BASICS OF

CARDIAC IMAGING
AND ANATOMY
Sarah Francesca R. Sy-Santos, MD
 OBJECTIVES

• Review basic cardiac anatomy and findings of chamber enlargement seen in

Chest Xray
• Overview of different cardiac imaging modalities, specifically its indications and
role in management (Echocardiography, Nuclear Imaging, Cardiac CT Scan
and MRI)
ANATOMIC POSITION

Situs Solitus: right atrium is on

the right.

Dextroposition: the heart is

shifted toward the right
hemithorax.

Dextrocardia: the cardiac apex is

directed to the right
Stephen Miller- Lawrence Boxt-Suhny Abbara- Mosby/Elsevier- 2009 Cardiac Imaging: The Requisites 3 rd Edition
NORMAL CARDIAC ANATOMY
MOGULS OF THE
HEART

1. AORTIC KNOB Prominence: ectasia, aneurysm, or

hypertension, Notching or a “Figure of
3”: Coarctation of the Aorta

2. MAIN PULMONARY Increased: Post stenotic Dilatation,

ARTERY COPD, Pulmonary Arterial HTN
Decreased: Pulmonary Atresia

3. PROMINENT ATRIAL Rheumatic heart disease

APPENDAGE Cardiac aneurysm, pericardial cyst,
mediastinal tumor
4. BULGE JUST ABOVE Ventricular Aneurysm
THE CARDIOPHRENIC
ANGLE
5. BULGE AT THE Pericardial Cysts, Prominent Fad Pad,
CARDIOPHRENIC Adenopathy
ANGLE
CHAMBER ENLARGEMENT
CHAMBER ENLARGEMENT:
RIGHT ATRIUM

>5.5 cm
CHAMBER ENLARGEMENT:
RIGHT VENTRICLE
CHAMBER ENLARGEMENT: LEFT ATRIUM

>7 cm
WALKING MAN
SIGN
DOUBLE
DENSITY SIGN
CHAMBER
ENLARGEMENT:
LEFT VENTRICLE

SCHMOO CONFIGURATION
HOFFMAN RIGLER SIGN
CHAMBER
ENLARGEMENT:
LEFT VENTRICLE

>1.8 cm

HOFFMAN RIGLER SIGN

WATER SHAPED
BOTTLE
CONFIGURATION
Global cardiomegaly
Pericardial effusion:
• Normal pericardial fluid- 20ml
• 200ml of pericardial fluid collection to
be detected by plain film radiography
CARDIAC IMAGING MODALITIES
Gerber, et al (2009) Ionizing Radiation in Cardiac Imaging
https://doi.org/10.1161/CIRCULATIONAHA.108.191650Circulation. 2009;119:1056–1065
ECHOCARDIOGRAPH
Y

• Initial cardiac evaluation of choice for a

known systemic, congenital, or acquired
disease that could be associated with
structural heart disease
• Echocardiography is useful in assessing the
cardiac chamber size and function.
• Doppler techniques (pulsed or continuous
wave) can be used to evaluate for abnormal
communications between the left- and right-
sided cardiac chambers, valve regurgitation,
and tissue motion.
TRANSTHORACIC
ECHOCARDIOGRAPHY

• Uses a fan-shaped beam of ultrasound directed through

a number of selected planes of the heart in a set of
standardized views of the cardiac structures
• These views are designated by the position of the
transducer, the orientation of the viewing plane relative
to the primary axis of the heart, and the structures
included in the image
 PARASTERNAL LONG AXIS VIEW OF
APICAL 4 CHAMBER VIEW
THE LEFT VENTRICLE (IN SYSTOLE)

AA B
PEAK WAVE
CONTINUOUS WAVE

C D
 TRANSESOPHAGEAL
ECHOCARDIOGRAPHY

• Less common way to perform echocardiography, in

which a specialized probe containing an ultrasound
transducer at its tip is passed into the patient’s
esophagus
• Disadvantages: more invasive test and requires
sedation
• Frequently used assess presence of thrombus in the left
atrium prior to procedure and to assist with
interventional cardiac procedures (eg balloon mitral
valvoplasty, percutaneous ASD and patent foramen
ovale closure, atrial appendage occluder device
implantation)
NUCLEAR
IMAGING

• Nuclear medicine uses small

amounts of radioactive materials
called radiotracers to image the heart
noninvasively.
• Provide unique information regarding
cardiac function, blood flow, and
myocardial inflammation.
RADIONUCLIDE VENTRICULOGRAPHY

• Noninvasive way to evaluate ventricular

function both visually and quantitatively.
• Its primary use today is in monitoring cardiac
function in patients receiving certain
chemotherapeutic agents (anthracyclines:
doxorubicin or daunorubicin) which are
cardiotoxic.
 MYOCARDIAL PERFUSION
IMAGING

• One of the most widely used nuclear cardiology techniques.

