4.other acquired heart disease

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CHAÅN ÑOAÙN HÌNH AÛNHBEÄNH TIM MAÉC PHAÛI KHAÙC

BS.NGUYEÃN QUYÙ KHOAÙNG

BS.NGUYEÃN QUANG TROÏNG

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DAØN BAØI� Beänh ñoäng maïch chuû.

� Beänh tim do cao huyeát aùp.� Phình ÑMC.� Hoäi chöùng Marfan.� Beänh Takayasu.

� Beänh cô tim.� Beänh cô tim giaõn nôû.� Beänh cô tim phì ñaïi.� Beänh cô tim haïn cheá.

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DAØN BAØI

� Nhoài maùu cô tim vaø caùc bieán chöùng.� Thieáu maùu cô tim.� Nhoài maùu cô tim.� Caùc bieán chöùng cuûa Nhoài maùu cô tim:

�Thoâng lieân thaát.�Hoäi chöùng Dressler.�Phình thaát.�Ñöùt nhuù cô.

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DAØN BAØI

� Beänh maøng tim.� Traøn dòch maøng tim.� Vieâm maøng tim co thaét.� Nang maøng tim.� Môõ ngoaøi maøng tim.

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BEÄNH TIM DO CAO HUYEÁT AÙP

� Thaát (T) daøy ñoàng taâm�Bôø (T) baøu sau ñoù bôø (T) traûi daøi,moûm tim nhö chuùc xuoáng döôùi voøm hoaønh (T).

� ÑMC leân cong qua (P) vaø bung roäng (>6cm)(Deùroulement aortique).� Chaån ñoaùn phaân bieät:Heïp van ÑMC

vaø Xô vöõa ñoäng maïch ôû ngöôøi giaø.

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� ÑMC coù theå ñoùng voâi.� Tuaàn hoaøn phoåi bình thöôøng.� Khi coù Suy tim�coù Taùi phaân phoái

tuaàn hoaøn phoåi,Phuø phoåi caáp.

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DEROULEMENT AORTIQUE (a>6cm)

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PHÌNH ÑOÄNG MAÏCH CHUÛ

� ÑMC ñöôïc chia ra ÑMC ngöïc vaø ÑMC buïng:� ÑMC ngöïc goàm ÑMC leân,Quai ÑMC

vaø ÑMC xuoáng.� ÑMC buïng goàm ÑMC treân thaän vaø

ÑMC döôùi thaän. � Bình thöôøng khaåu kính ÑMC leân lôùn

nhaát:3,3cm.

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� Ñöôïc xem laø phình ÑMC khi ñöôøng kính ÑMC>4cm;hình thoi, troøn,baùn nguyeät.

� Ñoaïn leân:Giang mai,Xô vöõa ñoäng maïch, Hoäi chöùng Marfan.

� Ñoaïn ngang:Xô vöõa ñoäng maïch,Chaán thöông.

� Ñoaïn xuoáng:Xô vöõa ñoäng maïch.

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PHÌNH ÑOÄNG MAÏCH CHUÛ-Vaùch ñoäng maïch chuû goàm 3 lôùp: I�intima,M�media,A�adventitia.

-Khi lôùp Intima bò raùch,maùu seõ traøn vaøo lôùp Media ñeå taïo thaønh loøng giaû (false lumen).

-Treân X quang quy öôùc,neáu coù ñoùng voâi quai ÑMC,thì Daáu hieäu Calcium (Calcium sign) gôïi yù ñeán Phình ÑMC boùc taùch (khoaûng caùch töø lôùp Intima ñoùng voâi ñeán bôø ngoaøi quai ÑMC >10mm).

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AORTIC DISSECTION

DeBakey:type I,II,III.

STANFORD:

-Type A:Type I+Type II.

-Type B:Type III.

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MECHANISMS OF AORTIC REGURGITATION IN PROXIMAL AORTIC DISSECTION

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AORTIC ANEURYSM

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AORTIC ANEURYSM

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ASCENDING AORTIC ANEURYSM

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-Saccular mass in the right mediastinum (large arrows).

-Curvilinear calcification (small arrow).

-The trachea is displaced posteriorly (double black arrows).

-Curvilinear calcification (small arrow).

SACCULAR ANEURYSM OF ASCENDING AORTA

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-The ascending aorta (large arrow).

-The trachea is displaced to the right side.

-A streak of calcium (small arrows) in the intima denotes a thin aortic wall.

FUSIFORM ANEURYSM OF THE ENTIRE THORACIC

AORTA

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-The lucency representing the intima flap (arrows) extends from the aortic root around the arch.

-The false lumen is less dense than the true lumen.

-Aortic regurgitation.

AORTIC DISSECTION

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-The intima flap (arrows) extending from the aortic root distally into the abdomen.

-Communication between the false lumen and the true lumen (curved arrow).

