Download Lecture07 RADIOLOGICAL EXAMINATION OF THE

RADIOLOGICAL
EXAMINATION OF THE
CARDIOVASCULAR SYSTEM
DEPARTMENT OF ONCOLOGY AND
RADIOLOGY
PREPARED BY I.M.LESKIV
METODS OF EXAMINATION

Echocardiography, radionuclide examinations and plain films are the
standard non-invasive imaging investigations used in cardiac disease.
Echocardiography has now become a particularly important imaging
technique that provides morphological as well as functional information. It
is excellent for looking at the heart valves, assessing chamber morphology
and volume, determining the thickness of the ventricular wall and
diagnosing intraluminal masses. Doppler ultrasound is an extremely useful
tool for determining the velocity and direction of blood flow through the
heart valves and within cardiac chambers. Radionuclide examinations
reflect physiological parameters such as myocardial blood flow and
ventricular contractility but provide little anatomical detail, whereas plain
radiographs are useful for looking at the effects of cardiac disease on the
lungs and pleural cavities, but provide only limited information about the
heart itself. MRI provides both functional and anatomical information but
is only available in specialized centres and is used only for specific reasons.
ROENTGENOGRAPHY

A complete roentgen study of the heart usually requires a minimum of four
projections: posteroanterior, left anterior oblique at approximately 60°,
right anterior oblique at approximately 45°, and lateral. The films are
exposed at a 6-foot distance, with the patient in the upright position and in
moderately deep inspiration. Magnification resulting from divergent
distortion is minimized by obtaining posteroanterior and anterior oblique
views to place the heart closer to the film (the anterior chest is adjacent to
film). A left lateral view (with the left side adjacent to film) also tends to
minimize magnification. To outline the esophagus, we use a barium
suspension as an aid in determining position and size of the aortic arch. In
addition, alteration in esophageal contour may reflect changes in the leftsided chambers. The use of ultrasound in determining cardiac chamber size
has decreased the use of the oblique projections, so that frequently the
cardiac examination is restricted to PA and lateral projections, usually
without barium in the esophagus.
Plain Radiography :
* The standard plain films for evaluation of cardiac diseases are the PA
view & Lateral chest film, the PA view must be sufficiently penetrated
to see the shadow within the heart, eg. The double contour of the Lt.
atrium & valve & pericardial calcification.
* It provides limited information's about the Heart.
* It provides limited information's about the effect of the cardiac
diseases on the lungs & pleural cavities.
We should assess the following points :

a- Heart (shape & size).

b- Great vessels (size, shape), Aortic arch (normally located to
the Lt. of the Trachea, we should exclude the signs of coarctation
of aorta).

c- If there is any calcification.

d- The main point is the examination of the Lung field for
altered blood flow & if there is any evidence of heart failure.
Normal CXR in PA view
Normal CXR in Lateral view
FLUOROSCOPY
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Cardiovascular fluoroscopy no longer has widespread use and in our
institution is largely limited to the evaluation of specific questions: i.e., the
presence of large pericardial effusions and the evaluation of aortic arch
anomalies. Generally, calcium is better seen on fluoroscopy then on plain
films and these observations may be made at the time of cardiac
catheterization. Minor amounts of calcification are best seen on CT. The
use of fluoroscopy has virtually disappeared in the study of congenital heart
disease because in general the patients require more definitive studies such
as cardiac catheterization, angiocardiography, ultrasonography, and MRI.
There are several disadvantages in cardiac fluoroscopy, one of the most
important of which is the amount of radiation to which the patient is
exposed.
The second disadvantage is distortion. Because the distance between the
target of the x-ray tube and the patient is short, there is considerable
enlargement of the cardiac silhouette and distortion of other thoracic
structures. This can be decreased by using longer distances between target
and the patient, and by using a small shutter opening, producing the central
beam effect. The third disadvantage is lack of permanent record. This is
obviated to a certain extent by the use of cine or videotape recording and
by roentgenograms obtained before the procedure.
ANGIOCARDIOGRAPHY

