心血管系统x线影像学课件

1、 IMAGING EXAMINATION OF THE HEART AND GREAT VESSEL LIU YUAN （刘源） Department of Radiology1st Affiliated Hospital of Shantou University Medical College Today a variety of simple and sophisticated imagingprocedures are available to provide detailed information about the structure and function of the he

2、art. These include : chest films, fluoroscopy echocardiography angiography computed tomography magnetic-resonance imaging radioisotope examinations cardiac enlargement pulmonary vascular abnormalities(cardiac calcifications)myocardial thickness and motion, precise chamber sizethe presence of valvula

3、r disease coronary artery disease pericardial diseasecardiac function1. Reontgenologic Examination Conventional Fluoroscopy Advantage: different projection view pulsation Shortage: temporary record not clear Teleradiography target-film distance 2 meters to avoid the distortion taken at the end of in

4、spirationMethod of examination and Normal x-ray anatomyposterior-anterior projection (P-A view,后前位) “Face to face”right atriumsuperior vena cave ascending aortaright cardiophrenic angleinferior vena caveleft cardiophrenic angle pad of fatthe appendage of LA aortic arch (bulb,knob)pulmonary artery se

5、gmentthe left ventricleRight border 2 arcsLeft border 3arcs The posterior-anterior viewLeft lateral view，左侧位 The left lateral viewAnterior border the ascending aortaright ventriclePosterior borderleft atriumleft ventricleinferior vena caveAortic windowthe retrosternal precardiac space Left anterior

6、oblique view (LAO) The left anterior oblique viewAnterior borderascending aortaright ventricleappendage of RAPosterior borderleft atriumleft ventricle left bronchusesophagus filled with barium“a drop of water”Right anterior oblique view (RAO) Angiocardiography Right sided angiocardiographysuperior v

7、ena cavepulmonary artery right atriumright ventricleright ventriclepulmonary arteryLeft ventriculography Aortographydescending aorta ascending aorta left atrium left ventricleA-P projectionLeft lateral view2). Respiration（呼吸）on expiration on inspiration 呼气 吸气3). Posture（体位） 4). Other facterson erect

8、 position立位on recumbent position（卧位）The section of the arch o and above it（主动脉弓层面和弓上层面）The normal manifestationThe section of the trachea bifurcationand right main bronchi （T4 level）(气管分叉水平、右主支气管水平）AAoDAoLPASVCAAoDAoSVC奇静脉（azygous v.)Es.The section of the branching right (右中间支气管) and left upper bron

9、chi (左上叶支气管)AAoDAoRPASVCLPAThe sections of the atria（心房层面）LARARVOTAoAoThe sections of the ventricular（心室层面）pericardium （心包)IVCAoLVRVRAesesAoIVCfatVertebralbodyMagnetic resonance imaging（MRI）Basic X-ray features in diseases of the heart and great vessels Enlargement of the heart Change in the pulmona

10、ry circulationEnlargement of the heart( position, contour )Left ventricular enlargement to the left and posterior inferiorly1. P-A view: Elongation of the left lower border (Apex extends to the left and downward The point of opposite pulsation shifts upward) The shape of the heart is like that of a

11、sabot - aortic configuration2. LAO view : the posterior and inferior border extends to the left and backward overlapping the spine, Left lateral view: backward and inferiorly, The retrocardiac space in front of the esophagus is obliterated.P-A LAO L-L normalLeft ventricular enlargementIVCRight ventr

12、icular enlargement-upward, both sides, anteriorly,1.P-A view: Prominent infundibulum and the main pulmonary segmentThe point of opposite pulsation pushed dawnwardApex of the heart blunt and elerated well above the diaphragm due to rotation of the heart to the left , apex formed by the RV The shape o

13、f the heart is like a pear - mitral configuration2.RAO view: The right ventricle and infundibulum bulging out the retrosternal precardiac space narrowed.3.LAO view and L-L view Encroachment of the retrosternal space Backward and upward displacement of the interventricular groove (LAO )P-A RAO LAO L-

14、Lright ventricular enlargementIVCnormalLeft atrial enlargement-posteriorly 1.P-A view: Double atrial contour on right border of the heart Double density at the base in a penetrated film 4 arcs on the left border du to the bulging of the LA as the 3rd arc2.RAO view and L-L view: Mild degree - pressur

15、e sign on the anterior wall of the esophagus Moderate degree - impression and displacement of the esophagus Severe degree - marked displacement and pressure on the esophagus3.LAO view: Left main bronchus elevated P-A RAO LAO L-LnormalLA and RV enlargementRight atrial enlargement-right and anteriorly

16、1.P-A view: Extension to the right side and the lower arc elongated longer than the upper arc2.LAO view: Bulging of the upper segment of the anterior border and elongation of the arc The angle with the aorta is getting smaller even as a right angle.P-A RAO LAO normalRA enlargement General enlargemen

17、t of the heart the enlargement of one or more chambers may be more significant1. P-A view - enlargement to both sides2. RAO and L-L view Retrosternal (precardiac) space narrowed Posterior compression and displacement of the esophagus generally Preesophageal or retrocardiac space obliterated in later