AORTIC DISSECTION

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AORTIC DISSECTION:T:true lumen,F:false lumen,I:intimal flap,LV:contrast in the LV�Aortic insufficiency.

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Lobular mass density (arrows) on the left side of the heart.

LAO

FUSIFORM ANEURYSM OF DESCENDING AORTA

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ANEURYSM OF ABDOMINAL AORTA: EXTENSIVE CALCIFICATION

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3 YEARS PRIOR: Normal appearing aorta.

Enlargement of the aortic knob (arrow).

�AORTIC DISSECTION

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Enlarged, elongated, tortuous, descending aorta.

TWO WEEKS LATER

-Increase in the width of the descending aorta (large arrows).

-Left pleural effusion (small arrows).

�DISSECTING ANEURYSM

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ASYMPTOMATIC FIVE DAYS LATER:Left hemothorax,the aortic outline has been obliterated by the blood �RUPTURE OF AORTIC ANEURYSM

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A:left hilar mass (arrow).

B:mass adjacent to the proximal descending aorta (arrow).

SACCULAR ANEURYSM

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TRUE CHANNEL:small arrows.

FALSE CHANNEL:double-headed arrows).

�DISSECTING ANEURYSM

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A tumor or an aneurysm?Opacification of the aorta

�KINGKING OF AORTA

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A:Dilated aortic arch.

T:Displaced trachea.

B:Compressed left main bronchus.

-All four cardiac chambers are dilated.

AORTIC ANEURYSM / IDIOPATHIC DILATED CARDIOMYOPATHY

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FALSE ANEURYSM: The intima and media are penetrated.False aneurysm typically has a narrow neck.

(TRUE ANEURYSM: contain all three layers).

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FALSE ANEURYSM: narrow neck.

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-False aneurysm in the region of the ligamentum arteriosum.

-The patient was involved in an automobile accident 3 months previously.

�TRAUMATIC AORTIC ANEURYSM

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18-year-old involved in motorcycle accident.

-Widening of the mediastinum.

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RUPTURE OF THE AORTA WITH FALSE ANEURYSM.

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AORTIC DISSECTION

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AORTIC DISSECTION:T�true lumen,F:false lumen,I:intima flap.

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AORTIC DISSECTION:AV:aortic valve,T�true lumen,F:false lumen,I:intima flap.

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MRI-INFRARENAL ABDOMINAL AORTIC ANEURYSM

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As.Aorta PA

True lumen False lumen Thrombosis

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PENETRATING AORTIC ATHEROSCLEROTIC ULCER

-Arrow:subintimal hematoma.

-Arrowhead:displaced intimal calcification.

DẤU HIỆU MẢNG VÔI(CALCIUM SIGN)

� Mảng vữa xơ của ĐMC nằm ở lớp áo trong, nếu vôi hoá ta sẽ thấy. Khi bị phình ĐMC bóc tách, máu len vào lớp áo giữa, làm gia tăng khoảng cách giữa lớp intima và adventitia. Nghĩ đến phình ĐMC bóc tách khi khoảng cách từ mảng vôi hoá đến bờ ngoài quai ĐMC > 10 mm.

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AORTIC DISSECTION

-Arrows:displaced intimal calcification.

-Small bilateral pleural effusions.

-Mild bibasilar atelectasis.

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AORTIC DISSECTION

-Arrows:intimal flap.

-Small bilateral pleural effusions.

-V:SVC.

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AORTIC DISSECTION

-t:true lumen.

-f:false lumen.

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AORTIC DISSECTION WITH LEFT RENAL ISCHEMIA

-Arrow:intimal flap.

-K:ischemia of the posterior aspect of the left kidney.

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RUPTURED AORTIC DISSECTION

-Arrowheads:intimal flap.

-Arrow:nasogastric tube.

-Hemorrhage infiltrates the soft tissues around the descending aorta.

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MSCT-AORTIC DISSECTION

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MSCT-AORTIC DISSECTION

(3D-surface display)

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AORTIC ANEURYSM

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Click here for movie

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CT MRI

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MRA

AORTIC DISSECTION

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AORTIC DISSECTION

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AORTIC ANEURYSM

Thrombosis in

the aortic aneurysm

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The fusiform aneurysm in the ascending aorta does not involve the aortic root.

LUETIC ANEURYSM

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CALCIFICATION IN THE ASCENDING AORTA – SYPHILITIC AORTITIS

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LUETIC AORTITIS

-“Egg-shell” calcification extends from the aortic annulus through the entire thoracic aorta.

-Calcification of the ascending aorta is also seen in pure atherosclerosis and,rarely,in Takayasu’s arteritis.

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Ascending aortic aneurysm with stenotic bicuspid aortic valve (arrows) is domed in this systolic frame�REITER’S SYNDROME

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Erosion of the vertebral bodies due to pulsations of an aneurysm.

