Radiology of Cardiac Disease

Cardiac silhouette consists of (4)
-pericardium and pericardial fluid >> minimal amount
-myocardium >> including epicardium and endocaridum
-0rigin of the major vessels
-blood inside the chambers
Why might a normal heart change size?
size may change SLIGHTLY with the cardiac cycle
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LEFT LATERAL
-apex looks rounded and pointing away
-convergence of crura
What lateral is this?
Why (with respect to the heart)?
LEFT LATERAL
-apex looks rounded and pointing away
-convergence of crura
RIGHT LATERAL
-cardiac silhouette appears longer
-points more upwards 
-parallel appearance of the crura
What lateral is this?
Why (with respect to the heart)?
RIGHT LATERAL
-cardiac silhouette appears longer
-points more upwards
-parallel appearance of the crura
What lateral view of the heart do cardiologists like because its more of a true representation of the heart in cardiac size/length?
R lateral
Why does the right lateral projection cause less rotation of the heart?
caudoventral mediastinal reflection prevents movement of the apex so apex appears longer
DV
apex is against the diaphragm
more natural position of the heart
apex is more to the left side
DV or VD? Why?
DV
apex is against the diaphragm
more natural position of the heart
apex is more to the left side
VD
heart falls away from diaphragm
apex rotates slightly forward
more distance between heart and diaphragm
apex towards midline not on the left
DV or VD? Why?
VD
heart falls away from diaphragm
apex rotates slightly forward
more distance between heart and diaphragm
apex towards midline not on the left
What breeds are barrel chested
bulldog
yorkshire terrier
dachshund
Cardiac size in barrel chested dogs
heart is relatively large and the trachea appears slightly elevated
Heart rads of normal golden retrivers
apparently large, square shaped heart on a lateral radiograph
How can cardiac size be assessed
using the vertebral heart scale aka VHS
Puppies heart sizes by VHS measurements are within the reference range for
adult dogs
1 = aorta
2 = left atrium
3 = caudal vena cava
4 = left ventricle
5 = right ventricle
6 = right auricle
7 = cranial vena cava
1 = aorta
2 = left atrium
3 = caudal vena cava
4 = left ventricle
5 = right ventricle
6 = right auricle
7 = cranial vena cava
1 = left atrium
2 = brachial artery
3 = left subclavian a
4 = aortic arch
5 = pulmonary a
6 = *left auricle* NOT left atrium
7 = thoracic aorta
8 = left ventricle
9 = caudal vena cava
10 = right ventricle
11= right atrium
12 = cranial vena cava
1 = left atrium
2 = brachial artery
3 = left subclavian a
4 = aortic arch
5 = pulmonary a
6 = *left auricle* NOT left atrium
7 = thoracic aorta
8 = left ventricle
9 = caudal vena cava
10 = right ventricle
11= right atrium
12 = cranial vena cava
What breed of dog? Why?
staffordshire bullterrier
> heart appears big but if you look at it objectively its not enlarged
What breed of dog? Why?
staffordshire bullterrier
>rounded, plump heart
What breed of dog? Why?
doberman pinscher
> heart looks longer
> more space in the chest vs the heart
> stands more upright
What breed of dog? Why?
doberman pinscher
> long, slender heart
Rad signs of heart disease
changes in size, shape, and evidence of R- or L- sided failure
Generally changes in the heart present as
enlargement
Which comparing heart size with width of ICS spaces
2.5 – 3.5 ICS for a dog
< 2.5 ICS for a cat
The size of the heart is similar to what organ
kidney
Height of the heart should be_ of the height of the thorax on lateral
60%
Width of the heart should be _ of the width of the thorax on DV
60%
Mean VHS in dogs
9.7 +/- 0.5
cut off at 10.6
Mean VHS in cats
7.5 +/- 0.3
cut off at 8.1
What breeds of dogs may exceed the range of a normal VHS
labradors
golden retrievers
boxers
CKCS
greyhound
whippet
lurcher
1. draw a line from the ventral contour of the bifurcation to the apex
2. draw another line at a right angle to your first one and measure the widest part of the heart
3. start at the cranial margin of t4 and overlay your measurements with the thoracic spine
4. count how many vertebrae it covers
How do you measure VHS?
