
the blood vessel with a volume of blood flowing.
When the area of blood vessel is reduced, resulting
restriction to the circulation pulmonary
hypertension and right heart (especially right
ventricle) hypertrophy

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Cor Pulmonale

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Chest X-Ray:
1. Lung abnormality
2. Right ventricle hipertrophy, protruding of
pulmonary artery, hilar widening,
bronchovascular marking decreasing.
3. Increasing radiolucency emphysema.
4. Left atrium & Left ventricle normal in size,
normal aorta, not visible Pulmonary vein

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Thank You

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