This method of contrast cardiac visualization has
been used widely for examination of patients
with all types of cardiac and pulmonary
diseases. The method is used in the diagnosis of
congenital and acquired cardiac disease.
Selective angiocardiography in which a small
amount of opaque medium (an organic iodide) is
injected into a specific chamber or vessel during
cardiac catheterization is used almost
exclusively.
CORONARY ARTERIOGRAPHY
AORTOGRAPHY
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CORONARY ARTERIOGRAPHY
Selective catheterization of the coronary arteries followed by injection of a
contrast medium (one of the organic iodides) is used in combination with
cineradiography rapid serial filming or videotaping to study the coronary
arteries. Details of technique are beyond the scope of this discussion.
AORTOGRAPHY
This examination consists of the injection of one of the organic iodides into
the aorta through a catheter introduced into one of its major branches and
placed into a desired position in the aorta. The examination has a place in
the investigation of patients with congenital and acquired problems of the
aortic arch. It is used in infants with congestive heart failure in whom there
is evidence of a left to right shunt and in whom patent ductus arteriosus is
suspected. Coarctation of the aorta in infants may also cause congestive
heart failure. The lesion can be defined by aortography. In adults,
aortography is used to define anomalies of the aortic arch and its branches
as well as in the study of the aortic valve and the coronary arteries. It is also
useful in patients with masses adjacent to the aorta in whom aneurysm is a
possibility and in patients suspected of having dissecting hematoma, and
traumatic or other aneurysms.
ULTRASONIC INVESTIGATION
OF THE HEART

The use of ultrasound in examination of the heart has increased greatly in
the past 20 years, and it is now well established and a widely used
diagnostic tool. Ultrasonic investigation is a noninvasive, safe, and
comfortable study that will demonstrate valve and chamber motion wall
thickness and size. Doppler examination allows determination of the cross
sectional area of a valve as well as quantification of gradients that may be
present. It is of value in the study of the hypertrophic cardiomyopathies
both with and without associated subaortic stenosis and in the study of the
congestive type in which there is chamber dilatation. With ultrasound, left
ventricular diameter and outflow configuration can be determined;
qualitative assessment of right and left ventricular size is possible, also. The
size of the left atrium can be measured accurately and left atrial myxomas
or other intraatrial tumors can be detected. Ultrasound is also useful in the
investigation of congenital heart disease, particularly in patients with
hypoplastic left-heart syndrome, double-outlet right ventricle, and right
ventricular volume overload. In addition, it is the most sensitive method for
determining the presence of pericardial effusion.
Echocardiography
(Cardiac US)
* It is the major or basic imaging technique used in cardiology.
* It gives important informations about the Morphology &
Function of the heart.
* It is an excellent technique to look for :
a- Heart valves.
b- Chamber morphology & volume.
c- Determining the ventricular wall thickness.
d- Any intra-luminal mass.
3 basic techniques are used in Echocardiography, & they are :

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
M-mode :
Two-dimensional sector scanning (Real time echo.)
Doppler echocardiography (Color, Pulse wave)
Echocardiography M-mode

* It is a continuous scan over a
period of time (5-10 seconds), with
pencil – beam of sound directed to
the site of interest.

* It can demonstrate chamber
dimensions, wall thickness, & valve
movement (mainly for Lt. ventricular
dimension in systole & diastole).
M-mode
Two-dimensional sector
scanning
(Real time echo.) :
* Demonstrates fun-shaped slices of the heart in motion.
* Standard examination consists of combination of short & long
axis views + 4 chamber view.
* Long & short – axis views : cross-section of the of the Lt.
ventricle + mitral valve + aortic valve, & it is done by placing
the transducer in the intercostal space, just to the Lt. of the
sternum.
* 4 chamber view : both ventricles, both atria, mitral & tricuspid
valves, & it is done by placing the transducer at the cardiac
apex & aiming upward & medially.
4 chamber view in 2 dimensional scan
Para-sternal long axis
Para-sternal short axis
Apical 4 chamber view
Para-sternal short axis
(at Mitral valve level)
Doppler echocardiography
(Color, Pulse wave) :
* Changing in the frequency of the sound waves are reflected
from moving objects, this change depends on the velocity of the
reflecting surface.
* RBCs are used as reflecting surface & the velocity of the blood
flow can be measured.
Doppler flow measurements
are used to :
1- Measure cardiac output or Lt. to Rt. shunt.
2- Detect & quantify valvular regurgitation.
3- Quantify pressure gradients across stenotic valves.
4- Quantify flow.
Trans-Esophageal
Echocardiography :
* By placing the U.S. probe in the esophagus immediately
behind the Lt. atrium, so it will view the heart from behind.
(A = normal descending thoracic aorta)
DETERMINATION OF CARDIAC SIZE

