CARDIAC IMAGING 1 Flashcards
What determines Thoracic Situs
- Tracheobronchial Tree
- Left PA above Left Bronchus (hyarterial bronchus)
- Right PA below Right Bronchys (eparterial bronchus)
- Left main bronchus longer than right main bronchus
Norwood procedure
- when is it done?
- what does the procedure entail?
- within days of birth (HLHS)
- tiny aorta is anastomosed to pulmonary trunk and arch is augmented with a graft
- ASD is enlarged
- PDA is ligated (to prevent overshunting)
- BT shunt between Right subclavian artery and right pulmonary artery
Where should the tip of an Intraaortic Balloon Pump (IABP) be?
Intraaortic Balloon Pump (IABP)
Tip should be located just distal to the takeoff of the left subclavian artery (LSA) and be 2–4 cm below aortic knob. Inflation may be seen during diastole.
The balloon should be located in the proximal descending aorta, just below the origin of the left subclavian artery. On a chest radiograph, it should be at the level of the AP window. This ideally results in the balloon terminating just above the splanchnic vessels 3.
Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 66474
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 19299
Pre cardiology workup for systolic murmur.
Patient Data
Age:60 years
Gender:Female
what is the dx?
what sign is demonstrated
- Pulmonary valvular stenosis - Chen sign and post stenotic dilatation of the left pulmonary artery
- The patient is rotated to the right.
- The left pulmonary artery is grossly enlarged.
- The right pulmonary artery and hilum appear normal.
- The peripheral pulmonary arteries are more prevalent in the left base compared to the right (Chen sign).
- Heart size is normal.
- The lungs and pleural surfaces are clear.
- No signs of pulmonary edema.
- Cardiology workup diagnosed pulmonary valve stenosis due to congenital bicuspid valvular anatomy.
Chen sign is described as the prominence of left basal pulmonary vasculature compared to the right base due to the asymmetric increase in pulmonary blood flow to the left lung. It is secondary to preferential blood flow into the left pulmonary artery after passing through the stenosed pulmonary valve during systole.
Enlargement of the left pulmonary artery is secondary to the same effect, causing post stenotic dilatation.
DDx of Boot shaped heart
- Paediatrics
- Tetralogy of Fallot
- Adult
- loculated pleural effusion
- cardiac anerysm
- Pericardial cyst
3 ddx of mesocardial Delayed Myocardial Enhancement (MRI)
Mesocardial Delayed Myocardial Enhancement (MRI)
- Hypertrophic cardiomyopathy (CM)
- Dilated CM
- Chagas disease
What are the three segments of the right cardiac margin?
- SVC
- RA
- IVC
5 Ddx T1 Bright Cardiac Lesions
T1 Bright Cardiac Lesions
- Benign
- Thrombus (no enhancement)
- Lipoma (T1 bright, use fat saturation)
- Myxoma (T2 bright, variable enhancement)
- Lipomatous hypertrophy of the interatrial septum
- Malignant (enhances)
- Angiosarcoma
Fontan
Glenn + closure of ASD + shunt between right atrium to left PA
What are the causes of post capilary hypertension?
3
3
- Postcapillary HTN
- Cardiac
- LV failure
- Mitral stenosis
- LA myxoma
- Pulmonary venous
- Idiopathic venoocclusive disease
- Thrombosis
- tumour
- Cardiac
Congestive Heart Failure by age
- Premature:
- First week:
- Second week:
- Infant:
- Child:
Congestive Heart Failure by age
- Premature: PDA
- First week: hypoplastic left heart syndrome (HLHS)
- Second week: coarctation
- Infant: VSD
- Child: ASD
aortic regurg has which of the following on Xray
- Calcification
- CHF
- Left atrial enlargement
- Left ventricular Enlargement
aortic regurg has which of the following on Xray
- Calcification
- CHF
- Left atrial enlargement
- Left ventricular Enlargement ++
What are the causes of Abnormal Left Heart Contour?
Re:
- Pressure overload
- Volume overload
- Wall Abnormalities
- Abnormal Left Heart Contour
- Pressure overload (normal heart size)
- Aortic or mitral stenosis
- Systemic HTN
- Coarctation
- Volume overload (large heart disease)
- Mitral or aortic regurgitation
- Shunts: ASD, VSD
- High-output states
- End-stage heart failure of any given cause
- Wall abnormalities
- Aneurysm, infarct
- Cardiomyopathy
- Pressure overload (normal heart size)
ET tube placement
Endotracheal Tube (ET)
Inflated cuff should not bulge tracheal wall.
