CV I - CLIN - VIDEO LECT Cardiovascular Diagnostic Imaging (Boulos)

To confirm the placement of devices and ensure there is no pneumothorax (ptx) after the procedure.

CT Chest without contrast is used to assess lung tissue, look for nodules/masses, and for lung cancer screening. CT Chest with contrast enhances visualization of blood vessels and soft tissues, making it effective for diagnosing infections, inflammation, and vascular malignancies.

Imaging modalities of the thorax typically include:

• Lungs: Right and left lungs with lobular structure
• Heart: Central organ in the thorax
• Major Blood Vessels: Superior vena cava, aorta, pulmonary trunk
• Diaphragm: Separates thoracic cavity from abdominal cavity
• Abdominal Structures: In many modalities, the abdomen is also included, showing:
  • Liver
  • Peritoneum
  • Spleen
  • Pancreas
  • Stomach (upper abdomen)

The imaging modalities for thoracic anatomy include:

1. Plain Radiograph (CXR)
2. CT (Computed Tomography)
3. MRI (Magnetic Resonance Imaging): cardiac, thoracic, and pulmonary focus
4. Nuclear Medicine: VQ (Ventilation-Perfusion), SPECT, PET (for perfusion)
5. Ultrasound: Echocardiogram (TTE, TEE, POCUS), POCUS for lungs using the BLUE protocol
6. Catheter Angiography

Common chief complaints include:

1. Chest pain
2. Trauma
3. Shortness of breath / Difficulty breathing
4. Cough
5. Syncope
6. Palpitations
7. Weight loss, fevers, night sweats
8. Screening for smoking history
9. Superficial issues like lumps, masses, or skin changes

• Soft tissue infections/abscesses
• Rib fractures
• Pulmonary contusions
• Pneumothorax
• Pneumonia
• Pleural effusion
• Pulmonary edema
• Pulmonary embolism
• Malignancy
• Empyema
• Septic emboli
• Foreign body
• Hardware dislodgement (ICD leads)

• Esophageal perforation
• Mallory Weiss vs Boerhaave
• Pericardial effusion, tamponade
• Aortic dissection
• Aortic aneurysm
• Occlusive myocardial infarction
• Endo/myo/peri-carditis
• Heart failure
• PFO (Patent Foramen Ovale)
• Congenital anomalies:
  • Hypoplastic left heart
  • Pulmonary atresia
  • Tetralogy of Fallot
  • Total anomalous pulmonary venous return
  • Transposition of the great arteries
  • Tricuspid atresia
  • Truncus arteriosus

1. Supine, upright 1View AP Chest XR: Used for general assessment.
2. 2 view upright CXR (PA, Lateral): Provides comprehensive views for better diagnosis.
3. Rib series: Specifically for evaluating rib injuries.

These films are selected based on symptoms like chest pain, shortness of breath, cough, or trauma to provide the right information for diagnosis.

An enlarged heart, or cardiomegaly, can indicate various conditions such as hypertension, heart valve disease, cardiomyopathy, or heart failure. It suggests that the heart is working harder than normal, which may lead to further complications if not addressed.

Prominent main pulmonary arteries on a chest X-ray may indicate pulmonary hypertension or increased blood flow to the lungs. This can be associated with conditions such as left heart failure, chronic lung disease, or pulmonary embolism. Further evaluation is often necessary to determine the underlying cause.

The transverse diameter of the heart can be assessed by measuring the distance between the left and right heart borders on a chest X-ray. An increased transverse diameter suggests cardiomegaly, which may be indicative of underlying heart conditions such as hypertrophy or dilated cardiomyopathy.

The three basic views of a Chest X-Ray (CXR) are:

1. AP View: The patient lies on their back, and the X-ray is taken from the anterior-posterior position.
2. PA View: The patient stands upright facing the X-ray machine, and the X-ray is taken from the posterior-anterior position.
3. Lateral View: The patient stands sideways in front of the X-ray machine, providing a side profile of the rib cage and lungs.

The ABCD approach includes the following components:

The Aortic knob represents the contour of the aorta as it arches over the heart, typically seen in the upper mediastinum on a chest X-ray.

The pulmonary vasculature includes the Right Hilum (Right pulmonary artery) and Left Hilum (Left pulmonary artery), which are critical for assessing blood flow to the lungs.

The Costophrenic angle is the angle formed between the diaphragm and the ribs, important for evaluating pleural effusions and other abnormalities in the lower lung fields.

