临床影像学教学课件（暨南大学）心脏与大血管的影像诊断

Imaging diagnosis of the heart and great vessels 周阳泱 暨南大学第二临床学院 深圳市人民医院影像教研室 TelEmail: 教学目标 4熟悉心脏大血管的常用检查方法及其适应症 4熟悉心脏大血管的正常X线、CT表现 4掌握心脏大血管疾病的基本影像学征象 4掌握循环系统几个常见病的典型X线、CT表 现 4Examination techniques 4Normal imaging anatomy 4Basic pathological features 4Diagnosis of cardiac diseases 4Cases 4What do we want to know? Display the position and the contour Display the inner details, such as the thickness of their wall, interatrial and interventricular septum, valve, etc. Evaluate the cardiac function, physiological condition of the heart. 4What is the aim we want? Make diagnose Assess the severity of the disease Detect complicating features Suggest the appropriate form of treatment 4 X-ray Fluoroscopy Radiography Angiocardiography 4Computed Tomography （CT） 4Magnetic Resonance Imaging （MRI） 4Ultrasonography 4Nuclear medicine Fluoroscopy 4advantage Cardiovascular contour, pulsation and surrounding structures related to the heart can be observed in various directions 4disadvantage Obscure No record 4The distance between focus and film: 2m 4Positions: PA, posteroanterior projection RAO, right anterior oblique projection：turn left 45 0600 +swallow barium LAO, left anterior oblique projection ：turn right 600 LL, left lateral projection： turn right 900+ swallow barium Radiography PA LAOLL RAO 4advantage display the contour pulmonary blood surrounding structures 4disadvantage overlap cant display the inner details non-dynamic Radiography CT 4Conventional CT Scan slow, seldom used 4Multi-slice CT fast: sub-second, large coverage high spatial and temporal resolution ECG gating technique CT EDV ESV continuous multi phase reconstruction （ 10% of the cardiac cycles） Detect calcification Angiography (enhanced) 42D/3D reconstruction of post-processing MPR: multi-planar reformation CPR: curved planar reformation MIP: maximum intensity projection SSD: shaded surface display VR: volume rendering VE: virtual endoscopy 3D 2D MSCT post -processing CPR MPRthin-MIP SSD VR VR cine MRI 4Display the heart, its internal morphology and surrounding mediastinal structure 4Multiple imaging planes 4High soft-tissue contrast discrimination between flowing blood and myocardium without contrast. Short-axis view of LV “Black blood” SE, T1WI Long-axis 2-chamber view 4-chamber view “White blood” MR cine MRA cardioangiography, CAG Cardiac catheterization- invasive X-ray imaging of the heart and great vessels following injection of contrast medium Display rapidly moving structures High clarity and resolution Hemodynamic information: pressure, oxygen saturation equipments 4rapid serial film equipment 4pressure injector 4needle, catheters, guidewire right ventricular angiographyleft ventricular angiography coronary angiogram Summary 4X-ray：routine examination, supply with fluoroscopy 4USB：first choice, except for special patients 4CAG：interventional , golden standard for CHD, great value for cardiac malformation 4CT and MR：less temporal resolution than US and CAG MR has better functional evaluation than CT CT has better calcifications detection than MR Perfusion imaging: evaluate myocardial ischemia Ultrasound X-ray DSA MRI CT Morphology Function Dynamic Heart Vessel 4Examination techniques 4Normal imaging anatomy 4Basic pathological features 4Diagnosis of cardiac diseases 4Cases Normal projection of heart and great vessels PARAOLAOLL PA LL RAO LAO Normal CT appearances arotic arch planePA plane Normal CT appearances Root of aorta plane Ventricles plane coronary anatomy X RCA LAD LCX VR RCA LCA 4Examination techniques 4Normal imaging anatomy 4Basic pathological features 4Diagnosis of cardiac diseases 4Cases 4Abnormal position 4Cardiac enlargement 4Dilatation of aorta 4Dilatation of pulmonary trunk 4Atrophy of pulmonary trunk 4Abnormal pulmonary circulation 4Abnormal position displacement 4Abnormal position malposition heartvisceral normal levocardialeftnormal levoversionleftinversus dextroversionrightnormal mirror-image extrocardiarightinversus mirror-image dextrocardia dextroversionlevoversion Cardiac enlargement 4Cardiac enlargement heart chamber wall thickness heart chamber enlargement 4cardio-thoracic ratio (CTR) 0.60severe T1+T2 r CTR= T1=maximum extension of the heart to the right of the midline T2=maximum extension of the heart to the left of the midline r = transverse diameter of the thorax, the maximum measurement of the thorax to the inside of the ribs Pediatric cardiac morphological changes Age3w2m12y26y714y CTR0.550.580.20.490.10.450.070.4 0.5 left atrial enlargement 4X-ray Double atrium shadow. (PA) 3 arches in right. The left atrial appendage forms convexity. 4 arches in left heart border. (PA) The left main bronchus is elevated. (PA) The esophageal middle segment is compressed and deviated backward. (LL, RAO) 4Cause mitral valve disease, left ventricular failure, etc The left main bronchus is elevated Double atrium shadow The 3rd pathologic arch The 2nd pathologic arch deviation of the esophagus nmild nmiddle nsevere right atrial enlargement 4X-ray PA: The lower of right atrial segment dilates to the right, bulging, the most prominence point is far high. H(RA)/H(heart)0.5 LAO: the length of the right atrial segment is more than half of that of cardiac anterior border. 4Cause right ventricular failure, ASD, tricuspid valve diseases, anomalous pulmonary venous drainage, atrial myxoma HRA Hheart HRA/Hheart0.5 left ventricular enlargement 4X-ray The left ventricular segment elongates, the apex extends downwards. Rounding of the apex of the heart. The shadow of the heart bulges behind the esophagus. The cardiac posterior space becomes narrow. 