Download - Imaging of the Heart
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Imaging of the Heart
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Imaging Modalities
CXR
CT
MRI
Doppler Echocardiography
TOE
Nuclear Imaging incl. PET
Angiography
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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
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Chest X Ray
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Chest X Ray
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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
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Heart Failure
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Right atrial enlargement
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Left ventricle enlargement
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Left atrial enlargement
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Pericardial Effusion
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Dextrocardia
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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
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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)
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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.
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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.
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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.
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Cardiac anatomy from right to left
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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)
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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.
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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).
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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
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Left ventricle
blood enters the left ventricle via the mitral valve
then enters the aortic valve via the left ventricular outflow tract.
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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)
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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
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Coronary Arteries
Coronary arteries in the right anterior obliqueprojection.
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
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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)
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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
position at the base of the anterior mitral leaflet.
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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
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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
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Short axis view aortic valve three leaflets of the aortic valve are seen left atrium behind the aortic root
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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
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Subcostal view provides nearly a perpendicular view of the interatrial septum permits it to use doppler to interrogate potential shunts between those chambers
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TOE
an invasive echo test
It evaluates
1. heart chamber size
2. pumping action
3. valve appearance and function
4. 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
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MRI
Full 3D capabilities Excellent soft-tissue contrast
Tradeoff: high spatial resolution/short acquisition time
Two main configurations:
1. Spin-echo entire change in magnetization used to create the image
high spatial resolution (0.5mm) very slow (13s for one slice)
2. Gradient-echo only a part of the change in magnetization used to
create the image
lower spatial resolution (1mm)
very fast ( 2s, real time)
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MRI
Pulse sequences:
1. Cardiac Gated T1WI (axial views): anatomical assessment
1. Gradient Echo (GRE) cine in short axis: assesses ventricular function, ejection fraction
1. Phase contrast MRA: estimates ventricular function, regurgitation
1. Gadolinium MRA: to define the anatomy
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Nuclear Imaging
Nuclear imagine evaluates how organs function, unlike other imaging methodsthat 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
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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
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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
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MUGA
Multiple Gated Acquisition Scan (radionuclide angiography)(RNA)
used to
evaluate heart function
by measuring ejection fraction