The Main pulmonary artery is a major vessel that carries deoxygenated blood from the right ventricle to the lungs for oxygenation, visible in the mediastinal area of a chest X-ray.

The Trachea appears as a midline structure in the neck and thorax, often seen as a radiolucent (dark) line on the X-ray, leading to the bronchi.

The Right hemidiaphragm is the right dome of the diaphragm, which separates the thoracic cavity from the abdominal cavity, and is typically higher than the left due to the liver's position.

The Left ventricle is one of the heart's chambers, responsible for pumping oxygenated blood to the body, and can be assessed for size and shape in a chest X-ray.

The Coracoid process is a bony projection from the scapula that can be identified in chest X-rays, providing reference for shoulder and upper thoracic anatomy.

The Azygo-oesophageal line is a radiographic landmark that helps in identifying the position of the azygos vein and the esophagus, important for assessing mediastinal structures.

The Left hemidiaphragm is the left dome of the diaphragm, which can be evaluated for elevation or depression, indicating potential pathologies such as pleural effusion or lung disease.

The anatomical structures related to the heart indicated on the chest X-ray include:

• Ascending aorta
• Aortic knob
• Main pulmonary artery
• Site of left atrial enlargement
• Double density left atrial enlargement
• Right atrium
• Descending aorta

The visible ribs on the chest X-ray and their positions are:

The major vessels and structures identified in the chest X-ray include:

• Clavicle
• Scapula
• Right main pulmonary artery
• Aortic arch
• Pulmonary trunk
• Superior vena cava
• Right brachiocephalic vein
• Left brachiocephalic vein
• Right subclavian artery
• Right subclavian vein
• Internal jugular vein
• Left common carotid artery

The organs visible in the chest X-ray and their locations are:

• Liver: Located in the lower right quadrant
• Stomach: Positioned below the diaphragm on the left side
• Spleen: Located in the upper left quadrant

Timing contrast in CTA protocols is crucial to highlight the vasculature of interest. For example, in trauma protocols, it is timed for the late arterial to early portal venous phase; in dissection protocols, it is timed for the aorta; and in pulmonary embolism (PE) protocols, it is timed for the pulmonary arteries.

ECG gating improves coronary calcium scoring by using the ECG to capture images during the least motion phase, specifically during diastole, which enhances the accuracy of the assessment.

The three primary planes used in CT imaging are:

1. Coronal - Divides the body into front and back portions.
2. Sagittal - Divides the body into left and right portions.
3. Axial - Divides the body into upper and lower portions.

The different types of windows in CT imaging include:

The three types of windowing in chest CT scans are:

1. Lung Windows: Optimized to image abnormalities of the lung parenchyma and to identify normal and abnormal bronchial anatomy.
2. Mediastinal Windows: Designed to display the mediastinal, hilar, and pleural structures effectively.
3. Bone Windows: Used to visualize bony structures clearly.

These windowing techniques manipulate the data from the original scan without needing to re-scan the patient.

In the axial CT scan, the aorta (Ao) is positioned posterior and slightly to the left of the pulmonary artery (PA).

In the coronal CT scan, the right atrium (RA) is located below and to the left of the left ventricle (LV).

In the sagittal CT scan, the left atrium (LA) is positioned below and to the left of the pulmonary artery (PA).

The axial chest CT scan shows the following anatomical structures:

• Subcutaneous fat
• Pectoralis major
• Pectoralis minor
• Intercostal muscles
• Internal Thoracic Vessels
• Sternum
• Superior Vena Cava (SVC)
• Aortic arch
• Trachea
• Right Lung
• Left Lung
• T5 Vertebra
• Latissimus dorsi
• Teres major
• Subscapularis
• Infraspinatus
• Scapula
• Levatores costarum
• Rhomboid muscles
• Trapezius
• Erector spinae

The sagittal chest CT scan displays the following key structures:

• Subcutaneous fat
• Clavicle
• Left Lung
• Manubrium
• Pectoralis major
• Costal Cartilage
• Aortic arch
• Main pulmonary trunk
• Aortic Root
• Pulmonary valve
• Right Ventricle
• Diaphragm
• Liver
• Rectus abdominis
• Sternum
• Left Atrium
• Pulmonary Vein
• Esophagus
• Stomach
• Coeliac axis / SMA
• Descending aorta
• T8, T9, T10, T11, T12, L1 (Vertebrae)
• Trapezius
• Rhomboid major
• Erector spinae

At the Five-Vessel Level, the following structures can be identified:

• Trachea (T): Appears as a dark, air-filled circle in the center.
• Esophagus: Indicated by an arrow.
• Right Brachiocephalic Vein (R): Located to the right of the trachea.
• Left Brachiocephalic Vein (L): Lies just posterior to the sternum.
• Innominate Artery (I): Visible from the patient's right.
• Left Common Carotid (C): Located next to the innominate artery.
• Left Subclavian Artery (S): Found further left from the common carotid.