Aortography reveals the saccular aneurysm (arrows).

Note:bulging of the intervertebral cartilage (which resists erosion).

55 yo male patient with abdominal pain and back pain

Ultrasound examinaton: Presence of “Ying Yan sign”: Aortic aneurysm

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HOÄI CHÖÙNG MARFAN

� Beänh lyù cuûa moâ lieân keát do thieáu huït fibrillin coù yeáu toá gia ñình (chromosome 15q15-21).

� Aûnh höôûng leân heä tim-maïch,heä xöông vaø maét.Vôùi heä tim-maïch,toån thöông xaûy ra >50% ngöôøi lôùn bò Hoäi chöùng Marfan.

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� Söï thoaùi hoùa cuûa lôùp Media daãn tôùi giaõn voøng van ÑMC vaø ÑMC leân.Tieáp ñeán laø hôû van ÑMC�Suy thaát (T).

� Boùc taùch ÑMC laø bieán chöùng thöôøng gaëp vaø thöôøng laø nguyeân nhaân gaây töû vong.

� Hôû van 2 laù thöôøng gaëp ôû treû em do coät cô dö thöøa�Sa van 2 laù.

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ECTOPIA LENTIS THUMB SIGN

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LONG EXTREMITIES AND DIGITS,TALL STATURE AND PECTUS CARINATUM

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-The aneurysm involves both the sinuses of Valsalva and the proximal half of the ascending aorta.


ANNULOAORTIC ECTASIA

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-The aneurysm involves both the sinuses of Valsalva and the proximal half of the ascending aorta.


ANNULOAORTIC ECTASIA

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A:aortic aneurysm of ascending aorta.

Arrows:smaller aneurysm of descending aorta.

MARFAN’S SYNDROME

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SPIN-ECHO MRI:

Dilated ascending aorta (5cm).

A 26-year-old woman with MARFAN’S SYNDROME

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BEÄNH TAKAYASU

� Vieâm ñoäng maïch Takayasu laø moät beänh vieâm maïn tính maø nguyeân nhaân chöa roõ,laøm toån thöông ÑMC vaø caùc nhaùnh ñoäng maïch lôùn.

� Beänh ñöôïc moâ taû laàn ñaàu tieân bôûi moät nhaø Nhaõn khoa ngöôøi Nhaät:Takayasu vaøo naêm 1908.

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BEÄNH TAKAYASU

� Thöôøng gaëp ôû ngöôøi treû <40 tuoåi, Nöõ/Nam=8/1.

� Beänh laøm taêng saûn lôùp Intima,thoaùi hoùa lôùp Media vaø xô hoùa lôùp Adventitia�Haäu quaû laø laøm heïp loøng ñoaïn ñoäng maïch bò toån thöông 85% soá cas,laøm giaõn loøng ñoäng maïch 2% soá cas vaø vöøa heïp vöøa giaõn chieám 13% soá cas.

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BEÄNH TAKAYASU

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BEÄNH TAKAYASU

THORACIC AORTOGRAM:No direct filling of any of the major arteries arising from the aorta except the coronary arteries.

Delayed film (right):collateral channels faintly fill the carotid and vertebral systems.

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BEÄNH TAKAYASU

-Clinical features of coarctation.

-”rat-tail” angiographic appearance of the descending aorta.

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BEÄNH TAKAYASU

Stenosis in a long segment of the aorta (thoracoabdominal) extending across the aortic hiatus of the diaphragm.

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BEÄNH TAKAYASU

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BEÄNH TAKAYASU

-Ascending aortic aneurysm.

-Stenosis of the proximal left common carotid artery (arrowheads) and left subclavian artery (open arrowheads).

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BEÄNH TAKAYASU

Extensive thin-line calcification associated with a diffusely dilated aorta in a 30-year-old woman.

�TAKAYASU’S ARTERITIS

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BEÄNH CÔ TIMÑAÏI CÖÔNG

� Nguyeân nhaân:� Theå tieân phaùt:Chöa roõ.� Theå thöù phaùt:Ngoä ñoäc,Nhieãm truøng,

Bieán döôõng.

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BEÄNH CÔ TIMÑAÏI CÖÔNG

� Phaân loaïi:� Beänh cô tim giaõn nôû (Dilated

cardiomyopathy).� Beänh cô tim phì ñaïi (Hypertrophic

obstructive cardiomyopathy).� Beänh cô tim haïn cheá (Restrictive

cardiomyopathy).

