Muscular organ that pumps blood
throughout the circulatory system.
Situated between two lungs in the
mediastinum
4 chambers – 2 atria / 2
ventricles
Right and Left atria are
separated from one another
by a fibrous septum
Interatrial Septum
Right and Left ventricles- by
Interventricular Septum
Upper part – memberanous
Lower part - Muscular
4 Valves
2 Atrioventricular Valves
Mitral and Tricuspid
between Atria and Ventricles
2 Semilunar Valves
Aortic and Pulmonary
placed at opening of blood vessels arising from ventricles
Left AV valveMitral Valve or Biscuspid Valve
Right AV valveTricuspid Valvehas 3cusps (anterior, superior,inferior)
Composed of
saddle-shaped fibrous annulus
2 leaflets (a semicircular anterior leaflet and a rectangular posterior leaflet)
2 commissures
2 papillary muscles (anterolateral and posteromedial)
chordae tendineae, which are fibrous tendons
that arise from the papillary muscles and insert on
the free edges of the leaflets
Half moon shaped
Made up of 3 flaps
Aortic Valve and
Pulmonary Valve
Open only towards aorta
and pulmonary artery and
prevent backflow of blood
into the ventricles.
is composed of a fibrous annulus,
3 cusps (right coronary cusp, left coronary
cusp, posterior or non-coronary cusp)
3 commissures that separate the cusps
fibrous annulus,
3 cusps
3 commissures separating the cusps.
Inspection – Apical impulse/pulsations
Palpation-apical impulse/thrills/palpable
heart sounds
Percussion-asses cardiac borders
Auscultation - murmurs
Plain Chest X Ray
Fluroscopy
2D Echocardiograpy
CT Scan
MRI
Radionuclide Imaging
Angiography
Teleroentgenogram
6 feet distance
Shoulders rotated forwards and downwards
Centering T7 verterbrae
High KvP technique
Left Atrium
Left Ventricle
Right Ventricle
Aorta
Main pulmonary artery
Inferior Vena Cava
Cardiac apex
Cardia - Site/Shape/Size/Borders
Enlargement of chambers
Aortic arch/pulmonary art
Pulmonary vascularity
Shift of Mediastinum
Diaphragm – level/tenting/flattening
CP Angles
CardioThoracic Ratio:Internal diameter of the thoracic
cavity from the Medial border of
the ribs at the level of Right
hemidiaphragm
Transverse cardiac measurement
as the horizontal distance the
most Lateral aspects of the left
and right margins of the heart
Normal CT Ratio Adults – 50%
Newborns - 57%
Infants – 55 %
Pure stenosis or Regurgitation or Both
Dilated aortic shadows
Aortic stenosis
Aortic Regurgitation
HTN
Coaractation of aorta
Aneurism of aorta
Dilated Pulmonaryartery
Pulmonary stenosis
PA HTN
idiopathic
Double density
Enlargement of LA
appendage
Upliftment of left
mainstem bronchus
Widening of carinal
angle
Lateral view:
Prominent
posterosuperior
cardiac border
Posterior
displacement and
upliftment of left
mainstem
bronchus
Usually subtle and difficult to determine in mild and moderate cases
Lateral prominence of right heart border often associated with increase in convexity
In severe chronic cases right heart border can become massively distended towards right side
The ventricle enlarges
towards the lateral
wall of the thorax in a
downward direction,
displacing the apex
laterally and inferiorly
Lateral View:
posterior displacement of the posterior inferior border of the heart
Hoffman-Rigler Sign: measured 2 cm above the intersection of the diaphragm & IVC;
(+) if posterior border extends more than 1.8 cm of IVC
Rounding and
upliftment of cardiac apex
Lateral view
Retrosternalfullness
contact of anterior
cardiac border
greater than 1/3 of
the sternal length
Volume Overload Pressure Overload
Right Atrium Tricuspid
Regurgitation
Tricuspid Stenosis
Left Atrium Mitral Regurgitation Mitral Stenosis
Right Ventricle Tricuspid
Regurgitation
Pulmonary
Regurgitation
Pulmonary Stenosis
Left Ventricle Mitral Regurgitation Aortic Stenosis
Levocardia:
the heart is predominantly in the left chest, and the cadiac apex points leftward
Dextrocardia:
the heart is predominantly in the right chest, and the cardiac apex points rightward
Mesocardia:
the heart is positioned in the midline, and the cardiac apex points directly inferiorly
Dextroposition (dextroversion):
the cardiac apex points leftward, but the heart is located predominantly in the right chest (typically due to extrinsic forces)
“SITUS” - pattern of anatomic arrangement.
