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Dr. Rahmad Mulyadi, SpRad Radiology Department University of Indonesia Jakarta

Anatomy of the Human Heart

Atrium - Top two chambers

Right Atria - receive blood from body Left Atria receive blood from lungs

Ventricles - Bottom two chambers

Right ventricle pumps blood to lungs to pick up oxygen Left ventricle pumps blood to the rest of the body

Coronary Arteries

Cells within the heart need oxygen

Two CAs carry oxygen-rich blood to heart muscle Right Coronary artery Left Main branches into two narrower arteries
Left Circumflex Left Anterior Descending

Diagnostic Studies
Invasive Cardiac catheterization Non Invasive Chest X ray Echocardiography Doppler Ultrasonography Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Nuclear Medicine.

Chest X-Ray
Analysis of chest film for cardiac disease : Cardiac enlargement : shape and size Overall : Cardiothoracic ratio (CTR) > 50% Selective chamber enlargement Pericardial effusions Secondary/associated pulmonary changes The mediastinum, for the size and location of the aorta and major systemic veins Great vessels changes calcify, elongation, aneurysm Position of pacemaker Extracardial anomalies that may be associated with heart disease The plain film is virtually never relied upon for the diagnosis of the nature if the cardiac lesion it is valuable as an indicator of the severity of any haemodynamic disorder in revealing cardiomegaly, state of the lungs, and to follow progress.

Computed Tomography
Computed tomography is a digitally based x-ray technique the resulting images arise from differential x-ray absorption of tissue, a feature that rests primarily on atomic weight (and thus the electron density) of the various tissues. The technique uses a narrowly collimated x-ray beam to irradiate a slice of the body the amount of radiation transmitted is collected by photomultiplier tubes and counted digitally. By rapidly acquiring views from numerous different projections, achieved by quickly rotating the tube and detectors around the body.

Once these transmission values are collected, they can be digitally filtered and back-projected mathematically (by a technique known as Fourier transformation) onto a matrix which represents fine differentiation of tissue densities The Hounsfield scale (bone is +1000 and air is -1000) , CT : single slice/ multislices (MSCT), can be displayed as a 3-dimensional structure. MSCT : native/contrast CT,CT angiography, perfusion CT. Computed tomography has the advantage of rapid acquisition of images, but employs ionizing x-ray radiation which must be used conservatively to avoid harmful cumulative biologic effect.

Noninvasive Diagnostic Studies

Echocardiography has great value in assessing congenital cardiac anomalies and should usually be the first advanced diagnostic study to be carried out if the history, the physical examination, the chest X ray, and the electrocardiogram suggest the presence of congenital heart disease.

Noninvasive Diagnostic Studies

The standard M-mode display and the two-dimensional display provide such information about cardiac anatomy as the size of the cardiac chambers, the connections of the great vessels, abnormalities of the valves, and subvalvular obstructions.

Noninvasive Diagnostic Studies

Doppler ultrasonography
Doppler ultrasonography is useful in detecting septal defects and directly assessing the amount of blood that shunts through the defect. The size of the shunt through a septal defect can also be estimated from Doppler ultrasound studies by comparing the velocity of the blood flow through the aorta with velocity through the pulmonary artery.

Transesophageal Echocardiography
Performed by using a miniature highfrequency (5 MHz) ultrasound transducer mounted on the tip of a directable gastroscope-like tube about 12mm in diameter. Because the transducer lies in the lower esophagus in close direct fluid contact with the posterior of the heart, the images are superb since there is no interference by lung tissue.

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging depends on immersing the body in a steady, strong magnetic field, commonly up to 1.5 Tesla (i.e. 15,000 Gauss for reference, the earth's magnetic field is about 0.5 Gauss). Some modern "whole-body" machines now operate at 4 or more Tesla. Hydrogen atoms, pervasive in the water which makes up about 70% of the body's mass, have a dipole property by virtue of their characteristic spins. Hydrogen spinning atoms, influenced by the permeating magnetic field precess in alignment with the dominant magnetic field Subjecting the body tissues to an additional magnetic field gradient a specific tissue slice of the body for imaging while absorbing this radiation in a resonant fashion.

Hydrogen atoms alter their net magnetic axis direction temporarily (excitation state) _rapidly decays to a lower energy state while emitting its own unique radio frequency signal detected by an external radiofrequency coil calculating images tissue-related images. Special pulse-echo sequences permit high level signals to be detected from flowing blood images of the vasculature and it's blood velocity characteristics. Functional MRI" detect differences oxygen-saturated and de-saturated blood. Brain processes of "thought" such as vision, motor control and speech can be detected (though at low spatial resolution) by virtue of their local oxygen consumption when activated.