4Cause Mitral valve stenosis, pulmonary heart disease, pulmonary artery stenosis, endocardial cushion defect. The left ventricular segment elongates, the apex extends downwards. Cardiac posterior space becomes narrow. right ventricular enlargement 4X-ray heart type shows mitral valve (pear) type. The apex becomes convex and raised. The pulmonary bay becomes flat or bulge. Retrosternal space becomes narrow, the area of contact between the front surface of the heart and the sternum increases . 4Cause Mitral valve stenosis, pulmonary heart disease, pulmonary artery stenosis, endocardial cushion defect. The apex becomes convex and raised pulmonary bay bulge Retrosternal space becomes narrow, the area of contact between the front surface of the heart and the sternum increases aorta dilatation The ascending aorta bulges to the right, the descending aorta bulges to the left dilatation of pulmonary trunk 4cause Pulmonary blood increase Pulmonary hypertension atrophy of pulmonary trunk 4cause Outlet of RV stenosis Pulmonary valve stenosis Pulmonary artery dysplasia abnormal cardiac contour 4A: mitral valve type (pear-shape) 4B: aortic type (boot-shape) 4C:A-B type 4D: generally increases type 4E: weird type abnormal pulmonary circulation 4An increase in pulmonary arterial blood flow. 4Cause congenital left-to-right shunt: ventricular septal defect (VSD), atrical septal defect (ASD), patent ductus arteriosus (PDA) high-output and low-resistance heart disease: hyperthyroidism, anemia 4X-ray appearance: Pulmonary bay is convex, two hilar shadows become large. The intrapulmonary artery branches extend outward and increase in size proportionally, lung markings are distinct. The pulsations of the hilar vessels and pulmonary arterial segment increase-hilar dance pulmonary blood plethora Normal plethora pulmonary oligaemia 4refers to a general reduction in pulmonary blood flow 4common disease: pulmonary artery stenosis, TOF, tricuspid valve stenosis 4X-ray findings The hilar becomes small, hilar vessels and right lower pulmonary artery decrease in size. Lung markings are small, rarefaction, lung fields are clear and distinct. Pulmonary artery branches are smaller than that of bronchus branches. The bronchial arteries develop collateral circulation. There are many small, bent network-like vascular shadows Normaloligaemia pulmonary arterial hypertension 4Ppa30mmHg 4pulmonary perfusion increases or resistance of pulmonary circulation increases. high flow pulmonary arterial hypertension: pulmonary engorgement, pulmonary perfusion increases. obstructive pulmonary arterial hypertension: pulmonary small vessels and capillary spasm and stenosis XX X-ray findings: pulmonary bay is convex; hilar truncation; enhanced pulmonary pulsation; right ventricular enlargement pulmonary venous hypertension 4Pulmonary venous regurgitation is obstructed with blood stasis in hilar. 4Ppv 10mmHg 4common diseases: rheumatic heart disease: mitral valve stenosis, mitral valve stenosis coexist insufficiency, left ventricular failure 4Upper lobe blood diversion distension of the upper lobe veins, constriction of the lower lobe veins 4Interstitial edema Ppv20mmHg Opacity of lung fields decrease obviously. Haziness of hilar structure septal lines: Kerley B, A, C lines X-ray findings B B C A costo-phrenic angle 4Ppv 25mmHg 4Usually coexist with interstitial edema. 4Exudation collects mainly in alveoli. 4X-ray findings: blurring patch-like shadows in one side or two sides lung fields, mainly in middle zone , developing in both lungs and having a perihilar or “butterfly-like” appearance. alveolar pulmonary edema 4Examination techniques 4Normal imaging anatomy 4Basic pathological features 4Diagnosis of cardiac diseases 4Cases 4Congenital heart disease atrial septal defect （ASD） tetralogy of fallot （TOF） 4Acquired heart disease coronary atherosclerotic heart disease rheumatic heart disease pericarditis others (such as benign/malignant tumor etc.) Atrial septal defect, ASD Clinical manifestation 4after exercise, the palpitation turns out, growth is normal. Later period pulmonary arterial hypertension and Eisenmanger syndrome 4auscultation on the 2nd and 3rd intercostal space at the left sternal border, systolic murmur can be heard. X-ray appearance 4pulmonary plethora 4RA enlargement 4RV enlargement 4Pulmonary bay is convex 4 The LA is normal 4Eisenmenger syndrom (PA hypertension): increasing enlargement of the central, lobar and segmental pulmonary arteries, narrowing of the peripheral pulmonary vesselsHilar truncation CT RV Pericarditis 4pericardial effusion 4constrictive pericarditis：pericardial thickness, adhesion, calcification pericardial effusion 4clinical and pathology etiological factors: tuberculous, pyogenes and viral. pathology: the heart is compressed, pericardial tamponade 4clinical appearance: fever, pericardial symptom, cardiac sound is distant. X-ray findings 4heart shadow is enlarged-bottle- shaped (moderate) or globular( large) 4dilatation of the superior vena cava 4the pulsation of heart border diminishes or disappears 4pulmonary vessels diminish (coexist left ventricular failure, lung stasis is seen.) Pericardial effusion 4definition adhesions between the visceral and parietal pericardial the formation of a solid fibrous connective tissue significantly limiting the systolic