• A small amount of radiotracer such as technetium (99mTc)
sestamibi is injected at both rest and stress. Images of the heart
are then acquired using a single-photon emission computed
tomography (SPECT) camera which detects the radiation
released by the tracer.
• UNMATCHED DEFECT: Defect is detected at stress but not at
rest ( presence of coronary artery narrowing resulting in stress-
induced myocardial ischemia)
• MATCHED DEFECT: Areas of myocardium that have a defect at
both rest and stress (scarred due infarct)
POSITRON EMISSION
TOMOGRAPHY (PET)

• Most commonly used in oncology and in the evaluation

of ischemia
• Provides information about the blood supply and
metabolic activity of the heart with images typically
acquired at both stress and rest
• Intravenous radiotracers used in PET perfusion imaging
include Rubidium-82, Nitrogen-13 ammonia, and
Oxygen-15 water
• Can be used to evaluate for inflammation in patients with
known or suspected cardiac sarcoidosis via Intravenous
injection of 18F-fluorodeoxyglucose (18F-FDG)
Examples of improved diagnostic reliability of PET vs.
SPECT MPI in the same patients.
(A) A 70-y-old man status, post CABG with no history of
MI. Exercise/rest SPECT images are normal but had
significantly reduced left ventricular ejection fraction.
PET MPI within 2 wk discloses a clinically occult
posterobasal MI.
(B) A 53-y-old man with exertional left arm pain. SPECT
images with dipyridamole stress are normal. PET
MPI within 2 wk demonstrates a reversible
inferoseptal perfusion defect

Impact of Myocardial Perfusion Imaging with PET and 82Rb on Downstream Invasive Procedure Utilization,
Costs, and Outcomes in Coronary Disease Management
Michael Merhige-William Breen-Victoria Shelton-Teresa Houston-Brian D'Arcy -
http://jnm.snmjournals.org/content/48/7/1069.abstract
 CARDIAC CT
• Important role in the evaluation of coronary and
cardiac anatomy.
• Oral and IV beta-blockers are sometimes given to
slow the heart rate to 60 or 70 bpm

Electrocardiogram (ECG) gated CT acquisition:

• a series of images, each obtained at one point in the
cardiac cycle
• allows analysis of changes in cardiac morphology
over the cardiac cycle, thus, providing a means of
evaluating cardiac function.
PROSPECTIVE GATING (“STEP AND SHOOT”):

• ECG-triggering synchronizes the x-ray exposure to specific portions of the cardiac cycle, allowing for
reduced radiation dose.
• During the remainder of the cardiac cycle, the CT tube current is turned off and therefore no radiation is
delivered. the table moves to the next region of the heart, and the scanner turns back on during the preselected
portion of the cardiac cycle.
• Reconstructions in phases outside that interval are not possible and function cannot be assessed.
RETROSPECTIVE GATING:
• Images are acquired throughout entire cardiac
cycle over multiple continuous heartbeats with
simultaneous ECG recording.
• Advantage of allowing for quantification of cardiac
volumes and function.
• Helpful in patients with arrhythmias as the scan
can be edited to remove data from irregular beats,
such as in a premature ventricular contraction.
• Higher radiation dose.
CORONARY ANGIOGRAPHY

• .

Stephen Miller- Lawrence Boxt-Suhny Abbara- Mosby/Elsevier- 2009 Cardiac Imaging: The Requisites 3rd Edition
Stephen Miller- Lawrence Boxt-Suhny Abbara- Mosby/Elsevier- 2009 Cardiac Imaging: The Requisites 3 rd Edition
CORONARY ANGIOGRAPHY

1. Determine the extent and location of stenoses

2. Grade the severity of each stenosis so that a
clinical decision can be made regarding both
treatment and prognosis.
3. Grade the morphology of the atherosclerotic
plaque

4. Evaluate the size of the vessel distal to the

stenosis to see if it is a suitable recipient for a
bypass graft or stent placement at the stenosis.

Stephen Miller- Lawrence Boxt-Suhny Abbara- Mosby/Elsevier- 2009 Cardiac Imaging: The Requisites 3 rd Edition
Coronary CT angiography (CTA)

• Widely performed to assess the coronary arteries accurately and noninvasively

• Has high diagnostic accuracy for CAD compared to catheter angiography.
• Not recommended for cardiovascular risk assessment in asymptomatic adults and nonacute chest pain

TARGET POPULATION
• low-risk patients with a family history of premature coronary heart disease (male first-degree relative <55 years
or female first-degree relative <65 years)
• Intermediate-risk factors (10-year risk of coronary heart disease of 10% to 20%) and no history of CAD
• Asymptomatic adults ≥40 years of age with diabetes can also undergo screening.
ROLE IN THE ACS

American College of Cardiology Foundation and the American College of Radiology (2016) 1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2015.07.007
 International Study of Comparative Health Effectiveness with
Medical and Invasive Approaches (ISCHEMIA TRIAL)

• Helps build the case for a central role of coronary CT angiography for the evaluation of symptomatic
patients suspected of having coronary artery disease.
• Started 2012- completed 2019
• Population (5179 patients): stable ischemic heart disease and moderate to severe ischemia on
noninvasive stress testing
 FINDINGS:
“Invasive” group, the rate of revascularization was high: 78% of patients underwent percutaneous
intervention or bypass surgery.
“Conservative” group, coronary angiography was not routinely performed in everyone, but 23% of
patients eventually did undergo revascularization during the follow-up period

 CONCLUSION:
“Invasive approach” was not associated with a reduction in the primary outcome of
cardiovascular death, myocardial infarction, hospitalization for unstable angina, hospitalization
for heart failure, or resuscitated cardiac arrest over a median follow-up of 3.3 years.

