Table Of ContentRadiology of the Heart
Cardiac Imaging in Infants, Children, and Adults
Hugo Spindola-Franco
Bernard G. Fish
Radiology
H
ofthe
eart
Cardiac Imaging in Infants,
Children, and Adults
With Contributions by
Robert Eisenberg, Charles B. Higgins,
Richard M. Steingart, and John P. Wexler
With over 552 halftone illustrations in 1202 parts
and 62 line illustrations
Springer-Verlag
New York Berlin Heidelberg Tokyo
Hugo Spindola-Franco, M.D., F.A.C.C., F.A.C.R., Professor of Radiology, Albert
Einstein College of Medicine, Yeshiva University; Attending Radiologist, Mon
tefiore Medical Center; Director of Cardiovascular Radiology, Montefiore Medi
cal Center; Consultant in Radiology and Medicine (Cardiology), Bronx Veterans
Administration Hospital, New York. Address correspondence to Department
of Radiology, Montefiore Medical Center, Moses Division, III East 210th Street,
Bronx, New York, U.S.A. 10467.
Bernard G. Fish, M.D., F.A.A.P., Assistant Professor of Pediatrics and Assistant
Professor of Radiology, Albert Einstein College of Medicine, Yeshiva University;
Associate Attending in Pediatrics (Pediatric Cardiology), Montefiore Medical
Center. Address correspondence to Department of Pediatrics, Monte
fiore Medical Center, Moses Division, 111 East 210th Street, Bronx, New York,
U.S.A. 10467
Library of Congress Cataloging in Publication Data
Spindola-Franco, Hugo.
Radiology of the heart.
Includes bibliographies and index.
I. Heart-Radiography. 2. Heart-Diseases
Diagnosis. I. Fish, Bernard G. II. Title.
[DNLM: I. Heart-radiography. 2. Heart Diseases
diagnosis. WG 141.5.R2 S757r]
RC683.5.R3S65 1985 616.1'20757 84--23631
© 1985 by Springer-Verlag New York, Inc.
Softcover reprint of the hardcover 1st edition 1985
All rights reserved. No part of this book may be translated or reproduced in any form
without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New
York 10010, USA.
The use of general descriptive names, trade names, trademarks, etc. in this publication,
even if the former are not especially identified, is not to be taken as a sign that such
names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly
be used freely by anyone.
While the advice and information in this book are believed to be true and accurate at
the date of going to press, neither the authors nor the editors nor the publisher can
accept any legal responsibility for any errors or omissions that may be made. The publisher
makes no warranty, express or implied, with respect to the material contained herein.
X-ray reproductions by Carlin Medical Photography, New York City.
Line drawings by Stanley R. Waine, Medical Multimedia Corp., 211 East 43rd Street,
New York, New York.
Text and cover design by Robert Hollander.
Typeset by Kingsport Press, Kingsport Tennessee.
9 8 7 6 5 432 1
ISBN-13:978-1-4613-8207-2 e-ISBN-13:978-1-4613-8205-8
DOl: 10.1007/978-1-4613-8205-8
Dedicated to
HAROLD G. JACOBSON, M.D.
The teacher, the scholar, the scientific father
and to our wives
EDITH BALDERAS DE SPINDOLA, JUDITH NAOMI OPHIR FISH
and our children, who patiently awaited completion of this book.
Foreword
In this unprecedented era of revolutionary developments in clinical imaging,
in no area of the body are dramatic breakthroughs better exemplified than in
imaging of the heart.
It is difficult for this writer to be objective about this work because he has
watched its development in the exceptionally capable hands of a cardiovascular
radiologist and a cardiovascular internist, functioning as an ideal amalgam in
its preparation. In the process, the author of this Foreword has developed an
unbounded enthusiasm for the content of the work.
At the outset it must be stressed that the dramatic gains in the develop
ment of new imaging modalities and the improvements in the old [e.g., ul
trasonography, echocardiography, radionuclides, computerized tomography
(CT), cineradiography, magnetic resonance (MR)] have changed our concepts
about the anatomy of a number of organ systems. Anatomy and even
physiology virtually are being rewritten. These changes apply particularly to the
chest (mediastinum), biliary tract, central nervous system (brain), heart
and great vessels and the hemodynamics of the cardiovascular system. The
authors have demonstrated in this exhaustive treatise how far our understand
ing of the many cardiac abnormalities has progressed, made possible by the
application of the new modalities and further advances in those already estab
lished, particularly echocardiography and radioisotope scanning. These de
velopments have altered and added significantly to our body of information,
particularly in the many complex congenital anomalies and in coronary artery
disease.
