Cardiac Radiography - Duke University · 2 4 5 7 8 9 1 6 3 Cardiac Anatomy 1. R brachiocephalic v./...

Cardiac Radiography

Jared D. Christensen, M.D.

Cardiacradiography

Jared D. Christensen, M.D.

OverviewBasic Concepts

Technique

Normal anatomy

Cases

Technique

3 Standard Views

Posterior-Anterior (PA) Anterior-Posterior (AP) Lateral

MagnificationR L

PA AP

Cardiac Anatomy

2

4

5

78

9

61

3

Cardiac Anatomy1. R brachiocephalic v./ SVC2. Ascending Aorta3. R atrium4. IVC5. L brachiocephalic v./ L

subclavian a.6. Aortic arch7. Main pulmonary a.8. L atrial appendage9. L ventricle

23-year old male with acute chest pain

Q Where is the abnormality?

A

B

C

D. It’s normal

Q Where is the abnormality?

A

B

C

D. It’s normal

Q Where is the abnormality?

A

B

C

D. It’s normal

�

Q

A. Mediastinal massB. Aortic dissectionC. Pulmonary embolismD. Lymphadenopathy

What is the most likely diagnosis?

Aortic Dissection - Marfan Syndrome

Chambers

Cardiac Chambers1. L Atrium

2. R Atrium

3. L Ventricle

4. R Ventricle1

23

4

Heart SizeCardiac Index:

A

B

A

B

Heart SizeCardiac Index:

A

B

A

B

Normal: ! 50%

Heart Size

D i l a t i o n

Hypertrophy

Volume

Pressure

Left Atrium

• Big left atrial appendage

• Retrocardiac double density

• Elevated left mainstem bronchus

Left Atrium

• Big left atrial appendage

• Retrocardiac double density

• Elevated left mainstem bronchus

Left Atrium

• Big left atrial appendage

• Retrocardiac double density

• Elevated left mainstem bronchus

Left Atrium

• Big left atrial appendage

• Retrocardiac double density

• Elevated left mainstem bronchus

Left Atrium

• Big left atrial appendage

• Retrocardiac double density

• Elevated left mainstem bronchus

Left Ventricle

• Enlarged left heart border

• Apex moves down and leftward

Left Ventricle

• Enlarged left heart border

• Apex moves down and leftward

Left Ventricle

• Enlarged left heart border

• Apex moves down and leftward

Right Atrium

• Divide hemithorax into thirds

• Right heart border is > ⅓

Right Atrium

• Divide hemithorax into thirds

• Right heart border is > ⅓

Right Atrium

• Divide hemithorax into thirds

• Right heart border is > ⅓

Right Ventricle

• Elevated cardiac apex

• “Boot-shaped” heart

Right Ventricle

• Elevated cardiac apex

• “Boot-shaped” heart

Right Ventricle

• Elevated cardiac apex

• “Boot-shaped” heart

Valves

ValvesTricuspid

Mitral

Aortic

PulmonicMT

PA

Valves

MT

PA

Valves

MT

PA

Valves

MT

PA

PA

T M

Q Which valve is calcified?

Q

A. AorticB. PulmonicC. Mitral D. Tricuspid

Which valve is calcified?

Heart Size

D i l a t i o n

Hypertrophy

Volume

Pressure

Valve Disease

Normal directional flow

Reversed directional flow

Stenosis

Insu!ciency

Valve doesn’t fully open

Valve doesn’t fully close

Mitral Insu"ciency

• Left atrium dilates

• Left ventricle dilates (over time)

• Normal pulmonary vasculature

Mitral Insu!ciency - Acute MI

Mitral Stenosis

• Left atrial hypertrophy/dilation

• Dilated pulmonary veins, then arteries

• Dilated right ventricle

Mitral Stenosis

Aortic Insu"ciency

• Left ventricle dilates

• Aorta may eventually dilate due to increased LV volumes

Aortic Insu!ciency

Aortic Stenosis

• Left ventricle hypertrophy/dilation

• Post-stenotic dilation of ascending aorta

• Pulmonary vessels are normal

Aortic Stenosis (& Insu!ciency)

Pulmonic Stenosis

• Right ventricle hypertrophy/dilation

• Post-stenotic dilation of pulmonary artery

Pulmonic Stenosis

Pericardium

PericardiumAnatomy:

‣ Visceral

‣ Space

‣ Parietal

6 weeks ago

Pericardial E"usion

Vasculature

VasculatureThoracic Aorta

Pulmonary Arteries

Pulmonary Veins

2 days later

4 days later

4 days later

Pulmonary Edema

Interstitial

Kerley B Lines

Interstitial Alveolar

Cases

1

Q What surgery has this patient had?

Q What surgery has this patient had?

A. AVRB. Cardiac TxpC. CABGD. Lung Txp

Q What surgery has this patient had?

A. AVRB. Cardiac TxpC. CABGD. Lung Txp

Q What surgery has this patient had?

A. AVRB. Cardiac TxpC. CABGD. Lung Txp

�

Q Which tube/line is malpositioned?

D

C

A

B

Q Which tube/line is malpositioned?

D

C

A

B

Q Which tube/line is malpositioned?

D

C

A

B�

R Mainstem Intubation

R Mainstem Intubation

52-year-old male with chest pain and dyspnea.

52-year-old male with chest pain and dyspnea.

2

Q Which chamber is abnormal?

Q Which chamber is abnormal?

A. Left atriumB. Left ventricleC. Right atriumD. Right ventricle

Q Which chamber is abnormal?

Q Which chamber is abnormal?

A. Left atriumB. Left ventricleC. Right atriumD. Right ventricle

�

Left Ventricle Aneurysm

54-year old male with chest pain and dyspnea

3

Q Which is the next most appropriate step in management?

Q

A. BiopsyB. PET-CTC. CTA D. Surgical resection

Which is the next most appropriate step in management?

Q

A. BiopsyB. PET-CTC. CTA D. Surgical resection

Which is the next most appropriate step in management?

Q

A. BiopsyB. PET-CTC. CTA D. Surgical resection

Which is the next most appropriate step in management?

�

Aortic Arch Pseudoaneurysm

Conclusions

ConclusionsLearn what is normal

Be systematic in your interpretation

‣ Contours, Chambers, Valves

Physiology predicts pathology

Jared D. Christensen, M.D.

Jared D. Christensen, M.D.

Cardiacradiography