Reynolds, H et al. American College of Cardiology- International Study Of Comparative Health Effectiveness With Medical and Invasive Approaches. (April 2020)
https://www.acc.org/latest-in-cardiology/clinical-trials/2019/11/15/17/27/ischemia
CORONARY ARTERY CALCIUM SCORE CT

• Valuable imaging technique used to quantify coronary artery

calcification.
• Well-established test for risk-stratifying asymptomatic patients DENSITY FACTOR X Grading of coronary
and is an independent predictor of long-term prognosis.
area of the artery disease (based
calcification speck= on total calcium score)
AGATSTON CACS AGATSTON SCORE
• semi-automated tool to calculate a score based on the extent DENSITY FACTOR: no evidence of CAD: 0
of coronary artery calcification detected by an unenhanced 130-199 HU: 1 calcium score
low-dose CT scan 200-299 HU: 2 minimal: 1-10
• entering the Agatston score into a CACS calculator, the 300-399 HU: 3 mild: 11-100
patient’s score can be compared to those of the same age, 400+ HU: 4 moderate: 101-400
gender, and ethnicity. severe: >400
• Higher CACS is indicative of a greater likelihood of
cardiovascular death.
CARDIAC MRI

• “The one stop shop”.

• Considered as the gold standard for evaluating cardiac
function and can differentiate between ischemic and
nonischemic etiologies of myocardial injury and
dysfunction
• Uses motion suppression techniques to cancel out
complex cardiac contractile motion.
Indications: assessment of cardiac size and function,
myocardial ischemia and viability, cardiomyopathies,
myocarditis, iron overload, valvular disease, vascular
diseases, and CHD.

Contraindications: implanted devices, such as

pacemakers and implantable cardioverter defibrillators
(ICDs)
 CARDIAC MRI
Cardiac MRI perfusion imaging:
• Used to characterize coronary flow reserve and myocardial perfusion under rest and stress conditions.
• First-pass imaging: contrast enhancement during the first pass of a contrast agent bolus through the
cardiac chambers and the myocardium is evaluated and measured.

Phase contrast MRI :

• technique that allows for reliable quantification of regurgitant and shunt flow volumes, visualization of
time-resolved flow patterns, and assessment of wall shear stress and turbulence.
• Common indications for phase contrast imaging include valvular disease and CHD.

Gradient Echo Magnetic Resonance Imaging:

• allows a short acquisition time.
• Uses the bright signal of the blood pool in these images results from flow-related enhancement
• Cine loop display demonstrates dynamic changes in the morphology of the heart, providing a means for
evaluating regional wall motion, ventricular function, and valvular dysfunction.
• GE images provides accurate indices of ventricular function and valvular dysfunction.
Late gadolinium enhancement (LGE):
• Method for assessing infarct and fibrosis, with prognostic value in patients with ischemic and
nonischemic cardiomyopathies.
• The presence, extent, and pattern of delayed enhancement are helpful in diagnosing and monitoring
patients with cardiomyopathies.
Parametric mapping
• Each tissue has its own characteristic range of T1 and T2 values, which may be altered in disease.
• Allows for quantification of myocardial tissue based on changes in T1, T2, and T2* relaxation times and
extracellular volume (ECV).
• Parametric mapping allows for quantification, potentially standardizing cardiac MRI measurements of
myocardial tissue properties.
REFERENCES:
• Stephen Miller- Lawrence Boxt-Suhny Abbara- 2009 Cardiac Imaging: The Requisites 3 rd Edition. Mosby/Elsevier
• Appropriate Utilization Of Cardiovascular Imaging in Heart Failure: A Joint Report Of the American College Of Radiology Appropriateness Criteria
Committee and the American College Of Cardiology Foundation Appropriate Use Criteria Task Force (2013)
https://www.sciencedirect.com/science/article/pii/S0735109713006980?via%3Dihub
• American College of Cardiology Foundation and the American College of Radiology (2016) 1546-1440/15/$36.00 n
http://dx.doi.org/10.1016/j.jacr.2015.07.007
• Gerber, et al (2009) Ionizing Radiation in Cardiac Imaging https://doi.org/10.1161/CIRCULATIONAHA.108.191650Circulation. 2009;119:1056–1065