In the mediastinal window, you can identify the aortic arch, superior vena cava, and trachea. Additionally, air in the esophagus can also be visualized.

Lung windows are used to maximize the ability to image abnormalities of the lung parenchyma and to identify both normal and abnormal bronchial anatomy.

In the axial view, the following structures can be identified:

1. Trachea (T)
2. Ascending Aorta (AA)
3. Descending Aorta (DA)
4. Superior Vena Cava (S)
5. Left Pulmonary Artery (P) (uppermost aspect)
6. Aortopulmonary Window (space under the arch of the aorta and above the pulmonary artery)

In the coronal view, the following structures can be seen:

1. Right Atrium (RA)
2. Superior Vena Cava (S)
3. Pulmonary Artery (P)
4. Left Ventricle (LV)
5. Aortic Valve
6. Left Atrial Appendage
7. Origin of the Great Vessels (indicated by a circle)

At the main pulmonary artery level, the following structures can be identified:

• Main Pulmonary Artery (MPA)
• Right Pulmonary Artery (RPA)
• Left Pulmonary Artery (LPA)
• Right Bronchi (RB)
• Left Main Bronchi (LB)
• Superior Vena Cava (S)

Additionally, the left pulmonary artery passes anterior to the Descending Aorta (DA), while the right pulmonary artery passes posterior to the Ascending Aorta (AA) and crosses to the right side.

The structures visible include the right ventricle outflow tract (RVOT), right atrium (RA), left ventricle (LV), aorta (Ao), left atrium (LA), and descending aorta (DA). A white arrow indicates where a pulmonary vein enters the left atrium.

The left atrium (LA) occupies the posterior and central portion of the heart, while the right atrium (RA) lies anteriorly and to the right of the left atrium, producing the right heart border.

One or more pulmonary veins may be seen entering the left atrium (LA), which is crucial for understanding the anatomy and function of the heart's chambers.

The anatomical structures identifiable include the right atrium (RA), right ventricle (RV), left ventricle (LV), interventricular septum (IVS), and the descending thoracic aorta (DA).

The right ventricle (RV) is more heavily trabeculated and has a thinner wall compared to the left ventricle (LV), which has a thicker wall.

In Image A, the following anatomical structures are visible:

• Trachea (T): Centrally positioned
• Aorta (Ao): Slightly to the right of the trachea
• Pulmonary Artery (PA): Branching to the left
• Right Main Bronchus (RMB) and Left Main Bronchus (LMB): Clearly labeled
• Bronchus Intermedius (BI): Pointed out
• An opaque region marked as C above the bronchi.

Image B highlights the bifurcation of the trachea into the right main bronchus (RMB) and left main bronchus (LMB). It provides a coronal view of this anatomical feature, with a small white arrow indicating the region just beyond the opening of the bronchus.

The bronchus intermedius is a short bronchial section located distal to the origin of the right upper lobe bronchus. It divides into the middle and lower lobe bronchi. In thoracic imaging, the presence of soft tissue posterior to the bronchus intermedius may indicate a tumor or adenopathy, which is clinically significant for diagnosis and treatment planning.

MRI provides anatomic and functional information about the heart. It can obtain images in 3D volumes during both end-systole and end-diastole, allowing for the calculation of stroke volume and ejection fraction. Additionally, MRI can reveal scarring from prior myocardial infarction (MI) and detect masses. It is particularly useful in evaluating congenital heart disease in children when other studies, like echocardiography, yield inconclusive results.

The three standard imaging planes used in cardiac MRI are:

1. Short Axis Plane
2. Horizontal Long-Axis Plane
3. Vertical Long-Axis Plane

The short-axis view of the heart best demonstrates the following structures:

• Right Ventricle (RV)
• Left Ventricle (LV)
• Interventricular Septum (IVS)

The horizontal long-axis view (4-chamber view) displays all four chambers of the heart, while the vertical long-axis view (2-chamber view) primarily shows the left atrium (LA) and left ventricle (LV).