The most commonly used are (1) measurement of transverse diameters; (2)
measurement of surface area; and (3) cardio-thoracic ratio. The transverse
diameter of the heart is the sum of the maximum projections of the heart to
the right and to the left of the midline; the measurement should be made so
as not to include epicardial fat or other noncardiac structures. The diameter
can then be compared with the theoretic transverse diameter of the heart for
various and weights. Surface area estimations based on artificial
construction of the base of the heart and of the diaphragmatic contour of
the heart. The cardiothoracic ratio is the ratio between the transverse
cardiac diameter and the greatest internal diameter of the thorax, measured
on the frontal teleroentgenogram. This is the easiest and quickest method of
measurement of cardiac size; an adult heart that measures more than one
half of the internal diameter of the chest is considered enlarged. The
method is gross, because the cardiothoracic ratio varies widely with
variations in body habitus. It can be useful, however, as a rough estimate of
cardiac size. The cardiothoracic ratio is most useful in assessing changes in
heart size or monitoring progression of disease, or as a response to therapy.
Heart Diseases
* Evidence of heart diseases is given by :
1- Size & shape of the heart.
2- Pulmonary vessels, which provide information about the
blood flow.
3- The lungs, which may show pulmonary edema.

Measurement of heart size. The transverse diameter of the heart is the distance
between the two vertical tangents to the heart outline. When the cardiothoracic
ratio (CTR) is calculated, the transverse diameter of the heart (B) is divided by
the maximum internal diameter of the chest (A)
Heart size :
* Cardio - Thoracic Ratio (CTR), is the maximum thoracic
diameter of the heart divided by the maximum thoracic
diameter, in adult CTR > 50% while in children CTR > 60%.
Heart size :
* Comparing with previous films chest-x-ray films is often
more useful.
- The transverse cardiac diameter varies with the phase of
respiration & with cardiac cycle, so if the change in the
cardiac size is < 1.5 cm; this is negligible because the heart
size is affected by breathing & cardiac cycle.
* Overall increase in the heart size means :
- Dilatation of more than one cardiac chamber.
- Pericardial effusion.
Chamber hypertrophy
and dilatation :
* Pressure overload (as in : Hypertension, Aortic Stenosis,
Pulmonary Stenosis), this will lead to
ventricular wall hypertrophy, & such change will produce
little change in the external contour of the heart, until the
ventricle fails.
* Volume overload (as in : Mitral Incompetence, Aortic •
Incompetence, Pulmonary Incompetence, Lt. to Rt. Shunt, &
Damage of the heart muscle), this will lead to dilatation of the
relevant ventricle, & this will cause an overall increase in the size
of the heart (increase in the transverse cardiac diameter).
* Because enlargement of one ventricle affects the shape of the
