Imaging of Congenital Heart Diseases
Review:
In determining cardiac problems via plain radiography
 Cardiac size

Pulmonary vascularity
Measure the heart length and divide by total length of thoracic cage
= Cardio-Thoracic Ratio
Assessment of Individual Chambers
 Remember the border forming structures o Right
 SVC
 Right Atrium
 Right Atrial Enlargement
 Right Ventricle

Rigth ventricular enlargement – upliftment in left border (usually RV enlargement); Retrosternal space obliteration in lateral view
 Left Atrium
 Left Atrial Enlargement o Double density in right cardiac border; a bulging cardiac waistline, widened caryna
(PA View)
 Left Ventricle
 Left Ventricular Enlargement
– border pointing downwards (vs upward upliftment in RVH)
Pulmonary Vascular Pattern

Divide lungs into zones. The inner lung zone has more vasculature. Inner>Mid>Outer (in terms of vasculature)

Upper, mid and lower lung fields. Upper Lung fields
(smaller caliber and less vasculature)
 Hypervascular = increased vascularity in lung fields/zones; fullness in hylum

Hypovascular = decreased vascularity
Congenital Heart Diseases
 Increased Vascularity o Cyanotic (Cyanotic vs. Acyanotic)
 Decreased Vascularity

Normal Vascularity
 Increased Venous Vascularity
Acyanotic CHD
 Atrial Septal Defects o Right atrium and Right ventricle are enlarged o Only heart defect with a small aorta o Blood is shunted to the RA, dilating it. o Right ventricular enlargement is not very obvious on a PA view (Use lateral view to assess RVE) o Large pulmonary arteries due to increased flow to RA; Constriction of pulmonary arteries = lung compensates for increase of blood flow from RA o Eisenmenger Phenomenon = reversal of pressures due to increased musculature of right ventricle (as response to chronic increase in volume towards the right side of the heart) = presence of symptoms
 Ventricular Septal Defects o Pulmonary arteries can be dilated or normal o Blood is shunted from left to right; RV dilates o Dilated pulmonary arteries.
 Patent Ductus Arteriosus o Blood is shunted from aorta to pulmonary artery
= dilation of pulmonary arteries o Difference vs. ASD = Aorta is NOT small; Aorta is dilated in PDA
 Coarctation of Aorta o Coarctation increases systemic pressure = left ventricular prominence o Figure of “3” sign o Rib notching = segment before coarc tries to supply collateral flow = causes pressure erosions in underside of the ribs.
Cyanotic CHD

Tetralogy of Fallot o Normal heart = TOF has varying severity, very mild TOF = “pink TOF”; characterized by a mild pulmonary stenosis o Decreased pulmonary markings o Pulmonary Arteries are small (concave) which give the “waistline” for the boot-shaped heart o RVH due to pushing against pulmonary stenosis
 Remember: upward displacement of cardiac apex (left-side upliftment) o The most common stenosis is infundibular
 Transposition of Great Arteries o Only cyanotic heart disease with INCREASED
VASCULARITY (wrong?) o Egg on its side o Apple on a stem o Aorta comes from RV, PA comes from your LV o Narrow vascular pedicle = lining up of PA and
Aorta (makes up the stem in “apple on a stem”) o “Mesocardia”
 Tricuspid Atresia

o Usually decreased vascularity (obligatory shunt = you need an ASD and VSD)
 Persistent Truncus Arteriosus o Increased Vascularity o Right side aortic arch in PTA and TOF o Type 1: solitary trunk that divides o Type 2: both right and left takes off separately from the back o Type 3: takes off from the side

Ebstein’s Anomaly o Balloon or box-shaped heart o Pathology: one cusp of your tricuspid (RA/RV) falls below (falls into right ventricle); atrialization of your right ventricle
 Total Anomalous Pulmonary Venous Return o Systemic collaterals account for the increased vascularity o Pulmonary Veins end up in your Right Atrium; patient needs an obligatory shunt (remember tricuspid atresia)
 Supracardiac – snowman appearance; figure “8” (recall figure 3 coarctation of aorta) appearance
 Cardiac: pulmonary vein drains into coronary sinus (drainage of your coronary veins)
 Infracardiac: pulmnonary veins drains into your IVC or one of your hepatic veins; “scimitar sign” = represents the abnormal vein
 Mixed – with various connections to the right side of the heart
Imaging of Acquired Heart Diseases
 Mitral Stenosis o Enlargement of LA o The most common way of diagnosing acquired
 heart diseases = 2D Echo

Mitral Insufficiency
 Aortic Stenosis
Tricuspid Valve Disease

Misc acquired Heat isease o Coronary Artery Disease
 Ring and loop technique – drawing a loop through the ring, ring signifies atrio-ventricular groove (bisection of atrium from ventricles); the loop is interventricular groove (where you can see the coronary arteries)
 2 ostia; LCX, LAD, LCA
 Tricuspid valve = three valves corresponds to three sinuses: right, left and non-coronary (posterior) sinus
 Coronary vessels located outside myocardial layer
 Left Main coronary Artery:
 LAD
 LCX

Ramus Intermedius
 LAD
 Diagonals - anterior wall of left ventricle
 Septal Perforators
 LCX

Obtuse marginals – supplies left lateral wall of left ventricle
 Atrial branches o Coronary Angiogram = gold standard for diagnosing coronary artery diseases; done by invasive cardiologists o Branches
 Right Coronary Artery (RCA)

Conus branch
 Sinoatrial node

Acute marginal branch

Posterior descending Artery
 Posterolateral ventricular branch

AV node branch o Dominance – determined by which side supplies posterolateral descending artery
 Right - most common (85%)
 Left
 Co-dominant o Bypass depends on how many arteries are clogged