1. draw a line from the ventral contour of the bifurcation to the apex
2. draw another line at a right angle to your first one and measure the widest part of the heart
3. start at the cranial margin of t4 and overlay your measurements with the thoracic spine
4. count how many vertebrae it covers
What is a normal CVC diameter?
0.6 +/-0.09 x length of vertebral body dorsal to the tracheal bifurcation
How is the cardiac long axis measured on the lateral thoracic projection?
measured from the ventral border of the L mainstem bronchus/ventral border of the carina to the most distant ventral contour of the cardiac apex
How is the cardiac short axis measured on the lateral thoracic projection?
measured from the widest point (in the central third region) perpindicular to the long axis
What does the cardiac long axis represent?
the combined size of the left atrium and left ventricle
What is vertebral heart size an indicator of
heart size in relation to body length
Levocardia
normal, apex to the left
Dextrocardia
heart more in the R hemithorax, apex pointing to the right
Situs solitus
normal position of thoracic and abdominal organs
Situs inversus
reversal of the normal thoracic and abdominal organs >> mirror image of normal
Diameter of the CVC in comparison to the aorta
ratio CVC/aorta
< 1 is normal > 1.5 indicates an abnormally wide CVC
Diameter of the CVC in comparison to the length of the vertebral body dorsal to the tracheal bifurcation
0.75 +/- 0.13 in dogs
Ddx of sinus inversus
a wrongly labeled radiograph
Heart function in dextrocardia
probably normal
double check by using the fundus of the stomach > on the left hand side
What is up with this cat?
“Lazy Heart”
normal in old cats
Rad signs of a lazy heart
> cardiac silhouette tilts/slumps cranially
> aorta may also appear tortuous aka a “lazy aorta”
Cardiac pathology with a normal heart size (8)
conduction disturbances
concentric ventricular hypertrophhy
endocarditis
acute myocardial failure
pericardial disease
acute ruptured chordae tendineae
myocardial neoplasia
myocarditis
Cardiac pathologies with a normal heart size must be assessed with
ECG and echocardiography
Cardiac and pericardial disease with *changes in shape and size* of the cardiac silhouette (6)
L sided cardiomegaly
R sided cardiomegaly
generalized cardiomegaly
pericardial effusion
congenital cardiac disease
acquired cardiac disease -> failure
Congenital cardiac diseases that lead to an abnormal shape/size of the cardiac silhouette (3)
Fallot tetralogy
PDA
septal defects
When with pericardial effusion NOT show up as abnormal on a radiography
only a small amount
How do congential cardiac diseases cause morphological changes to the heart?
they have hemodynamic consequences leading to volume overload leading to morphological changes
Rad signs of left atrial enlargement (4)
> loss of caudal cardiac “waist”, caudodorsal bulding
> elevation of the caudal stem bronchi, if severe atrial enlargement selective elevation of the left bronchus
> splitting of the bronchi on DV/VD
> compression of left stem bronchus possible
Rad signs of left ventricular enlargement (2)
> elongation of the cardiac silhouette
> tracheal elevation
“Cowboy sign”
bronchi get pushed back by an enlarged atrium
2 broad causes of left atrial enlargment
volume overload
pressure overload
Ddx left atrial enlargement from volume overload
*mitral valve insufficiency*
diastolic dysfunction of the L ventricle
PDA with L>R shunt
VSD with L>R shunt
aorticopulmonary septal defect with L>R shunting
endocardial fibroelastosis
What is the most common cause of acquired heart disease?
mitral valve insufficiency
What breed get endocardial fibroelastosis?