other, so it is only occasionally possible to get the classical feature
Lt. or Rt. Ventricular enlargement.
Lt. Ventricular enlargement
- Lt. Ventricular enlargement, the cardiac apex is displaced
downwards and to the left. Note also that the ascending aorta
causes a bulge of the right mediastinal border - a feature that is
almost always seen in significant aortic valve disease.
Lt. Ventricular enlargement
in a patient with Aortic
Incompetence
Rt. Ventricular enlargement
- Rt. Ventricular enlargement, the cardiac apex is displaced
upward (to the Lt. of diaphragm). Note also the features of
pulmonary arterial hypertension - enlargement of the main pulmonary
artery and hilar arteries with normal vessels within the lungs.
Rt. Ventricular enlargement in a
patient with Primary Pulmonary
Hypertension
Lt. Atrial Enlargement :
* When it produces Double Contour, the Rt. border of the
enlarged Lt. atrium is seen adjacent to the Rt. Cardiac
border within the main cardiac shadow.
Lt. Atrial Enlargement in a patient with Mitral
Valve Disease showing the “Double Contour
Sign” (the left atrial border has been drawn
in) and dilatation of the left atrial
appendage (LAA) (arrow).
Lt. Atrial Appendage : The enlarged LAA should not be
confused with dilatation of the main pulmonary
artery. The main pulmonary artery is the segment
immediately below the aortic knuckle. The LAA is
separated from the aortic knuckle by the main
pulmonary artery
Rt. Atrial Enlargement
* Will produce an increase of the Rt. cardiac border, & often
accompanied by enlargement of Superior Vena Cava
(SVC).
Valve movement deformity
& calcification
Plain X-ray films :
* Calcification is the only could be obtained directly related
to the morphology of the valve.
* Calcification is better seen by fluoroscopy.
* It occurs in mitral valve &/or aortic valve in rheumatic
heart diseases; & if it occurs in aortic valve alone
(especially in adults) it is mainly congenital aortic stenosis.
* It is the easiest & the best to see calcification by the
lateral view by drawing a line from the junction of the
diaphragm & the sternum to the Lt. main bronchus, so :
- If the calcification is below & behind, means mitral valve.
- If the calcification is above & in front, means aortic valve.
* If the line dissects the calcification, both valves (mitral &
aortic) are calcified.
* Calcification of the mitral valve ring + elderly patient is
occasionally seen in mitral regurgitation.
Valve calcifications
Mitral Valve
Calcifications
Valve calcifications
Aortic Valve
Calcifications
Ventricular Contractility
* General uniform decrease contractility in valvular disorder,
congenital cardiomyopathy, & multi-vessel coronary artery
diseases.
* If there is focal decrease in contractility +/- dilatation in
IHD.
* Increase contractility of the Lt. ventricle will cause
hypertrophy as in aortic stenosis, HTN, & hypertrophic
obstructive cardiomyopathy (HOCM).
THE ADULT HEART
Position of oesophagus (not
opacified in this instance)
Pericardial disease