Tip of ET should be above the carina and below thoracic inlet:
Neutral neck: 4–6 cm above carina
Flexed neck: moves tip inferiorly by 2 cm
Extended neck: moves tip superiorly by 2 cm
DDx for Atoll (Reverse halo)
- Organizing pneumonia
- fungal pneumonia
- TB
- Wegener’s
- pulmonary infarct
What devices are imaged?
Where are the leads placed?
1 PPM
2: Implantable cardioverter-defibrillator (ICD)
How often is a right sided Aortic arch a/w Congenital heart disease?
What are the top 5 associatied Congenital Heart diseases?
- Right AA and CHD
- Associations
-
Right AAs are associated with CHD in 5%
- TA, 35%
- Tetralogy of Fallot, 30%
- Pulmonary atresia with VSD, 20%
- TGA, 5%
- Tricuspid atresia, 5%
- DORV
- Pseudotruncus
- Asplenia
- Pink tetralogy
-
Right AAs are associated with CHD in 5%
- Associations
- Right Aortic Arch. The aortic knob is not visible in its normal position on the left (redarrow). The knob (white arrow) and descending thoracic aorta (black arrows) are seen on the right. This patient did not have congenital heart disease.
- http://learningradiology.com/notes/cardiacnotes/rightarchespage.htm
http: //learningradiology.com/notes/cardiacnotes/rightarchespage.htm
DDx of Pulmonary Edema in NewBorns
- Cardiac
- Edema + large heart:
- hypoplastic RV or
- LV edema + normal heart:
- TAPVC below diaphragm
- TTN
- Pulmonary lymphangiectasia
- Other rare CHD causing obstruction to pulmonary venous return:
- Pulmonary vein atresia
- Cor triatriatum
- Supravalvular mitral ring
- Parachute MV
what does coronary dominance mean?
Dominance
- This refers to the artery that ultimately supplies the diaphragmatic aspect of the interventricular septum (IVS) and the LV.
- 85% of patients have right-sided dominance: RCA is larger than LCA and gives rise to the AV nodal artery.
- 10% of patients have left-sided dominance: LCA is larger than RCA and gives rise to the AV nodal artery.
- 5% of patients have a balanced coronary artery tree (codominant): two posterior descending arteries are present, one from the left circumflex and one from the rca
4 Complications of Swan Ganz Catheter placement
Complications
- Pulmonary infarct
- Pulmonary hemorrhage
- PA pseudoaneurysm
- Infection
- aka
- Swan-Ganz catheter (or ‘the yellow snake’)
- USES
- continuous cardiac output monitoring
- central temperature monitoring
- measurement of pulmonary artery pressure (can also measure RA and RV pressures during insertion)
- measurement of mixed venous saturations
- estimation of diastolic filling of left heart (normal PCWP 2-12mmHg)
- Settings it is commonly used are:
- right ventricular failure
- pulmonary hypertension
- weaning failure of cardiac origin
- post-cardiac surgery
https://litfl.com/pulmonary-artery-catheter/
most common location for bronchial atresia
apico-posterior segment of left upper lobe
Aortic Stenosis has which of the following on Xray
- Calcification
- CHF
- Left atrial enlargement
- Left ventricular Enlargement
Aortic Stenosis has which of the following on Xray
- Calcification +++
- CHF
- Left atrial enlargement
- Left ventricular Enlargement
ddx for small heart
- Addison’s disease
- cachectic state
- constrictive pericarditis
Bentall procedure
composite graft replacement of aortic valve, aortic root, and ascending aorta with re-implantation of coronary arteries into graft
- used to treat combined aortic valve and ascending aorta disease, including Marfans
Vanishing lung syndrome
idiopathic cause of giant bullous emphysema, results from avascular necrosis of the lung parenchyma and hyper inflation
- favors bilateral upper lobes
- defined as bullous disease occupying at least 1/3 of a hemithorax
- most common in young men
Hughes Stovin syndrome
- recurrent thrombophlebitis and pulmonary artery aneurysm formation and rupture
What are the causes of Precapilary Hypertenion?
Classification
Precapillary HTN
Vascular
- Increased flow: L-R shunts
- Chronic PE
- Vasculitis
- Drugs
- Idiopathic
Pulmonary
- Emphysema
- Interstitial fibrosis
- Fibrothorax, chest wall deformities
- Alveolar hypoventilation
What are the complications of ETT placement to look out for?
