심장영상진단학 세종병원영상의학과김양민
X - 선의발견 At 1895, Wilhelm Conrad Roentgen, a German scientist, discovered X-rays... - 2010 Perfusionist symposium -
X- 선의특성 빛과같은전자기파의일종 렌즈에통하여도굴절되지않는다 거울이나금속면에서반사되지않는다 물질을직선으로투과한다 밀도가높은물질일수록투과하기어렵다 - 2010 Perfusionist symposium -
X- 선감쇄계수 Attenuation Coefficient 뼈, 석회화, 금속이물 : X- 선투과어렵다 = 감쇄계수가높다 연부조직 ( 물, 혈액, 근육, 고형장기 ) 중간정도 회색 공기, 지방 X- 선투과쉽다 = 감쇄계수가낮다 뼈석회 연부 지방 공기 - 2010 Perfusionist symposium -
X- 선감쇄계수 폐 감쇄계수가낮은공기로되어검다 대부분의경우 ( 염증, 출혈, 허탈, 종괴 ) 희게된다 폐기종, 기흉 더검게 종격동 / 심장 연부조직 ( 근육, 혈관, 혈액 ) 으로되어구별이안된다 pneumo-mediastinum or -pericardium, calcification 복부 가스, 석회화를제외하고구별이안된다 - 2010 Perfusionist symposium -
정상 X- 선영상
비정상 X- 선영상
조영제 Contrast media, Dye( 물감 ) 감쇄계수가높은물질 - 희게보임 원하는조직에주입하여다른조직과대조되어구별 1. 장관조영제 ( 위장, 대장 ) : 바륨 2. 심장혈관조영제 : 요오드, 옥소 (I) CT, Angiography, IVP 과민반응 : 두드러기, 구토, 쇼크, 사망, 신독성 3. MR 조영제 : 가돌리늄 부작용없음 ( 피부, 신독성 ) - 2010 Perfusionist symposium -
위장, 대장조영술 - 2010 Perfusionist symposium -
심장혈관조영술 - 2010 Perfusionist symposium -
영상의학과촬영기 X-선 : 방사선 일반촬영기 ( 흉부, 복부, 근골격계 ) CT 촬영기 C-arm 촬영기, 간접촬영기 ( 간촬 ) 자기장고주파 MRI (magnetic Resonance Imaging, 자기공명영상 ) 초음파 초음파촬영기, Echocardiography( 심초음파 ) - 2010 Perfusionist symposium -
방사선과영상 1. 투사영상 (Projectional imaging) 단순촬영 UGI, Colon study, IVP, HSG 혈관조영 2. 단면영상 (Cross-sectional imaging) 초음파 MRI, CT, SPECT * 3 차원영상 (3-dimensional imaging) CT, MRI, Echo - 2010 Perfusionist symposium -
투사영상 (Projectional imaging) X- 선튜브 필름 영상장치 3 차원을 2 차원의영상으로기록 장기가겹친다 - 깊이정보가소실 단순촬영, 혈관조영, 투시검사 (UGI, HSG)
단면영상 (2-D image) 2 차원의단면으로영상 CT, MRI, Echo
3 차원영상 2 차원영상을컴퓨터로재구성한영상 CT, MRI, Echo 2-D source image 3-D rendered image 200600622 송병석 Bridge
순환계 폐순환 체순환
심장의구조 4 cardiac chambers Atrium ( 심방 ) : 정맥혈을저장, RA / LA Ventricle ( 심실 ) : 동맥혈을박출, RV / LV 4 great vessels Vein ( 정맥 ) : SVC IVC, Pulmonary vein Artery ( 동맥 ) : Aorta, Pulmonary artery * 4 cardiac valves - 2010 Perfusionist symposium -
PA PV RV LV Ao SVC Ao SVC RA RCA PA RV LAA LAD LV FO IVC IVC
심장해부와영상진단이어려운이유 * Tilting of cardiac long axis Rotation of septum Curved ventricular septum Crossing V-A connections (LVOT-RVOT) 전후상하비대칭 좌우비대칭 심실중격-평면이아니다 좌우심실유출로 : 평행하지않음 - 2010 Perfusionist symposium -
Connection (Junction) Atrio-ventricular : paralell -Cross criss-cross heart Ventriculo-arterial : cross - Paralell TGA Ao PA Ao PA LA RA LV RA LV RV RV
4 Cardiac Valves Valve ( 판막 ) : 역류방지혈액을한방향으로보냄 방실판 Atrio-ventricular valve Tricuspid v. ( 삼첨판 ) Mitral v. ( 승모판 ) 반월판 Semilunar valve Pulmonary v. ( 폐동맥판 ) Aortic v. ( 대동맥판 )
영상에응용되는용어 심첨 (Apex of the heart) 심기저 (Base of the heart) 심장축 (Cardiac long axis) 심단축 (Cardiac short axis) Base of Ventricles - 4 cardiac valves - Atrioventricular groove Kim YM Applied anatomy
Pericardium
Layer of Heart Epicardium Coronary artery
Ao RA PA RV LAA LV LV LA RA CS LCX * RCA PDA RV - 2010 Perfusionist symposium - OM LAD conal RCA AM
Ao PA LAA Ao PA RA LCX conal LCX RCA RV LAD LV RCA AM LAD D AM - Acute marginal branch
Free-wall branch of LCA LAD D PA Ao OM LCX Diagonal branch (D) 대각지 LAD 의분지, 대각선주행 D1, D2, D3 Obtuse marginal branch (OM) 둔각지 LCX의분지, 둔각영역 OM1, OM2, OM3 Ramus intermedius(ri) 중간지 LAD 와 LCX 사이에서분지
LA PLSA LCX CS * RA LCX OM * RCA LV PDA RCA PDA RV PLB PLB- Postero-Lateral Branch
좌전하행동맥 * Left Anterior Descending artery (LAD) 주행 : 전방심실간구에서주행하며심첨을싸고돎 분지 : 중격지 (septal branch), 대각지 (diagonal branch) 3 분절 - 근위부 : Os to origin of first septal branch (S1) - 중간부 : proximal half of the segment distal to S1 - 원위부 : distal half of the segment distal