Echocardiography is ideally suited to detect pericardial fluid. Since patients are examined
supine, fluid in the pericardial space tends to flow behind the left ventricle and is recognized as
an echo-free space between the wall of the left ventricle and the pericardium. A smaller amount
of fluid can usually be seen anterior to the right ventricle. Even quantities as small as 20-50 ml
of pericardial fluid can be diagnosed by ultrasound. The nature of the fluid cannot usually be
ascertained, and needle aspiration of the fluid may be necessary; such aspiration is best
performed under ultrasound control. Pericardial effusion can also be recognized at CT and
MRI, although they are rarely performed primarily for this purpose. Computed tomography
and MRI are particularly useful for assessing thickening of the pericardium, whereas
echocardiography is poor in this regard.
It is unusual to be able to diagnose a pericardial effusion from the plain chest radiograph.
Indeed, a patient may have sufficient pericardial fluid to cause life-threatening tamponade, but
only have mild cardiac enlargement with an otherwise normal contour. A marked increase or
decrease in the transverse cardiac diameter within a week or two, particularly if no pulmonary
oedema occurs, is virtually diagnostic of the condition. Pericardial effusion should also be
considered when the heart is greatly enlarged and there are no features to suggest specific
chamber enlargement . Pericardial calcification is seen in up to 50 % of patients with
constrictive pericarditis. Calcific constrictive pericarditis is usually postinfective in aetiology,
tuberculosis and Coxsackie infections being the common known causes. In many cases no
infecting agent can be identified. The calcification occurs patchily in the pericardium, even
though the pericardium is thickened and rigid all over the heart. It may be difficult or even
impossible to see the calcification on the frontal view. On the lateral film, it is usually maximal
along the anterior and inferior pericardial borders. Widespread pericardial calcification is an
important sign, because it makes the diagnosis of constrictive pericarditis certain.
Pericardial Diseases
20 – 50 ml of pericardial fluid is diagnosed by echo.•
Needle aspiration is needed to insure the nature of the
fluid.•
CT scan & MRI can show the pericardial effusion; but more important is to measure •
the thickness of the pericardium where thickness of the pericardium where echo. is
poor.
* Unusual to diagnose pericardial effusion by plain-X-ray because the patient may
have pericardial effusion to cause a life-threatening tamponade; but only mild heart
enlargement with otherwise normal contour.
Marked increase or decrease in the transverse diameter
shadow within on or two weeks + No
pericardial effusion.
of the cardiac
pulmonary edema is virtually diagnostic of
•
Marked increase in the cardiac size + no specific chamber + normal pulmonary •
vasculature (flask shape) (& the outline of the heart become very sharp) is diagnostic of
pericardial effusion.
Pericardial calcification is seen in 50% of patient within constrictive pericarditis, which •
is usually due to TB or Coxsackie's virus infection.
Best seen on lateral CXR, along the anterior & inferior surface, because it may possible •
on frontal CXR.
* Usually the calcification is an important sign for constrictive pericarditis.
Pericardial Effusion
Pericardial Effusion due to Viral
Pericarditis
Pericardial Effusion
Congestive Cardiomyopathy,
this appearance usually
confused with Pericardial
Effusion
Pericardial effusion. The heart is
greatly enlarged. (Three weeks
before, the heart had been normal in
shape and size.) The outline is well
defined and the shape globular. The
lungs are normal. The cause in this
case was a viral pericarditis. This
appearance of the heart, though
highly suggestive of, is not specific to
pericardial effusion. (Compare with
(b).) (b) Congestive cardiomyopathy
causing
generalized
cardiac
dilatation. This appearance can easily
be confused radiologically with a
pericardial effusion.
A
B
Pericardial calcification in a patient with severe constrictive
pericarditis. The distribution of the calcification is typical. It
follows the contour of the heart and is maximal anteriorly and
inferiorly. As always, it is more difficult to see the calcification
on the PA film. (This patient also had pneumonia in the right
lower lobe.)
Pericardial Effusion
Large Pericardial Effusion
on an apical 4-chamber
view echocardiogram
Large pericardial effusion on an apical fourchamber view echocardiogram. (b). CT scan
showing fluid density (arrows) in pericardium.
LA, left atrium; LV, left ventricle; RA, right
atrium; RV, right ventricle.
Pericardial Effusion
CT-scan shows fluid
density (arrows) in
the Pericardium
Pericardial Calcifications
Pericardial Calcification in a
patient with Severe Constrictive
Pericarditis
Pericardial Calcifications
Pericardial Calcification in a
patient with Severe Constrictive
Pericarditis
Pulmonary vessels