The three-chamber view is significant as it is similar to the coronal view and is designed to demonstrate certain cardiac structures effectively, providing a comprehensive view of the heart's anatomy and function.

In the axial view of cardiac MRI, the right ventricle (RV), left ventricle (LV), and the descending aorta are visible.

The coronal view of cardiac MRI identifies the right atrium, left ventricle (LV), aorta (Ao), and the main pulmonary artery.

The sagittal view of cardiac MRI shows the right ventricle (RV), pulmonary artery (PA), left atrium (LA), and aorta (Ao).

In cardiac MRI images, blood is depicted as bright (i.e., white).

Nuclear medicine uses radioactive compounds to evaluate physiological processes. In pulmonary assessments, a VQ scan is used to evaluate for pulmonary embolism (PE). In cardiac assessments, SPECT and PET scans are utilized for perfusion imaging.

Comparing ventilation and perfusion scans helps identify areas of the lung that may be receiving air but not blood flow, or vice versa. This can indicate conditions such as pulmonary embolism or chronic obstructive pulmonary disease (COPD). Understanding the relationship between these two scans is crucial for accurate diagnosis and treatment planning.

Density values in ventilation and perfusion scans reflect the amount of air and blood flow in different regions of the lungs. Higher density values typically indicate better function, while lower values may suggest obstruction or reduced blood flow. Analyzing these values helps in assessing lung health and identifying potential pathologies.

The primary purposes include:

1. Detecting myocardial ischemia and infarction
2. Determining left ventricular ejection fraction (LVEF)
3. Assessing regional wall motion

Radiotracer principles are significant because:

• A radiotracer can only reach myocardial cells if there is adequate blood supply (perfusion).
• The myocardial cell must be viable to take up the tracer; if not, there will be decreased uptake of the tracer, indicating potential issues with perfusion or viability.

Myocardial perfusion scanning is usually performed with a stress test, which can be either:

1. Physical stress test
2. Chemical stress test

This is done both pre and post the stress test to evaluate changes in perfusion and wall motion.

The three different planes of the heart are short axis, horizontal axis, and vertical axis.

The labels identifying the sections of the short axis view are Apical, Short Axis, and Basal.

The sections labeled in the horizontal axis view are Inferior, Horizontal Axis, and Anterior.

The labels used to identify the sections of the vertical axis view are Septal, Vertical Axis, and Lateral.

The different types of ultrasound techniques used in thoracic assessment include:

1. Transthoracic Echocardiography (TTE)
2. Transesophageal Echocardiography (TEE)
3. Point-of-Care Ultrasound (POCUS)
   • Cardiac
   • Pulmonary

Ultrasound can evaluate various cardiac conditions, including:

• Valvular issues: Stenosis and regurgitation
• Effusions: Pericardial effusion
• Septal defects: Atrial and ventricular septal defects
• Thrombus: Presence of blood clots
• Wall motion abnormalities: Assessing heart muscle function
• Chamber sizes and function: Evaluating heart chambers and their performance
• Pressure measurements: Estimating pressures within the heart
• Ejection Fraction (EF): Measuring the percentage of blood pumped out of the heart with each beat.

Ultrasound can be used as a stand-alone test or in conjunction with stress testing to assess cardiac function and detect abnormalities under stress conditions. This combination helps in evaluating the heart's performance during increased physical demands, providing insights into potential ischemic conditions or functional limitations.

The ejection fraction (EF) during the initial catheterization was 45%.

The ejection fraction (EF) during the 6-month follow-up echo was preserved at 60-65%, indicating significant improvement but still noting systolic dysfunction.

The standard echocardiographic windows include:

Invasive coronary angiography is used for:

1. Diagnosis of coronary artery disease (CAD)
2. Assessment of coronary artery anatomy and function
3. Evaluation of myocardial perfusion
4. Guidance for interventions such as stenting or balloon angioplasty
5. Monitoring of heart function, including ejection fraction (EF)

Right Heart Catheterization:

• Measures pressures in the right atrium, right ventricle, and pulmonary artery.
• Assesses pulmonary circulation and right heart function.

Left Heart Catheterization:

• Evaluates the left atrium, left ventricle, and coronary arteries.
• Primarily used for diagnosing and treating coronary artery disease.

Fluoroscopic guidance is essential in invasive coronary angiography as it:

• Provides real-time imaging of the heart and blood vessels.
• Allows precise placement of catheters and contrast injection.
• Helps in visualizing the coronary arteries and identifying any blockages or abnormalities.