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BEÄNH CÔ TIMBEÄNH CÔ TIM GIAÕN NÔÛ

� Coøn goïi laø Beänh cô tim sung huyeát.� Nguyeân nhaân:Phaàn lôùn khoâng tìm ra

nguyeân nhaân.� Di truyeàn:6,5%.� Dinh döôõng:Thieáu Vitamin B1.� Nghieän röôïu,Thuoác (Adriamycine).� Nhieãm truøng (Vi khuaån,virus).� Beänh collagen maïch maùu.� Sau sanh…

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� Laâm saøng:Thöôøng thaàm laëng vaø töø töø.� Khôûi ñaàu thöôøng laø Suy tim.� Coù töøng ñôït Nhoài maùu phoåi.� Coù khi loaïn nhòp.� Coù theå ñoät töû.

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� X quang:� Giaõn nôû caùc buoàng tim+Co boùp

keùm�Tim to hình baàu,deã laàm vôùi Traøn dòch maøng tim,Beänh Ebstein.

� Hôû van 2 laù,Hôû van 3 laù.� Taùi phaân phoái tuaàn hoaøn phoåi.

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� Sieâu aâm:� Giaõn roäng caùc buoàng tim.� EF giaûm roõ.� Thöôøng coù spontaneous contrast

(“smoke”) trong buoàng Thaát (T),coù theå thaáy Huyeát khoái trong Thaát (T).

� Hôû van 2 laù,3 laù.

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-Enlarged all chambers.

-Redistribution.

-Slight pulmonary edema.

-Small right pleural effusion.

AFTER FULL TREATMENT

-Normal heart size.

-Normal pulmonary vasculature.

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BEÄNH CÔ TIMBEÄNH CÔ TIM PHÌ ÑAÏI

� Ñaëc ñieåm laø phì ñaïi khoâng ñoái xöùng Thaát (T) (Vaùch lieân thaát daøy hôn thaønh sau thaát (T)) vaø buoàng tim khoâng giaõn.

� Nguyeân nhaân:� Di truyeàn:50%.� Taêng Catecholamin.� Roái loaïn chuyeån hoùa Calci.

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� Cô cheá:� Thaønh thaát daøy do phì ñaïi caùc teá baøo

cô tim�Caûn trôû söï höùng ñaày maùu.� Do söï daøy khoâng caân ñoái cuûa vaùch

lieân thaát�Ngheõn buoàng toáng Thaát(T).� Do coät cô bò dòch chuyeån ra

tröôùc�Chuyeån ñoäng ra tröôùc cuûa van 2 laù trong thì taâm thu�Hôû van 2 laù.

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� Laâm saøng:� Khoù thôû do RLCN taâm tröông Thaát (T).� Côn ñau thaét ngöïc:Thieáu maùu cô tim

do taêng khoái löôïng cô tim.� Ngaát khi gaéng söùc:do loaïn nhòp,coù theå �ñoät töû.

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� X quang:� Tim to ít hoaëc vöøa.� Neáu coù Hôû van 2 laù thì Nhó (T) to.� Angiography:Loøng tim nhoû,hôû van 2 laù.

� Chaån ñoaùn phaân bieät:� Heïp van ÑMC (Beänh cô tim phì ñaïi

khoâng coù phình ÑMC leân).� Hieän nay chaån ñoaùn nhôø Sieâu aâm,MRI.

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� Sieâu aâm:� ASH (+):Asymmetric septal hypertrophy.

(Duøng TM mode ño ôû thì taâm tröông: IVS/LVPW≥1,3).

� SAM (+):Systolic anterior motion of MV.� Ngheõn buoàng toáng Thaát (T)(△P thay ñoåi

moãi ngaøy).� Hôû 2 laù vôùi ñoä naëng thay ñoåi moãi ngaøy.

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Extreme left ventricular hypertrophy

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End-diastolic RAO left ventriculogram�Normal

size and shape of the left ventricle.

End-systolic RAO left ventriculogram �Small left ventricular cavity with mild mitral regurgitation.Increased distance between the ventricular cavity and the coronary arteries �Myocardium becomes thickened in systole �HCM (Hypertrophic cardiomyopathy).

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Asymmetric septal thickening (23mm) and a small left ventricular cavity.

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End-diastolic magnetic resonance angiogram �Asymmetric hypertrophy

with septal thickening (S).

End-systolic magnetic resonance angiogram �

Myocardial thickening that affects the entire myocardium.

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Oblique cine MRA (outfow 2-chamber view) � Prolapse

(arrow) of the posterior mitral leaflet in early systole.

Oblique cine MRA (outfow 2-chamber view) � Prolapse of the posterior mitral leaflet with a small

signal intensity loss due to regurgitation (arrow)�HCM.

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MRA

NORMAL HEART

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MRA

NORMAL HEART

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HYPERTROPHIC CARDIOMYOPATHY

Myocardial hypertrophy

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HYPERTROPHIC CARDIOMYOPATHY

Myocardial hypertrophy

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BEÄNH CÔ TIMBEÄNH CÔ TIM HAÏN CHEÁ

� Coøn goïi laø Beänh cô tim thaâm nhieãm,ñaëc tröng bôûi baát thöôøng chöùc naêng taâm tröông(Taêng ñoä cöùng vaùch tim�Haïn cheá ñoå ñaày thaát),trong khi chöùc naêng taâm thu bình thöôøng hoaëc chæ giaûm nheï.

