Radiological diagnostics of Cardiovascular System

1. The Radiological
Diagnostics of the
Cardiovascular System

2. The methods of the
cardiovascular system
examination
1. Fluoroscopy
2. Roentgenography
These methods are performed in
following positions:
- direct;
- first oblique (rigth);
- second oblique (left);
- left lateral

4. 3. Fluorography.
4. Tomography.
5. Angiography of the peripheral vessels
(arterio-, phlebo-, lymphography).
6. Angiocardiography.
7. Computed tomography.
8. Ultrasonography.
9. Magnetic resonance imaging.

5. Sponsored
Medical Lecture Notes – All Subjects
USMLE Exam (America) – Practice

6. ULTRASOUND

7. ULTRASOUND

12. VCS
RPA LPA
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13. RV
RA AA
LV
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14. Algorithm of the heart
examination
1. The evaluation of the thorax (its shape, ribs
location, distance between the ribs).
2. The evaluation of the level and mobility of the
domes of diaphragm, sinuses (phreno-costal,
phreno-cardiac).
3. The evaluation of the pulmonary vasculature
(the symptoms of the arterial, venous
hypertension, width and structure of the
radices of the lungs).

15. 4. The evaluation of the shape and position
of the cardiovascular shadow, heart
size and its chambers.
5. The evaluation of the cardiac and
vascular function (amplitude, pulsation,
rhythm, synchronism of the pulsation of
the cardiac chambers, tonus of the
miocardium).
Test Valsalva

16. The arcs of the heart in
3 positions
A. In direct anterior position the left
contour is made by 4 arcs, which
corresponds to the chambers and
vessels.
- The first arc – arc of aorta, which is
visible after 3 years old. Oftenly in that
area thymus is visualized.

17. - The second arc – pulmonary trunc and
the beginning of the left pulmonary artery.
- The third arc is made by the auricle of the
left atrium and is clearly visible in case of its
dilatation.
- The fourth arc – left ventricle.
The second and third arcs makes the weist
of the heart.

18. The right contour is made by two
arcs:
- The first arc - vena cava superior or
ascending aorta;
- The second arc – contour of the right
atrium.
The angle between these arcs is
called atriovasal.

20. Б. Right (first) anterior oblique
position.
There are anterior (retrosternal) and
posterior (retrocardial) contour of the
cardiac shadow. On anterior contour
there are 3 arcs: ascending aorta,
pulmonary trunk and left ventricle.
Posterior contour: aorta, left and right
atriums.

22. B. Left (second) anterior oblique
position.
In retrosternal area there are 3 arcs:
ascending aorta, right atrium and right
ventricle.
In retrocardial area – aorta, left atrium
and left ventricle.
In this position ascending aorta, arc of
aorta, descending aorta and left atrium are
making aortic window, which normally has
to be transparent.

24. The main radiological symptoms
of the cardiovascular diseases
І. The syndrome of mitral shape of
the heart with its asymmetric
enlargement.
а) mitral shape with enlargment of its
one chamber – right ventricle:
- in case of the pulmonary diseases
and pulmonary artery disorders with the
pulmonary hypertension;
- opened Botallo's duct (ductus
arteriosus).

25. б) mitral shape with enlargment of its two
chambers – right ventricle and left atrium:
- in case of mitral stenosis.
в) mitral shape with enlargment of its three
chambers – right ventricle, left atrium and left
ventricle:
- in case of mitral valve insufficiency;
- combined mitral valvular pathology;
- mitral and aortic valvular pathology
with the domination of mitral.

26. Radiological symptoms of the
mitral shape of the heart in
direct position
1. The enlargement of the 2 and 3rd
arcs (waist of the heart) on the left
contour.
2. the angle between these arcs is
decreased.
3. Dislocation of the right atriovasal
angle upwards.
4. Inconstantly – enlargement of the
4th
arc in the left.

31. ІІ. The syndrome of the aortic shape of
the heart.
а) aortic shape of the heart with the
enlargement of the left ventricle:
- miocardial diseases (primarily
miocarditis);
- miocardial infarction.

32. б) aortic shape of the heart with the
enlargement of left ventricle and aorta
dilatation:
- arterial hypertension;
- aortic valve insufficiency;
- aortic stenosis;
- combined aortic disease;
- aortic and mitral valvular disease with
the domination of aortic.
в) aortic shape of the heart with the
dilatation and elongation of aorta:
- atherosclerosis of aorta.

33. Radiological symptoms of the
aortic shape of the heart in direct
position
А) obligatory:
1. deep incisura between 1st and
4th arc in the left.
2. Clear waist of the heart.
3. Elongation of the 4th
arc in the left.

34. B) optional:
1. Enlargement of the first arc in
right side in case of the dilatation of the
ascending aorta.
2. Enlargement of the first arc in left
side in case of the dilatation of the arc of
aorta;
3. Dislocation of the right atriovasal
angle downwards.

38. ІІІ. The syndrome of the
trapezoidal and round shapes of the
heart.
- diffuse miocardial diseases;
- pericardial effusions.

