X-ray picture of heart lesions

Cardiac ischemia. Myocardial infarction

Coronary heart disease is caused by a violation of coronary blood flow and a gradual decrease in myocardial contractility in ischemic zones. Violations of the contractile function of the myocardium can be detected using various methods of ultrasound diagnosis. The easiest and most accessible of them is echocardiography. In this case, the unevenness of contractions of different sections of the left ventricular wall is determined. In the ischemic zone, a decrease in the amplitude of the motion of the ventricular wall during systole is usually observed. The thickness of the interventricular septum and the systolic thickening of the myocardium are reduced. The left ventricular ejection fraction is reduced with increasing left ventricular contractions (further, the right ventricular ejection fraction decreases). Local violations of contractility are observed at a time when there are still no significant signs of circulatory insufficiency.

Valuable information about the blood flow in the heart muscle allows you to obtain radionuclide studies - perfusion scintigraphy and single-photon emission tomography. With the help of these techniques, not only qualitative but also, crucially, a quantitative characteristic of the depth of damage to the heart muscle can be obtained. Beta-dionuclide methods are especially effective when carrying out load tests, in particular, bicycle ergometric test. Scintigrams of CT1-chloride are performed twice: immediately after exercise and after rest (for 1 to 2 hours). In patients with myocardial ischemia, the initial scintigram shows a decreased fixation of the RFP. Normalization of the scintigraphic picture after rest testifies to the transient violation of blood circulation - stress-induced ischemia. If the previously registered defect accumulation RFP is preserved, then there is a persistent loss of blood circulation, usually as a result of scar formation on the myocardium.

Computer tomography may also prove useful in the diagnosis of coronary heart disease. The area of the ischemic muscle under conditions of intravenous contrasting has a lower density and is characterized by the lag of the contrast peak. In this zone, the systolic thickening of the myocardium was reduced, the mobility of the inner contour of the ventricular wall was reduced.

The final conclusion about the state of coronary blood flow is made based on the results of coronorography. According to X-ray images, coronary arteries filled with contrasting matter with their branches of the 1-3th order can be identified, localization and nature of pathological changes can be established (constriction and tortuosity of vessels, irregularity of their contours, occlusion in thrombosis, presence of marginal defects in sites of atherosclerotic plaques, ). However, the main purpose of coronary angiography is to determine the necessity and development of tactics for carrying out transluminal angioplasty or a complex surgical intervention, aortocoronary shunting.

The main clinical manifestation of myocardial ischemia is known to be permanent or recurrent pain in the region of the heart. However, similar pain can occur with myocardiopathy, aortic stenosis, dry pericarditis, lung and diaphragm diseases, motor disorders of the esophagus and neurocirculatory disorders. Below in the form of a diagnostic program, tactics of radiation examination are presented in the differential diagnosis of these pathological conditions.

One of the widely used methods of treating ischemic disease caused by stenosis or obstruction of the coronary artery or its branch is percutaneous transluminal angioplasty. A narrow catheter with a balloon is inserted into the narrowed segment of the vessel under X-ray control. Inflation of the balloon is sought to reduce or eliminate stenosis and restore coronary blood flow.

Acute myocardial infarction is recognized on the basis of the clinical picture, the results of electrocardiography, the study of cardiospecific enzymes and the concentration of myoglobin in serum. However, in doubtful cases, as well as to clarify the localization and volume of the infarct and the state of pulmonary circulation, radial methods are used. Even in the ward or intensive care unit, chest radiography can be performed. Immediately after a heart attack, the pictures show an increase in the shadow of the heart, there is venous plethora of the lungs, especially in the upper lobes, due to a reduction in the pumping function of the heart. With worsening of the patient's condition, plethora turns into interstitial edema or mixed interstitial-alveolar edema of the lungs. As the patient's condition improves, edema and pulmonary embolism disappear. In the first 2 weeks after a heart attack, the size of the heart on repeated radiographs decreases by about a quarter, and in young people it is slower than in older people.

Ultrasound can also be performed at the patient's bedside. In the first hours of the disease, it is possible to identify areas of general or local disturbance of left ventricular contractility, note its expansion. Particularly characteristic is the appearance of a hypokinesia site in the zone of blood supply disturbance during hyperkinesia of intact adjacent sites. Repeated ultrasound is important to distinguish a fresh infarct from cicatricial changes. Sonography makes it possible to recognize such complications of the infarct as a rupture of the papillary muscles with a violation of the function of the mitral valve and the rupture of the interventricular septum.

Direct visualization of the myocardium can be achieved with scintigraphy or single-photon emission tomography. The ischemic zone is able to accumulate Tc-pyrophosphate and thus create a limited area of hyperfixation (positive scintigraphy). With the introduction of a T1-chloride patient, the scintigraphic picture of the heart is opposite: against the background of a normal image of the cardiac muscle, the defect accumulation of the RFP (negative scintigraphy) is determined.

