Cardiovascular System (CVS)

On completion of this chapter, students should be able to:

• Describe the anatomic components of the cardiovascular system.

• Explain the appearance of the various portions of the heart on
conventional chest radiographs.
• Describe each segment of the cardiac cycle.
• Discuss the role of other imaging modalities in the diagnosis
treatment, and management of cardiovascular disorders.
• Differentiate among the major congenital anomalies of the
cardiovascular system.
• Identify the pathogenesis of the pathologies cited and typical
treatments for them.
• Describe, in general, the radiographic appearance of each of the
given pathologies.
 ANATOMY AND PHYSIOLOGY

• Consists of the heart, arteries, capillaries, and veins.

• Pulmonary circulation (transports blood between
the heart and lungs for exchange of blood gases).
• Systemic circulation (transports blood between the
heart and the rest of the body).
 Heart

• as a pump to propel the blood throughout the body

via the circulatory vessels.
• lies in the anterior chest within the mediastinum,
generally readily visible on a chest radiograph.
• Divided into two upper chambers (right and left
atria, and two lower chambers, termed the right
and left ventricles )
• Lies in an oblique plane within the mediastinum; PA
CXR not clearly demonstrate all chambers of the
heart.
• A frontal projection of the chest
shows a cardiac silhouette,
– two thirds of the heart lying
to the left of midline;
– the right side is composed
mainly of the right atrium,
and the left side is composed
mainly of the left ventricle.
– The right ventricle lays
midline within the cardiac
shadow and is located
anterior to the right atrium
and left ventricle.
– The left atrium is located
midline and is the most
posterior aspect of the
heart .
• Lateral CXR best
demonstrate the right
ventricle and the left
atrium :
– right ventricle
constitutes the
anterior portion of the
cardiac silhouette,
– the left atrium and the
left ventricle constitute
the posterior portion
of the cardiac shadow
• Contains three tissue layers
– endocardium (innermost layer, smoth). Valves located
within and between the various chambers also composed
of endocardium, able to prevent the backflow and
passage of blood when the valve is closed even though
thin.
– myocardium (middle layer, muscular, thickest layer),
– Epicardium (outermost layer, protective covering) .
• The entire heart enclosed within a pericardial sac,
contains small amount of fluid to lubricate the heart
as it contracts and relaxes, thus reducing friction.
• In the normal heart, the right atrium
receives deoxygenated blood from the
body via the superior and inferior
venae cavae.
• The deoxygenated blood passes
through the right atrioventricular or
tricuspid valve into the right ventricle.
• The right ventricle contracts during
systole, thus propelling blood to the
lungs through the pulmonary valve and
pulmonary trunk, which bifurcates into
the right and left main pulmonary
arteries, respectively.
• The exchange of gases occurs at the
capillary– alveolar level within the
lungs, and the nowoxygenated blood is
returned to the left atrium via the four
pulmonary veins.
• Oxygenated blood flows from the
left atrium to the left ventricle via
the left mitral valve.
• The left ventricle is responsible for
pumping oxygenated blood
throughout the systemic
circulatory system; therefore, the
left ventricle has a thicker layer of
myocardium and contracts with
greater force than does the right
ventricle.
• Oxygenated blood flows through
the aortic valve into the aorta
when the left ventricle contracts.
 Cardiac Cycle

• The contraction of the myocardium - systole, and the

subsequent relaxation is termed diastole.
• The pacemaker of the heart is the sinoatrial (SA) node,
which is located in the upper portion of the right atrium
near the superior vena cava.
• Electrical current is transmitted through the myocardium,
resulting in a heartbeat.
• Electrocardiography(ECG) graphically demonstrates this
electrical activity. P wave, PR interval, QRS complex, T
wave, and QT duration.
• The P wave is the graphic display of the spread of the
electrical impulse from the atria.
• The PR interval shows the amount of time required for
the electrical impulse to travel from the SA node to the
ventricular muscle fibers.
• The spread of the electrical impulse through the
ventricles is displayed by the QRS complex
• Period in which the ventricles recover from the spent
electrical impulse is graphically displayed by the T wave.
• The QT duration represents the total time from
ventricular depolarization (QRS) to ventricular
repolarization (T).
 Circulatory Vessels