- Misplacement: atelectasis secondary to bronchial obstruction
- Tracheomalacia occurs above cuff pressures of 25 cm H 2 O
- Tracheal rupture; radiographic findings include:
- Pneumothorax
- Pneumomediastinum
- Subcutaneous emphysema
- Tracheal stenosis
- Dislodged teeth
- Laceration of nasooropharynx
What sign is this?
7 x ddx for this condition
7 x DDx Pericardial Effusion
WATER BOTTLE SIGN
- Transudate
- CHF
- AMI
- Post Op
- Autoimmune
- Renal Failure
- Infectious
- Viral
- Tumour
- Pericardial Mets
Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 7142
4 x ddx Pneumopericardium
Pneumopericardium
- Iatrogenic (aspiration, puncture)
- Cardiac surgery
- Barotrauma
- Fistula from bronchogenic or esophageal carcinoma
what is the problem here?
The correct and dislodged locations of the atrial lead tip are highlighted (blue circles).
Case Discussion
A right atrial lead should show a J-shaped curve on the frontal radiograph (anterior and superior).
It is easy to diagnose a dislodged or misplaced catheter if you have an old study to compare. The cardiologist should be informed that the lead is dislodged.
If no old study is available, then suggest this finding and recommend cardiology evaluation.
Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 37396
5 DDx of Subendocardial Delayed Myocardial Enhancement (MRI)
- Delayed Myocardial Enhancement (MRI)
-
Subendocardial
- Ischemic (coronary territory)
- Amyloid (diffuse)
- Cardiac transplant (diffuse)
- Systemic sclerosis (diffuse)
- Hypereosinophilic syndrome
- Mesocardial
- Hypertrophic cardiomyopathy (CM)
- Dilated CM
- Chagas
- Transmural
- Ischemia
- Myocarditis
- Sarcoid
- Subepicardial
- Myocarditis
- Sarcoid
- Chagas
- Nodular/patchy enhancement
- Amyloid
- Myocarditis
- Sarcoid
-
Subendocardial
what condition is pictured?
Twiddler’s Syndrome
Twiddler’s syndrome is a malfunction of a pacemaker due to the patient’s manipulation of the device and the subsequent dislodging of the leads.
This results in malfunctioning of the pacemaker or sometimes stimulation of other structures like phrenic nerve or brachial plexus.
Here a patient with a normally placed ICD on the left image.
Months later there was malfunction due to ICD box and lead rotation (yellow arrow) and retraction (white arrow).
https://radiologyassistant.nl/cardiovascular/devices/cardiovascular-devices#pacemakers
MNEMONIC
How to assess cardiac disease on Chest Xray
- She sells Cheese around Paris, Come lets buy some
- SSCeAPvCLBSt
- Situs
- Size
- Chamber enlargement
- Aorta
- Pulmonary vasculature
- Cacification
- Lungs
- Bones
- Soft tissues
8 ddx Coronary Aneurysm
Coronary Aneurysm
- Atherosclerotic
- Congenital
- Periarteritis nodosa
- Kawasaki disease
- Mycotic
- Syphilis
- Trauma
- CABG (saphenous vein > IMA)
What is the definition of Pulmonary venous Hypertension?
Pulmonary wedge >12mmHg
7 causes of Superior rib notching
- Superior Rib Notching
- Abnormal osteoclastic activity
- Hyperparathyroidism (most common)
- Idiopathic
- Abnormal osteoblastic activity
- Poliomyelitis
- Collagen vascular diseases
- rheumatoid arthritis,
- systemic lupus erythematosus
- Local pressure
- Osteogenesis imperfecta
- Abnormal osteoclastic activity
DDx of Cyanotic Heart Disease
- DDx of Cyanotic Heart Disease
- Ask yourself the questions
- Normal or increased pulmonary vascularity?
- Cardiomegaly?
- Ask yourself the questions
- Increased vascularity
- 5 T’s
- TGA (Most common) EGG ON A STRING
- TA
- Tricuspid Artresia
- TAPVR (FIGURE 8/SNOW MAN)
- Tingle Ventricle
- 5 T’s
- Normal vascularity
- Cardiomegaly
- Epsteins (BOX SHAPED HEART)
- No cardiomegaly
- Fallot (BOOT SHAPED HEART)
- Hypoplastic Right Heart
- Cardiomegaly
what makes up the Posterior cardiac margin on a lateral chest xray?
