Cardiovascular Measurements_Kimura (1)

Cardiovascular
Radiologic Measurements: A Concise Review

Radiologic Society of North America Annual Mee:ng.
November 2012. Chicago, Ill.
Dario Maida-‐Urrea,MD; Eric Kimura-‐Hayama, MD; (erickimura@ctcardiomexico.com)

Ins:tuto Nacional de Cardiología Ignacio Chávez, Grupo CT Scanner. Mexico city, MEXICO
CT Scanner de
México
ct scanner group-‐incich department of radiology
Aims of the exhibit and content organiza:on
Purpose 1. Describe and define normal radiologic measurements of cardiac structures.
2. Describe and define normal radiologic measurements of thoracic vascular structures.

Content 1. Cardiac measurements in secEonal imaging (Echocardiography, CT and MRI): how to do it
and normal values?
• LeN and right ventricular and atrial chambers: end systolic and end diastolic
measurements and wall thickness
• Other measurements: atrial septal defect measurements
2. AorEc and pulmonary artery measurements: how and where are measurements done
and normal values?
• AorEc root, ascending aorta, aorEc arch (aorEc knob) and descending aorta
• Main pulmonary artery and right/leN branches
3. Pediatric Z-‐score: What is it, how is it obtained and how interpretaEon is made?

Introduc:on
RaEonale § With the advent of newer imaging technologies, in parEcular MR and MDCT, the number
of studies for cardiovascular evaluaEon has increased
§ ApplicaEon of uniform criteria is necessary to make data comparable, in parEcular when
a paEent has been scanned by different modaliEes. In addiEon, these measurements
should also be standardized in order to ease interpretaEon of follow-‐up studies
§ A lack of measurements is common in daily basis pracEce

How to begin?
Cardiac axes § CV evaluaEon starts by obtaining cardiac planes —either for MDCT or MRI— because
body axes are different from cardiac axes. These are divided into:
§ Short axes are obtained at the basal, mid and apical thirds
§ Long axes or radial views are composed of 2, 3 and 4-‐chamber views
Short Axes Basal Mid Apical
Long Axes 4-Ch 2-Ch 3-‐Ch
Ginat D et al. AJR 2011;197:808-‐915.

How to obtain cardiac planes?: 2-‐chamber view
STEP 1: In the
transaxial image
where all 4
chambers are
seen (“false 4
chamber view”)
(red dot), trace a
line from the
center of the
mitral valve to the
LV apex using the
four chambers
view in the body
axial plane. This
line will create a
2-‐chamber view
(green dot)
Ginat D, AJR, 2011:

197:808-‐915

Short-‐axis views
STEP 2: From the 2-‐
chamber view (red dot)
obtained from step 1,
draw a line with the same
orienta:on, i.e. from the
center of the mitral valve
to the LV apex. The
resul:ng image represents
a short axis view (green
dot). When blue line
moves towards the apex
(double head arrows), the
LV is divided into basal,
mid and apical thirds
Ginat D, AJR, 2011: 197:808-‐915.

4-‐chamber view
STEP 3: From the
short axis view
(red dot) obtained
from step 2, trace
a line from the
center of the LV
cavity to the
basal inferior RV
angle (purple
line). The
resultant image
(green dot) is a
true 4-‐chamber
view. No:ce an
atrial septal
defect present in
this case (arrow)
Ginat D, AJR, 2011:

197:808-‐915
ct scanner group-‐incich Radiology Ddepartment

epartment/PET-‐CT Unit
of radiology
3-‐chamber view
STEP 4: From the basal
short axis view obtained
from step 2 (red dot)
where the LV outflow
tract can be seen, trace
a line from the center of
the LV cavity to its
outflow tract (purple
line). The resultant
image is a 3-chamber
view (green dot)
Ginat D, AJR, 2011: 197:808-‐915

What is next?
Cardiac phase selecEon § The next step is selecEon of cardiac phases: best diastole and best systole
1 2 3 4 5 6 7 8 9 10 11 12
13 14 15 16 17 18 19 20 21 22 23 24
Which frames are best diastole and

systole?
Best diastole Best systole

What is measured and in which planes?
CARDIOVASCULAR STRUCTURE PLANE

LeN ventricle diastolic and systolic diameter Three chamber view
Septal and lateral leN ventricle wall thickness Three chamber view
Right ventricle diastolic and systolic diameters Four chamber view
Right ventricle free wall thickness Four chamber view
LeN atrium Three chamber view
Right atrium Four chamber view
AorEc root Three chamber view
Ascending aorta and aorEc arch Double oblique sagihal view (“candy cane” plane)
Main pulmonary artery Axial plane at the level of the ascending aorta
Right pulmonary artery Axial plane at the level of the IVC and right main bronchus