� Bieåu hieän laâm saøng gioáng nhö Vieâm maøng tim co thaét maïn tính.

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� Nguyeân nhaân:� Amyloidosis.� Sarcoidosis.� Hemochromatosis.� Loeffler’s eosinophilic endocarditis.� Infiltration leuceùmique.� Fibrose endomyocardique.

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� Trong ñoù hay gaëp nhaát laø Amyloidosis.� Do laéng ñoïng moät protein baát thöôøng

ôû nhieàu moâ,cô quan.� Thaâm nhieãm laøm daøy taát caû caùc thaønh

phaàn cuûa tim:cô,vaùch,van�Hôû taát caû caùc van tim.

� TDMT töø ít ñeán vöøa.� 20% beänh nhaân cheát vì Suy tim.

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-Amyloid infiltration in the ventricular septum,left ventricular free wall and apex (arrows).

-Enlarged atria.

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� Laâm saøng: Beänh lyù hieám.� Meät khi gaéng söùc.� Phuø chi.� Suy tim.

� X quang:� Tim to ít.� Taêng aùp TM phoåi.� ÑM phoåi (P) & (T) to ít.

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� Sieâu aâm:� Daøy ñoái xöùng Thaát (T).� Thaønh sau Thaát (T) vaø vaùch lieân thaát

coù hoài aâm laám taám (ground-glass).� Hôû van 2 laù,3 laù naëng hôn Hôû van

ÑMC,ÑMP.� TDMT (+)�(++).

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� Chaån ñoaùn phaân bieät:� Heïp TM phoåi.� Myxome nhó (T).� Vieâm maøng ngoaøi tim co thaét.

� Chaån ñoaùn xaùc ñònh:Giaûi phaãu beänh.

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-Thickening of the LV due to infiltration.

-Thickening of the valves and biatrial enlargement.

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SPIN-ECHO MRI:

-Variable high density signal within the myocardium.

-Dilated right atrium (closed curved arrow).

-Enlarged IVC (open curved arrow).

-IVS has an abnormal contour (straight arrow)� High right ventricular pressures.

�RESTRICTIVE CARDIOMYOPATHY

(AMYLOID CARDIOMYOPATHY).

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LEFT VENTRICULAR ABNORMALITIES

IN THE CARDIOMYOPATHIES

DILATED RESTRICTIVE HYPERTROPHIC

1.LV cavity size

2.Free wall thickness

3.Mitral regurgitation

4.Wall motion

5.Mural thrombi

6.Systolic function

7.Diastolic function

8.Ejection fraction

9.Cardiac output

-Increased

-Slightly increased, normal,or decreased

-Mild to moderate

-Global hypokinesis

-Frequently

-Decreased

-Normal

-Decreased

-Decreased

-Normal to increased

-Slightly to moderately increased

-Variable

-Normal to decreased

-Occasionally

-Normal

-Decreased




-Septal to free wall ratio > 1.3

-Obstruction(-):none to mild

Obstruction(+):mild to severe

-Hyperkinetic

-None




-Decreased,normal,or increased

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NHOÀI MAÙU CÔ TIM & BIEÁN CHÖÙNGTHIEÁU MAÙU CÔ TIM

� Goïi laø Thieáu maùu cuïc boä cô tim hay Suy ñoäng maïch vaønh maïn khi cô tim khoâng ñöôïc töôùi maùu ñaày ñuû do beänh lyù cuûa ñoäng maïch vaønh.

� Coù nhieàu nguyeân nhaân,nhöng >90% laø do Xô vöõa ñoäng maïch.

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� Chaån ñoaùn döïa vào:Lâm sàng, ECG, các men tim, Sieâu aâm,Chuïp ÑM vaønh, MSCT,MRI,nhấp nháy đồ.

� X quang qui öôùc:� Boùng tim bình thöôøng.� Ñoùng voâi ôû ÑM vaønh.

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RIGHT CORONARY ARTERY

A.Plaque of atheroma (arrow).

B.Encircled lumen of the artery (arrow-two years later).

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Calcification of the proximal branches of both anterior descending and circumflex coronary arteries.

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Calcification in the left anterior descending (LAD) and the left circumflex arteries.

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Calcification in the left main coronary artery

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COLORS ALL STRUCTURES WITH AN ATTENUATION OF GREATER THAN

130HU PINK � No calcium is present in the LAD or diagonal branch.

Calcification in the LAD artery.

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Calcification in the LM, LAD arteries.