atrial situs is usually concordant with
visceral situs (stomach on left, liver on
right); hence these two are described
together
Situs solitus:
the morphologic right atrium is to the right
of the morphologic left atrium
the gastric air bubble is on the left side, and
the liver is on the right
Situs inversus:
the morphologic right atrium is to the left of
the morphologic left atrium
the gastric air bubble is on the right side,
and the liver is on the left
Situs ambiguous:
this term is used when identification of
visceroatrial situs is not possible due to
paucity of anatomic markers
Normal ArborizationPattern
• tapering from medial to
lateral
• outer 1 cm of lungs has no
markings
• tapering from bottom to up
• preferential flow to lung
bases
• increase in caliber of vessels
inferiorly
• Blood vessel accompanying
bronchi should be 1:1
Increase in perfusion may be seen as an increase in the calibre of the blood vessels
Decrease in perfusion is seen as darker lungs and very few appreciable vessels
Pulmonary Oligemia
• Vascular shadows reduced
• Occurs in TOF
• pulmonary artery HTN
• Critical Pulmonary Stenosis with reversal of
shunt
Pulmonary Plethora
• Vascular shadows are numerous
• Seen in lateral 1/3 rd of lung fields
• End on vessels are more in no (>5)
• Left atrial or right atrial enlargement usually
Pulmonary Venous hypertension• in PVH equalization of vascualrity
>12mm Hg – upper lobe veins=lower lobe Cephalization
upper lobe veins more prominent
>15mm Hg – Kerley B lines(lateral,septal)
Kerley A lines(longer,linearreaching hilum)
>25mm Hg – frank alveolar edema
Seen in Mitral Valve disease
• Perihilar haziness
• Bronchial cuffing (signet ring and thick outline)
• Redistribution of blood flow
Pulmonary EdemaPulmonary venous pressure > 25-28mm Hg
Typical Batwing appearance seen
Seen in Mitral valve diseases
AORTIC STENOSIS
Causes:
• Calcification of Congenitally deformed bicuspid valve in Men > 30yrs
• Degenerative calcific disease in middle aged/elderly patients
• Rheumatic Heart Disease
• Degeneration of a normal trileaflet aortic valve
Calcification of valve usually indicates gradient across valve of > 50mm Hg
Symptoms
Chest pain/shortness of breath/syncope
Mechanism
Deposition of Calcium on aortic cusps obstruct the outflow by their bulk as well as by stiffening of cusps – Stenosis
Area (cm2 ) Mean Gradient(mm Hg)
NORMAL 3 Few
Mild 1.5-2 <25
Moderate 1-1.5 25-40
Severe 0.6-1.0 >40
Critical <0.6 >70
Normal-sized heart or mild cardiomegaly
Left ventricular hypertrophy (muscular)
+/- pulmonary venous hypertension
Dilated ascending aorta only (the rest of the
aorta normal) due to jet of blood from
stenosis
+/- calcification
Calcification of aortic valve
Thickening
Increased echogenecity
Reduced mobility of the valve leaflets
Acoustic shadowing behind the calcification
Coronal
gradient-echo
MRI image
Calcification of
aortic valve
produces a
signal void
Causes
Damage to valvular cusps
• Rheumatic heart disease
• Endocarditis
• Marfan’s syndrome – dilatation of aortic root
• Syphilis
• Luetic aortitis
• Aortic dissection
• Connective tissue diseases
Volume overload on LV
Cardiomegaly
Left ventricular enlargement
Dilated ascending aorta and aortic arch due to large blood volume
Normal pulmonary vascularity
Sitting Dove sign
Color Doppler – jet of regurgitation
Continuous wave doppler interrogation of
the regurgitant jet in LV
Pulse wave doppler sampling of flow in
aortic arch to detect any abnormal reversal
flow
Doppler images taken in the parasternal long-axis view.
(A) A very small central regurgitant jet indicating mild aortic regurgitation.
(B) (B) A much broader based jet in a patient with severe aortic regurgitation
MITRAL STENOSIS
Cause: Rheumatic fever
Multiple episodes of
Acute Rheumatic Fever
causes PanCarditis
Other causes: (Rare) congenital anomalies,
prior exposure to chest radiation,
mucopolysaccharidosis,
severe mitral annular calcification,
left atrial myxoma
Infective endocarditis
Carcinoid syndrome
Fabray’s Disease
Hurler’s syndrome
Whipple’s Disease
• Fusion of the leaflet commisure
• Shortening and thickening of chorda
tendinae
Reduction of flow
Mitral stenosis occurs
•Left atrial pressure ↑
•Left atrium enlarges
•Cephalization
•Pulmonary Interstitial Edema
•Pulmonary Artery Hypertension develops
•Pulmonary Vascular Resistance increases
•Right Ventricle enlarges
•Pulmonic regurgitation develops
•Tricuspid annulus dilates
•Tricuspid insufficiency
•RV failure
Effect of MS on Lungs
Pulmonary arterial hypertension develops
muscular hypertrophy and hyperplasia
increased pulmonary vascular resistance
Chronic edema of alveolar walls -> fibrosis
Pulmonary hemosiderin deposited in lungs
Pulmonary ossification may occur
Area (cm2 ) Mean Gradient(mm Hg)
NORMAL 4-6 Few
Mild >1.5 <5
Moderate 1-1.5 5-10
Severe <1.0 >10
Enlargement of left
atrial appendage
Early – normal heart
size and subtle signs
of left atrial
enlargement
Straightening of
left heart border
Small aortic knob
Double density of
left atrial
enlargement
Severe and longstanding cases – calcification
of the valve
Cephalization
Elevation of
main stem
bronchus
Widened carinal
angle
Leaflet thickening or
calcification (hockey-stick deformity of the mitral valve
leaflets is typical)
leaflet mobility
commissural or
sub-valvular fusion
Echocardiography (parasternal
long axis) shows marked thickening of
mitral leaflets with restricted mitral valve
orifice (doming anterior leaflet). Left atrial
(LA) enlargement is evident.