Siamese and Burmese kittens
Ddx left atrial enlargement from pressure overload
-LV hypertrophy -> mitral insufficiency
-congential mitral valve stensosis
-cor triatriaum sinister
-atrial or ventricular neoplasia inferfering with transvalvular flow
What are 3 causes of LV hypertrophy?
subaortic stenosis
hypertrophic cardiomyopathy
cats with restrictive cardiomyopathy
What breeds are predisposed to subaortic stenosis?
Boxer, Golder Retriver, German Shepherd, Newfoundland, Pointer, Rottweiler, Bulldog, Bullterrier
DDx: L ventricular enlargement, volume overload
*mitral valve insufficiency*
aortic insufficiency
PDA L>R shunting
VSD
endocrdial cushion defect
aorticopulmonary septal defect
AV fistula
DDx: L ventricular enlargement, pressure overload (3)
subaortic stenosis
systemic hypertension >> CRF, hyperthyroidism, hyperadrenocorticism
hypertrophic cardiomyopathy in cats
Hypertrophic cardiomyopathy in cats is secondary to
hyperthyroidism, acromegaly
L sided cardiomegaly
-apex is prominent, plump and round
Dx?
Rad signs?
L sided cardiomegaly
-apex is prominent, plump and round
L sided cardiomegaly
Dx?
L sided cardiomegaly
Dx?
Is this dog compensating or uncompensating?
Rad signs?
Dx = L sided cardiomegaly
Venous congestion = vessels are wider/thicker than the 9th rib = not compensating
>bulge at level of the L atrium
Dx?
Is this dog compensating or uncompensating?
Rad signs?
Dx = L sided cardiomegaly
Venous congestion – not compensating
>separation of the caudal mainstem bronchi
ddx R atrial enlargement, volume overload
• Tricuspid valve insufficiency
• ASD with L-‐> R shunting
• AV fistula
ddx R atrial enlargement, pressure overload
-R ventricular hypertrophy leading to tricupsid insufficiency due to pulmonic stenosis, Tetralogy of Fallot
-atrial or ventricular neoplasia interfering with transvalvular flow
-cor pulmonale
-congenital tricuspid valve stenosis
-cor triatratum dexter
ddx R ventricular enlargement, volume overload
-tricuspid valve insufficiency
-pulmonic valve insufficiency
-VSD and ASD
-endocardial cushion defect
-AV fistula elsewhere in the body
ddx R ventricular enlargement, pressure overload
-2ry to L heart failure or mitral valve disease
-pulmonic stenosis
-pulmonary hypertension (cor pulmonale)
-congenital heart disease
-2ry to chronic upper airway obstruction
Causes of pulmonary hypertension causing R ventricular enlargment
Dirofilariosis
PTE
PDA
COPD
high altitude disease
pulmonary AV fistula
pulmonary vasculitis
Congenital heart diseases
VSD
PDA
mitrial valve dysplasia
aorticopulmonary septal defect
cor triatriatum sinister
Rad signs of R atrial enlargment: DV and lateral
DC: bulge at 9-11 o clock
lateral: increased CrCd dimension at level of atria
+/- CVC
Rad signs of R ventricular elargement: DV and lateral
Lateral: *increased sternal contact* > 3.5 sternebrae
DC: inverted D shape; marked R sided bulge at 5-9 o clock
Signs of R-sided failure (4)
enlarged CVC
hepatomegaly
ascites
pleural effusion is common in cats
Dx?
Rad signs?
R sided cardiomegaly
> sternal contact
increased CrCd dimension at level of atria
R sided cardiomegaly
-bulge over the R side
Dx?
Rad signs?
R sided cardiomegaly
-bulge over the R side
R sided cardiomegaly
-inverted D
-apex disappears
Dx?
Rad signs?
R sided cardiomegaly
-inverted D
-apex disappears
Dx?
Rad signs?
R sided cardiomegaly
-inverted D shape
>> Cor pulmonale
Dx?
Rad signs?
