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Um nope. Mhm. Uh, so welcome to the session. I'm doing a teaching on cardiac radiology. My name is Doctor Janina. I'm a consultant at Liverpool University Hospital Trust. And it's my privilege to deliver this teaching for you today. Um, for those of you who are here live and for you also tune in in on the video, Hopefully you can get something out of it. Um uh, So I'm going to start off by talking about the anatomy related to cardiac imaging. You can't really get very far in radiology without knowing anatomy, because it's the basis of how we look at things and how we work things out. So I'll just be doing some diagnostic diagrammatic illustrations of the heart and how that corresponds, then looking at imaging. So if we know what we're looking at in diagram form, then we can work it out on the imaging. Then I'll talk briefly about when we choose imaging. What imaging? We, um, select for certain pathologies and when and why, and then look at some images. So that will be chest X rays, CTS and some MRI imaging. I will not be discussing echo in this talk. Uh, There's probably not time for that. Um, and that's probably best done by a cardiologist. And then we'll do some cases. And there's a little short quiz at the end just to see what we've learned, basically from the session. So So just in terms of the diagram, very basically, Um, I just want to start. Wanted to start quite, uh, first principles, Really? So, as you probably all know, the lungs oxygenate the blood, and then the blood basically enters the left. The oxygenated blood ends the left side of the heart. And then, um, it leaves the left side of the heart still oxygenated travels to the rest of the body where it delivers the oxygen, becomes deoxygenated blood and returns back to the right side of the heart. And then from the right side of the heart, it goes back to the lungs to become oxygenated. So very simple. Um, that's the basic idea of how the blood travels. Then when we look at a slightly more complicated version of the diagram, essentially, this illustrates more of the anatomical, um, parts of the heart. So we've got the oxygenated blood, which comes from the lungs, and it actually goes via the pulmonary veins into the left atrium and then from the left atrium. It goes via the bicuspid valve, um, into the left ventricle and from the left ventricle. It goes via the aortic valve into the aorta, which, uh, curls up superior Lee and then the aorta supplies, um, the body with the oxygenated blood. And then after the oxygenated blood has supplied, um, all various organs, it returns as deoxygenated blood to the right side of the heart, as we saw before. This is via the inferior vena cava and the superior vena cava into the right atrium via the tricuspid valve into the right ventricle and then up into the pulmonary valve and then the pulmonary arteries on either side and back into the lungs to become re oxygenated. So, um, as you can imagine, the heart beats um, and both the left and right ventricle contract at the same time. So that pushes the blood out of the pulmonary valve and the aorta at the same time. So it's a dynamic process that's happening, obviously, is, uh, in an unconscious process. We're all doing it all the time, and our hearts are working very hard. So when we start looking at imaging, it's very important to have all of these structures in your mind. And you know where the blood is traveling from and to so that when you're looking at imaging, um, essentially know the structures that you're looking at and what they're supposed to be doing and the direction of flow. Um, so that is essentially where we start. Um, so where we start in terms of imaging for chest X rays, Um, this is needed in a wide range of, um, situations but related to the heart. Uh, normally a lot of patient's present with chest pain. They may also have shortness of breath or may present after a collapse. We also do a chest X raise in the situation of sepsis, if there's trauma, or if there's also suspect as Asafa Juul or bowel perforation. We also do chest X rays. There's a wise and much more extensive list of why we would do chest X rays. But the most important ones in terms of cardiac pathology and imaging are the first three that I've put involved there. Um, and then why are we doing the chest X ray um, it's essentially to look for pathology, to look for the cause of the chest pain or the shortness of breath or collapse and look for the cause of the symptoms. And so what can we see on a chest X ray? We can't see everything. I think the a lot of people outside of radiology think. Well, if I get some sort of imaging, then I will have the answer. But as you do more radiology, you start to learn that actually, depending on what you're looking for, will depend on what imaging you want and because things like chest X ray can only show you a certain number of things or maybe indicate a certain number of pathologies. So, for example, a chest X ray can show you in terms of cardiac pathology, an enlarged heart or an abnormally large contour, which may indicate a pericardial effusion. It might also demonstrate an enlarged aorta or an aneurysmal aorta thoracic aorta. You can also see plural effusions if they're large enough, which may indicate cardiac pathology. You can see features of heart failure in terms of the heart size and pulmonary features, and then, also very importantly, want to look for other sorts of clues relating to cardiac pathology. So, have they got a pacemaker on the chest X ray? Are they're surgical clips telling you that they've