To evaluate : Cardiac structure Cardiac chamber Valvular heart diseases Pericardial diseases Congenital heart diesases Functional imaging in ischemic heart disease Magnetic Resonance Coronary Arteriography coronary artery.

Chest x ray

Features that are typically examined on a chest X-ray Every doctor will have a different approach to examining chest X-rays. A commonly used mnemonic for what to look for on a chest X-ray is: It May Prove Quite Right (but) Stop And Be Certain How Lungs Appear:
I = Identification (name, age, sex, indication for X-ray) by mas M = Markers (differentiate left from right - diagnose dextrocardia) P = Position - the spinous process of T4 should be between the heads of the clavicle (if it isn't the body is rotated) Q = Quality - is the film penetrated properly. In a properly penetrated film the vertebral interspaces should be visible behind the central (cardiac) shadow R = Respiration - chest X-rays are typically done with full inspiration (but) S = Soft tissue - look for subcutaneous emphysema (suggestive of trauma), soft tissue swelling A = Abdomen - look for free abdominal air (suggests penetrating trauma, peritonitis, or recent surgery) B = Bone - look for fractures (these tend to be at the lateral aspects because of the mechanics bending moment largest at lateral aspect) C = Central shadow (cardiac silhouette) - greater than 50% of lateral distance in frontal view at the diaphragm suggests cardiac enlargement (usually secondary to heart failure) or a pericardial effusion). A widened mediastinum may suggest aortic dissection. H = Hila (of the lungs) - can be affected in lung disease, malignant processes and infection (hilar lymphadenopathy). L = Lungs - for consolidation, interstitial lung disease (reticular, nodular or reticulonodular), honeycombing, miliary pattern, granulomas, lung masses A = Absent structures/Apices of the lung (for pneumothorax

Another approach is to examine first any major abnormality, and then "review areas":

the apices, the hila, behind the heart (it must be remembered that lung can be seen through the heart), the cardiophrenic angles, the costophrenic angles, beneath the diaphragm, and then bone and soft tissues.

Typical views PA (posterior-anterior) view - The patient faces away from X-ray source - Xrays pass from their source to patients back through the body to exit through the anterior body wall to expose the film AP (anterior-posterior) view - The patient faces the X-ray source - these are typically done in the ICU Lateral view The most common view is the PA (posterior-anterior) and is frequently done with a left lateral view (so one can identify the location of abnormalities in 3D space). PA views are preferred to AP views (which are often done with mobile/portable X-ray equipment), but much less convenient in the ICU setting or when a patient cannot otherwise leave their bed. PA views are preferred because the central shadow is better defined, the magnification of the heart is reduced, radiation to the breast tissue is reduced, and less of the lungs obscured by the heart/pericardial sac.

Additional views
DecubitusDecubitus - useful for differentiating pleural effusions from consolidation (e.g. pneumonia)and Loculated effusions from free fluid in the pleura. if the thickness of linear fluid exeeds 1cm its mondatory to pleural tap must be done "Tapping pluid"(N.A.Exeer,MD). In effusions, the fluid layers out (by comparison to an upright view, when it often accumulates in the costophrenic angles). Lordotic view - used to visualize the apex of the lung, to pick-up abnormalities such as a Pancoast tumour. Expiratory view - helpful for the diagnosis of pneumothorax Oblique view Lordotic

Lateral viewThe cardiac silhouette in this view is oval in shape and occupy the anterior half of the thoracic cage. The ascending aorta and right ventricle form the anterior border, while the left atrium and left ventricle form the posterior border.

The frontal film

Pleura not normally visible

Pulmonary artery

R main bronchus

L main bronchus

Gastric air bubble

Blood-filled pulmonary vessels cast soft gray shadow and typically taper out to periphery, while bronchi and bronchioles are air filled and do not cast a shadow on the image

The frontal chest film

may be acquired PA

or AP
Aortic knob Ascending aorta Descending aorta RA RV LA

View the film as though the patient is facing you with his left on your right If the film is unmarked, remember your anatomy (heart and aortic arch are left of midline)


Look at the diaphragm and upper abdomen

~ interspace

The diaphragm is a musculotendinous sheet separating the thoracic and abdominal cavities

The left and right hemidiaphragms are usually well seen on PA and lateral films

The plane of the right diaphragmatic dome is usually about half an interspace higher than the left

Normal lateral film

typically left chest is placed against detector to minimize cardiac magnification



Barium Swallow/ Cor analisa

Normal Chest X-ray

Cardiac Structures
More central in younger infants and children More on the L side in older infants and teens

In AP view if < 2 years take up to ~ 65% If > 2 years - ~ 50%

Mitral Stenosis (MS)