MITRAL REGURGITATION
Degenerative valve or chordal tissue Prolapsed leaflet
Ruptured chordae
Myxomatous degeneration
Secondary to ischaemic heart disease or cardiomyopathyDilated mitral annulus
Papillary muscle dysfunction
Papillary muscle rupture
Rheumatic mitral disease
Infective endocarditis
Hypertrophic cardiomyopathy
In acute MRAcute Pulmonary edema
Heart is not enlarged
In chronic MR-LA and LV are markedly enlarged
Volume overload
-Pulmonary vasculature is usually normal
LA volume but not pressure is elevated
In Marfan’s SyndromeEnlargement of aortic root
Acute non-rheumatic mitral regurgitation. (A) Frontal view in the acute phase.
Heart size – nomral
even in the presence of high left atrialpressure as evidenced by the preferential dilatation of the upper-lobe vessels and interstitial oedema
The acute lesion of rheumatic fever is mitral
regurgitation, not stenosis
The largest left atria ever are produced by mitral regurgitation, not mitral stenosis
2D Echo – morphological abnormality
Doppler – assessment of regurgitation
Prolapse of posterior leaflet- regurgitation
jet will be directed superiorly to the roof of
the left atrium near aortic root
Proplapse of anterior leaflet – jet will be
directed inferiorly
TransoesophagealEchocardiography
Assess exact nature
and severity of the
lesion
Shows evidence of regurgitation secondary to lesions of right heart or pulmonary Hypertension
Causes:
Bacterial Endocarditis -Staphlycoccal
Late feature of Rheumatic Heart Disease
Metastatic carcinoid Disease
Normal area – 10.5 cm2 Mean gradient – 40-45mmHg
Enlargement of Right atrium
Prominent bulging or elongated right
heart border
+/- SVC or IVC prominence
Tricuspid stenosis. (A) The right heart border has bulged to
the right and its radius of curvature has increased.
(B) In the lateral view, the gap
between the front of the heart
and the sternum is filled in.
Commonly aortic and mitral valves
2Types – Mechanical / Biological
Mechanical
~Ball and cage type(rare)
~Tilting disc type
Single – Bjork-Shiley
Bileaflet- St Jude or carbomedic
Biological
Stentmounted porcine xenografts
(pig valve tissue mounted on a frame)
or homograft valves (human tissue, usually without additional mechanical support)
Visible on Echocardiography
Small orifice size than the original valve
Doppler – slightly restrictive pattern
Structure FractureStructure fractures have been reported
in some types of mechanical valves;
CXR using microfocus,
Fluoroscopy and CT have been useful
in identifying fractures
Porcine BioprosthesisThe major problem with porcine bioprostheses
is their poor durability.
5th post of year - Cusp tears, degeneration,
perforation,fibrosis and calcification appear
10th year 20% will fail and require
reimplantation
Incidence - 0.9 to 4.4%,
most frequent - within 6 months of valve
replacement
Organisms – Streptococcus, Staph aureus,
Candida albicans
Transoesophageal Echocardiography
Vegetations
Small(1-5mm) very large(2-3cm)
Damaging free edge of leaflets or leaflet
perforation ->Valve regurgitation
Abscess formation
Transoesophageal echocardiogram in the long-axis plane. The bicuspid aortic valve shows large
vegetations on opposing leaflets (A)
(arrow).
The shortaxis view confirms the bicuspid
anatomy and shows the
'kissing' vegetations on
opposing leaflets (B) (arrow).
Helps in assessing post-op complications
MRI is limited in vegetation detection
because of the artefacts generated by
ferromagnetic components
useful for assessing pseudoaneurysms
produces a set of
images at different
stages of the cardiac
cycle that can be
viewed dynamically
Any marked
turbulence of flow of
blood is
demonstrated as
black signal voidAt the level of aortic valve in pt with
aortic valve stenosis
Acquired is Very Rare
May be due to Carcinoid Disease and
Endocarditis
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