Calcification in the circumflex artery

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Động mạch vành phải

Động mạch vành xuống trước trái

Hẹp 80% LAD

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Normal perfusionMyocardial ischemia:LAD and right

coronary artery territories.

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NHOÀI MAÙU CÔ TIM & BIEÁN CHÖÙNGNHOÀI MAÙU CÔ TIM

� Beänh coù taàn suaát töû vong cao #30%.� 90% ôû beänh nhaân Xô vöõa ñoäng maïch.

Maûng xô vöõa bò nöùt,loeùt�taïo laäp cuïc maùu ñoâng laøm taéc ngheõn caáp tính ÑMV.

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� Hoäi chöùng Suy ÑMV caáp (laâm saøng):� Taéc ngheõn ÑMV taïm thôøi<30 phuùt:

Côn ñau thaét ngöïc khoâng oån ñònh.� Taéc ngheõn ÑMV<60 phuùt:

Nhoài maùu cô tim khoâng soùng Q.� Taéc ngheõn ÑMV>60 phuùt:

Nhoài maùu cô tim coù soùng Q.

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� X quang qui öôùc:� Boùng tim hôi to hoaëc to.� OAP khi vuøng nhoài maùu >25% khoái

thaát (T).

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-Enlarged heart size.

-Pulmonary edema due to left heart failure.

ACUTE MYOCARDIAL INFARCTION

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NHOÀI MAÙU CÔ TIM & BIEÁN CHÖÙNGBIEÁN CHÖÙNG

� Thoâng lieân thaát:0,5-1% caùc tröôøng hôïp.� Xuaát hieän vaøi tuaàn�vaøi thaùng sau NMCT.� 2/3 naèm ôû phaàn tröôùc gaàn moûm.1/3 naèm

ôû phaàn sau. � Hoäi chöùng Dressler:<20%.

� Xuaát hieän vaøi tuaàn�vaøi thaùng sau NMCT.

� Tim to do Traøn dòch maøng tim.� Traøn dòch maøng phoåi,Vieâm ñaùy phoåi.

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6 weeks after myocardial infarction:

-Pericardial effusion.

-Bilateral pleural effusions.

-Consolidation of the left lung base. DRESSLER’S SYNDROME

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4 weeks after myocardial infarction:

-Pericardial effusion.

-Left pleural effusion.

-Consolidation of the left lung base.

6 weeks later.

-Decreased heart size.

-Decreased pleuropneumonic process.

3 months later.

-Normal heart size.

-Normal lung fields.

DRESSLER’S SYNDROME

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� Phình thaát:12-15% caùc tröôøng hôïp.� True aneurysm: NMCT�Phình thaát.

Thöôøng ôû vuøng moûm phía tröôùc.� False aneurysm: Leõ ra vôõ tim nhöng

nhôø maøng ngoaøi tim bao boïc�Phình to ra.Thöôøng ôû vuøng sau beân hoaëc maët döôùi.

� X quang:Bôø tim phình ra,coù theå ñoùng voâi.

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VENTRICULAR ANEURYSM

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CALCIFICATION IN THE LEFT VENTRICULAR ANEURYSM

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CALCIFIED RIGHT VENTRICULAR ANEURYSM

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VENTRICULAR ANEURYSM

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Thinning of the myocardial wall (arrow).

OLD SEPTAL INFARCTION

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FALSE ANEURYSM

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FALSE ANEURYSM

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� Chaån ñoaùn phaân bieät:�Nang maøng tim:Thöôøng ôû goùc taâm hoaønh (P).

�U tuyeán öùc:ÔÛ treân vaø tröôùc.�False aneurysm: Thöôøng vôõ,hieám khi coøn soáng soùt (Trong vaùch khoâng coù maïch maùu).

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� Ñöùt nhuù cô:1% sau NMCT.� X quang boùng tim gaàn nhö bình

thöôøng,ñoâi khi tim to do giaõn Thaát (T),Nhó (T) tuøy möùc ñoä.

� Chuïp buoàng tim,SA tim:Sa van 2 laù,van 2 laù phaát phôùi.

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BEÄNH MAØNG TIMTRAØN DÒCH MAØNG TIM

� Nguyeân nhaân:Coù raát nhieàu nguyeân nhaân.� X quang TDMT:Muoán coù thay ñoåi treân X

quang,löôïng dòch phaûi>200ml. � Bình thöôøng giöõa laù thaønh vaø laù taïng coù

# 20ml dòch giuùp maøng tim tröôït leân nhau.

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� Neáu TDMT<100ml�Löôïng ít.� Neáu TDMT100-500ml�Löôïng vöøa.� Neáu TDMT>500ml�Löôïng nhieàu.

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� Chæ soá T/N>0,5.Khi Traøn dòch quaù nhieàu cho hình aûnh baàu röôïu.