• Arteries - blood vessels that carry blood away from the Heart, named
for their location or the organ they supply
– outermost layer: adventitia, the middle layer : media, innermost
layer :intima.
– The internal, tubular structure : lumen.
• Veins - blood vessels that carry blood to the heart.
– composed of the same three layers;
– venous walls are thinner than arterial walls
– contain valves at set intervals to help with blood return to the heart.
• Capillaries- microscopic vessels that connect arteries and Veins.
– responsible for the exchange of substances necessary for nutrient
and waste transport.
IMAGING CONSIDERATIONS
 Radiography
• CXR provides information about heart shape and size, demonstrating
the great vessels and vascular changes within the lung fields.
• Radiographer control patient posture, degree of inspiration, correct
positioning, geometric factors, and exposure technique selection.
• CXR should be taken in erect position if possible to avoid enlargement
of heart due to abdominal organs push the diaphragm and the heart
up into the thoracic cavity .
• Maintain good inspiration to avoid distortion of heart shape and size .
• SCJ should be an equal distance from the spine, and the scapulae
should be rolled forward out of the lung fields on a well-positioned PA
chest radiograph.
• Lateral chest radiograph, the arms and shoulders should be placed
above the patient’s head to ensure that they are above the apices.
• CXR obtained using a 72-inch SID - decrease magnification of the heart
to an approximate factor of 10%.
• anode-heel effect, placing the anode over the apical region and the
cathode toward the base of the lungs, distributing the radiographic
density more evenly throughout the chest radiograph.
• Adequate penetration of the mediastinal structure : high kilovoltage.
• Vascular markings within the chest help the physician assess
ventricular function. The pulmonary vessels also provide information
about pulmonary artery pressure. Dilatation of these vessels often
indicates problems with the right ventricle.
• Exposure times of one tenth of a second or less should be used,
whenever possible, to decrease involuntary cardiac motion, heart
motion may increase the size of the cardiac shadow. The heart may
look larger if the radiograph is exposed during diastole.
• Well-positioned diagnostic chest radiographs are crucial in the
diagnosis and treatment of cardiovascular disorders.
• In a normal adult, the transverse
diameter of the cardiac shadow should
be less than half the transverse diameter
of the thorax on a PA erect chest
radiograph.
• An enlarged heart (cardiomegaly)-
indicative of many cardiovascular
disorders and is a nonspecific finding.
• The CTR, A normal measurement should
be less than 0.5
• Bone abnormalities of special concern
include scoliosis and pectus excavatum.
 Echocardiography
• Encompasses a group of noninvasive sonographic (ultrasound) procedures that
can provide detailed information about heart anatomy, function, and vessel
patency
• May be performed using M-mode, two-dimensional (2-D) imaging, spectral
Doppler, color Doppler, or stress echocardiography.
• M-mode echocardiography (motion) uses a stationary ultrasound beam to
provide an examination of the atria, ventricles, heart valves, and aortic root,
allowing evaluation of left ventricular function
• 2-D imaging allows for spatially correct, real-time imaging of the heart, provides
multiple tomographic projections of the heart and great vessels in a cinelike
(dynamic imaging) presentation, visualizing the ascending and abdominal aorta in
cases of suspected aneurysm.
• Transesophageal echocardiography (TEE)- patient swallows a mobile, flexible
probe containing the transducer, heart’s structure can be readily visualized
without interference from such structures as skin, the rib cage, and chest muscles.
It is especially helpful in imaging the aortic arch and aortic root
• Stress echocardiography combines an exercise test with an echocardiogram to
 Nuclear Cardiology