The plain chest film provides a simple method of assessing the pulmonary
vasculature. Even though it is not possible to measure the true diameter of
the main pulmonary artery on plain film, there are degrees of bulging that
permit one to say that it is indeed enlarged. Conversely, the pulmonary
artery may be recognizably small. The assessment of the hilar vessels can
be more objective since the diameter of the right lower lobe artery can be
measured: the diameter at its midpoint is normally between 9 and 16 mm.
The size of the vessels within the lungs reflects pulmonary blood flow.
There are no generally accepted measurements of normality, so the
diagnosis is based on experience with normal films. By observing the size
of these various vessels it may be possible to diagnose one of the following
haemodynamic patterns.
Increased pulmonary blood flow: Atrial septal defect, ventricular septal
defect and patent ductus arteriosus are the common anomalies in which
there is shunting of blood from the systemic to the pulmonary circuits (socalled left to right shunts), thereby increasing pulmonary blood flow. The
severity of the shunt varies greatly. In patients with a haemodynamically
significant left to right shunt (2:1 or more), all the vessels from the main
pulmonary artery to the periphery of the lungs are large. This radiographic
appearance is sometimes called pulmonary plethora. There is reasonably
good correlation between the size of the vessels on the chest film and the
degree of shunting.
Pulmonary Vessels
* It is not possible to measure the diameter of the MPA from
the plain film (usually subjective); but if there are variable
degrees of bulging, means enlarged MPA.
* Assessment of the hilar pulmonary arteries is more
objective & the diameter of the Rt. lower lobe artery at its
mid-point (normally 9 – 16 mm).
* The size of pulmonary vessels with the lung reflects the
pulmonary blood flow.
* Increase pulmonary blood flow is seen in ASD, VSD, &
PDA, & all of these will lead to Systemic to Pulmonary (Lt.
to Rt. shunt) & these will to increase pulmonary blood
flow.
Pulmonary Vessels
* Hemodynamically significant Lt. to Rt. shunt is (2/1 ratio
or more) & this will produce CXR findings; if less ratio
there will be no CXR findings & all the pulmonary vessels
will (from the MPA to the periphery of the lung) will be
enlarged, & this is called "Pulmonary Plethora".
* There is good correlation between the size of the vessel
on CXR & degree of the shunt.
* Decrease pulmonary blood flow, all the vessels are small
"Pulmonary Oligemia".
* The commonest cause of decrease pulmonary blood flow
is TOF & pulmonary stenosis.
* Obstruction of the Rt. ventricle outflow + VSD will lead to
Rt. to Lt. shunt.
* Pulmonary stenosis will cause oligemia only is severe
cases & babies or very young children.
Decreased pulmonary blood flow: To be recognizable radiologically, the reduction in
pulmonary blood flow must be substantial. The pulmonary vessels are all small, an
appearance known as pulmonary oligaemia. The commonest cause is the tetralogy of Fallot,
where there is obstruction to the right ventricular outflow and a ventricular septal defect
which allows right to left shunting of the blood. Pulmonary valve stenosis only causes
oligaemia in extremely severe cases in babies and very young children.