had previous surgery? Can you see a heart valve? Um, are there is there surgical emphysema or evidence of recent surgery? Because that could sort of give you an indication of what pathology may be causing that chest pain or shortness of breath at that point in time. So it's a bit of a jigsaw to try and, um, pull apart what you make out of a chest X ray. But if you've got a clear sort of symptom of chest pain and then you know, right, I'm looking for and a large chart or I'm looking for features of heart failure, then you know, yes, a chest X ray will help. And let's look for those features. Chest X rays obviously are also useful in looking at pathology and the lung, so we won't be going into that, but also to bear in mind when you're ordering a chest X ray, there's lots of pulmonary pathology that you can see so obviously, um, infection, and so you might see consolidation um, and density on a chest X ray. We also do chest X rays and can see fibrosis. Obviously, there's a large amount of a lung cancer that we also pick up so you can see a lung mass is. You can see pleural disease and plural abnormalities as well on chest X ray, as you can see some bones as well. On the chest X ray, you can see fractures. Bone deformities. Sometimes you may even see a bone tumor. If it's large enough, you may see destruction, and you may see each see features of arthritic change in bones. And they're not forgetting, obviously, chest X rays under the diaphragm. You may see gas abnormally present there or gas in the mediastinum, which may indicate perforation of the esophagus or the bow and then soft tissue. We don't normally do chest X rays to look specifically at soft tissues, but you can sometimes identify some abnormalities there. Um, just, um, sort of as an extra. So if we just look at a normal chest X ray, so this is a normal X ray of the chest. Um, you will have seen these before, and certainly after medical school When you're a doctor, you will see lots of these chest X rays. Um, so it's important to really spend a bit of time and decide what you can and can't see from a chest x ray. So, um, what you can see, um, this is a normal chest X ray. So in this x ray, you can see the lungs, and they should be radio loose or generally quite black or dark. Anything with air. So also the trachea. Here you can see air within the trachea, and then you can see that the it bifurcates into the into the carina so you can follow the airway. There, you can see the ribs as radio dense so they should be outlined is more bright or white. Uh, you can see clavicles. You can see the spine through all of these structures. You can see the pedicles. You can follow the contour of the spine. Um, and then you can also follow the outline of the diaphragm. Each heavy diaphragm should be a thin, um, white line that you can see. This is airway within the stomach. But it's not perforation because it's a within the stomach, and this is too thick. If it was a thinner line, you might suspect. But this looks like normal gas in the stomach. And then you should see a last but not least. Obviously, we're here to talk about the the heart and the cardiac contour. So this density in the center of the chest, it's important to look at the lungs. But this is the heart, and this is the normal cardiac silhouette that you should expect to see with lungs around it. You should be able to see the vascular structures, the pulmonary vessels behind the heart as well. So it is white or bright, but there are Oh, this is white, but you should be able to see the vascular structures behind it. So so that is a normal chest X ray. And this is the place to really start in cardiothoracic imaging because you want to imprint this on your mind as a normal chest X ray. And then everything around that you should start to look into and spot and think Oh, okay, that's not normal. What is? What could it be? So let's move on. So if you first look at this chest X where you might think? Oh, God, that's the heart. But how am I supposed to see more than that? So as we look at the diagram diagrammatic version of the heart this this is the meeting for a DPP 445. Right, But so this is the cardiac, um, anatomy that is demonstrated on the chest X ray. I had to learn this for science. If everyone stays muted just for the presentation. If you have questions, please. You have any questions? Put it on the chat and someone will be able to answer your question. Thank you. So if you're looking at chest X ray, you should in your mind also know what this cardiac silhouette is. But in knowing what that is, you need to know what what you're actually looking at. So if we we superimpose a diagrammatic version onto the chest X ray, you can see that the right atrium and the right ventricles are here on the right side of the heart. And just to confuse things that will be on the left side of your image. So everything and radiology is the reverse. So, actually, as you're looking at the picture, it's on the left side but this is actually the right atrium and right ventricle. The Ivc and the Spc come in, um, at the lateral borders. And then here you can see the left ventricle and the left atrium, and then this is the aortic arch coming up here. So on the chest, the plain chest X ray, you should be able to see the aortic arch coming up around here. And the S V. C is this straight line that comes up, um, laterally on that side. So if you see any abnormality in the Contour, you really need to know where these anatomical structures are in terms of then trying to work out what is enlarged and therefore what the pathology is. So that's what