Clinical Anatomy-Radiology CVS Correlates

For Meds 2012 January 28, 2010 Sue Moffatt with contributions from teachers from Anatomy, Radiology, Cardiology, Respirology and Pathology

We will be able to:

Relate gross anatomy and histology to the clinical examination and the interpretation of a standard chest xray Identify cardiomegaly, ventricular enlargement, pulmonary edema and pleural effusions on a standard chest xray Describe the principles of additional imaging such as angiography, CT and echocardiography to the assessment of common cardiovascular diseases and appreciate the application of anatomy to interpreting these tests

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Helpful Resources
Felsons Principles of Chest Roentgenology 3rd Ed
Chapters 1, 2, 3 and 12

Expanded Clinical Skills preparation: http://www.meded.virginia.edu/courses/rad/cxr/index.ht ml: wonderful website for introduction to principles and basic images

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Radiology concepts

Projections
PA:
Posterior to Anterior Standard

AP:
Anterior to posterior Suboptimal Used when patient is too sick to stand Structures appear different because of their distance from the film

Radiology
Projection:
The further away the object (ex. heart) is from the film:
the larger the object appears the margins are less sharp
important in interpreting heart size
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Basic Cardiac Anatomy

seen on x-ray as interfaces between different densities

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Moore 3rd Ed

Norrmal Chest Xray PA and Lateral Views

Important Anatomy

Heart Borders and Major Vessels

RIGHT HEART BORDER SVC Right pulmonary artery Right atrium

LEFT HEART BORDER Aortic arch Aortopulmonary window (AP window) Main pulmonary artery Left pulmonary artery Left atrial appendage Left ventricle

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Important Anatomy on the Lateral

The Cardio-Thoracic Ratio

The cardiac silhouette may be increased by cardiac chamber hypertrophy, dilation, or fluid in the pericardium the cardiothoracic ratio is an index of enlargement of the cardiac silhouette Measure the maximal horizontal diameter of the cardiac outline and divide it by the maximum interior horizontal diameter of the thorax Normal ratio is < 0.5

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Cardiac (12 cm)

Thoracic (28 cm)

Cardio Thoracic Ratio Depends on Projection

PA view (standard) AP view (portables)

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Remember: The heart is anterior Cardiothoracic ratio for heart is 0.5 in the PA view, 0.63 in the AP view

supine vs standing shows very different images - can lead one to believe that the patient has cardiomegaly - portable films by definition are erratic

Is this heart a normal size and shape?

Cardio-Thoracic Ratio

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Cardiac 16 cm

Thoracic 30 cm

Patient
size ratio too small

Normal the left ventricle is enlarged - can tell because heart is expanding laterally and apex shifting laterally

Which Ventricle is Enlarged?

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Which Ventricle is Enlarged?

left ventricular hypertrophy
normal

Left Ventricular Hypertrophy

Left Ventricular Hypertrophy

In the PA view, the lateral border of the enlarged LV moves laterally, and the apex moves down and out

Left Ventricular Hypertrophy

In the lateral view, the enlarged LV moves down and back

Right Ventricular Hypertrophy

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Right Ventricular hypertrophy is best seen on the lateral border of right ventricle touching the sternum projection

Right Ventricular Hypertrophy and pulmonary artery enlargement

right ventricle touches entire sternum

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Right Ventricular Hypertrophy

Normal

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entire sternum touched by heart

ottom third of sternum touched

The normal RV contacts only the lower 1/3 of the sternum. An enlarged RV will contact the lower

Cor Pulmonale
Right Ventricle
right ventricle bigger than left bc of congenital problems

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Left Ventricle

Normal

Cor Pulmonale

Heart-Lung Unit = 2 pumps and an oxygenator

lungs

Right ventricle: Pumps blood through the oxygenator Left Ventricle: Pumps blood out to the organs

left ventricle
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right ventricle

Normal Lung
Air-filled alveoli lined with capillaries running in a delicate Normal interstitial Alveoli tissue
ripples in the alveoli are capillaries D - alveolar duct A - alveolus

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Left sided Cardiac Disease Lung Disease (Pulmonary Edema)

LA pressure (often 2 to LV dysfunction) pulmonary venous pressure and pulmonary capillary pressure pulmonary edema pleural effusion

Capillary pressure

backs up in pulmonary capillaries that cannot handle the pressure - leaks into alveolar spaces leading to edema

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thicker - crackle when they open upon inspiration

Interstitial Edema

Normal

Interstitial Edema

white opacity in the lungs here is fluid. If pressure continues to build up, it will leak into the alveolar spaces.

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Alveolar edema

Normal

Alveolar Edema

Chronic Pulmonary Edema with Effusions

characteristic features of pleural effusion what are the physical findings - dull percussion, decrease breath sounds fremitus decreased - can't hear it or feel it

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Pleural Fluid on CT

fluid pooling as patient lies backwards

Echocardiography
Uses reflection of sound Non-invasive Dynamic No dye required
can assess ventricular function, chamber filling, valve stenosis and regurgitation, pericardial fluid, estimate pulmonary artery pressures and large pulmonary arteries

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Normal Echocardiogram

LV LA

looking down into the heart

RV RA

best at looking at left ventricle the more the areas differ, the more contractile the ventricle

LV Function on Echocardiography
Diastole Systole

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The Ejection Fraction: in index of contractility % of the amount of EDV ejected durign systole
End Diastolic Volume End Systolic Volume End Diastolic Volume
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Assessing Major Vessels

Thoracic Aortic Aneurysm

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1 A

Normal A) edge of ascending aorta

1) edge of ascending aorta 2) knob

Note the enlargement of the ascending and descending aorta

Pulmonary Vasculature Angiography

The Pulmonary Vascular Bed

Note the lush blood supply of the pulmonary capillaries that perfuse the alveoli

Pulmonary Embolus
CLOT

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(thromboembolism - starts somewhere else ex. leg, and moves to lung) A pulmonary embolus is a clot, usually originating from the legs, that passes through the right heart and lodges in the pulmonary arteries, obstructing flow to the lungs and left heart.

Acute saddle pulmonary embolus

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obstructs flow out of right heart and lungs - instant hypotension

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Pulmonary Emboli on CT Scan

Main pulmonary artery

left

right

Angiography
Invasive Requires dye Provides detail of anatomy of perfused vessels Guides percutaneous interventions
1) hepatic artery 2) renal 3) superior mesenteric 4) inferior mesenteric

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2 3

Abdominal Aortic Aneurysm

Clinically, atherosclerosis may result in compromise of flow to distal organs, or rupture of major arteries.

Found: palpation, incidental finding Most often found upon rupture

Abdominal Aortic Aneurysm on CT

Before Rupture After Rupture

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Aneurysm in atherosclerotic aorta

Blood leaking from the ruptured aorta

Coronary Angiography

Normal Left Coronary Artery Angiogram

Normal PA CXR A = aortic knob B = R atrium C = R ventricle D = L ventricle E=

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F = carina G= H + I = diaphragm J= K= L=

Normal lateral CXR

A = R ventricle B = L atricum
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E= G= FL and FR = C + D: C - R hemidiaphragm D - L hemidiaphragm