This work is presented in ten chapters. Chapter 1 consists of an updated
delineation of normal anatomy of the heart and great vessels; Chapter 2 consti
tutes an introductory but thorough discussion of the clinical application of echo
cardiography (including Doppler echocardiography); Chapter 3 deals with the
almost startling newly discovered efficacy of cardiovascular nuclear medicine
(contributed by Drs. Richard Steingart and John Wexler); Chapter 4 discusses
an increasingly important subject-ischemic heart disease; Chapter 5 describes
in detail the various forms of valvular heart disease; Chapter 6 evaluates the
various cardiomyopathies in depth; Chapter 7, by far the largest of the book,
is divided into six sections describing both the commonplace and the esoteric
congenital abnormalities of the heart and great vessels. This chapter constitutes
a monograph unto itself, discussing a very complex subject in superb detail
and with great clarity; Chapter 8 details the various neoplasms of the heart;
the number of neoplasms considered is extraordinary; Chapter 9 discusses dis
eases of the pericardium; and finally, Chapter 10 is a contribution from Dr.
vii
viii Foreword
Charles B. Higgins of the University of California at San Francisco on imaging
of the heart by magnetic resonance.
This work is encyclopedic in its scope and yet brilliantly organized and written
with admirable lucidity. The authors go into the most minute detail regarding
even the most obscure of lesions. The tome is a thoroughly scholarly effort.
The reproductions are of superior quality lending to the enhancement of an
impressive array of descriptive illustrations of an unusually large volume of
material-both commonplace and esoteric. A very considerable, very thorough,
yet relevant bibliography is appended to each chapter, promising to be of inestim
able value to the scholar in the field.
In all instances, the authors diligently correlate the interrelationship of the
anatomical features, the clinical data, the findings on echocardiography, the
hemodynamics, the application of radionuclides where appropriate. In addition,
a description in depth of the imaging (radiological) features with plain films,
cine radiography for opacification studies, and other "state of the art" imaging
techniques is presented. Even a concise but pragmatic discussion of treatment
in each disorder is provided.
It is very difficult to write an objective Foreword for this work. This enthusias
tic evaluation of the treatise probably overcomes any degree of objectivity in
evaluating the tome and yet the author of this Foreword has no compunction
about being biased in this instance. In a sense this Foreword constitutes a review
of the book-a review that appears to sing constant paeans of praise for the
quality and scope of the work. If the impression is gained that this writer is
prejudiced, so be it. Calling it "like you think it is" is still fundamentally a
sound aphorism, even if the judgment of the "caller" is suspect.
This important work is an unusual example of a cooperative effort by a
clinical cardiovascular radiologist and a clinical cardiovascular internist in the
production of a treatise of great scope and significance. In this writer's judgment,
an outstanding contribution has been prepared on a highly complex but funda
mentally important subject-a contribution badly needed in the discipline of
cardiac radiology. This treatise should prove to be of inestimable value to a
whole array of different groups of physicians: the general radiologist, the primary
care physician in all areas, the residents in training, all medical students and,
of course, the cardiac radiologist and cardiac internist. The work, with its deftly
organized presentation of inexhaustible details, promises to become a landmark
on the subject.
The authors are to be congratulated on the preparation of an important
contribution on a complex but overwhelmingly vital subject.
HAROLD G. JACOBSON, M.D.
Preface
The purpose of this book is to provide comprehensive coverage of all aspects
of cardiovascular disease. Each topic is presented systematically and concisely
leading the reader to correlate clinical findings and non-invasive studies with
invasive studies and treatment modalities.
A detailed description of the patterns of pulmonary vasculature and a new
classification of congenital heart disease based on radiological findings should
facilitate an accurate diagnosis in simple as well as complex cardiac defects.
The stepwise approach used in this book is used by the authors in the evalua
tion of patients and in the instruction of trainees as well as colleagues.
Weare confident that by using this approach others will become proficient
in a field which has been, even for sophisticated professionals, an impenetrable
enigma.
ix
Acknowledgments
We are grateful to many people who contributed to this work, including members
of the Departments of Radiology, Medicine, Pediatrics, and Cardiothoracic Sur
gery at Montefiore Medical Center and the Albert Einstein College of Medicine.
Among those who cooperated extensively in performing hemodynamic and angi
ographic studies and in providing an atmosphere of learning were Drs. Doris
Escher, Richard Grose, and Norman Solomon. Drs. Grose and Solomon, through
their friendship, their understanding, and their willingness to assume extra re
sponsibility, provided an atmosphere conducive to the development and comple
tion of this work. Dr. Mark Greenberg reviewed the chapter on Valvular Heart
Disease and made many helpful suggestions. Other members of the Division
of Cardiology who contributed were Drs. Janet Strain, Robert Rosenblum, and
Thasana Nivatpumin.