we have in our mind when we look at a chest X ray at an abnormal cardiac contour. We're looking at those structures. Um, so this is an abnormal chest X ray. So if in the chat, if any of you just want to write whatever you notice about this chest X ray and then we'll go through what we can see, um, just quickly, anyone just put something down. If you can give you a few seconds. And then, uh, if nobody answers, then we'll carry on. Yeah, great. So some of these written Dan's written cardiomegaly, so that's great. Exactly. So the heart border is enlarged. Um, any more comments on that, or we can move on and then go into a bit more detail. So the heart is enlarged. The lungs actually look okay with this, uh, that's relevant in as we move on. But can you also come and comment on this second chest X ray, and then we'll compare them. So do you think What do you think of the heart border on this one? Do you think it's normal, or do you think it's also enlarged? So just for time purposes, I'm gonna give you the answer. Yes. Great. Um, so they're both enlarged, But what I'm trying to demonstrate here is, although they're both enlarged, can you? I'm trying to just sort of tease out that, actually, uh, they're completely different shapes or, um, that the enlargement is in a different, um, in a different way. So, on this image here, on the right side of your screen, actually, the enlargement is predominantly on this left side. Um, yes, exactly. right on the chat. So on this image, it's actually the left ventricle. Um, that is enlarged in isolations, which you can see if somebody has uncontrolled high BP. So this is left ventricular enlargement here, but no other convincing features of heart failure in the acute phase. Now, on this side, the heart is more what we call a globular shape. Exactly. So on the chap, that's right. So this is a pericardial effusion. So I've put them side by side just for you to appreciate that they're both cardiomegaly, but the one this image on the left actually demonstrates a more globular shape, and this shape is indicative of pericardial effusion. Uh, there won't be any fluid around this, in large part, is actually heart itself. That's that's enlarged. So I've just tried to demonstrate this as the normals of myocardial silhouette. And then around it will be the fluid. And that's why it takes references. The boat on the right testicle. Sorry. Um, and then on the left side, this is the left ventricular hypertrophy. The left ventricle is enlarged. Great. That's really good. Um, and if you see a pericardial effusion in practice, if the previous chest X rays have been normal. This could be an emergency, especially if your patient is out of breath and has an abnormal E c g. Because, um, as fluid increases around the heart, it actually restricts the ability of the heart to pump adequately. And that can limit how much blood flows, effectively getting around the body and returning from the heart. Um, so that's just those plane without my annotations on there. Great. So, um, this is just another illustration. So, um, this is a CT on the right, a corona low version, that of a CT of this exact chest X ray. So you can see that the heart size is enlarged. Although this is an AP film. So you'd normally want to comment on a, uh, on a p a, uh, projection. But the CT, you can also demonstrate You can also see that the heart is enlarged so as well as an enlarged heart. Here, we've got some lung changes. Can anybody tell me what these lung changes are? If anyone's seen this before, Um, so, um, we do have a line in as well on the left side, which is a peripheral line probably to support the patient with medications or fluids. We've got a large house, and then we've got increased density in the peri highland regions, um, as well as, um, within the lungs. So we call this peri Hila. Um um, Perry. Highly consolidation. There's no there's a there's a pleural effusion on the right side and possibly a small on the left side. So putting that all together, this is the appearance of pulmonary edema. So when you see an enlarged heart, it indicates that the patient might have cardiac failure, and in the acute phase, or if they become unwell or decompensate them, they can get acute pulmonary edema. And this they describe as Bat's wing pulmonary edema. Because, um, if you can try and imagine that these are the wings of the bats on either side of the highly region. So, um, that's acute pulmonary edema, and you don't only get pulmonary edema from heart failure. You can get pulmonary edema from lots of causes. So, um, you can get neurogenic, um, pulmonary edema or after a pneumothorax. If you re inflate them too quickly, you can get, um, re inflation pulmonary edema. So there's lots of reasons, But the most common that we see or I see is after heart failure, You get a call me edema. Um, so if we move on ct, um, so essentially, we've looked at some chest X rays. So you've done your chest x ray, and you still I'm not sure what the what the underlying cause of the symptoms are or it doesn't quite match up. So we do CT, which is a three d form of imaging, Um, and that is used in, um, situations of trauma to look at any injury to the chest. Also, if the patient has chest pain, but it's not explained by the E c G or chest X ray findings, Um, we also obviously image with CT if there is suspicion of lung cancer or in lung fibrosis. Um, and also pre intervention of coronary disease. We're doing more and more imaging in terms of before they actually go for invasive angiograms for cardiovascular coronary artery. Uh, atherosclerosis. Sclerotic disease. Um, just