R sided cardiomegaly
-wide base
-looks kinda square
-loss of ovoid shape
>> trachea looks elevated so there might be some L sided enlargement
Dx?
Hypertrophic cardiomyopathy
> thickening of the ventricular walls grows to the sides so we can’t always see it on rads
Feline cardiomedaly
on DV/VD projections = enlargement of the atria causes the
Dx?
Rad signs?
Feline cardiomedaly
on DV/VD projections = enlargement of the atria causes the “Valentine heart” appearance
What typical bulges appear with the enlargment of the atria in the DV/VD projection?
aortic or pulmonary trunk, and the left auricle
When is generalized cardiomegaly normal?
athletic breeds: greyhound and some young dogs >> mm get big when they exercise
When is generalized cardiomegaly artefactual?
pericardial and mediastinal fat; expiration
Ddx generalized cardiomegaly
fluid overload
bradycardia
end-stage LHF due to mitral valve insufficiency
congenital cardiac dz’s
non-inflammatory myocardial dz
pericardial effusion
congential peritoneopericardial diaphragmatic hernia
GENERALIZED CARDIOMEGALY
-heart takes up more space than lung
-lots of sternal contact
-trachea is pushed up
-very straight, upright, caudal outline
-outline not receding towards the hilus
-all the chambers are enlarged
Dx?
Rad signs?
GENERALIZED CARDIOMEGALY
-heart takes up more space than lung
-lots of sternal contact
-trachea is pushed up
-very straight, upright, caudal outline
-outline not receding towards the hilus
-all the chambers are enlarged
lungs look well ventilated, pt is compensating
Is the dog compensating for HF?
lungs look well ventilated, pt is compensating
pericardial effusion
-very large globoid cardiac silhouette
-signs of R-sided failure
Dx?
Rad signs?
pericardial effusion
-very large globoid cardiac silhouette
-signs of R-sided failure
Dx?
besides the heart, what organ sh0uld you also check
Percardial effusion with signs of R sided failure
>> check the cr abdomen for enlargement of the liver or abdominal effusion
Dx?
Rad signs?
>> pulmonary congestion and cardiogenic pulmonary edem
>> L sided failure
-very upright heart
– sided enlargment
-hilus is poorly visible because lungs have increased patchy opacity
-very big veins
-air bronchograms
Alveolar
this dont is not compensating and needs tx
What lung pattern is this?
Alveolar
this dont is not compensating and needs tx
HEART BASE MASS
-pericardial effusion
-change in the R atrium
-odd shape of cardiac silhouette
Dx?
Rad signs?
HEART BASE MASS
-pericardial effusion
-change in the R atrium
-odd shape of cardiac silhouette
Ddx of a heart base mass
neoplasia: aortic body tumor/chemodectoma
ectopic thyroid tumor
ectopic parathyroid tumor
large tumor of the R atrium >> hemangioSA
HEART BASE MASS
-odd shape of cardiac silhouette
Dx?
Rad signs?
HEART BASE MASS
-odd shape of cardiac silhouette
Most common congenital cardiac condition in the dog
PDA
failure of ductus arteriosus to close
Rad signs of PDA
-segmental enlargement of the descending aorta
-enlarged pulmonary a due to increased pressure and flow
-enlarged L atrium, possible L auricle due to increased blood flow
-enlarged L ventricle due to dilation followed by hypertrophy
-enlarged pulmonary aa and vv due to volume and pressure overload
-“three knuckle sign” on DV radioraphs >> enlarged aorta, pulmonary artery, L auricle
PDA
-long cardiac silhouette
-elevation of the trachea and stem bronchi
-extension of the L atrium
Dx?
Rad signs?
PDA
-long cardiac silhouette
-elevation of the trachea and stem bronchi
-extension of the L atrium
PDA
-3 bumps!
-L sided enlargement
Dx?
Rad signs?
PDA
-3 bumps!