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
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Pulmonary arterial hypertension: The pressure in the pulmonary artery is dependent on
cardiac output and pulmonary vascular resistance. The con ditions that cause significant
pulmonary arterial hypertension all increase the resistance of blood flow through the
lungs. There are many such conditions including:
various lung diseases (cor pulmonale);
pulmonary emboli;
pulmonary arterial narrowing in response to mitral valve disease or left to right shunts;
idiopathic pulmonary hypertension.
Pulmonary arterial hypertension has to be severe before it can be diagnosed on plain
films and it is difficult to quantify in most cases. The plain chest film features are
enlargement of the pulmonary artery and hilar arteries, the vessels within the lung
being normal or small. When the pulmonary hypertension is part of Eisenmenger's
syndrome (greatly raised pulmonary arterial resistance in association with atrial septal
defect, ventricular septal defect or patent ductus arteriosus, leading to reversal of the
shunt so that it becomes right to left), the vessels within the lungs may also be large, but
there is still disproportionate enlargement of the central vessels.The reason for
pulmonary arterial hypertension may be visible on the chest film; in cor pulmonale the
lung disease is often radiologically obvious, and in mitral valve disease and other.
Pulmonary Arterial Hypertension
* The pressure in the pulmonary artery depends on :
1- Cardiac output.
2- Pulmonary vascular resistance.
* Conditions that cause significant pulmonary arterial
hypertension all increase the resistance of blood flow
through the lungs, examples :
1- Various lung diseases (cor pulmonale).
2- Pulmonary embolism.
3- Pulmonary arterial narrowing in response to mitral
valve diseases or Lt. to Rt. shunt.
4- Idiopathic pulmonary hypertension.
Pulmonary Arterial Hypertension
* By CXR :
There will be enlargement of the mean pulmonary artery +
the hilar pulmonary artery, vessels within the lung tissue
are normal or small.
* Eisenmenger's syndrome :
Greatly raised pulmonary artery resistance in association
with ASD, VSD, & PDA leading to reverse shunt (i.e. : Rt.
to Lt. shunt).
Pulmonary Arterial Hypertension
* The cause of pulmonary arterial hypertension may be
visible on the CXR as cor pulmonale & mitral valve
diseases.
Pulmonary Arterial Hypertension
due to ASD & Eisenmenger's
syndrome
Pulmonary Venous Hypertension
* The commonest causes of pulmonary venous hypertension
are :
1- Mitral valve diseases.
2- Lt. ventricular failure.
* In normal upright person (by CXR) the lower zone vessels
are larger than the upper zone.
* In pulmonary venous hypertension the upper zone vessels
are enlarged.
* In severe cases, the upper zone vessels become larger
than that of the lower zone, & eventually Pulmonary
Edema will supervene & may obscure the blood vessels.
Pulmonary Venous Hypertension
Pulmonary Venous Hypertension
in a patient with Mitral Valve
Disease
Pulmonary oedema: The common cardiac conditions causing pulmonary oedema are left
ventricular failure and mitral stenosis. Cardiogenic pulmonary oedema occurs when the pulmonary
venous pressure rises above 24-25 mmHg (the osmotic pressure of plasma). Initially, the oedema is
confined to the interstitial tissues of the lung, but if it becomes more severe fluid will also collect in the
alveoli. Both interstitial and alveolar pulmonary oedema are recognizable on plain chest films.
Interstitial oedema: There are many septa in the lungs
which are invisible on the normal chest film because 
they consist of little more than a sheet of connective
tissue containing very small blood and lymph vessels.
When thickened by oedema, the peripherally located
septa may be seen as line shadows. These lines, known
as Kerley В lines, named after the radiologist who
first described them, are horizontal lines never more
than 2 cm long seen laterally in the lower zones. They
reach the lung edge and are therefore readily
distinguished from blood vessels, which never extend
into the outer centimetre of the lung. Other septa
radiate towards the hila in the mid and upper zones
(Kerley A lines). These are much thinner than the
adjacent blood vessels and are 3-1 cm in length.
Another sign of interstitial oedema is that the outline
of the blood vessels may become indistinct owing to
oedema collecting around them. This loss of clarity is
a difficult sign to evaluate and it may only be
recognized by looking at follow-up films after the
oedema has cleared. Fissures may appear thickened
because oedema may collect against them.
Alveolar oedema: Alveolar
oedema is a more severe
form of oedema in which
the fluid collects in the
alveoli. It is almost always
bilateral, involving all the
lobes. The pulmonary
shadowing is usually
maximal close to the hila
and fades out peripherally
leaving a relatively clear
zone that may contain
septal lines, around the
edge of the lobes. This
pattern of oedema is
sometimes referred to as
the 'butterfly' or 'bat's
wing' pattern.
Septal lines in interstitial pulmonary oedema, (a) Left upper zone showing the septal lines
known as Kerley A lines (arrowed) in a patient with acute left ventricular failure following a
myocardial infarction. Note that these lines are narrower and sharper than the adjacent
blood vessels, (b) Right costophrenic angle showing the septal lines known as Kerley В lines
in a patient with mitral stenosis. Note that these oedematous septa are horizontal nonbranching lines which reach the pleura. One such line is arrowed.
B
Bat-Wing Appearance Alveolar oedema in a patient with acute left ventricular failure
following a myocardial infarction. The oedema fluid is concentrated in the more central portion
of the lungs leaving a relatively clear zone peripherally. Note that all the lobes are fairly equally
involved.
Aorta