with CT, you just need to bear in mind for those of you who will go on to do more radiology or have an interest in radiology, um, ct chests obviously are quite specific to what you're looking for. So, uh, in terms of trauma, we would give contrast through a cannula, and we would do that in the arterial phase so we would time it so that the contrast is actually demonstrated in the arterial arteries and in the arterial, um, system system. And then if you were looking for something like a pulmonary embolus, you would want the contrast to basically be illuminated in the, um, in the pulmonary artery phase, you would have to time it so that the contrast is in the pulmonary artery is at that point when we do coronary artery, um, angiograms. We basically get the patient on the CT, scan it and put the contrast in so that it's phase through the at the time when the blood goes through the coronary arteries. Um, that also quite a specific scan in that obviously, the heart's beating all the time. And if you take an image or a picture, imagine taking a photo of anything moving. It will be blurred. So for coronary arteries, because the vessels are a few millimeters big, we actually gate these studies, so the patient needs to have e c g. Monitoring on. They also get their BP and heart rate monitored, and we give them be two blockers to basically reduce the heart rate. So to make it nice and relaxed. And that's because we try and basically take snapshot pictures at certain points of the G so that we can minimize that movement of the heart image. So we minimize the movement artifact, and we can see the vessels better. Um, so that's quite a specialized scan. Um, and we also do, um, cts of the chest without any contrast. But we do it in a way of doing a high resolution, which basically gives you more detail, um, of certain lung structures. And we do that with the patient lying prone, which means on their tummy, um, supine lying on their back. And that's to basically look at the effect of different positions on the lung structure. So ct chest, it's not all one thing. It depends what you're looking for. And then we try and tailor the contrast in the right place, um, and position a patient appropriately, in order to answer our question of of what we're really trying to look for um So So that's more important for if any of you go into radiology, which hopefully some of you might, um, so enough about why we do it and the different ways this is a CT image. So when you first start looking at CT scans, um, we actually can look at them in different planes. So this is an actual slice of the heart, and just in terms of our orientation of what structures these actually are. So this is a correct This is a corona or slice. So that's imagine that the person stood in front of you. People can sometimes orientate themselves better thinking about it like that. So this is the heart and the left ventricle left atrium. So if we were to do a horizontal slice through this Corona plane, this is what you would see in the axial plane. And this is how we report most of our imaging is actually to the actual, um, through the actual views. So here we can see the left atrium, the left ventricle, and this is the right ventricle and the right atrium. And for those of you looking a bit closer, this is the myocardium. So you might notice that on the left side and you can see and appreciate in myocardium here with the papillary muscles that enter into the into the cavity. And then this is the interventricular septum, which you can still just about appreciate. But then, on the right side, this is normal. You should not be able to convincingly see much of a myocardium on the right side, and it will be there. It's just it's just quite thin compared to the left side. And if you think about that physiologically, um, that's completely appropriate because the left side of the heart obviously has to work harder and pump all that blood to get it go all the way around the body before it returns. So it needs a bigger muscle mass to to achieve that. Um So, um, so this is how we look at it in axial plane. And then in Corona, well again, you can see the great vessels coming off the SPC from the right side and then the aorta, which, um, curves around. So CT allows you a three D reconstruction really of the heart and to appreciate all the vascular structures. Um, so this is just to demonstrate how we look at it in Corona plane from anti or from the front of the patient to the back of the patient. So from anterior to posterior, that's what your heart looks like. I'll just play that again. Hopefully. So just through the chest. And as you will probably notice, the heart is at the anterior portion of the chest. Um, so it's an anterior structure. Um, so So that's basically how it is live, sort of in the chest itself. Um, so if we then move on, this is again an actual slice where you can see that nice myocardium of the left side of the heart and the right side of the heart. And this is a slice to demonstrate. So when we report these, it actually tells you as you scroll up and down which way you are on that side. So this is a sagittal. So this is looking from the side, and this is quite a nice slice to really look at the thoracic aorta. So this is the art of the aorta, and you can see, um, the, uh, the major vessels from the arts coming across, and then the thoracic aorta descending thoracic aorta coming down. And these are all so different. Brightness is you might wonder why that is just because of the phase of contrast. So, um, it's not showing any abnormality. It's just showing where the contrast