Cardiovascular ImagingM. J. McCowin, MD

Clinical Professor of Radiology, UCSF

G. Caputo, MDProfessor of Radiology, UCD

Cardiac Imaging studies requested before

Cardiology consult• Chest x-ray (L. Antonietti, MD)

• Nuclear Medicine

• Echocardiography

• ?MRI

• ?CT

Chest x-ray

• Cardiac Contour size and shape

• Poor for pericardial effusions

• Left ventricular failure

• Right ventricular failure

PA heart < ½ chest diameter

Chamber Enlargement

LA

LV

RV

RA

LV

RV

la append

LA

Cardiac Contours: enlarged RA, LA, and RV in mitral stenosis

New enlarged LV due to aneurysm

Aortic Valve calcified due to AS

4 chamber enlargement due to MS/MI

PA and Lateral vs AP portable

Magnification of the heart with AP portable x-ray

PA in

Radiology

AP as a

portable

Large Cardiac Contour

Large cardiac contour

• AP portable magnifies• Lordotic film magnif• Kyphotic film minim• Rotation changes• Pericardial effusion

looks like cardiomegaly

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

Relationship of aortic arch,pa,azyg v. to trach carina

Heart Failure

Interstitial Edema

• Bronchovascular thickening and indistinctness

• Vessels get bigger and busier

• Vessels seen more to the periphery

• Kerley lines (less common)

Which vessels are bigger, busier,more peripheral?

Dry Wet

Airspace Edema

• May be cardiogenic or non-cardiogenic

• Very non-specific: aspiration, atypical pna, hemorrhage, etc.

• ARDS will persist and become coarse over time

Air-space edema

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

Nuclear Med. Perfusion Studies: Thallium (potassium-like is extracted in

K-ATPase pump), Sestamibi etc.

• Normal Stress Rest Perfusion

stress

rest

stress

rest

Cardiac anatomy as seen in SPECT nuclear imaging

short axis, horiz. long., vert .long.

Diagram of short axis perfusion images: Would you pay full price for this donut?

YES! the“donut”is all there.

(normal septal thinning)

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

Circumferential data confirms reversible inferoseptal ischemia

Reversible ischemia (ant/sept/apex)& stress-induced lv dilation

Transient ischemic myocardial dysfunction

S

R

R

S

R

S

Fixed lateral perfusion deficit. (fixed “bite out of donut”)

stress

rest

stress

rest

Cardiac Wall Motion with quantitative ejection fraction

(chemo rx)

Regional wall motion

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

MRA cong double arch post-op ligation of left arch

Dilated LV and RA

Ao valv, pap muscle, rt pleural fluid, dilated lv

Coronal MRI shows aorta, av, lv(can eval for stenosis and regurg)

Spin echo “black blood” anatomy

Gradient echo “white blood” function & flow

CT coronary angiography

CT coronary angiography

CT coronary angiography

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

Ultrasound

• Abdominal Aortic Aneurysm

• Carotid Artery Disease (Atherosclerosis)

• Peripheral artery disease

• Vascular shunt evaluation

• Venous disease: DVT etc.

Ultrasound of Carotid Artery

CCA

ICA

ECA

Ultrasound of Carotid Artery note: brain, kidneys, heart must have

both systolic & diastolic flow

systole

diastole

Atherosclerotic Plaque

Ultrasound for Venous Dx

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

Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm MR

Abdominal Aortic Aneurysm CTA with 3D Rendering

R/o aortic dissection

• CTA• MRA• TEE

MRA for central and peripheral Arteries and veins

Aortic Trauma

Aortic Trauma

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.

Pulmonary Artery Emboli Nuclear Medicine Perfusion Scan

CTAngiography for pulmonary artery emboli

Peripheral Vascular Disease

PVD after balloon Rx

Endovascular Stents

Endovascular repair of aneurysm

Endovascular repair of aneurysm

Acute Chest Pain: will CTA become the one stop shop?

CTAngiography for pulmonary artery emboli

Aortic dissection

CT coronary angiography

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!

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 !