Radiologi Fakultas Kedokteran Unissula

RADIOLOGI
FAKULTAS KEDOKTERAN UNISSULA

 JANTUNG
 PEMBULUH DARAH BESAR

Non radiologis :
Elektrocardiogram
Echocardiogram
Radiologis:
Tanpa kontras ( X foto toraks)
Dengan kontras (Angiografi, MSCT jantung)
Nuklir
 Posisi PA
 Simetris
 Inspirasi cukup
 Bentuk dada normal
 FFD : 1,8 m – 2 m
Poyeksi rutin: PA dan lateral.
Proyeksi tambahan : obliq kanan-kiri,
dengan esofagus diisi barium.
Proyeksi Posteroanterior (PA)
Batas kiri :
Tonjolan I : arkus aorta.
Tonjolan II : arteri pulmonalis (pada anak-anak
kadang agak besar).
Tonjolan III : aurikel atrium kiri (biasanya tidak
menonjol)
Tonjolan IV : ventrikel kiri
Batas kanan:
Tonjolan I (pelebaran sisi mediastinum):
vena kava superior
Tonjolan II: garis lurus menuju arkus aorta
(aorta ascenden, biasanya tak terlihat)
Tonjolan III: kadang ada (v. Azygos).
Tonjolan IV: atrium kanan.
PROYEKSI
PA
Proyeksi lateral
Batas depan: ventrikel kanan
(belakang sternum), ke belakang
menjadi lengkung aorta.
Batas belakang (1/3 tengah):
atrium kiri.
Batas belakang bawah: ventrikel
kiri.
Ascending aorta
PROYEKSI
LATERAL
Left Atrium
Left Ventricle
Right
ventricle
 Konvigurasi.
 Letak/situs.
 Ukuran.
CTR
M
M: Garis tengah kolumna

vertebra torakalis.
A: jarak antara M dgn
batas kanan jantung yg
terjauh A
B
B: jarak antara M dgn
batas kiri jantung yg
terjauh.
C
C: garis transversal dari
dinding toraks kanan ke
dinding toraks kiri
RUMUS CTR
CTR: A+B X 100 %

C
N : CTR ≤ 50 %
Kardiomegali: > 50 %
Cardiothoracic Ratio—Pitfalls
 Portable AP vs. PA films

 Depth of respiration—inspiration vs. expiration
 Thoracic deformity—pectus excavatum; in the elderly
 Pulmonary diseases that depress the diaphragm
(emphysema)
 Abdominal diseases that elevate the diaphragm
(hepatomegaly, ascites, pregnancy)
 Obesity
 Less magnification on a PA Chest radiograph
because:
 The heart is closer to the cassette
 X-ray source is 6 ft. from the cassette

AP PA
INSPIRASI EKSPIRASI
Not only does pectus excavatum widen the transverse cardiac diameter,
but frequently will cause blurring of the right heart border.
CT demonstrates why pectus excavatum causes
widening of cardiac shadow
Patients with chronic obstructive pulmonary disease (COPD) usually
have a narrow heart due to the hyperinflated lungs
Does Cardiothoracic ratio work from birth to age 5?
 Problems:
 Thymus
 Degree of inspiration
 Importance of Lateral
view
Enlarged infant heart. A vertical line through the trachea
does intersect the heart.
 Hypertrophy
 Usually does not cause cardiac enlargement
 May affect cardiac contour
 Dilatation
 Frequently causes cardiac enlargement
 Usually affects cardiac contour

Left Ventrikel :
Cardiac apex bulged down and left
Hoffman Rigler sign (+) ( X Foto LAT ) : the
posterior border of the left ventrikel extends
1.8 cm or more posteriorly to the posterior
border of the inferior V.Cava at level 2 cm
cephalad to their crossing
LV dilatation with downward bulge
Left Atrium :
Esophagus displaced posteriorly
Prominen left auricle
Prominence of the upper posterior border of
the heart on Lateral view
Dense left atrial shadow, double contour on the
right
Elevated left main bronchus
Right Ventrikel :
Cardiac enlargement toward left with elevated
apex.
Filling of retrosternal space
May displace right atrium toward right
May displace left ventricle backwards
Right Atrium:
Right heart border beyond 1/3 of the right
hemitorax
May fill the retrosternal space
Rare as solitary finding
Right atrial enlargement causes lateral bulge of R heart border—least
reliable of all of the chamber enlargements e.g. can be prominent normally
Congestive heart failure (CHF) : the result of
insufficient output because of cardiac failure, high
resistance in the circulation or fluid overload.
Left ventricle (LV) failure >>, Cardiac output
Pulmonary venous pressure
Dilatations of pulmonary vessels 
Leakage of fluid into intertitial & pleural space
 Into alveoli resulting in pulmonary edema
Cardiomegaly
 Pulmonary vascular redistribution
 Vascular unsharpness due to interstitial edema
 Pleural effusion
 Septal lines
Kerley B—fluid distended interlobular septae

Kerley A—fluid distended central connective
tissue septae
Views of the upper lobe vessels of a patient in good condition (left)
and during a period of CHF (right). Notice also the increased width
of the vascular pedicle (red arrows).
Alveolar edema
Left side
pulmonary edema
is less common
 Ultrasound—most common
 CT—the heart and great vessels are well
visualized on chest studies done with I.V contrast
 MRI
CT CARDIAC
Indication and patient selection
 CAD risk factor required to have a coronary CTA.
 Primary CAD risk factor:

Cigarette smoking
Hypertension
Elevated LDL (>130mg/dl)
Low HDL( < 40 mg/dl)
Diabetes mellitus
Family history
 Assesment post by-pass graft
 Anomali vascular.
 Triple rule out in chest painCAD, dissecting aorta

(DA) and pulmonal emboli (PE)
Severe CAD,calcium score
> 500 units.
tn.HS,69th.
Riwayat AMI,
hiperlipidemi
Rekomendasi penanganan pasien berdasarkan calcium score
Calcium score risk recommendation
0 no atherosclerotic plaque healthy diet,stop
CAD risk very low smoking.
1-10 minimal plaque burden ,
CAD risk low +tight control of
DM and hypertension,
consider of using statin.
11-100 mild plaque burden,
CAD risk moderate +statin,aspirin
101-400 moderate plaque burden
CAD risk high +exercise program,
folic acid, vit.E
> 400 extensive plaque burden +stress test,coronary
angiography
Prognosis in calcium score
In 2000,The American College of Cardiology together with

American Heart Association, base on EBCT calcium score
in correlation with prognosis of CAD :
1.Zero calcium score: possibility of atherosclerosis
plaque is very low, no evidence of CAD.
2.Positive calcium score : confirm the present of CAD.
3.High calcium score : possibility of vessel disease is
high .
4.Severe calcium score : consistent with moderate-to-
high risk CAD in 2-5 years.
Impression of the interpretation:
 Normal CTA : rutine check up
 Mild Coronary Artery Disease:

Recommend the patient to consult a cardiologist for
risk factor assessment and possible statin +aspirin
therapy.
 Moderate CAD:
Consult cardiologist for statin and aspirin therapy as
well as a nuclear stress test.
 Severe CAD:
Recommend for heart catheterization
Stenosis proximal LAD
Stenosis proximal LAD and LCX
CTA coronary does not meant to
replace coronary angiography
CTA coronary is a screening

modality in CAD risk patient
with no symptom.
In patient with high risk coronary
heart disease and high calcium
scoring, it is better to proceed for
direct coronary angiography .
 Sometimes suggested
by PA and lateral chest
x-ray
 Ultrasound is the best
diagnostic method
 CT also capable of
diagnosing
 Thrombus in LV or atrial appendage most
common—2ndary to MS, atrial fib.,
cardiomyopathy—echo best
 Myxoma—usually near atrial septum
 Lipoma
 Primary (sarcomas) or metastatic tumors
(breast or lung most common).
Left atrial myxoma in a 60-year-old man
 Trans-esophageal echo (TEE) and MRI are
reliable diagnostic methods for dissection
but spiral CT most commonly used because
of availability
 Angiography is the gold standard
Aortic aneurysm
(arrow)
Descending thoracic aortic aneurysm with mural thrombus at the
level of the left atrium
•Double aortic knob sign (40% of patients)
•Diffuse enlargement of the aorta
•Tracheal displacement to the right
•Pleural effusion
•Pericardial effusion
•Cardiac enlargement
•Displacement of a nasogastric tube
•Left apical opacity
Plain anteroposterior view of the chest demonstrates
a wide mediastinum
Sagittal gradient-echo
MRI image obtained in
early systole shows a jet of
blood flowing through the
intimal tear from the
smaller anterior true
lumen into the larger
posterior false lumen.
 Valvular Heart Disease—chamber
enlargement
 Congestive Heart Failure
 Congenital Heart Disease—pulmonary
vascularity
 Some Aortic Aneurysms
 Pulmonary AVM
 Coronary artery calcification—screening test for
coronary artery disease particularly
 Cardiac Masses
 Pericardial disease
 Pulmonary AVM
 Aortic aneurysms or dissections
 Multiplanar imaging of cardiac anatomy
and pathology
 Aneurysms and dissections
 Intracardiac thrombi and tumors
 Coronary artery disease
 Congenital heart disease
References
 Gunderman RB: Essential Radiology. The Circulatory System: The
Heart and Great Vessels. Thieme 103-174
 Stanford W, Thompson BH: Imaging of Coronary Artery
Calcification. Rad Clinics North Am 37#2:257-272, 1999
 Duerincikx AJ: Coronary MR Angiography: Rad Clinics North Am
37#2:273-318, 1999
 Lipton MJ, Coulden R: Valvular Heart Disease. Rad Clinics North
Am 37#2:319-339, 1999

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RADIOLOGI

FAKULTAS KEDOKTERAN UNISSULA

 PEMBULUH DARAH BESAR

M: Garis tengah kolumna

CTR: A+B X 100 %

 Portable AP vs. PA films

 X-ray source is 6 ft. from the cassette

 May affect cardiac contour

 Usually affects cardiac contour

 Vascular unsharpness due to interstitial edema

Kerley B—fluid distended interlobular septae

 Primary CAD risk factor:

 Assesment post by-pass graft

 Triple rule out in chest painCAD, dissecting aorta

0 no atherosclerotic plaque healthy diet,stop

CAD risk very low smoking.

1-10 minimal plaque burden ,

CAD risk low +tight control of

11-100 mild plaque burden,

CAD risk moderate +statin,aspirin

101-400 moderate plaque burden

CAD risk high +exercise program,

folic acid, vit.E

> 400 extensive plaque burden +stress test,coronary

In 2000,The American College of Cardiology together with

 Mild Coronary Artery Disease:

CTA coronary is a screening

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