is at that point in time. Um, so again, I'm just going to demonstrate how we appreciate the different axial and corona slices through a CT. So as you go through on the actual slices, you can see how that comes down so you can kind of match up and appreciate which structure is where and how that correlates into what you're looking at on your axial slices. So if we just play that again so this is the actually the arch of the aorta. These are the pulmonary arteries that the superior border of the heart. And then you've got your right side of the heart and the left side of the heart here with some contrast in the, um and then as we come in theory, Lee, you obviously get into the anthem there. So So that's kind of how we look at imaging. Um, we look at them in three D planes, and then we get a good appreciation of anatomy in time and space as well. Um, this is a non gated study, so just as I was sort of mentioning before about coronary vessels, So I'm just going to show you where the coronary vessels are, So, uh, I'll just try and cause it at the right time because they're very small. So what? I was trying to say this is a non gated study. So So this is not e c g um, um, sort of targeted. So this is just a snapshot of the patient. Any point in the cardiac cycle This is the left anterior descending coronary artery. So it's very a very small structure. Um, and that's just one of the coronary arteries, and it's quite blurred. So we would need to gate that with the e c g to really sort of make that a nice, clear image and not be affected by movement. Artifact. Just try and show you the Yeah, So this is the further So this is just a smudge. But this is actually where the right coronary artery origin is. So again, you'd want to see a nice vessel here and all you can see is a smudge. So that's just illustrating how we can't assess coronary arteries unless you do a dedicated study. Um, but we can obviously see, um, you know, the pericardial pericardial sac around the heart, and we can see the heart in some detail on plain seating. Okay, so I've got a case now, so, um, this is a CT. Um, pace. It's a 70 year old man, and he's had a fall in the bathroom and landed on his right side. So on the three d reconstructions, you can already see that there are some rib fractures on that side. Oops. And so this is the CT That corresponds to this, Um, this gentleman's case. So can anybody see anything on these images? Um, so we've got axial slice here, and then a corona lll slice through this, um, at this level. So can anybody see anything in the heart? The mediastinum or the lungs? Anything that's jumping out at you on those sections. Anything at all? Oh, a Nilla. I think you're drawing on the presentation. I'm not sure if you're attending to do that. I don't. If you can possibly, uh, erase that, that would be useful. But I appreciate what you're demonstrating. Um, so there is, um there is some air around the mediastinum. Very good. Oh, I can see that you're unable to a mute. So that's that's good for me to know. You can write in the chat, or I'll just keep talking. Um, someone put in the chat lung infiltration. Oh, great. Okay, Yes. So I'll just go through the findings here. So, um, on this act, this is the tricky And this is the Archer Bill. Just so that's encompassed in the mediastinum here, sensually So there's abnormal gas. Um, here, which shouldn't be there. Basically. So we call that pneumomediastinum. And then if you look at the lungs on either side so this area corresponds to this side of the of the lungs, the right side. So this is a pneumothorax. So this lung has actually collapsed here, and this is all just air within the pleural space. So it's a large pneumothorax with new, more mediastinum. This is normal air rate of lung on this side. But I just put the corona up so you could appreciate that the air actually tracks all the way around the heart abnormally. Here So this is new mo Mediastinum, but also pneumopericardium in. And this was because of the patient's rib fractures that he's had. So he's That's a traumatic cause, um, we wouldn't actually treat from pneumomediastinum. They treat the pneumothorax, they put a drain in and let the air be released. But the air in the mediastinum would just dissipate naturally, as long as the pneumothorax has been treated. Um, and clinically, if you saw this patient, you can also see that there is gas in the subcutaneous tissue. So if you are clinically assessing this person, you might feel their skin sounds actually, and feels a bit a bit like when you pop bubble wrap, it makes that kind of sound and that sort of feeling, and that's called surgical emphysema. Um, just trying to move on. Okay, um, so air in the mediastinum. So that's pneumomediastinum. And then large amount. Yeah. So just the new math, all rights and pneumomediastinum. Um, so in terms of, um, the moving on to M R imaging, we actually do MRI of the heart as well. And this is additionally useful and interesting, because you can actually view the heart in motion. So unlike CT and S X rays, which is a snapshot of time cardiac motion we actually take, uh, it's recorded. The cardiac motion is recorded so you can watch how it moves and see how it performs. Cardiac MRI is sort of reserved. If you suspect that there's a morphological abnormality with the heart, it's it to investigate cardiomyopathy. These. We also do see ischemia or in fault, on on MRI. But it's not really to demonstrate the infarct in that you probably have, um, information about the infarct from E. T. G. Um, blood test. But it's more, um, to basically illustrate whether