39. The radiological symptoms of
the trapezoidal and round
shapes of the heart
1. The transverse diameter is larger
than longitudinal;
2. The phreno-cardiac angles are
blunt (miocarditis) or acute (exudative
pericarditis);

40. 3. The cardiac contractions are
weak, but visible (miocarditis) or not
visible (exudative pericarditis);
4. The arcs of heart are smoothed
(miocarditis) or not visible (exudative
pericarditis);
5. Cardiac shadow is changed with
the change of the body position
(exudative pericarditis).

48. IV. The syndrome of the limited
vascular dilatation:
- atherosclerosis;
- syphilis;
- aneurism.

49. V. The syndrome of the limited
vascular narrowing:
- coarctation of aorta;
- aortic stenosis;
- isolated stenosis of the pulmonary
artery;
- obliterative endarteriitis;
- obliterative atherosclerosis.

50. Methods of research of coronary vessels
Invasive:
*Coronary angiography -
the "gold standard"
*Intravascular ultrasound
Not invasive:
Stress ECG
Stress Echo
Scintigraphy,
Perfusion MRI
MSCT of the heart
with a quantitative evaluation
the degree of calcification
coronary arteries and
non-invasive
coronary angiography

51. Indications for MSCT of the heart
- patients with symptomatic coronary artery disease ;
- no symptoms of coronary artery disease but with risk factors for coronary heart
disease for evaluation of the coronary vessels (with hypercholesterolemia , diabetes ,
hypertension , smoking) ;
- after stenting / bypass surgery to avoid restenosis in the stented segments;
- in the early post-MI to determine the location and area of myocardial damage , to​​
detect thrombotic masses in the chambers of the heart
- Post-MI to study the functional parameters of the left ventricle

52. MSCT: Methods «Smart Score»

54. Technique of MSCT coronary angiography

56. AcquisitionAcquisition
MSCT coronary angiography

57. Left Coronary Arteries
З-D реконструкция Поперечные КТ-срезы

58. Right Coronary Arteries
З-D реконструкция Поперечные КТ-срезы

59. Cardiac Veins
3-D reconstruction Transverse CT slices

60. Cardiac Arteries
MSCT imaging of the coronary arteries
MIP - Maximum Intensity Projection, VR-Volume Rendered image

61. A - with plaque and stenosis of the LAD about 50%;
B - with calcification and soft tissue plaques, total stenosis of LAD and RCA.
a б

62. MSCT - coronary angiography, 3-D images:
A-when coronary arteries are not changed;
B-with signs of local calcification of left coronary artery;
C-with signs of diffuse calcification of the left coronary artery of its branches.
а
b
c

63. COMPARISON OF DATA MSCT coronary angiography WITH DATA
ICG
not changed
coronary arteries

64. COMPARISON OF DATA MSCT coronary angiography
WITH DATA ICG
A subtotal stenosis of LAD and the first
diagonal artery due to soft tissue
component

65. Classification:
differentiation type of
atherosclerotic plaque
according
MSCT coronary
angiography
A) + AA): calcified nodule;
B) + BB): calcified plaque;
C) +CC): soft plaque;
D) + DD): mixed plaque.

66. Дифференциация атеросклеротической бляшки
Type VI atherosclerotic lesion with extensive lipid accumulation (Lc = lipid core) and small intra-
plaque hemorrhage (Hb) within the atherosclerotic widened intima (I) and media (M) cell layer.
(А) Corresponding multidetector-row CT (MDCT) image shows a soft tissue lesion with a mean
density of 40 HU.
(B) In contrast to lipid-rich plaques, purely fibrous (F) plaque (Type Vc) without calcium
demonstrate significantly higher attenuation (90 HU) on MDCT.
(C) “Calcified nodules” or “spotty” lesions contain little pieces of calcium (Ca) that was
removed in the process of preparing the slides. On MDCT the calcification can be easily detected and
partly covers the adjacent fibrous soft tissue (110 HU).

67. calcified plaque

68. Data analysis MSCT coronary angiography after
interventional procedures (stenting)

69. MSCT myocardial infarctionAcute
MI After 5 mon.

70. CardIQ Function

71. The advantages of MSCT coronary
angiography:
- High information;
- Less radiation and contrast load than
the ICG;
-Does not require hospitalization;
-Lack of endovascular interventions ;
-Psychologically easier tolerated.
Disadvantages of MSCT coronary angiography:
-For CT angiography requires multidetector CT
devices with cardioversion;
-Long processing time and the large amount of
data (from 1500- 2000tys. slices;
- Difficulties timber heating CT data in patients
with heart rhythm disturbances (arrhythmias ,
tachycardia);

72. Congenital cardiac diseases
Radiologically there are three groups of
the diseases:
1 group – diseases with the arterial
shunt into the venous blood stream at the
level of the heart or main vessels; in this
case the volume of the blood in small
circulation is increasing. Defect of the
interatrial septum and interventricular
septum, opened arterial duct,
aortopulmonary fistula.

73. 2 group - diseases with the venous
shunt into the arterial blood stream
(Fallot's tetrad, transposition of the main
vessels without the stenosis of the
pulmonary artery).
3 group – diseases without the
shunt, with normal small circulation
haemodynamics, but with the barrier of
the blood flow. Isolated pulmonary
stenosis, aortic coarctation, valvular
stenosis of aorta.