Posterior cardiac margin has two segments:
- LV
- Left atrium (LA)
What does volume overload cause in the heart?
what are the main causes?
What size is the heart?
- Volume overload causes DILATATION
- Examples
- regurgitation
- shunts
- heart size in increased
what is Eisenmenger Physiology
what are 4 causes
- Eisenmenger Physiology
- Chronic L-R shunt causes high pulmonary vascular resistance, which ultimately reverses the shunt (R-L shunt with cyanosis).
- Causes
- VSD
- ASD
- PDA
- ECD
Rastelli procedure
- used to correct TGA, pulmonary outflow obstruction, or VSD
- VSD used as the LVOT - baffle is placed in RV to divert flow as VSD to aorta
- pulmonary valve is oversewn and conduit is inserted between RV and PA
Mitral Stenosis has which of the following on Xray
- Calcification
- CHF
- Left atrial enlargement
- Left ventricular Enlargement
- Calcification +
- CHF +
- Left atrial enlargement +
- Left ventricular Enlargement
Complications of Fontan?
- right atriomegaly and arrhythmia
- plastic bronchitis
https://www.frontiersin.org/files/Articles/627660/fped-08-627660-HTML/image_m/fped-08-627660-g001.jpg
Where should the tip of a Swan Ganz Catheter be placed?
- Swan-Ganz Catheter
- Tip should be located in left or right PA, within 1 cm of hilum.
- There should be no loops in RA, RV (may cause arrhythmias).
- Image 1
- Swan-Ganz catheter now lies in the left pulmonary artery.
- Moderate bilateral effusions have developed, slightly larger on the right
- Volume loss in the left lower lobe persists.
- Image 2
- Suboptimal portable AP radiograph with cut-off of both apices (ICU patient).
- Pulmonary artery catheter inserted via right IJV route, passing into the descending right pulmonary artery. The tip is positioned too far distally and ideally to be withdrawn a few centimetres.
- ETT in good position. NGT tip projected over the mid thoracic spine and needs to be repositioned.
- Left basal consolidation.
- https://radiopaedia.org/cases/62236/studies/70400?lang=gb&referrer=%2Farticles%2Fpulmonary-artery-catheter%3Flang%3Dgb%23image_list_item_41492130#findings
What are the 4 segments of the left cardiac margin?
Left cardiac margin has four segments:
- Aortic arch (AA) (more prominent with age)
- Main pulmonary artery (PA) at level of left main stem bronchus
- Left atrial appendage (may not be visible in normal hearts)
- Left ventricle (LV)
RV is usually not seen in frontal projection
what is the appropriate position of Epicardial Pacing Wires?
Epicardial Pacing Wire ( Fig. 2.4 )
Wires are typically anchored in the anterior myocardium; some slack may be left in pericardium. Multiple wires may be present. Wires exit through anterior chest wall.
https://radiopaedia.org/cases/retained-pacing-wire?lang=gb
The retained pacing wire lies inside the red circle.
Case Discussion
Very difficult to identify retained piece of pacing wire from the time of the CABG.
This is important to identify given the risks of entering the MRI magnet.
Inverting films if often very helpful in identifying subtle metallic densities on plain radiograph
There are two types of cardiac conduction devices. What are they?
What are the locations of common pacemaker wire positioning?
There are two types of cardiac conduction devices (CCD’s):
- Pacemakers that pace the heart during periods of bradycardia.
- Inplantable cardioverter-defibrillators (ICD’s) that are capable of defibrillating the heart to prevent cardiac arrest.
Pacemakers can have leads, that pace:
- Right atrium = atrial appendage.
- Right ventrical = tip in apex.
-
Left ventricle = lead through the coronary sinus ends in posterior cardiac vein,
- used for cardiac synchronization therapy in patients with bundle branch blocks.
- Epicardial - placed on ventricle mainly used in cardiac surgery.
Mitral Regurgitation has which of the following on Xray
- Calcification
- CHF
- Left atrial enlargement
- Left ventricular Enlargement
Mitral Regurgitation has which of the following on Xray
- Calcification
- CHF
- Left atrial enlargement ++
- Left ventricular Enlargement +
Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 43190
what are the 3 wall motion abnormalities?