that in fact has caused a scar that is then affecting the function and the motility. The motion of the my card e um, so it's really to assess the motion, um, and the function of the heart. Um and then so m r, we do lots of different sequences. There's a plethora of different choices of sequences, so we really tailor it to the pathology that suspected, um, so if you're looking for a scar, we would give contrast. Whereas if you're looking for, uh, certain types of my my, uh, Claudia Mark, these like sarcoid's you might wait it on t one and t two slightly differently. So depending on what you suspect, clinically, we would tailor the m r to what we're looking for. Um, So, um, this so this, uh these are some images from m r. But I just want to demonstrate, um, what it actually looks like. So this is a four chamber sini of a hard back MRI. So it actually shows you how the heart is pumping, um, in real time. And it also shows you how the myocardial muscle is contracting. Um, and how the chambers are emptying and filling as well. For those of you who have eagle eyes, um, it also lets us look at the valves. So the A V valves and also the pulmonary and aortic valves as well on different sequences. Just gonna see if I can remove the pen that's on there. I'm not sure I can, but anyway, we'll crack on without, so again. So this is M. R. Is very different in this way that you can actually see how the heart is moving, and that's important to give information about the function of the heart, which no other imaging can really do. Um, so this is obviously another different cardiac m R. Which I will play. And can anybody right on the chat? Um, yes. So those cardiac images were normal. This I'll just go back if I can. Yes. So these were normal. This is normal heart motion. Believe it or not, you get used to what it what it looks like. And obviously between patient's, there's some variability. But that's good contract ability. All through. There's no regional motion defect there and this. So this is normal cardiac MRI. So then, if we move on, if you imprint that in your mind, it's just a taste of really this Carjacking. Well, it's quite specialized, so just sort of giving you a flavor. So this is another cardiac MRI. It is a four chambers. So it's showing you four chambers that right age and right ventricle left age. Um, left ventricle. Um, so can anybody say anything that they notice about this MMR at all in the chat? This is an abnormal scam. Can anybody see anything that looks different or looks abnormal? I'll play it again. Just keep it on playing so you can see the valves a bit better on this scan, which is lovely, actually. And obviously there's a whole whole textbook on valvular disease. Yeah, so thank you, Sue. If vetting your answer on. So this is the left ventricle, and this is that the muscle myocardium. And like we said before, the right side should be sort of paper thin, so that's okay. And then these are the papillary muscles that sort of come into the cavity. But this much is extremely abnormal. It's really thickened. And if you look at the the ability for it to contract, it is contracting. But the volume is decreased, and the effective contraction and volume ejection is also significantly reduced. So this is called left venture particular hypertrophy. And this can be obstructive or non obstructive. So the more worrying one is, you might have those hypertrophic obstructive cardiomyopathy. And this is the pathology that you may have heard of. It happens in athletes. It happens in young people, and they have sudden cardiac death. It's on AutoZone, more dominant pathology. And basically, you get this abnormal thickening up of the muscle. It becomes very hypertrophied. Um, so, um, as you'll be learning in medical school. The difference between hyperplasia and hypertrophy is that hypertrophy A is an increase in size of the cells, whereas hyperplasia an increase in number. So this is hypertrophy. This is an increase in the size, and the my the my card ran becomes very thickened. But actually you think it could contract better if it was really, you know, a chunky muscle. But actually, what happens is it's so thick and that it's not allowing the volume of blood to actually enter the left ventricle anymore. It's taking up too much space, and it's not effectively contracting anymore because the MYOCARDIUM actually becomes less effective at contracting. So this is an important pathology to be aware of. And it's a It's a form of sudden cardiac death in young people. So that's great. Just just a flavor. I wouldn't expect you to obviously diagnose it, but just to have a look at this, I'm going to compare the normal heart there with the hypertrophied left ventricle There. Great. OK, so I'm aware of time so we'll just keep going. Um, yeah. So I had perch hypertrophic obstructive cardiomyopathy. So that's that. So, um Okay, so we're moving on to the quiz now, just in the last 10 minutes. So just a few last questions and for you to try and, uh, answer yourself or, um uh, and or a note down yourself, and then we'll go through the answers. So what chamber of the heart is in this region on the chest X ray. Um, so just write down your answers, and then we'll go through them. And then what about this one? And this question to what chamber of the heart is in this region? Great. And then what major vessel is this? And then we looked at this before, So if anyone can remember this a bit of a test of whether you're paying attention. Uh, what is the cause of this patient's chest pain? And it's obviously an emergency. So you need to alert somebody senior to