Definition :

Obstruction to left ventricular blood inflow at the level of the mitral valve (MV)

Mitral stenosis
Mitral stenosis is a heart valve disorder that narrows or obstructs the mitral valve opening. Narrowing of the mitral valve prevents the valve from opening properly and obstructs the blood flow from the left atrium to the left ventricle. This can reduce the amount of blood that flows forward to the body. The main risk factor for mitral stenosis is a history of rheumatic fever but it may also be triggered by pregnancy or other stress on the body such as a respiratory infection, endocarditis, and other cardiac disorders

Mitral Stenosis
Tests may include: Chest x-ray a test that uses radiation to take pictures of structures inside the chest Electrocardiogram (ECG, EKG)a test that records the heart's activity by measuring electrical currents through the heart muscle Echocardiogram a test that uses high-frequency sound waves (ultrasound) to examine the size, shape, and motion of the heart; in this test, the sound waves are passed through a transducer that is placed onto your chest. Transesophageal echocardiogramuses the same ultrasound techniques to create an image of your heart, but gives a more detailed image. In this test, the transducer is passed down your esophagus (the tube in your throat that runs from your mouth into your stomach), to allow a better examination of the mitral valve. Cardiac catheterization an x-ray of the heart's circulation that is done after injection of a contrast dye Holter monitora portable EKG device that you wear for 24 or more hours, to detect heart rhythm abnormalities that often accompany mitral stenosis

Mitral Stenosis

Mitral Stenosis - upper lobe blood diversion.

Trivial enlargement of the transverse diameter of the heart. Left atrium causes double outline (opposite right arrow) and is somewhat dilated. Left atrial appendage is dilated, causing a prominence of the left border (opposit left arrow). Upper lobe vessels larger than lower lobe vessels, that is, upper lobe blood diversion. An arrow points to a dilated upper lobe vein.




Mitral Regurgutation (MR)/ Mitral Insufficiency (MI)


Incomplete closure of mitral valve during left ventricular systole leading to retrograde blood flow into left atrium.

Mitral regurgitation

Acute mitral regurgitation

Chronic mitral regurgitation

Mitral Regurgitation
Chest X-ray Heart size may be normal in mild cases or in acute regurgitation Cardiomegaly (due to left atrial and left ventricular enlargement in significant chronic mitral regurgitation


The echocardiogram is commonly used to confirm the diagnosis of mitral regurgitation. Color doppler flow on the transthoracic echocardiogram (TTE) will reveal a jet of blood flowing from the left ventricle into the left atrium during ventricular systole. Because of the inability in getting accurate images of the left atrium and the pulmonary veins on the transthoracic echocardiogram, a transesophageal echocardiogram may be necessary to determine the severity of the mitral regurgitation in some cases. Factors that suggest severe mitral regurgitation on echocardiography include systolic reversal of flow in the pulmonary veins and filling of the entire left atrial cavity by the regurgitant jet of MR.

Transesophageal echocardiogram of mitral valve prolapse

The Role of Imaging in Detection Congenital Heart Disease

Fetal Circulation
For the fetus the placenta is the oxygenator so the lungs do little work Shunts are necessary for survival - Ductus venosus (by passes liver) - Foramenovale(RLatriallevel shunt - Ductusarteriosus(RLarterial level shunt With first few breaths lungs expand and serve as the oxygenator (and the placenta is removed from the circuit) Foramen ovale functionally closes Ductus arteriosus usually closes within first 1-2 days

Cardiac Position: Dextrocardia

Situs inversus

Situs solitus

Chest X-ray examination

Cardiac Size
To examine size and shape of the cardiac To examine the enlargement of each cardiac chamber

Chest X-ray examination

Rule-out pulmonary parenchymal disease
Evaluate pulmonary blood flow
increased versus decreased blood flow

Noninvasive Diagnostic Studies

Computed tomography (CT)
CT provides a good display of the anatomic abnormalities associated with congenital heart disease and offers advantages over echocardiography in demonstrating anomalies involving the great vessels.