18、al view 3. LAO view Trachea bifurcation splayed Trachea displaced in childrenChange of pulsation of the heart and aorta1. In aortic valve insuffiency - pulsation of the left ventricle and the aorta increased markedly2. In pericarditis - pulsation may disappear completely 3. Other situation General e

19、nlargement of the heart心肌病Pulmonary hila 肺门-projection of the root of lung,Lung markings（肺纹理）自肺门肺野呈放射状分布的树枝状影（A、V等）Lung markings Normal Pulmonary VasculatureIncreased Pulmonary VasculatureNormal Pulmonary VasculaturePulmonary Arterial HypertensionNormal Pulmonary Vasculaturedecreased Pulmonary Vascu

20、latureNormal Pulmonary VasculaturePulmonary Venous Hypertension(redistribution)ABA: the patient had lymphatic spread of carcinomaB: the patient with mitral valvular disease and a history of repeated episodes of congestive failureKerley,s B-lines represent thickened interlobular septa seen close to t

21、he chest wallNormal Pulmonary VasculatureIncreased Pulmonary VasculaturePulmonary Venous Hypertension(redistribution)Pulmonary Arterial Hypertension肺水肿 Principles in radiological diagnoses of heart disease:1) changes in the pulmonary vasculature2) size and contour of the heart ,size of different cha

22、mbers3) changes of the aorta4) pulsations of the heart and great vessels5) correlation with clinical information (murmu)What is the most difficult for radiologic diagnosis in the heart disease?Diagnosis of the common diseases of cardiovascular system Mitral stenosis(MS) Rheumatic lesion involve the

23、mitral valve mostly.Simple stenosis is about 50% of all cases of rheumatic disease.x-ray signs:a. Pulmonary Venous Hypertension - enlarged blurred hilar shadows, redistribution of pulmonary blood flow, septal lines can be seen.b. LA and RV enlarged. LV and aorta small. Enlargement and mitral configu

24、ration of the heart with prominent waistc. As pulmonary venous hypertention progresses, all signs of pulmonary arterial hypertention may appear.d. Hemosiderosis appear in long standing case as miliary shadows of 1-2mm in size.normalMS :Pulmonary Venous Hypertension ,LA and RV enlargementnormalMS :Pu

25、lmonary Venous Hypertension ,LA and RV enlargement MS+ MI (41.7%): MS + LV enlargement Aortic Insufficiency (AI) a. LV enlarged . b. Ascending aorta dilated. Heart enlarged as boot shape. c. Forcible pulsation of LV and aorta (Fallen pulse). MD+AI MD + bootshaped heart LV more large Ascending aorta

26、dilated Fallen pulse Hypertensive heart disease definition a. Heart enlarged with aortic configuration.b. LV enlarged with bulged border, rounding and elongation of the ventricle at first, then extending to the left and downward. Point of opposite pulsation moves upward. c. Generalized widening of t

27、he aorta with increased pulsation of the LV and AOe. In LAO the LV extends posterioly and aortic window widened.Coronary heart diseasePlain film: Normal; Enlargement of the heart with pulmonary venous hypertension; Ventricular aneurysm;Coronary artery anatomyAnteror decending branch Coronary arterio

28、graphy carried out commonly in patients with symptoms of ischemic heart diseaseRAOLAOA-P projectionCoronary artery anatomyLeft coronary arteriogram(RAO) Diffusely atherosclerotic left coronary artery: the luminal narrowing of the entire arterialtree, multiple sites of stenosis, the formation of coll

29、ateral branchesNormalLeft coronary arteriogram(LAO)Right coronary arteriogram(LAO)Atherosclerotic right coronary artery in a patient with an acute myocardial infarction catheter tipIntraluminal thrombusstenosis catheter tipNormalIntraluminal thrombusstenosisAngiography of the coronary arteryMRI and

30、CTCPR(curve planar reconstruction)MIP(maximum intensity projection)VR(volum Recon.)MIPParicarditis A. Pericardiac effusion No change if the fluid is below 300ml in amount1) Enlarged in the shape of a flask or of globular shape, with loss of the arcs of the heart, shortness of the aortic pedicle shad

31、ow2) Widening of superior vena cava, and pulmonary markings decreased 3) Pulsation of the heart diminished or disappeared except that of the aortaThe fluid around the contours of the heart as a circular zone which is hypodense( )in comparison to the myocardium ( )separeted from the subepicardial fat

32、ty tissue which is present in varying amounts 心包积液与 扩张型心肌病B. Constrictive pericarditis Adhesions and fibrosis between the two layers limitation of the contraction and diastole 1) The arcs of the heart disappeared and the border become straight. The heart tends to be of triangle or polygonal 2) Size of heart normal or slightly enlarged.3) Dilatation of superior vena cava4) the pulmonary vasculature5) Calcification of the pericardium is a characteristic sign occur in about 12-15% of the cases (X-ray film). 6) Pulsation may be redused or absent,