see whether they need treatment. And this is a cardiac CT, just a slice. And just for you, really keen people where we go on, can you see any abnormality at all on this CT as to be the cause of the chest pain? I'll be very impressed if any of you know about this or have seen anything like this before. It's just one of those extra cases to see. Um, And then, uh, this is a Sydney. So just a sort of video recording, like we said. Um, and what does it demonstrate? Just the left atrium. The left atrium, the left ventricle. Right. Atrium. Right. Atrium. Right ventricle. So this is me hoping that sort of orientated you a bit on some of the slices will will allow you to sort of work out where we are. Um Oh, sorry. Just move on. Okay, so here we are, the answers. So, yes, I can see in the chat in the chat that some of you got that right. It's the right atrium. Well done. So you'll know you can orientate yourself what you're seeing there. This is the left ventricle. So yeah, I'm sure most of you now know that on imaging, everything's flipped. So, actually, on the right side of that image, it's the left ventricle, the aorta. Very good. So sometimes it's very important to look at this contour because if this is massively dilated or you lose the contour, you need to worry about aortic pathologies, aneurysms, dissections, hemorrhage, rupture. So that's a very important structure to look at. Um, And also, if you lose that contour, there may be some mass or something next to it. Um, and and then, yes, pericardial effusion. You're very good at this before. So as a cause of well, it can be a cause of an acute, um cardiomegaly And this case, I just put in for interest. I don't expect any of you to necessarily know it, but this is a hypodense. So it sort of dark gray hyperdense recall. It's not enhancing with contrast like, um, the chamber of the heart. And it's actually in the region of the valves. So if you see something and the left atrium that's associated with the valves, this is the most common tumor. It's actually a tumor. It's a left atrial myxoma. So the tumor is not actually aggressive itself, but just where it is can cause functional problems. And they do normally go to surgery for that because it can cause, um, it can cause dilation of the atrium vegetable because they're basically the flow of the blood, as you can imagine, isn't it effectively going through? So that's just one in for a bit of extra fun. Um, and this some of you may have got this just shows so you can see that there's a big sort of relatively good my cardio muscle. There's this must be the left side of the heart pumping blood around the body. So this is the left ventricle. But you can also see the valves, in which case you can also see some of the left atrium. So this we call a to chamber Sydney. So because you can see two chambers, some of the other cities I showed you with four chambers. But this is the two chambers, Sydney. So good. So hopefully if you can start to orientate yourself, that's really good. And the first step in looking at, um, imaging. And just before we go, I've got a couple of minutes before I can answer any questions. Um, this is just another video for good fun. Um, this hopefully is an actual image through a CT, which you all now can orientate yourself. Hopefully, um and it's just a common pathology that you all see massive heart. I'll play it a few times, and I just want you to appreciate a few findings here, so we can already see. See there's fluid, which lies dependent because I imagine the patient's lying down on the couch of plural effusions. Big Heart. And then there's fluid around the heart, a bit a trace of fluid around the heart, small pericardial effusion. And this is actually just fluid. In the wrong place is a big heart plural effusions, pericardial effusions, and I've not given you the long windows, but there is some long changes. So this is pulmonary edema, acute palm redeeming and heart failure. Um, so that's basically just an extra case that I emission this, but thank you, everyone, if you're still paying attention, that was quite a lot to fit in, but it's it's more just to give you a flavor of carjack imaging. What we do, what we can see. Um, some of the limitations and how we just go step by step from chest X rays to CT sometimes, and m R. If you really have a specific question with regards to a specific pathology. But when you first become doctors, it's good to get your head around chest X rays, and then, if you haven't further interest, then you can really get into CT's them are. But, uh, so I'm just going to have a look to see if there's any questions on the chat I can answer. Um, is cardiac hypertrophy reversed upon remover of the stressor? Um, I think, um, so so hypertrophic cardiomyopathy or a talk about cardio cardiac myopathy or just general cardiac hypertrophy. So cardiac hypertrophy all that means is thickening of the muscle. So people who have high BP, like we saw in the case, um, right at the start, just with the increase the larger left ventricle. Just try and get the image up. So if you have uncontrolled high BP and you've got a big left ventricle, you get an element of hypertrophy because the volume in the left side of the heart increases. So you need a bigger muscle to push all that blood through. So you get an element of hypotrophy from, um, increased volume and high BP. So you can. There is an element of reversibility but basically need to treat the cause. So if it's BP that's causing the cause, um, causing the hypertrophy, then you can improve the BP. And then, like any muscle If you don't have to use it