With increasing age the aorta elongates. Elongation necessarily involves unfolding,
because the aorta is fixed at the aortic valve and at the diaphragm. This unfolding
results in the ascending aorta deviating to the right and the descending aorta to the left.
Aortic unfolding can easily be confused with aortic dilatation.
 True dilatation of the ascending aorta may be due to aneurysm formation or secondary
to aortic regurgitation, aortic stenosis or systemic hypertension.
 The two common causes of aneurysm of the descending aorta are atheroma and aortic
dissection. A rarer cause is previous trauma, usually following a severe deceleration
injury. The diagnosis of aortic aneurysm may be obvious on plain film but substantial
dilatation is needed before a bulge of the right mediastinal border can be recognized.
Atheromatous aneurysms invariably show calcification in their walls and this
calcification is usually recognizable on plain film. Computed tomography with
intravenous contrast enhancement is very useful when aortic aneurysms are assessed. It
is important to know the extent of aortic dissections as those involving the ascending
aorta are treated surgically while those confined to the descending aorta are usually
treated conservatively with hypotensive drugs. Standard echocardiography shows
dissection of the aortic root but transoesophageal echocardiography shows dissections
distal to the aortic root and in the descending aorta as well. Dissecting aneurysms can
also be shown with CT and MRI and these non-invasive techniques have largely
replaced aortography, which is only performed in selected cases.
 Two congenital anomalies of the aorta may be visible on plain films of the chest:
coarctation and right-sided aortic arch, a condition that is sometimes seen in association
with intracardiac malformations, notably tetralogy of Fallot, pulmonary atresia and
truncus arteriosus. It can also be an isolated and clinically insignificant abnormality. In
right aortic arch, the soft tissue shadow of the arch is seen to the right, instead of to the
left, of the lower trachea.
Aortic dissection, (a) Transoesophageal echocardiogram
showing the true (T) and false (F) lumina in the
descending aorta. CT scan showing the displaced intima
(arrows) separating the true and false lumina in the
ascending and descending aorta. MRI scan showing the
displaced intima in the ascending and descending aorta
(arrows). AAo, ascending aorta; DAo, descending aorta;
PA, pulmonary artery.
MSCT vs. references method of conventional
angiography*
•16 row MSCT : Sensitivity
92-95%
•
86-93%
Specificity
• positive predictive value
79-80 %
• negative predictive value
97 %
* K Nieman,Lancet ,2001
Attention: MSCT is exellent method in
excluding coronary artery disease in patients
with non-specyfic chest pain.(Ch.Becker)
MSCT – EVALUATION OF STENTS

Visualization and availability stents for analysis
50-77%
 Patency stents
- sensitivity 75%
- specificity 96 %
 Occluded stents
 sensitivity 98-100%
-
Schuijf JP, Am J Cardiol 2004,94(4),427
MSCT – evaluation of aorto-coronary
by-passes
Closed aorto-coronary graft
- specificity 97%,
- sensitivity 98%
Narrowing
- specificity 75%
- sensitivity 92%
After 3 years from 20-to 30% by-passes are occluded
Silber S iwsp. Herz 2003, 2;126-35
Coronary Artery Disease
Diagnostic possibilities of MSCT
NONINVASIVE ANGIOGRAPHY OF CORONARY
ARTERIES

Evaluation of coronary anatomy, morphology and anomalies of the
origin, calcium scoring (CS).

Identification of soft and calcification plaques and their
- location
- range
- length
Assessment of myocardial function



Thickness and wall motion
Hemodynamic paramters
Myocardial perfusion
MSCT – coronary calcium score – the
relationship to coronary artery disease.

Studies using serial MSCT scans indicate that the
annual progression of coronary calcium varies
between 30% to 50% in symptomatic or
asymptomatic nontreated high –risk individuals.

In patients treated effectively with lipid-lowering
medication the progression of coronary calcium score
varies between 0-20%.
Schmermund A i wsp. Cardiol Clin 2003,21(4)
Coronary Calcium Scores according to Varying
Age and Sex (ECTB)
(10377 asymptomatic pts)
During a mean follow-up of 5 years , the death was - 2,4%
Risk-adjusted relative risk values of coronary calcium were:
11-100
1,64
101-400
1,74
401-1000
2,54
> 1000
4,03
as comapred with score of 10 or less (p<0,001 for all values)
Shaw LI i wsp. , Radiology 2003;228,826
64 MSCT – STENTS AND BY-PASS
Occluded by-pass for CX, implanted 3 stents in CX, all patency