- Hypokinesis
- Akinesis
- Dyskinesis
DDx of MASSIVE Cardiomegally in a new born
- Box shaped heart (RIGHT ATRIAL ENLARGEMENT)
- Ebstein anomaly
- Uhl disease
- focal or totoal absence of RV myocardium
- Tricuspid atresia
- Herniation of liver into pericardial sac
- massive pericardial effusion
Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 43277
6 Complications of intra-aortic balloon pump placement
Complications
- CVA (position too high)
- Renal or mesenteric ischemia (position too low)
- Aortic dissection
- Limb ischemia
- Infection
- Note initial positions of electrodes as they may migrate
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.109.929810
What is the correct placement of a CVL?
what should you always look for/rule out?
what are 3 signs of impending catheter perforation?
- Central Venous Lines
- Tip should end in the SVC below the anterior first rib.
- Always rule out pneumothorax.
- Left-sided course of the line is indicative of left-sided SVC draining into coronary sinus.
- Signs of impending catheter perforation (hemothorax, pneumothorax) include:
- Position of the tip against the vessel wall
- Sharply curved catheter tip
- Infection, thrombosis
- PAH
- Primary PAH (young females, rare)
- Secondary PAH
- PA stenosis
- Williams syndrome (infantile hypercalcemia)
- Rubella syndrome
- Takayasu disease
- Associated with CHD (especially tetralogy of Fallot)
- PA dilatation
- Poststenotic jet
- AVM: Osler-Weber-Rendu disease
- Aneurysm cystic medial necrosis
- Behçet syndrome
- Takayasu disease
What makes up the anterior cardiac margin on the lateral view?
Lateral View ( Fig. 2.2 )
Anterior cardiac margin has three segments:
- Right ventricle (RV) is in apparent contact with sternum
- Main PA
- Ascending aorta
11 causes of
Inferior Rib Notching
- Inferior Rib Notching
- Aortic obstruction
- Coarctation
- IAA
- SA obstruction
- Blalock-Taussig shunt (upper two ribs)
- Takayasu disease (unilateral)
- Severely reduced pulmonary blood flow (very rare)
- Tetralogy of Fallot
- Pulmonary atresia
- Ebstein anomaly
- SVC obstruction
- Vascular shunts
- Arteriovenous malformation (AVM) of intercostals
- Intercostal neuroma
- Osseous abnormality (hyperparathyroidism)
- Aortic obstruction
Case courtesy of Dr Abdallah Al Khateeb, Radiopaedia.org, rID: 43490
What are the 5 causes of a small heart?
- Normal variant (deep inspiration)
- Addison disease
- Anorexia nervosa/bulimia (case)
- Dehydration
- Severe chronic obstructive pulmonary disease
Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 47176
6 Skeletal Abnormalities and Heart Disease
- Skeletal Abnormalities and Heart Disease
- Rib notching:
- coarctation
- Hypersegmented manubrium, 11 pairs of ribs: (CASE)
- Down syndrome
- Pectus excavatum: prolapsed MV
- Marfan syndrome
- Multiple sternal ossification centers:
- cyanotic CHD
- Bulging sternum:
- large L-R shunt
- Scoliosis:
- Marfan syndrome
- tetralogy of Fallot
- Rib notching:
- Case courtesy of Dr Raj Sohawon, Radiopaedia.org, rID: 37385
Ddx of Acyannotic Heart Disease
- Increased Pulmonary vascularity
- L to R shunt
- LA enlargement (indicates shunt is not in the LA)
- VSD (normal AA)
- PDA (Prominent AA)
- Normal LA
- ASD
- Endocardial Cusion defect
- PAPVC and sinus venosus ASD
- LA enlargement (indicates shunt is not in the LA)
- L to R shunt
what is the definition of pulmomary arterial hypertension?
P Sys > 30mmHg
what is this?
Automatic implantable cardioverter defibrillators
AICDs are common cardiac devices designed for both patient monitoring and therapy in case of ventricular tachycardia or fibrillation. AICDs consist of various combinations of sensing and shocking electrodes. They are frequently combined with a pacemaker as a bundled system for the patient, treating both the patient’s established arrhythmia and also acting as a fail-safe system should ventricular fibrillation or ventricular tachycardia occur.
Some types of AICD have leads that are implanted in the subcutaneous soft tissues (i.e. outside the thoracic cavity) 5.
Pre-exchange CXR: There is fracture involving the insulation of the pacemaker lead
Case courtesy of Dr Jayanth Keshavamurthy, Radiopaedia.org, rID: 27694
