Cardiovascular system

 Introduction
 Anatomy and pathology
 Summary
 Introduction
1. History : anatomy of cardiovascular
Cardiovascular -- 16 th century -- autopsy, ECG

2. Modalities
Without x ray
ECG
MRI
Radiopharmacy Nuclear medicine Tc 99 m th 204
Introduction
With X - rays
Without contrast media : chest X rays, fluoroscopy,
EBCT
With contrast media: Esophagography,
interventional cardiography EBCT

3. Indication : Suspect abnormalities of CV and

lung disease based on clinical diagnosis
 ANATOMY AND PATHOLOGY
1. Chest X Ray
Standard projections and technical consideration :
high Kv 120-145, lov 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 = ½ 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 -- PA, AA
Right anterior oblique projection : LA,RA,
RV--AA
Left anterior oblique projection : RV --
RAA, 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 --> 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 - prominent-
mediastinal enlargement
 pulmonal artery widening(MPA)
– volume increase--- L to R shunt, VSD,
VSD,PDA
– obstruction in periphery artery
ASD,VSD,PDA  Pulmonary art >------ capillaries
in lungs >, pulmonary veins>MPA at hilum >>
Pulmonary artery >> -fibrosis, emphysema,
atelectasis, and pulmonary veins congestion of
lungs
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
 Dextroversion
 Mesoversion
 Levocardi
Dextrocardia : heart, aorta and apex are in the right
hemithorax
Most often accompanied by situs inversus
Dextroversion : heart turns right
• Heart in right hemothorax
• Apex turned down
• LV at frontal side
• RV turns right-posteriorly
Mesoversion : heart in the middle of thoracal cavity
Levocardi : - heart in left hemithorax
- abdominal organ in right side
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
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
3. Rotation of the heart
Rotation to left side , cause of RVE, aortic
arch  small and rounded, LV 
To latero - posterior
Rotation to right side, cause of great LVE,
RV  dextro-lateral, RA  dextro-
posterior, aortic arch  descending
aorta on the left side of vertebral
column
CONGENITAL ANOMALY
 Abnormality of the septum

 Abnormality of the great arteries ---

shape and position
 Abnormality of chamber of the heart

 Abnormality of position
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
ASD secundum > ASD primum
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 close to upper
sternum
• 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 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
N
 Pulmonary vascularities
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 : 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 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 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 lower
lung
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 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 with
decrease pulmonary vascularity

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
Aorta : prominent (post stenotic dilatation)
RV, LV  N
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
Aortic anomalies/abnormalities
Etiology : - inflammation process
- degenerative process
- traumatic factor
- congenital
 Aortitis
 Aortasclerotic
 Aortaelongation
 Aortic aneurysm
 Coarctatio aortae
 Vascular ring
 Pericard abnormalities
Etiology : - infection
- trauma
1. Cardiac tamponade
2. Pericardial effusion
3. Pericarditis
4. Pericardial cyst

Cor pulmonale
Heart disturbances because of chronic
pulmonary diseases