좌회선동맥 Left Circumfrex artery (LCX) 주행 : 좌측방실구 분지 : 둔각지 (obtuse marginal branch, OM), 동결절지 (sinus nodal branch), 2 분절 좌심방회선지 (LA circumflex artery) - 근위부 : Os to large first OM (OM1) - 원위부 : segment distal to OM1
우관상동맥 Right Coronary Artery (RCA) 주행 : 우측방실구-후방심실간구 (PDA) 분지 : 누두지 (conal branch), 동결절지 (sinus nodal branch), 예각지 (acute marginal branch, AM) 후하행지 (posterior descending artery, PDA) 후외지 (posterolateral branch, PLB) 3 분절 : 3등분하여근위부, 중간부, 원위부
Segmental classification of coronary artery branches (American Heart Association) Right coronary artery (RCA) Left anterior descending artery (LAD) Left circumfrex artery (LCX) 1-RCA proximal 2-RCA middle 3-RCA distal 4-PDA - Posterior desc. artery AM - Acute marginal branch SN - Sinus node branch 5-LM - Left main 6-LAD proximal 7-LAD middle 8-LAD distal 9-D1 - first diagonal branch 10-D2 - second diagonal branch * RI Ramus intermedius (Intermediate branch) 11-LCX proximal 13-LCX distal 12-OM1- first obtuse marginal branch 14-OM2- second OM branch
Septal supply of LV LAD Septal branch RCA TV Ao PV S1 LAD 중격지 S1, S2, ant 2/3 septum post. descending artery PDA post 1/3 septum PDA S LAD LAD
심장영상 Simple Chest Radiography Angiocardiography Echocardiography RI : SPECT, GBP, PET CT : MDCT(multi-slice CT) MRI : Cardiac MRI
심장의크기 Cardio-thoracic ratio ( CT ratio ) = B + C A B A C 정상 CT ratio 성인 : 50% 영유아 : 60%
Echo vs. CT/MRI * Echocardiography Accurate definite diagnosis, easily applicable, portable 높은시간해상도 : 빨리움직이는심장의영상에는최고 Sonic window : 폐나뼈에가리면안보인다 Penetration limit : 깊게멀리있으면잘안보인다 CT / MRI 낮은시간해상도 : 움직이는심장의영상은어렵다 No sonic window limit No penetration limit - wide view 가리는게없고어느방향으로든잘보인다. - 2010 Perfusionist symposium -
Sonic Window( 초음파창 ) Window avoiding preclusive structure such as lung, ribs, sternum Thymus in thorax (early childhood) Th 13/F r/o PDA 200712422 이지혜
MRI : Anatomy Spin echo technique Black blood technique Excellent spatial resolution Good natural contrast btwn cavity and wall Indication Congenital heart disease : complex CHD, Adult CHD, postop. Great vessels in mediastinum : Aorta & arch, Pulmonary artery & vein Complete echocardiography
MRI : Function Gradient echo technique White blood technique Good temporal resolution : Cine MRI, VENC MRI Functional parameter Volume, Mass, Wall motion, thickening Flow, Pressure Gradient Gold standard among non-invasave study Compete with echocardiography
MR images Black blood image White blood image Structure Perfusion, Viability Wall motion, Function Flow, Strain 200208889 양순애 199616092 최호광
Indication of CT in CHD Aorta : COA, arch anomaly Pulmonary artery : stenosis or sling Pulmonary vein : stenosis or anomalous connection Central airway : anomaly or compression Mediastinum : postop mediastinitis, hematoma Intracardiac anomaly : MDCT -심초음파로잘안보이고움직이지않는것
Coronary CT Angiograohy 관상동맥영상의어려움 가늘고구불구불하다 심하게움직인다 CT 는공간해상도는높으나시간해상도가낮다. Coronary CT 영상방법 삼차원영상을얻는다 움직임이적은이완기에영상을얻는다 beta blocker : 심장박동수를낮춘다 적응증 관상동맥협착진단 관상동맥우회술혈관의폐쇄 관상동맥석회화의정량 - 2010 Perfusionist symposium -
Coronary CTA : Ischemic Heart Disease Normal anatomy and Congenital anomalies Coronary artery stenosis/occlusion CABG patency Coronary calcium scoring Stent patency Atherosclerotic plaque Myocardial perfusion, viability LV function, regional wall motion - 2010 Perfusionist symposium -
Whole body CTA Aorta & Runoff Coverage : thoracic inlet - foot (165 cm) chest, abdomen, pelvis and lower extremities in one scan break regional boundaries Rotation = 0.5 sec Pitch = 1.375 Scan Time = 12 sec Speed = 13.7 cm/sec Contrast media: 4 ml/sec, 100 ml - 2010 Perfusionist symposium -