� Ñaëc ñieåm cuûa boùng tim to laø thay ñoåi nhanh theo thôøi gian.

� Tuaàn hoaøn phoåi giaûm haún ñi (tröôøng phoåi saùng).

� Xoùa goùc taâm hoaønh (P)�khoâng ñaëc hieäu.

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� Phim nghieâng� Epicardial fat pat sign: Khoang maøng tim ñöôïc giôùi haïn phía tröôùc bôûi lôùp môõ trung thaát (mediastinal fat) vaø phía sau bôûi lôùp môõ epicardial (epicardial fat),khi khoang naøy daøy treân 2mm�Hoaëc laø daøy maøng tim,hoaëc laø TDMT.

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NORMAL PERICARDIUM

-The pericardial cavity is seen as a high-attenuation stripe (arrows) flanked by mediastinal and epicardial fat.

-CS:coronary sinus.

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NORMAL PERICARDIUM

-The pericardial cavity is seen as thin band of low signal (arrows) flanked by mediastinal and epicardial fat.

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� Fluoroscopy (coù gía trò):Tim khoâng ñaäp hoaëc giaûm ñaäp.

� Phim naèm ngöûa:Dòch doàn leân treân�Tim to troøn hôn vaø cuoáng tim ngaén.

� Choïc doø dòch vaø bôm hôi vaøo ta thaáy ñöôïc möïc thuûy-khí ôû khoang maøng tim.

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� Beänh nhaân naèm tö theá Left lateral decubitus: Chích CO2 vaøo tónh maïch�Ño khoaûng caùch (a) töø boùng khí ñeán bôø (P) tim,bình thöôøng a≤ 4mm.Khi a>4mm �Traøn dòch maøng tim hoaëc daøy maøng tim..

� Ngaøy nay:Sieâu aâm chaån ñoaùn TDMT toát hôn nhieàu (hôn X quang vaø caû CT).

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� Cheïn tim (cardiac tamponade):Xaûy ra khoâng tuøy thuoäc vaøo löôïng dòch,maø tuøy thuoäc vaøo thôøi gian taïo dòch nhanh hay chaäm.

� Laâm saøng:Khi hít vaøo,HA taâm thu giaûm 10mmHg.

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� X quang:� Boùng tim to nhanh theo thôøi gian.� TMCT giaõn,quai TM azygos phoàng.� Fluoroscopy:Tim ñaäp giaûm.

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PERICARDIAL EFFUSION (“water-bottle” configuration)

-Enlarged heart size with clear heart border.

-Normal pulmonary vasculature.

DẤU HIỆU BẦU NƯỚC(WATER-BOTTLE SIGN)

� Tràn dịch màng tim nhiều, khiến bóng tim bè ra như bầu nước.

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PERICARDIAL EFFUSION


-Clear heart border.

-Normal pulmonary vascularity.

CARDIAC FAILURE


-No clear heart border (interstitiel edema), Kerley’s line, pleural effusion.

-Redistribution.

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-Symmetric enlargement of the cardiac silhouette (arrowheads).

-Decreased pulmonary vasculature.

-Obliteration of the right cardiophrenic angle (large arrow).

� PERICARDIAL EFFUSION

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Following pericardial tap and air injection� air-fluid level (large arrow),true cardiac border (small arrows),note the normal thickness of the pericardium.

Sau khi chọc hút dịch màng tim

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TRAØN DÒCH MAØNG TIM


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Water-bottle configuration. Note the distance between the right heart border and the Swan-ganz catheter as

it passes through right atrium (arrows).

Increased density of the fluid-filled pericardiac sac (P) is bordered anteriorly

and posteriorly by the lucencies of the

epicardial and the medisatinal fat.

Notice the separation between the right heart border of

pericardium (arrows) and the lateral extent of the cavity of the

RA.

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INTRAVENOUS CARBON DIOXIDE INJECTION (left lateral decubitus position)

Carbon dioxide in the RA and SVC (black arrows).

The pericardiac space is widened (between white arrows).(Normal ≤ 4mm).

�Either pericardial effusion or a thickened pericardium.

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INTRAVENOUS CARBON DIOXIDE INJECTION (left lateral decubitus position)

Carbon dioxide in the RA and SVC (b,d).

The pericardiac space is widened (a,c). (Normal ≤ 4mm).

�Either pericardial effusion or a thickened pericardium.

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DIAGNOSTIC PNEUMOPERICARDIUM

After removal of 25ml of pericardial fluid and replacement with 25ml carbon dioxide (g).

�Thickened parietal pericardium

�TUBERCULOUS PERICARDITIS

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A band of fluid attenuation (arrows) surrounding the heart.

SPIN-ECHO MRI:Pericardial effusion is seen as a homogeneous signal void (arrows) surrounding the heart, subjacent to the pericardial fat.