3-‐chamber view LV measurements
LV diameters and § End-‐diastolic and systolic diameters (yellow lines): Obtained at the juncEon of the basal-‐
myocardial thickness mid ventricular thirds.
§ Useful to determine the presence of dilataEon
§ Myocardial thickness: useful to determine the presence of hypertrophy
§ Anteroseptal (red line): At the level of the LV basal segment
§ Posterolateral wall (orange line): At the level of the LV basal segment
NORMAL VALUES
Diameters
• End-‐diastolic: 44.5 ± 5.3 mm
END-‐DIASTOLE
• End-‐systolic: 27.6 ± 5.2 mm
END-‐SYSTOLE
Thickness
• Anteroseptum: 8.4 +/-‐ 1.9 mm
• Posterolateral: 7.5 +/-‐ 1.8 mm
Hundley WG et al. Society for Cardiovascular MagneEc Resonance

guidelines for reporEng cardiovascular magneEc resonance
examinaEons. J Cardiovasc Magn Reson 2009;11:5.

Short-‐axes views LV measurements INCICh
Instituto Nacional
de CardiologÍa
Ignacio ChÁvez
LV volumes, ejecEon fracEon, cardiac output and

cardiac index
§ These measurements are obtained manually or
computed-‐assisted in the end-‐diastolic and end-‐
systolic cardiac phases for both MRI and MDCT
§ LV endocardial and epicardial areas in each
image frame are performed in the short-‐axis
view, from basal to apical segments (6-‐8
images)
§ Papillary muscles are excluded
§ End-‐diastolic volume (EDV) and end-‐systolic

volume (ESV) are calculated as the endocardial
volume at end-‐diastole and end-‐systole
respecEvely
Cain P et al. Age and gender specific normal values of leN ventricular mass, volume
and funcEon for gradient echo magneEc resonance imaging: a cross secEonal study.
BMC Medical Imaging 2009, 9:2 doi 10.1186/1471-‐2342-‐9-‐2.
ct incich/ct
scanner sgcanner
roup-‐incich department oof f radiology
department radiology
Lek ventricle volume, mass and func:on INCICh
Instituto Nacional
de CardiologÍa
Ignacio ChÁvez
Commonly used formulas and normal values

§ Stroke volume (SV) = EDV -‐ ESV
§ EjecEon fracEon (EF) = SV / EDV
§ Cardiac output (CO) = SV x HR
§ LV mass is usually taken from the end-‐diastolic images by delineaEng the epicardial contour
§ Cardiac index (CI) = CO/BSA (units: l/min/m2) (where BSA is the body surface area in m2)
Mean +/-‐ SD Male Female
LV ejecEon fracEon (%) 69 +/-‐ 6 69 +/-‐ 6 (57-‐81) 69 +/-‐ 6 (57-‐81)
LV mass (g) 112 +/-‐ 27 123 +/-‐ 21 (81-‐165) 96 +/-‐ 27 (42-‐150)
LV end-‐diastolic volume (mL) 150 +/-‐ 31 160 +/-‐ 29 (102-‐218) 135 +/-‐ 26 (83-‐187)
LV end-‐systolic volume (mL) 47 +/-‐ 15 50 +/-‐ 16(18-‐82) 42 +/-‐ 12 (18-‐66)
LV Stroke volume 104 +/-‐21 112 +/-‐ 19 (64-‐150) 91 +/-‐ 17 (57-‐125)
Cain et al. Age and gender specific normal values of leN ventricular mass, volume and
funcEon for gradient echo magneEc resonance imaging: a cross secEonal study. BMC
Hudsmith LE et al. Normal Human LeN and Right Ventricular and LeN Atrial Dimensions Using Medical Imaging 2009, 9:2 doi 10.1186/1471-‐2342-‐9-‐2.
Steady State Free Precession MagneEc Resonance Imaging. J Cardiovasc Magn Reson 2005;7: Pennell DJ. Ventricular volume and mass by CMR. J Cardiovasc Magn Reson 2002;4,507–
775-‐782. 513.
ct
ct sscanner
canner ggroup-‐incich
RV measurements
RV diameters and § End-‐diastolic and end-‐systolic diameters: They are obtained at basal segment, drawing a
myocardial thickness line approximately at the level of the tricuspid valve from inner wall to inner wall at the
widest point
§ Useful to determine RV:LV raEo which is abnormal in cases of pulmonary hypertension
§ Free wall: It is measured at mid segment in end-‐diastole
§ Useful to determine the presence of hypertrophy
The 4-‐Ch view is the cardiac plane to measure the RV diameters NORMAL VALUES
Diameters
END-DIASTOLE
END-SYSTOLE
• End-‐diastolic: 32.1 ± 5 mm
• End-‐systolic: 23.4 ± 5 mm
Myocardial thickness (free wall): 4.9 ± 1