as much, it will become less thickened. Unfortunately, once it's become quite thick and you you kind of stretch the muscles and then the conductivity, uh, worsens. You can get arrhythmias and things like that. Now hypertrophic cardiomyopathy is a genetic inherited disorder with the real thickening that we saw on the EMR and that, unfortunately, is hereditary and you don't reverse that. Really. So, in which case, normally these people are monitored. They might have. They might have pacemakers, or they might have surgery to basically make sure that their function stays appropriate. Um, when I can see, Lauren says, When is cardiac MRI needed? So, um, like, were saying, it's in very specific situations, So it's in young people. It's usually to look for morphology. So if they've done an echo, which is an ultra sound of the heart, through the through the chest, and they've seen that the function in a young person is abnormal and maybe they've seen that the flow is is slightly atypical. They might think that there's a morphological or some sort of congenital abnormality in the heart, so we'd want to see the chambers and if there's any morphological abnormality and then, uh, and then cardiomyopathy. So there's a wide range of cardio myopathy is that I'll let you read about, um, but if you're investigating for that, that can have an effect on function. So you might want an MRI for that. And then it's mainly, um, if you if you spot a mass on CT or on Echo again, we'd want to assess that further with them. Are you can? But it's mainly to look at this. It's mainly to look at function in adults because there's a reduction in function and they want to answer. Is there a cause that we can treat medically or surgically? That will help, Um, so just try and scroll to see if there are any other. Uh uh. I want to ask what kind of MRC the echo can't. So I'm not an expert on Echo. I won't pretend to be, and the echo is an ultrasound scan, so it does show you live dynamic movement of the heart of what that is doing in front of you as you do the echo. But that basically just shows you a very base basic view of how the valves are moving and the general size of the heart. It doesn't give you that spatial spatial resolution. It doesn't give you contrast into the chambers. It doesn't show you any defects in the heart, and it will. It might show you thickening, but it won't. It won't be as easy to depict. Um, and it it won't. It might show you how the myocardium is moving, but it's better to basically do function with M R than it is echo, although you you can get an idea with echo. So it's basically a higher resolution, um, tool for for when you have a suspicion of pathology on Echo, Echo's are done more cheaply and more readily available. Um, and they don't take as long. And obviously m r. If anyone's ever had an M r. It's very noisy, and some people can't tolerate it because of the pacemakers or because they've got metal foreign bodies or mainly because of claustrophobia. So, um, so that's a kind of idea. I'm just gonna scroll a bit further to see if there are any one any other questions? Um, so, yeah, I'm a bit conscious that we're going over from now so, um, I can't see any of just on a little bit of scrolling. I couldn't see any of the comments, but yes, thankfully gone. There's one right at the end. How to identify. Sorry, I can't. How? How to identify pneumomediastinum A great question as well. All the questions have been really good. Um, so pneumomediastinum air in the mediastinum. So, um, symptomatically the patient might be out of breath. They might have had a history of trauma they might have had, um they might have had some sort of pressure on a closed glottis. So sometimes, if people, um, have ventilation or things like that that can cause a barrow trauma. Basically, um, they might have a history of bath. They might be short of breath. You might have discomfort on swallowing or discomfort on breathing. You do a chest X ray, and you will see you might see gas outlining the outlining the heart contour. So I did try to find one on chest X ray and you want me to sign. But it was so busy because the patient was so unwell that it wasn't really a good illustration on chest X ray. But if you can imagine this image on the chest X ray. You're looking for this Lucent line around the heart, and you may also see lucency around the mediastinum so you can see that on a chest X ray. And if you have suspicion of that, then you go onto CT and then you will see you will see this appearance. So hopefully that answers your question for that. But it we don't like like I was sort of mentioning before. We don't treat pneumomediastinum. It's more. What's the cause of this air in the wrong place? And if it's something else, like a pneumothorax, then we would treat the pneumothorax if you see what I mean, or if there's a trick eel Oh, uh, injury source or a stabbing Where there was a trick eel injury, you might need to not treat the air around it, but you might need to go for surgery to repair the trachea. If it's a large, a large lacerations or if there's an esophageal perforation and they need to go to surgery so you don't treat the air, you sort of look for the cause of it and then and then treat that so hopefully that helps. Okay? And so if there are any other questions, I'm happy to answer them. But otherwise, thank you very much for attending. Um, and I'm listening to my interest of cardiac imaging. Thank you. Thank you, Doctor. Lee, I would like to say that was remarkably managed. A fascinating, excellent lecture. So thank you. Thank you very much. Thank you.