-L sided enlargement
Rad findings in HWD
-R ventricular hypertrophy due to pulmonary hypetension
-dilation of the main pulmonary a
-enlarged pulmonary aa/tortuosity
-peripheral focal or multifocal alveolar pattern from PTE caused by dead adult worm fragments and 2ry allergic pneumonia
-hepatomegaly, ascites, sometimes pleural effusion due to RHF
Rad findings of HWD changed with
duration of infection and worm burden, ocation of the forms, and rate and degree of cardiac compensating
HWD
-enlarged pulmonary a
-enlarged pulmonary lobar aa
-tortuosity
-patchy alveolar infiltrates
Dx?
Rad signs?
HWD
-enlarged pulmonary a
-enlarged pulmonary lobar aa
-tortuosity
-patchy alveolar infiltrates
HWD
-enlarged pulmonary a
-enlarged pulmonary lobar aa
-tortuosity
-patchy alveolar infiltrates
Dx?
Rad signs?
HWD
-enlarged pulmonary a
-enlarged pulmonary lobar aa
-tortuosity
-patchy alveolar infiltrates
Tortuous pulmonary a
HWD
dx?
Tortuous pulmonary a
HWD
worms in right atrium and its distending
aka parallel hyperehoic linear echoes
HWD
dx?
worms in right atrium and its distending
aka parallel hyperehoic linear echoes
HWD
Selective angiography
specific cathter placement into ascending aorta, L ventricle, or L atrium
Non-selective angiography
catheter is placed via peripheral v to terminal cranial or caudal VC or R atrium
What is required to do angiography
general anesthesia
Medium of angiography
water soluble iodinated constrast medium
Angiography: when is the contrast in the right heart chambers? left heart chambers?
4-5 s = right heart chambers
5-6 s = left heart chaambers
How often do you take rads in angiography
intervals of 1-2 s
Angiography helps in the dx of
dilatations, defects, PDA, valvular insufficiencies and defects, stenoses, filing defects, relative chamber size with thickened walls, etc
What type of angiography is this?
selective R sided cardiac angiography
> helps to see cranial contour of the heart
> contrast outlines R ventricle, *pulmonary a and lobar aa*
What type of angiography is this?
selective L sided cardiac angiography
> in-flow view
>contrasts outline of left ventricle, atrium, *pulmonary veins*
Ddx increased diameter aa and vv
– L>R shunt: PDA, VSD. ASD
-peripheral arteriovenous fistula
-iatrogenic IV fluid overload
-fluid retention 2ry to decreased cardiac output
Ddx increased diameter aa only
-dirofilariosis, angriostrongylosis, aelurosrtongylosis
-thromboembolic disease: dirofilariosis, DIC, trauma, angiostrongylosis, renal disease, septicemia, pancreatitis, hyperadrenocorticism
-severe chronic lung disease
Cardiac causes of venous enlargement only (general)
volume overload
primary myocardial disease
Cardiac causes of venous enlargement only, volume overload
mitral insufficiency, early left to right shunts > PDA, VSD
Cardiac causes of venous enlargement only, primary myocardial disease
myocardial failure (arrhythmias, fibrosis), dilatory cardiomyopathy, hypertrophy CMP, restrictive CMP
Noncardiac dysfunction causes of venous enlargement only (general)
left atrial obstruction
Noncardiac dysfunction causes of venous enlargement only from left atrial obstruction
mass (neoplastic or inflammatory) at heartbase, thromboses within left atrium
measurements are compared with vertebral length on lateral radiograph
DV = 10.2 +/- 1.45
VD = 10.2 +/- 0.83
VHS on a DV radiograph?
VD?
measurements are compared with vertebral length on lateral radiograph
DV = 10.2 +/- 1.45
VD = 10.2 +/- 0.83
measurements are compared with vertebral length on lateral radiograph
VHS = 3.4+/- 0.25
VHS on a DV while just assessing the short axis
measurements are compared with vertebral length on lateral radiograph
VHS = 3.4+/- 0.25
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