Radiation methods are necessary for the recognition of postinfarction aneurysm. With ultrasound scanning and CT, thinning of the ventricular wall in the aneurysm area, paradoxical pulsation of this part of the wall, deformation of the ventricular cavity and reduction of the ejection fraction are noted. Dopplerography can detect vortex movement of blood in an aneurysm and a decrease in the rate of blood flow in the region of the top of the ventricle. Both on sonograms and on computer tomograms, intracardiac thrombi can be detected. Determine the zone of myocardial infarction and obtain a direct image of an aneurysm of the heart with MRT.

Mitral defects

Radiation diagnosis of mitral heart defects is based mainly on ultrasound and radiographic data. If the mitral valve is not sufficient, it does not fully close its valves during systole, which leads to the dropping of blood from the left ventricle into the left atrium. The latter is filled with blood, the pressure in it rises. This is reflected in the pulmonary veins that flow into the left atrium, developing venous plethora of the lungs. The pressure increase in the small circle is transmitted to the right ventricle. Its overload leads to myocardial hypertrophy. The left ventricle also expands, because at each diastole it takes an increased volume of blood.

The radiological picture of mitral valve insufficiency consists of changes in the heart itself and in the pulmonary pattern. The heart acquires a mitral form. This means that the waist is flattened, and the right cardiovascular angle is above the normal level. The second and third arcs of the left contour of the cardiac shadow protrude into the pulmonary field in connection with the expansion of the pulmonary cone and pulmonary artery trunk. The fourth arc of this contour lengthens and approaches the middle-clavicular line. With severe valve failure, pulmonary veins are defined as a manifestation of venous pulmonary embolism. In the images in oblique projections, an increase in the right ventricle and the left atrium appears. The latter pushes back the esophagus along an arc of large radius.

The value of ultrasound is determined by the fact that the morphological picture is supplemented by data on intracardiac hemodynamics. The expansion of the left atrium and left ventricle is revealed. The amplitude of the opening of the mitral valve is increased, vortical movements of blood are recorded above its valves. The wall of the left ventricle is thickened, its contractions are strengthened, and the reverse (regurgitation) flow of blood into the left atrium is determined in the systole.

When narrowing the mitral orifice, the flow of blood from the left atrium to the left ventricle is obstructed. The atrium expands. The blood remaining in it at each systole prevents the emptying of the pulmonary veins. There is a venous pulmonary stasis. With a moderate increase in pressure in a small circle, only an increase in the caliber of pulmonary veins and an expansion of the trunk and main branches of the pulmonary artery occur. However, if the pressure reaches 40-60 mm Hg, there is a spasm of pulmonary arterioles and small branches of the pulmonary artery. This leads to an overload of the right ventricle. He must overcome two barriers: the first - at the level of stenosis of the mitral valve and the second - at the level of spasmodic arterioles.

Radiographic examination in the case of stenosis of the mitral orifice also shows a mitral configuration of the heart, but it differs from a mitral valve insufficiency. First, the waist of the heart is not only smoothed, but even bulges at the expense of the pulmonary cone, the pulmonary artery trunk and the left atrial appendage. Secondly, the fourth arc of the left contour of the heart is not elongated, since the left ventricle is not enlarged, but, on the contrary, contains less blood than in the norm. The roots of the lungs are enlarged due to the branches of the pulmonary artery. The consequence of lymphostasis and edema of interlobular septa are narrow thin strips in the lower anterior regions of the pulmonary fields - the so-called Curly lines.

The most indicative is the ultrasound picture of stenosis of the mitral orifice. The left atrium is enlarged. The valves of the mitral valve are thickened, their image on sonograms can be layered. The rate of diastolic cover of the mitral valve flaps is reduced, and the posterior wing begins to move in the same direction from the anterior valve (in the norm, on the contrary). With dopplerography, the control volume is primarily located above the mitral valve. The curve of the dopplerogram is flattened, in pronounced cases the blood flow has a turbulent character.

As in the X-ray study, and in sonography, lime deposits in the mitral ring can be detected. On sonograms they cause strong echoes, on the roentgenograms - crooked shadows of irregular shape, often grouped in a ring of uneven width. The greatest sensitivity in the detection of calcification is CT, especially performed on an electron beam tomograph. It allows you to register even microcalcinosis. In addition, CT and sonography make it possible to determine the formation of a thrombus in the left atrium.

In an isolated form, each of the mitral vices occurs infrequently. Usually there is a combined lesion with the formation of mitral valve insufficiency and simultaneous stenosis of the orifice. Such combined vices have features of each of them. The peculiar pathological condition of the mitral valve is its prolapse, i.e. Sagging one or both of its valves into the cavity of the left atrium at the time of contraction of the left ventricle. This condition is recognized by ultrasound in real time.

Aortic defects

If the aortic valve is insufficient, its valves do not provide a seal to the left ventricle: in diastole, part of the blood from the aorta returns to its cavity. There is a diastolic overload of the left ventricle. In the early stages of defect formation, compensation is achieved by increasing the stroke volume. Increased ejection of blood leads to augmentation of the aorta, mainly in its ascending part. Myocardial hypertrophy of the left ventricle develops.

