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Cardiovascular ImagingM. J. McCowin, MD
Clinical Professor of Radiology, UCSF
G. Caputo, MDProfessor of Radiology, UCD
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Cardiac Imaging studies requested before
Cardiology consult• Chest x-ray (L. Antonietti, MD)
• Nuclear Medicine
• Echocardiography
• ?MRI
• ?CT
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Chest x-ray
• Cardiac Contour size and shape
• Poor for pericardial effusions
• Left ventricular failure
• Right ventricular failure
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PA heart < ½ chest diameter
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Chamber Enlargement
LA
LV
RV
RA
LV
RV
la append
LA
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Cardiac Contours: enlarged RA, LA, and RV in mitral stenosis
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New enlarged LV due to aneurysm
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Aortic Valve calcified due to AS
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4 chamber enlargement due to MS/MI
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PA and Lateral vs AP portable
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Magnification of the heart with AP portable x-ray
PA in
Radiology
AP as a
portable
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Large Cardiac Contour
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Large cardiac contour
• AP portable magnifies• Lordotic film magnif• Kyphotic film minim• Rotation changes• Pericardial effusion
looks like cardiomegaly
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Heart Failure
• RIGHT HEART• LE edema• Ascites• Cxr large rt heart• Cxr large azygous v• Often due to LHF or
Pulmonary dx
• LEFT HEART• Cardiomegaly• Pulmonary Edema• Pleural Fluid
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Relationship of aortic arch,pa,azyg v. to trach carina
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Heart Failure
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Interstitial Edema
• Bronchovascular thickening and indistinctness
• Vessels get bigger and busier
• Vessels seen more to the periphery
• Kerley lines (less common)
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Which vessels are bigger, busier,more peripheral?
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Dry Wet
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Airspace Edema
• May be cardiogenic or non-cardiogenic
• Very non-specific: aspiration, atypical pna, hemorrhage, etc.
• ARDS will persist and become coarse over time
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Air-space edema
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Cardiac imaging requested prior to Cardiology consult
• Nuclear Medicine– Perfusion– Wall motion– Viability– Shunts
• ?MRI – Pericard, chd, valv, shunts,
perfusion, wm• ?CT
– Pericard calc, CA calc, cta for CA
• Echocardiography– Pericardial fluid
– Valve function, integrity/vegetations
– Wall motion
– Shunts
– Congenital heart dx
– ?contrast agents
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Nuclear Med. Perfusion Studies: Thallium (potassium-like is extracted in
K-ATPase pump), Sestamibi etc.
• Normal Stress Rest Perfusion
stress
rest
stress
rest
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Cardiac anatomy as seen in SPECT nuclear imaging
short axis, horiz. long., vert .long.
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Diagram of short axis perfusion images: Would you pay full price for this donut?
YES! the“donut”is all there.
(normal septal thinning)
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Thallium stress/rest:reversible ischemia inf/septum
c/w RCA disease stress
rest
stress
rest
large “bite”out of donut!
“donut bite” fills in at rest
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Circumferential data confirms reversible inferoseptal ischemia
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Reversible ischemia (ant/sept/apex)& stress-induced lv dilation
Transient ischemic myocardial dysfunction
S
R
R
S
R
S
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Fixed lateral perfusion deficit. (fixed “bite out of donut”)
stress
rest
stress
rest
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Cardiac Wall Motion with quantitative ejection fraction
(chemo rx)
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Regional wall motion
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Imaging requests by Cardiology
• Nuclear Medicine Myocardial Viability FDG study
• MR for perfusion, viability, myocardial function, CHD, evaluation of anatomy and flow, shunts, wm, pericardial dx
• Cardiac angiography for coronary artery assessment, CHD, valve and shunt assess
• Cardiac angio for RX! plasty, stent, ASD,chd
• CT: CABG eval, CTA for coronary as. , contrast agents for ischemia
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MRA cong double arch post-op ligation of left arch
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Dilated LV and RA
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Ao valv, pap muscle, rt pleural fluid, dilated lv
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Coronal MRI shows aorta, av, lv(can eval for stenosis and regurg)
Spin echo “black blood” anatomy
Gradient echo “white blood” function & flow
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CT coronary angiography
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CT coronary angiography
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Vascular Imaging
Non-Invasive• Ultrasound: carotid,
AAA, pvd, venous• CTA: Aor Dissect,
Aneurysm, PE, Trauma
• MRA: Aor Dissect, Aneurysm, Veins
Invasive & RX• Angiography/Venogr• Balloon Dilatation• Stents• Embolization• Vascular shunts
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Ultrasound
• Abdominal Aortic Aneurysm
• Carotid Artery Disease (Atherosclerosis)
• Peripheral artery disease
• Vascular shunt evaluation
• Venous disease: DVT etc.
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Ultrasound of Carotid Artery
CCA
ICA
ECA
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Ultrasound of Carotid Artery note: brain, kidneys, heart must have
both systolic & diastolic flow
systole
diastole
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Atherosclerotic Plaque
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Ultrasound for Venous Dx
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CTA and MRA for Vascular Disease
• CTA• Aortic Dissection• Aortic Aneurysm• Peripheral Vascular
Disease• Aortic Trauma• Pulmonary Emboli
• MRA• Aortic Dissection• Aortic Aneurysm• Peripheral Vascular
Disease
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Abdominal Aortic Aneurysm
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Abdominal Aortic Aneurysm MR
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Abdominal Aortic Aneurysm CTA with 3D Rendering
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R/o aortic dissection
• CTA• MRA• TEE
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MRA for central and peripheral Arteries and veins
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Aortic Trauma
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Aortic Trauma
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Intravenous Contrast1. A large-bore (>22g, preferably an 18g or >) peripheral
IV is required and is best placed in the right arm because the venous drainage is closer to the heart than the left arm.
2. PICC lines and many other central lines cannot be used for this rapid power injection.
3. Note also that intravenous iodinated contrast may be contraindicated in some patients, particularly those with a history of contrast allergy and patients with renal insufficiency (creatinine > 1.5).
4. Additional caution regarding contrast is needed for patients in heart failure, a history of a serious allergy of any kind, multiple myeloma, diabetes particularly if on metformin (glucophage), or if a recent large contrast bolus has not yet been cleared from the body.
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Pulmonary Artery Emboli Nuclear Medicine Perfusion Scan
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CTAngiography for pulmonary artery emboli
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Peripheral Vascular Disease
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PVD after balloon Rx
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Endovascular Stents
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Endovascular repair of aneurysm
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Endovascular repair of aneurysm
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Acute Chest Pain: will CTA become the one stop shop?
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CTAngiography for pulmonary artery emboli
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Aortic dissection
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CT coronary angiography
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CTA: one stop shop for chest pain?
• Same CTA:• Rules out aortic dissection• Rules out pulmonary emboli• ? Rules out coronary disease? Perhaps with
64 slice and up CT and image processing
• Currently our Radiology Resident’s worst nightmare!
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Cardiovascular Imaging
NON-INVASIVE for DX• Ultrasound• Nuclear Medicine• CTA (inc. coronary)• MRA• Chest x-ray
INVASIVE for DX & TX• Coronary arteries• Fine detail of arteries• Lots of Therapeutic
Possibilities !