mm

RV volumes and func:on INCICh
Instituto Nacional
de CardiologÍa
Ignacio ChÁvez
§ Similarly, RV volumes are obtained in either

short-‐ or long-‐axes (4-‐chamber views)
ct incich/ct
scanner sgcanner
Normal RV volumes and func:onal parameters
RV ejecEon fracEon (%) 61 +/-‐ 6 59+/-‐ 6 (47-‐71) 63 +/-‐ 5 (53-‐73)
RV mass (g) 38 +/-‐ 8 41 +/-‐8 (25-‐57) 35 +/-‐7 (21-‐49)
RV end-‐diastolic volume (mL) 173 +/-‐ 39 190 +/-‐ 33 (124-‐256) 148 +/-‐ 235 (78-‐218)
RV end-‐systolic volume (mL) 69 +/-‐ 22 78 +/-‐ 20(38-‐118) 56 +/-‐ 18 (20-‐92)
RV Stroke volume 104 +/-‐21 113 +/-‐ 19 (75-‐151) 90 +/-‐ 19 (52-‐128)
Hudsmith LE et al. Normal Human LeN and Right Ventricular and LeN Atrial Dimensions Using
Steady State Free Precession MagneEc Resonance Imaging. J Cardiovasc Magn Reson 2005;7:
775-‐782.

LA measurements
Cardiac axes § Both LA size and volume are measured at the end-‐systole (parameters taken from echo
examinaEons)
§ The most reliable form using the ellipse method obtained from 3-‐ and 4-‐chamber views
There are 3 diameters:
1) Anteroposterior (AP): measured in
a 3-‐chamber view in end-‐systole,
perpendicular to the LA wall from
inner wall to inner wall (red line). This
is the most commonly used measure
in MDCT
2) Inferosuperior (IS): obtained in a 4-‐

chamber view from the mitral plane
to the back wall (yellow line).
3) Transverse (T): measured in a 4-‐

chamber view from medial to lateral
walls of the LA (orange line).
LA volume = (AP x IS x T)(0.523) Panupong J et al. Three methods for evaluaEon of leN atrial volume. Eur J Echo 2008;9:351–355

Normal LA volumes and diameters
Longitudinal diameter (cm) 4-‐Ch 5.7 (4.3-‐7.0) 5.9 (4.5-‐7.2) 5.5 (4.1-‐6.9)
Transverse diameter (cm) 4-‐Ch 4.1 (3.0-‐5.1) 4.1 (3.0-‐5.2) 4.1 (3.0-‐5.1)
Anteroposterior diameter (cm) 3-‐Ch 3.2 (2.2-‐4.2) 3.3 (2.3-‐4.2) 3.1 (2.1-‐4.1)
Maximal LA volume (mL) 97 +/-‐ 27 103 +/-‐ 30 89 +/-‐21
Minimal LA volume (mL) 44 +/-‐ 13 46 +/-‐14 41 +/-‐ 11
Jiamsripong P et al. Three methods for evaluaEon of leN atrial volume. Eur J Echo 2008;9:351–355.
Maceira AM et al. Reference leN atrial dimensions and volumes by steady state free precession
cardiovascular magneEc resonance. J Cardiovasc Magn Reson 2010;12:65.

Aor:c measurements
Modified from “Uncommon Congenital and Acquired AorEc Diseases : Role of
§ Measurement of aorEc diameters requires to correctly define the aorEc MulEdetector CT Angiography”. Kimura Hayama et al. RadioGraphics 2010; 30, 30:
segments allowing accuracy and reproducibility. A clear definiEon of 79-‐98
terms is necessary because confusion sEll exists about the terminology of
the aorEc root and its arch
§ The thoracic aorta has been segmented in various ways. The most
accepted is shown in the figure: 1) aorEc root, 2) ascending aorta, 3)
aorEc arch, 4) isthmus, and 5) descending aorta. The aorEc root is further
divided into three planes:
§ 1a) AorEc annulus or valvular plane
§ 1b) Coronary sinuses plane
§ 1c) Sinotubular juncEon
§ The aorEc arch is divided into:

§ 3A) Proximal arch: Distal to the innominate artery (BT)
§ 3B) Distal arch: Distal to the leN common caroEd (LCC)
The normal diameters of the proximal arch (3A), distal arch (3B), and isthmus (4) should be at least 60%, 50%,
and 40% of the diameter of the ascending aorta (2). In an infant, the segments of the aorEc arch (3A, 3B, and
4) have a maximal length of 5 mm. Arrows indicate areas where aorEc measurements are usually taken

Aor:c measurements
§ To measure aorEc root diameters, we must obtain a cardiac 3-‐
chamber view at end-‐systole
§ Normal diameters are shown below:
AorEc root measurements: 1) AorEc annulus: yellow line. 2) Valsalva sinuses: orange
line. 3) Sinotubular juncEon: red line. NoEce that the LV is in maximum systole in a 3-‐
chamber view
Pulmonary artery measurements: MPA
Main pulmonary artery § Diameter of MPA is obtained in the transaxial plane prior to its bifurcaEon, in a plane where
the ascending aorta is displayed. Diameter of MPA can be visually compared with that of the
(MPA)
ascending aorta. The normal raEo is 1:1 or less
§ The pulmonary artery maximum diameter is 30 mm
Normal vs abnormal main pulmonary artery. Normal

main pulmonary artery/ascending aorta raEo 1:1.
Abnormal raEo: The MPA is dilated, with an abnormal
raEo
Castañer E et al. Congenital and Acquired Pulmonary Artery Anomalies in the Adult: Radiologic
Overview. RadioGraphics 2006;26:349-‐371.

Pulmonary artery measurements: RPA INCICh
Instituto Nacional
de CardiologÍa
Ignacio ChÁvez
Right pulmonary artery (RPA)
§ The right pulmonary artery is measured where it runs parallel to
the right main bronchus and the pulmonary vein crosses beneath
(green arrow)
Coussement AM, Gooding CA. ObjecEve radiographic assessment of pulmonary vascularity in children.
Radiology 1973:109:649-‐654.

Pulmonary artery measurements: ounlow tract
How to obtain the RV outlow tract
PV
In a transaxial image at the level of the MPA, a sagihal view of the right ventricular outlow
tract is created tracing a line parallel to the long axis of this vessel (yellow line). In the I
resulEng image (green dot), we measure the RV infundibulum and pulmonary valve plane
Normal vs abnormal infundibulum (I) and pulmonary valvular plane (PV).
In paEents with Tetralogy of Fallot, obstrucEon of RV outlow tract (arrow) may be seen associated with
pulmonary valvular dysplasia or supravalvular obstrucEon
Z-‐scores of cardiac structures
DefiniEon
§ The parameter Z is a mathemaEcal calculaEon (equivalent to the standard deviaEon)
used to know the limits of normal cardiac and vascular structures in children and
adolescents. Calculated z-‐scores are oNen used to normalize these measurements
to the paEent's body size represented as body surface area
§ It was proposed in 2008 by Michael Pehersen, who examined 782 healthy paEents
with age range from 1 day to 18 years, with 2D echocardiography and M mode,
measuring 21 cardiovascular structures and performing each regressional equaEons
to relate the diameter of these structures with the body surface area of each paEent
§ It is available online and free for consult in the website: www.parameterz.com
In clinical prac:ce, Z-‐scores are used to analyze the normal vs abnormal diameters of
several cardiovascular structures. This informa:on is relevant during the follow-‐up of
pa:ents, in certain circumstances represen:ng the gatekeeper in surgical decisions

Z-‐scores
§ In the following slides we present some examples of how Z-‐scores are obtained...

AorMc CoarctaMon
COA
18
incich/ct scanner Radiology Department/PET-‐CT Unit
Aortopulmonary Window
19
incich/ct scanner Radiology Department/PET-CT Unit
Tetralogy of Fallot
20
incich/ct scanner Radiology Department/PET-CT Unit
Conclusions
In summary 1. Radiologic measurements are useful tools during evaluaEon of cardiac and vascular
structures
2. Measurements from secEonal imaging (i.e. echocardiography, nuclear medicine, MRI and
CT) must be performed following precise paramaters due to the dynamic nature of
cardiovascular structures (systole and diastole)
3. Appropriate measurement of cardiovascular structures is basic during interpretaEon and
allows a “universal” language among radiologists and cardiologists


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Cardiovascular

Radiologic Measurements: A Concise Review

Dario Maida-­‐Urrea,MD; Eric Kimura-­‐Hayama, MD; (erickimura@ctcardiomexico.com)

ct scanner group-­‐incich department of radiology

§ A lack of measurements is common in daily basis pracEce

ct scanner group-­‐incich department of radiology

Long Axes 4-Ch 2-Ch 3-­‐Ch

Ginat D et al. AJR 2011;197:808-­‐915.

