Ventricular Septal Defect

(VSD)
Small VSDs, the chest radiograph is usually normal

Large VSD: The presence of right ventricular hypertrophy, olegeimic lung fields
(pulmonary hypertension or an associated pulmonic stenosis), gross
cardiomegaly with prominence of both ventricles, the left atrium.
Ventricular Septal defects
 30–50% of small defects close spontaneously, most
frequently during the 1st 2 yr of life.
 Small muscular VSDs are more likely to close (up to 80%)
than membranous VSDs are (up to 35%).
 infants with large defects have repeated episodes of
respiratory infection and heart failure despite optimal
medical management.
 Surgical repair prior to development of an irreversible
increase in pulmonary vascular resistance (usually prior to
the patient's second birthday).
Atrial Septal Defect

 Enlargement of the
right ventricle
 Enlargement of atrium
 Large pulmonary artery
 increased pulmonary
vascularity is.
Primary Pulmonary Hypertension

 Prominent pulmonary
artery.
 Prominent right
ventricle
 Prominent vascularity
in the hilar areas
 Decreased vascualr
marking in the
periphery.
 No treatment
 Tetralogy of Fallot

 Ventricular septal
defect
 Pulmonic stenosis
 Overriding aorta
 Right ventricular
hypertrophy

Cyanotic
Congestive Cardiac Failure

 Enlarged heart
 Plethoric lung fields
specially at bases
Boot shaped heart in pt. with
TOF
Snow man or figure8 in pt. with TAPVR
Situs inverses
Aortic Coarctation
10-day old girl with CHF; 8 cc contrast,

3D CT
CT
Patent Ductus
Arteriosus

CT MR
Shunt Lesion: Septal Defects
ASD

ASD/VSD
Post ASD repair
 normal frontal view
L

AV

MV

Gray’s Anatomy, wordpress

Source Undetermined
 normal lateral view

AV

MV

Patrick Lynch, wikimedia commons

Source Undetermined
 Enlarged
Right Atrium

Source Undetermined

Source Undetermined
 Enlarged
Right Ventricle

Source Undetermined

Source Undetermined
 Enlarged
Right Ventricle
(lateral CXR)

Source Undetermined

Source Undetermined
 Enlarged
Left Atrium

Source Undetermined

Source Undetermined
 Enlarged
Left Atrium

calcified
mitral Source Undetermined

annulus

Source Undetermined
 Enlarged
Left Ventricle

Source Undetermined

Source Undetermined
54 year old with dyspnea on exertion

a) mitral valve disease

b) atrial septal defect
c) primary PHTN
Source Undetermined
d) pulmonary edema Source Undetermined
54 year old with dyspnea on exertion

a) mitral valve disease

b) atrial septal defect
c) primary PHTN
Source Undetermined Source Undetermined
d) pulmonary edema
 24 year-old
with heart
murmur

a) pulmonic stenosis
b) ASD
c) fluid overload
d) primary PHTN

Source Undetermined
 24 year-old
with heart
murmur

a) pulmonic stenosis
b) ASD
c) fluid overload
d) primary PHTN

Source Undetermined
 Small Heart
Pericardial or Myocardial

Disease?
Use physical exam to
Pericardial Calcifications
differentiate
Small Heart

 Kussmaul’s sign and

pericardial knock are
consistent with
constrictive pericarditis
 Globally Enlarged Heart
Pericardial Disease

 Pericardial Effusion

– “Oreo” Sign
 Fluid collection between epicardial and
retrosternal fat pads

– WIDE vascular pedicle

 RA pressures are high due to constriction and
therefore do not allow blood to easily return to
the RA
Oreo Sign
Myocardial Failure or Pericardial
Effusion?

Wide Vascular Pedicle

Visible Borders of
Mediastinum

Pericardial Effusion
Myocardial Failure or Pericardial
Effusion?
Globally enlarged heart
Narrow VPW

Myocardial Failure
Gehlbach, Brian K., et al. The Pulmonary Manifestations of Left Heart Failure. Chest. 2004; 125: 669-682.
 Valvular Disease =
Unequal chamber enlargement

Small/Normal Heart Big Heart

• Valvular Stenosis • Valvular Insufficiency
- Chambers are pressure overloaded- Chambers are volume overloaded
- Mild dilation of chambers may be -seen, but dilation
Marked general of
hypertrophy
chambers is
not seen on chest radiograph
Chest radiograph
– Decreased pulmonary blood

Aortic Stenosis
flow with normal flow
distribution
– Narrow vascular pedicle
– Increased LVP (may have mild
LV enlargement)
– Post stenotic dilation of aorta
 Atrial Septal Defect…Why?