• assessment of cardiovascular disease include myocardial perfusion

scans, gated cardiac blood pool scans, and positron emission
tomography (PET).
• useful in assessing coronary artery disease (CAD), congenital heart
disease, and cardiomyopathy.
• A myocardial perfusion scan is the most widely used procedure in
nuclear cardiology. It may be performed on patients with chest pain of
an unknown origin, to evaluate coronary artery stenosis, and as a
follow-up to bypass surgery, angioplasty, or thrombolysis. It is especially
useful in detecting regions of myocardial ischemia and scarring .
• Gated cardiac blood pool scans, sometimes called radionuclide
ventriculograms or multiple gate acquisition scans (MUGA), are used to
evaluate ventricular function and ventricular wall motion.
 Computed Tomography

• Noninvasive modality used to assess cardiac and vascular disease.

• Multidetector (or multislice) scanners provide the highest image
quality, and electron beam CT (EBCT) may also be used to image the
heart.
• Cardiac scoring is performed without the use of a contrast agent,
evaluating the amount of calcium (hard plaques) present in the
coronary arteries.
• EBCT used to examine the heart, particularly as related to coronary
artery calcifications. It uses a scanning focused x-ray beam to
provide complete cardiac imaging in 50 milliseconds (ms)—fast
enough to “freeze” heart motion without the need for ECG gating.
• Multidetector volumetric CT units with specialized cardiac software
are most commonly used to perform calcium scoring and have
better reproducibility compared with EBCT examinations.
 Magnetic Resonance Imaging
• to evaluate many cardiac, mediastinal, and great vessel anomalies.
• It may be used to evaluate myocardial wall thickness and chamber volumes, and
is especially helpful in diagnosing right ventricular dysplasia.
• MRI is highly effective in the evaluation of viable versus nonviable myocardium.
• Most protocols involve obtaining imaging sequences and putting them into
motion using a cine loop to evaluate how well the valves of the heart are
functioning.
• Contrast-enhanced MRI can demonstrate myocardial perfusion, and blood flow
velocities within the heart can be measured.
• The advantage of MRI is the production of images with high spatial resolution
and, thus, higher quality images.
• MRI is a valuable tool for imaging the anatomy, function, and disease of the heart
and is fast becoming a “one-stop shop” for noninvasive cardiac imaging.
• MRI is also used to evaluate aortic aneurysms, dissections, and aortic stenosis,
especially in patients who are unable to have contrast enhanced CT scans
because of renal failure.
• Contrast-enhanced magnetic resonance angiography (MRA) is widely used to
evaluate the vasculature from the aorta to the brain.
 Angiography
• performed to evaluate cardiovascular disease for diagnostic purposes or for
therapeutic reasons.
• traditional diagnostic angiography is being challenged by less invasive
procedures such as MRA and CTA..
• Angiocardiography is performed by injecting the contrast material into the
heart chambers and obtaining cine images of the heart and the great vessels in
motion.
• Therapeutic angiography continues to steadily increase through expanded use
of interventional procedures.
• Percutaneous transluminal coronary angioplasty (PTCA) is a therapeutic
procedure commonly performed to open stenotic coronary vessels and place a
stent in a narrowed vessel to maintain its patency.
• Thrombolysis is a procedure in which a high-intensity anticoagulant such as
streptokinase is dripped over a period of hours directly onto a clot to dissolve
it .
• With embolization, devices such as coils are used to clot off vessels.
 CONGENITAL AND HEREDITARY
DISEASES

• Patent Ductus Arteriosus

• Coarctation of the Aorta
• Septal Defects
• Transposition of the Great Vessels
• Tetralogy of Fallot
 VALVULAR DISEASE

• rheumatic fever.
• Valvular stenosis
 CONGESTIVE HEART FAILURE

• Right-sided failure
• Left-sided failure
COR PULMONALE
 DEGENERATIVE DISEASES

• Atherosclerosis
• Coronary Artery Disease
• Myocardial Infarction
ANEURYSMS
 VENOUS THROMBOSIS

• Phlebitis
• thrombophlebitis.
 PULMONARY EMBOLI

• thromboembolism