Radiographic examination determines the aortic shape of the heart. The waist of the heart as a result of the elongation and convexity of the arch of the left ventricle is markedly deepened, underlined. With sonography, deep and rapid contractions of the left ventricle and the equally sweeping pulsation of the ascending aorta immediately strike the eye. The cavity of the left ventricle is enlarged, the diameter of the supralubital aorta is enlarged. Important and additional data: hypertrophy of the myocardium of the left ventricle and small-amplitude oscillation of the anterior valve of the mitral valve from the return wave of blood.

With the other aortic defect - stenosis of the aortic orifice - the left ventricle does not completely empty into the systole phase. The remainder of the blood, together with the blood flowing from the left atrium, creates an additional volume, as a result of which the cavity of the left ventricle expands, therefore, on the roentgenograms, the heart assumes an aortic shape. The arc of the left ventricle is rounded and shifted to the left. In parallel, the ascending part of the aorta widens, because a strong stream of blood rushes into it through the narrowed hole. In general, the picture is similar to aortic insufficiency, but there is a distinctive feature: if you perform fluoroscopy, then instead of rapid and deep contractions of the heart, slow and strained movements of the left ventricular wall are observed. Naturally, this sign - the difference in the nature of the movement of the gastric wall with two types of aortic defect - should be detected by ultrasound, and fluoroscopy is only possible in the absence of these echocardiography.

On sonograms, an increase in the size of the left ventricular chamber and a thickening of the myocardium are clearly visible, the compacted valves of the aortic valve and their reduced divergence into the systole are clearly revealed. Simultaneously, a pronounced turbulent character of the blood flow at the level of the aortic valve and in the supra-valvular space is noted. With aortic defects, especially with stenosis, deposits of lime in the area of the fibrous ring and valve flaps are possible. They are detected both on X-ray examination, on X-ray, tomograms, computer tomograms, and on sonograms.

The combination of stenosis and aortic valve insufficiency in both X-ray and ultrasound studies is manifested by a combination of signs of each of the defects. It should be noted that the aortic configuration of the heart on the radiographs is not only aortic defects, but also diseases such as hypertension, atherosclerosis of the aorta.

Interventional interventions for heart defects, mainly for mitral stenosis, include valvuloplasty. For this purpose, a balloon catheter is used: when the balloon is inflated, the solder joints between the valves are broken.

Congenital malformations

The manuals on internal diseases and surgery contain a description of numerous anomalies in the development of the heart and large vessels (congenital malformations). Radiation methods play an important and sometimes decisive role in their recognition. Even with the usual X-ray examination, the position, size and shape of the heart, aorta, pulmonary artery, upper vena cava and the nature of their pulsations are established. For example, in abnormal venous drainage of the lungs, a large vein emerges against the background of the lower sections of the right lung, which does not go to the left atrium, but in the form of a curved trunk it follows the diaphragm (the "scimitar" symptom) and further into the lower vena cava. Clearly recorded are anomalies such as the reverse location of internal organs, dextrocardia, underdevelopment of the left branch of the pulmonary artery, etc. Of particular importance is the evaluation of the blood filling of the lungs. With such vices as the open arterial (botalla) duct, aortopulmonary window, atrial or interventricular septal defect, Eisenmenger complex, blood flow to the small circle (left-hand shunt) is observed, as the blood pressure in the left ventricle and aorta is higher than in the pulmonary artery system . Therefore, in the analysis of the X-ray picture, the arterial plethora of the lungs immediately rises to the eyes, and vice versa, in the case of defects in which the flow of blood into the small circle is disturbed (tetrad and triad of Fallot, pulmonary stenosis, Ebstein's anomaly), there is a decrease in vascularization of the lungs. Dopplerography with color mapping and magnetic resonance angiography make it possible to conduct a direct recording of blood flow and volumetric flow velocity in the chambers of the heart and large vessels.

Let us add in conclusion that radiation studies are very important both for monitoring the course of the postoperative period and for evaluating the long-term results of treatment.

Pericarditis

Dry pericarditis initially does not give symptoms when examining the methods of radiation diagnosis. However, as the thickening and compaction of the pericardial sheets, its image appears on sonograms and computer tomograms. Significant pericardial fusion leads to deformation of the shadow of the heart on the radiographs. Lime deposits in the pericardial shvarts are especially vivid. Sometimes the heart on the roentgenograms as if enclosed in a calcareous shell ("the heart of the heart").

Accumulation of fluid in the pericardium is confidently recognized with the help of ultrasound diagnostic methods. The main feature is the presence of an echoes-free zone between the posterior wall of the left ventricle and the pericardium, and with a larger volume of fluid - both in the area of the anterior wall of the right ventricle and behind the left atrium. The amplitude of the pericardial movements naturally decreases significantly.

Equally confidently diagnosed cardiac effusion in CT and MRI. To a certain extent, it is possible to judge the nature of the effusion according to CT data, since the impurity of blood raises the absorption of X-rays.

The accumulation of fluid in the pericardial cavity leads to an increase in the shadow of the heart on the roentgenogram. The shadow of the organ takes a triangular shape, the image of the heart arcs is lost. If it is necessary to drain the pericardial cavity, it is carried out under ultrasound control.