The common access sites for catheterization are:

1. Radial Artery

   • Less invasive, lower complication rates, faster recovery.

2. Femoral Artery

   • More traditional approach, allows for larger catheters, but higher complication rates.

Iodinated contrast is used in invasive coronary angiography because:

• It provides excellent visualization of blood vessels.
• It enhances the contrast between the coronary arteries and surrounding tissues on imaging.
• It is generally well-tolerated, although allergic reactions can occur in some patients.

Assessing coronary arteries and ejection fraction (EF) is significant because:

• It helps identify areas of stenosis or blockage that may require intervention.
• Evaluating EF provides insight into the heart's pumping ability and overall function.
• Together, these assessments guide treatment decisions and predict patient outcomes.

The purpose of stenting in invasive coronary angiography is to:

• Open narrowed or blocked coronary arteries to restore blood flow.
• Support the arterial wall and prevent re-narrowing (restenosis).
• Improve symptoms of angina and reduce the risk of heart attacks.

The key risk factors for heart disease in this patient include:

1. Family history of heart disease (father and brother both passed away from heart attacks at age 50).
2. Age (52 years old).
3. Obesity (BMI of 38).
4. Tobacco use (30 years).
5. Sedentary lifestyle (desk job, fairly sedentary).

The patient developed chest pain 5 minutes into the treadmill testing and exhibited ECG changes.

The patient was sent to the ER for further evaluation and management.

Cardiomegaly is defined as a cardiac silhouette that occupies more than 50% of the chest diameter on a chest X-ray.

The coronary angiography shows a critical, elongated stenosis in segments I-II of the LAD, characterized by an unstable plaque and overlapping thrombotic material.

The angiographic outcomes after revascularization and stenting of the LAD show TIMI 3 flow, indicating successful restoration of blood flow.

TIMI 3 flow indicates normal blood flow through the coronary artery, suggesting successful revascularization and stenting of the affected area.

Nuclear medicine perfusion testing could also be considered for follow-up after the initial catheterization.

Bilateral pleural effusions in CHF typically indicate fluid accumulation due to increased pressure in the pulmonary circulation. The right pleural effusion is often slightly larger than the left, which is a common finding in CHF. A large left pleural effusion alone may suggest other causes such as malignancy or tuberculosis (TB).

In congestive heart failure, it is common for the right pleural effusion to be slightly larger than the left. This size difference can help in diagnosing CHF, while a large left pleural effusion alone may warrant further investigation for other underlying conditions such as malignancy or TB.

The bat-wing pattern indicates central airspace disease that spares the lung periphery, suggestive of pulmonary edema rather than other airspace diseases like pneumonia. It is often seen in conditions such as rapidly developing cardiac failure, including massive myocardial infarction and papillary muscle rupture.

The bat-wing pattern is typically observed in:

1. Rapidly developing cardiac failure
2. Massive myocardial infarction
3. Papillary muscle rupture

These conditions lead to the characteristic central airspace disease seen in the pattern.

A chest X-ray highlights the lungs, heart, ribs, and clavicles. The lungs appear as dark, translucent areas, while the heart is a dense shadow centrally located. The ribs curve around the chest, and the clavicles are visible at the top.

The chest X-ray shows a large mediastinal soft-tissue mass, which represents a large aneurysm of the proximal descending aorta.

An aneurysm measuring 6.7 cm is at significant risk for rupture, indicating a critical condition that requires close monitoring or intervention.

The anteroposterior chest X-ray shows the width and depth of the heart, as indicated by the black arrow. This can help assess the heart's size and potential abnormalities.

A Stanford type A aortic dissection involves the ascending aorta, as seen in image A where an intimal flap is present in the ascending aorta. In contrast, a type B dissection, shown in image B, involves the descending aorta with a normal-appearing ascending aorta and an intimal flap in the descending aorta.

The intimal flap is the characteristic lesion of an aortic dissection, indicating the presence of a dissection. The smaller lumen typically represents the true lumen, while the larger lumen is the false lumen, formed by blood dissecting through the media of the aorta.

In planar images, normal anatomy is typically represented as follows:

• Axial images: Organs are viewed in cross-section, allowing for assessment of their size and shape.
• Coronal images: Structures are viewed from the front, providing a view of the anterior and posterior anatomy.
• Sagittal images: Organs are viewed from the side, allowing for evaluation of lateral structures and relationships.