LUL Oligemia

rrow VPW

ulmonary Venous LV Dilation

HTN
 Mitral and Tricuspid
Chest Radiograph
Insufficiency
– Marked dilation of LA
– Pulmonary flow inversion
Tr Chest radiograph
– Marked dilation of RA
– Wide vascular pedicle
Decreased with Cephalization

Larger vessels

Small Vessels
 Evaluate the Vessels:
Cardiogenic Edema
 Cardiogenic edema occurs secondary to
hydrostatic forces and therefore
predominately occurs in the lower lobes
 Most commonly secondary to left heart
failure (acute or chronic)
 Vascular indistinctness
 Which represents edema?

Vascular Indistinctness Well-defined vessels

Cardiogenic Edema
MRI
Perfusion w/ Gadolinium

http://radiographics.rsnajnls.org/cgi/content/full/21/4/1047
Tags and Perfusion
Coronary Artery Imaging
More Angiograms
RCA: MR and Conventional
Fast Spin-Echo
Ct angio
 (a) RAO view along the interventricular groove shows
LAD, with mixed atherosclerotic lesion (arrowhead)
with calcified components in the proximal course of
the vessel.
 (b) LAO view in plane RCA with calcified nodules
(arrowheads) along the course of the vessel.
 (c) LAO "spider" view shows (LAD and its diagonal
branches, with soft-tissue-attenuation plaque
(arrowhead) in the anterior aspect of the left main
coronary artery (LM) wall.

U. Joseph Schoepf. Radiology 2004;232:18-37

 Multiplanar
reformations: image
data can be rearranged
in arbitrary imaging
planes, with image
quality comparable to
that of the original
transverse sections. left anterior descending coronary artery in a patient
with CAD.

U. Joseph Schoepf. Radiology 2004;232:18-37

  Three-
dimensional
display: 3D post
processing is a means of
displaying information in
an intuitive fashion. The
most commonly used
Left: Anteroposterior cranial projection shows LAD
and Cx.
technology for 3D display
Right: Volume rendering in anteroposterior cranial of the coronary arterial
projection shows left main coronary artery with its tree is volume rendering.
branches, LAD and Cx.

U. Joseph Schoepf. Radiology 2004;232:18-37

 Contrast-enhanced 16-detector
row CT coronary angiography.
Colored volume rendering of
right coronary artery (RCA)
displayed in slightly cranial right
anterior oblique.

U. Joseph Schoepf. Radiology 2004;232:18-37

Patient with superdominant anomalous right coronary artery (AnRCA) supplying the majority of the
myocardium. (a) Selective conventional angiographic image and (b) volume-rendered 3D reconstruction
(cranial right anterior oblique perspective) from contrast-enhanced 16-detector row CT coronary
angiography.
U. Joseph Schoepf. Radiology 2004;232:18-37
 (LIMA) bypass graft. Anastomosis has been created
between left internal mammary artery and left anterior
Colored volume-rendered view from anterior
descending coronary artery (LAD) territory. Note
perspective, derived from 16-detector row CT
extensive atherosclerotic changes in the native vessels.
angiography, 3 venous bypass grafts VCABG-
LAD, VCABG-Cx, and VCABG-RCA. Additional
left internal mammary artery bypass graft
(LIMA-BG), also to the LAD
U. Joseph Schoepf. Radiology 2004;232:18-37
 (a) Colored 3D volume-
rendered view from right
posterior oblique perspective
reveals luminal narrowing
(arrowhead) of artery
proximal to the stent. (b)
Maximum intensity
projection and (c) multiplanar
reformation in oblique
coronal planes show patent
stent lumen and mixed
atherosclerotic lesion (arrow)
with calcified and
noncalcified components as
the cause of stenosis
proximal to the stent. (d)
Conventional angiographic
image in left anterior oblique
projection confirms stent
patency and presence of
stenosis.

U. Joseph Schoepf. Radiology 2004;232:18-37

 (A) Volume rendering technique
demonstrates stenosis of right
coronary artery below the acute
marginal branch as well as
nodular coronary calcifications
largely extrinsic to the right
coronary lumen and (B) normal
left coronary artery. (C, D)
Maximum-intensity projection
of the same arteries
demonstrates severe soft plaque
stenosis of the right coronary
artery and superficial calcific
plaque. (E, F) Invasive coronary
angiography of the same
arteries

Gilbert L. Raff . JACC 2005; 46:552-557

 Typical examples of reformatted
magnetic resonance (MR) (left
panels), and multidetector row
computed tomography (MDCT)
(center panels) and
corresponding quantitative
coronary angiography (QCA)
images (right panels)
 (A) Normal right and left
coronary arteries by MR, MDCT,
and QCA.
 (B) Isolated mid-RCA stenosis.
 (C) Two-vessel disease involving
the mid-LAD, and left circumflex
coronary artery

Joëlle Kefer. JACC 2005; 46:92-100