We acknowledge the faculty and staff of the Bronx Veterans Administration
Hospital, especially the late Dr. Kam F. Chan and Dr. Howard Friedman,
who provided acccess to material from that institution and invited the senior
author to provide teaching conferences. The material for this book stems from
a collection gathered in preparation for conferences at Montefiore Medical Center
and at the Bronx VA.
Drs. Michael V. Cohen, Maxine Rosoff, and Naftali Neuberger were especially
helpful in contributing echocardiograms on adults. Dr. Robert Eisenberg with
Drs. Rajamma Mathew and Henry Issenberg performed the pediatric cardiac
catheterizations at Montefiore Medical Center.
Special thanks are due to Drs. George Robinson, Lari Attai, Robert Frater,
Abraham Merav, and Richard Brodman, who not only contributed material,
but more importantly provided surgical correlation with the angiocardiographic
studies.
Dr. James Scheuer had maintained a standard of excellence within his division
and has encouraged close cooperation between the Divisions of Cardiology and
the Department of Radiology.
Dr. Spindola-Franco has been particularly fortunate to be able to work and
develop under giants in the field of Radiology: Dr. Harold G. Jacobson, Dr.
Herbert L. Abrams, and Dr. Douglass F. Adams in the United States and the
late Jorge Ceballos Labat in Mexico, who taught discipline and uncompromising
excellence.
Dr. Jacobson noted the abundance of material being collected and insisted
that it be brought together into a book. He also diligently reviewed and meticu
lously edited the entire manuscript and made innumerable helpful changes.
Dr. Jacobson deserves full credit for the existence of this book.
xi
xii Acknowledgments
Drs. Sven Paulin, Richard Gorlin, and Michael V. Herman at Harvard Medi
cal School and Drs. Seymour Sprayregen and Thomas C. Beneventano at Monte
fiore Medical Center also taught special skills required, and served as models
for excellence in teaching.
Dr. Spindola-Franco's former associates in Cardiac Radiology, Enrico Cap
piello, Robert Greenbaum and Elliot Wein, and his present associate, Ayodeji
Fayemi, have contributed material and have enabled Dr. Spindola-Franco to
spend the time required to write this book.
Zina Zilo, Chief Technologist in the Cardiac Catheterization Laboratory,
in cooperation with Lilly Sharaz and Kevin Early, photographed innumerable
cineangiographic studies, from which many of the illustrations were selected.
The late Dr. Dennison Young, former Director of Pediatric Cardiology at
Montefiore Medical Center and a pioneer in the field of congenital heart disease,
was most influential in Dr. Fish's training and continued as his mentor until
his recent death. Dr. Fish also trained with Dr. Norman Talner at Yale Univer
sity, who encouraged excellence in academic pursuits.
Mr. Michael Carlin deserves credit for the superb work he did in converting
all of the roentgenographic studies into photographic prints. The excellent draw
ings were produced by Mr. Stanley Waine.
The staff of Springer-Verlag have been enthusiastic in their cooperation in
the production of this book. In addition to their meticulous attention to technical
details, the production staff coordinated the process in such a way as to make
an overwhelming and complex task manageable.
Mrs. Eleanor Schultz deserves special mention. Her patience and diligence
in preparing the manuscript contributed in a major way to the quality of this
book. She functioned as a research and editorial assistant, checking innumerable
details, proofreading text and bibliography, and communicating with the pub
lisher.
Contents
FOREWORD Harold G. Jacobson, M.D. vii
PREFACE ix
ACKNOWLEDGMENTS xi
CONTRIBUTORS XVll
1 NORMAL HEART AND GREAT VESSELS 1
Normal Heart
Cardiomegaly 3
Pulmonary Vasculature 10
Bibliography 25
2 INTRODUCTION TO ECHOCARDIOGRAPHY 27
Physical Principle 27
Composite M-Mode Views (Arc Scans) 41
Real-Time Two-Dimensional Imaging of the Heart 44
Left Ventricular Performance 54
Echocardiography Using Contrast Material 55
Increased Pulmonary Artery Pressure 55
Doppler Echocardiography 55
Bibliography 69
3 CARDIOVASCULAR NUCLEAR MEDICINE 73
Richard M. Steingart and John P. Wexler 73
Principles of Cardiovascular Nuclear Medicine 73
Ischemic Heart Disease 89
Valvular Heart Disease 97
Pediatric Applications 101
Acknowledgment 102
References 102
4 ISCHEMIC HEART DISEASE 107
Radiological Examination 107
Coronary Arteriography 109
Left Ventriculography 139
xiii
Description:In this unprecedented era of revolutionary developments in clinical imaging, in no area of the body are dramatic breakthroughs better exemplified than in imaging of the heart. It is difficult for this writer to be objective about this work because he has watched its development in the exceptionally