Ginat D, AJR, 2011:

ct scanner group-­‐incich department of radiology

Ginat D, AJR, 2011: 197:808-­‐915.

ct scanner group-­‐incich department of radiology

Ginat D, AJR, 2011:

ct scanner group-­‐incich Radiology Ddepartment

Ginat D, AJR, 2011: 197:808-­‐915

ct scanner group-­‐incich department of radiology

Which frames are best diastole and

ct scanner group-­‐incich department of radiology

CARDIOVASCULAR STRUCTURE PLANE

Right ventricle diastolic and systolic diameters Four chamber view

Right ventricle free wall thickness Four chamber view

LeN atrium Three chamber view

Right atrium Four chamber view

AorEc root Three chamber view

ct scanner group-­‐incich department of radiology

• End-­‐systolic: 27.6 ± 5.2 mm

Hundley WG et al. Society for Cardiovascular MagneEc Resonance

ct scanner group-­‐incich department of radiology

LV volumes, ejecEon fracEon, cardiac output and

§ End-­‐diastolic volume (EDV) and end-­‐systolic

Commonly used formulas and normal values

Mean +/-­‐ SD Male Female

LV ejecEon fracEon (%) 69 +/-­‐ 6 69 +/-­‐ 6 (57-­‐81) 69 +/-­‐ 6 (57-­‐81)

Myocardial thickness (free wall): 4.9 ± 1

ct scanner group-­‐incich department of radiology

§ Similarly, RV volumes are obtained in either

Mean +/-­‐ SD Male Female

RV ejecEon fracEon (%) 61 +/-­‐ 6 59+/-­‐ 6 (47-­‐71) 63 +/-­‐ 5 (53-­‐73)

RV mass (g) 38 +/-­‐ 8 41 +/-­‐8 (25-­‐57) 35 +/-­‐7 (21-­‐49)

ct scanner group-­‐incich department of radiology

2) Inferosuperior (IS): obtained in a 4-­‐

3) Transverse (T): measured in a 4-­‐

ct scanner group-­‐incich department of radiology

Mean +/-­‐ SD Male Female

Minimal LA volume (mL) 44 +/-­‐ 13 46 +/-­‐14 41 +/-­‐ 11

ct scanner group-­‐incich department of radiology

§ The aorEc arch is divided into:

ct scanner group-­‐incich department of radiology

§ The pulmonary artery maximum diameter is 30 mm

Normal vs abnormal main pulmonary artery. Normal

ct scanner group-­‐incich department of radiology

Right pulmonary artery (RPA)

ct scanner group-­‐incich department of radiology

ct scanner group-­‐incich department of radiology

ct scanner group-­‐incich department of radiology

ct scanner group-­‐incich department of radiology

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Dario Maida-‐Urrea,MD; Eric Kimura-‐Hayama, MD; (erickimura@ctcardiomexico.com)

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

Long Axes 4-Ch 2-Ch 3-‐Ch

Ginat D et al. AJR 2011;197:808-‐915.

ct scanner group-‐incich department of radiology

Ginat D, AJR, 2011: 197:808-‐915.

ct scanner group-‐incich department of radiology

ct scanner group-‐incich Radiology Ddepartment

Ginat D, AJR, 2011: 197:808-‐915

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

• End-‐systolic: 27.6 ± 5.2 mm

ct scanner group-‐incich department of radiology

§ End-‐diastolic volume (EDV) and end-‐systolic

Mean +/-‐ SD Male Female

LV ejecEon fracEon (%) 69 +/-‐ 6 69 +/-‐ 6 (57-‐81) 69 +/-‐ 6 (57-‐81)

ct scanner group-‐incich department of radiology

Mean +/-‐ SD Male Female

RV ejecEon fracEon (%) 61 +/-‐ 6 59+/-‐ 6 (47-‐71) 63 +/-‐ 5 (53-‐73)

RV mass (g) 38 +/-‐ 8 41 +/-‐8 (25-‐57) 35 +/-‐7 (21-‐49)

ct scanner group-‐incich department of radiology

2) Inferosuperior (IS): obtained in a 4-‐

3) Transverse (T): measured in a 4-‐

ct scanner group-‐incich department of radiology

Mean +/-‐ SD Male Female

Minimal LA volume (mL) 44 +/-‐ 13 46 +/-‐14 41 +/-‐ 11

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology

ct scanner group-‐incich department of radiology