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SPIN-ECHO MRI:The increased signal tissue surrounding in the space between the visceral pericardium and the external cardiac contour

(long arrows) is the inflamed parietal pericardium � TUBERCULOUS PERICARDITIS.

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STAB INJURY TO THE EPIGASTRIUM

-Fibrosis of the right upper lobe was an incidental finding.

A FEW DAYS LATER

-Cardiac enlargement.

-Decreased pulmonary vasculature.

CARDIAC TAMPONADE

Following evacuation of the pericardial blood.

�Normal heart size.

(free air under the right diaphragm due to abdominal surgery).

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SUPERIOR VENA CAVAGRAM

-Dilated SVC.

-Reflux into the azygos vein and IVC.

� CARDIAC TAMPONADE

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CARDIAC TAMPONADE WITH RIGHT VENTRICULAR COLLAPSE (ARROWHEADS)

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BEÄNH MAØNG TIMVIEÂM MAØNG TIM CO THAÉT

� Tuoåi 30-50,Nam/Nöõ=3/1.� Nguyeân nhaân:Sau Vieâm maøng ngoaøi tim

caáp,sau chaán thöông,sau phaãu thuaät maøng ngoaøi tim,lao,Coxackie, Histoplasmose, H.influenza type A,B Autoimmune:RAA,Lupus…

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� X quang:� Tim khoâng to hoaëc to ít.� Nhó (T) to trong 20% tröôøng hôïp.Khi

Vieâm co thaét�maùu trôû veà tim khoù khaên.� Ñoùng voâi (50%) ôû nhó (P),hieám khi ôû nhó

(T) vì maët sau khoâng coù pericarde,Thaát (T) ít hôn thaát (P) do thaát (T) ñaäp maïnh (Ngöôïc vôùi ñoùng voâi trong cô tim).

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� X quang:� TMCT giaõn do maùu khoù veà tim.� TDMP coù theå keøm theo (60%).

� Chaån ñoaùn phaân bieät:Beänh cô tim haïn cheá.� Maøng tim khoâng daøy,khoâng ñoùng voâi.� Cô tim daøy vaø söï co boùp giaûm trong 2

thì (taâm thu vaø taâm tröông).

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� CT vaø MRI raát coù ích trong chaån ñoaùn Vieâm maøng ngoaøi tim co thaét.� 50% beänh nhaân coù voâi hoùa maøng ngoaøi

tim,deã daøng nhaän thaáy treân CT.� Daøy maøng tim deã thaáy treân MRI.

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-Normal heart size.

-Dilated SVC (arrows).

-Dilated azygos vein (arrowheads).

-Dilated HV.

-Dilated IVC.

�CONSTRICTIVE PERICARDITIS

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SPIN-ECHO MRI: Intermediate signal intensity band between the epicardial fat and the pericardial fat (curved arrow and black arrows)

is thickened pericardium � CONSTRICTIVE PERICARDITIS

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The pericardium is irregularly thickened (arrows) �CONSTRICTIVE PERICARDITIS.

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PERICARDIAL CALCIFICATION (RIGHT VENTRICLE)

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Pericardial calcification (closed arrow).

Dilated IVC (open arrow).� CONSTRICTIVE PERICARDITIS.

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CONSTRICTIVE PERICARDITIS

Thickening of the pericardium

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BEÄNH MAØNG TIMNANG MAØNG TIM

� 3/4 naèm beân (P),1/4 naèm beân (T).� Hieám khi coù caû 2 beân,luùc ñoù seõ khoù

phaân bieät vôùi TDMT.� Hình nghieâng:Nang naèm phía tröôùc

döôùi.� Sieâu aâm:Hình aûnh echo troáng (Spring-

water cyst).� Chaån ñoaùn phaân bieät:Môõ ngoaøi maøng

tim (CT�ño tyû troïng)

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PERICARDIAL CYST

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CALCIFIED PERICARDIAL CYST

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PERICARDIAL CYST

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PERICARDIAL CYST / ASBESTOSIS

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PERICARDIAL CYST

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BEÄNH MAØNG TIMMÔÕ NGOAØI MAØNG TIM

� Thöôøng coù nhöng khoâng nhieàu.� Moät soá tröôøng hôïp lôùp môõ naøy to nhö

moät lipoma�Boùng tim to ra.� Sieâu aâm:Echo keùm (khoù chaån ñoaùn

phaân bieät vôùi Xuaát huyeát).� CT:chaån ñoaùn chính xaùc nhôø ño tyû

troïng.

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ĐỐ VUI ĐỂ HỌC

Chest X Ray of 54 y. old male patient for heath check up.

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No dyspnea,no dysphagia Normal ECG and cardiac US.

CT scan shows low attenuation structure around the heart

Mediastinal lipomatosis

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4.other acquired heart disease

Health & Medicine

Transcript of 4.other acquired heart disease