Indications: Cardiac CT
Detection of disease or pathology

i.e., diagnosis
Improve clinical decision making (Not first imaging) No role in defining normal anatomy No role in assessing function Not a screening tool

Mitral Regurgitation
Chest X-ray Heart size may be normal in mild cases or in acute regurgitation Cardiomegaly (due to left atrial and left ventricular enlargement in significant chronic mitral regurgitation

Extracardiac great vessel anomalies Intracardiac shunt lesions Diagnosis of cardiac congenital diseases atrial septal defects ventricular septal defects Evaluate post-operative anatomy usually complex cyanotic heart disease

Pulmonary Sling:
Left pulmonary artery arises from right pulmonary artery


Aortic Coarctation
10-day old girl with CHF; 8 cc contrast,



Patent Ductus Arteriosus



In patent ductus arteriosus, pulmonary blood flow, LA and

LV volumes, and ascending AO volume are increased

AO = Aorta LA = Left aorta LV = Left Ventricle PA = Pulmonary artery

Shunt Lesion: Septal Defects



Post ASD repair

Post-operative Evaluation:

Grafts subclavian arteries to pulmonary arteries

Graft right atrium to pulmonary artery

Noninvasive Diagnostic Studies

Magnetic resonance imaging (MRI)
MRI provides information similar to that provided by CT.

MRI offers better resolution than CT without the disadvantages of the radiopaque contrast medium used in that technique.

Invasive Diagnostic Studies

Cardiac catheterization and selective angiocardiography
are the most definitive diagnostic techniques currently available for use in congenital heart disease. Noninvasive studies often provide information that is equivalent to that obtained from cardiac catheterization and is sufficient for planning surgical treatment.

Congenital Heart Disease (CHD)

Simple way to classify is: Acyanotic CHD (LRshunts) Cyanotic CHD (RLshunts) Obstructive lesions


Defect between R and L heart Resistance to pulmonary blood flow PBF hypoxemiaandcyanosis


Obstructive Lesions
80% have bicuspid aortic valve

AP view The pressure in the left atrium is higher than the right atrium. therefore, a defect in the atrial septum will result in left to right shunting of blood. The increased blood volume flowing through the right heart and pulmonary vasculature will cause prominant pulmonary vascular markings on chest X-Ray, and in moderate to severe cases there will also be cardiomegaly due to right atrial enlargement causing prominance of the right heart border.

Lateral View Prominant pulmonary vasculature is noted, particularly in the hilar region. In severe cases the right ventricle is dilated, this will be manifested by fullness of the anterior border of the heart in the lateral views resulting in obliteration of lung tissue normally noted in between the heart and sternum.


Lateral View Prominant pulmonary vasculature is noted, particularly in the hilar region. In severe cases the right ventricle is dilated, this will be manifested by fullness of the anterior border of the heart in the lateral views resulting in obliteration of lung tissue normally noted in between the heart and sternum.

Atrial Septal Defect

Hole between the two atria Blood flows left to right PFO Patent foramen ovale fails to close Right atrium and ventricle becomes dilated Too much blood to the lungs


Atrial Septal Defect

ASD with Eisenmenger syndrome

Chest X-ray
The pulmonary vascular markings increased The main pulmonary artery segment dilated Cardiac enlargement (RV,RA) Diameter of ascending aorta is small to normal


Ventricular Septal Defect

Hole between the two ventricles Left to right shunt majority Dilated right ventricle too much blood to lungs increase in pulmonary pressure Smaller defects can close spontaneously


AP view The pressure in the left ventricle is higher than the right during systole. This will result in left to right shunting across the VSD, throughout systole. The increased pulmonary blood flow will cause prominent pulmonary vasculature. The right ventricle will become hypertrophied with moderate to large amount of shunt leading to cardiomegaly. The left atrium will become dilated due to increase pulmonary venous blood return. In the AP view, this will be manifested by widening of the carinal angle since the left atrium is situated just below the right and left main bronchi as they bifurcate.


Lateral view This view best demonstrates the left atrial dilatation. The dilated left atrium will cause the esophagus to dilate, as noted in this figure with Barium swallow.


Ventricular Septal Defect








PDA patent ductus arteriosus

Connection Left Pulmonary Artery to Aorta PDA Problem :
Too much blood going to lungs Increased PA pressure Increase RV Long term damage to lungs and birth

PDA patent ductus arteriosus









PDA patent ductus arteriosus

Tetralogy of Fallot (TOF)

ventricular septal defect, that allows blood to pass from the right ventricle to the left ventricle without going through the lungs a narrowing (stenosis) at or just beneath the pulmonary valve that partially blocks the flow of blood from the right side of the heart to the lungs the right ventricle is more muscular than normal (RVH) the aorta lies directly over the ventricular septal defect (over-riding aorta)

Tetralogi Fallot
VSD Aorta di atas VSD Obstruksi aliran ventrikel kanan Hipertrofi ventrik. Kanan

Cyanotic congenital heart disease

Tetralogy of Fallot (TOF)





Tetralogy of Fallot
Boot shape
RVH lifting apex loss of PA knob

Non Invasive imaging test is an evolving and promising modality but its application needs to validated with rigorous clinical investigations. Ultimately, appropriate selection of a noninvasive imaging test for a given patient should be evidence-based.