cardiac imaging

Postgraduate Education

BS Physical Therapy, Silliman University, 1996

BS Zoology, MSU-Iligan Institute of Technology 1999

Doctor of Medicine, Mindanao State University-College of Medicine

Post-graduate Internship

University of the Philippines, Philippine General Hospital

2003-2004

Internal Medicine Residency

University of the Philippines, Philippine General Hospital

2004-2007

Fellowship in Cardiology

University of the Philippines, Philippine General Hospital

2008-2011

Affiliations

Fellow, Philippine College of Physcians

Fellow, Philippine Heart Association

Diplomate, Philippine College of Cardiology

JILL IRENE Z. CAPISTRANO MD, FPCP, DPCC

Dr. Jill Irene Z. Capistrano, FPCP,DPCCINTERNAL MEDICINE-CARDIOLOGY

Postero-Anterior (PA) View

SVC

IVC

Postero-Anterior (PA) View

RA

Postero-Anterior (PA) View

RV

Postero-Anterior (PA) View

PA

Postero-Anterior (PA) View

LA

Postero-Anterior (PA) View

LV

Postero-Anterior (PA) View

Aorta

Postero-Anterior (PA) View

Postero-Anterior (PA) View

Right border

Superior vena cava

Right atrium

Inferior vena cava

Postero-Anterior (PA) View

Right border

Superior vena cava

Right atrium

Inferior vena cava

Left border

Aortic knob

Main pulmonary trunk

Left ventricle

Postero-Anterior (PA) View

Pulmonary Arteries

Right

Postero-Anterior (PA) View

Pulmonary Arteries

Right

Left

Postero-Anterior (PA) View

Pulmonary Arteries

Right

Left

Pulmonary VeinsLA

Lateral View

RA

SVC

IVC

Lateral View

RV

Lateral View

Lateral View

LA

Lateral View

LV

Lateral View

Aorta

Lateral View

Lateral View

Left atrium

Left ventricle

Lateral View

Left atrium

Left ventricle

Right ventricle

Lateral View

Aorta

Main Pulmonary Artery

Inferior vena cava

Lateral View

Pulmonary Arteries

Left

Right

Pulmonary Veins

Systemic Approach

Overview or overall glance at the film

Check cardiac position and situs

Cardiac size

Chamber enlargement

Great vessels

Lungs

Ancillary findings

Overview or overall glance at the film

Is it

adequate

or optimal for

cardiac evaluation?

Overview or overall glance at the film

Things to consider:

Position

Inspiration

Exposure

Overview or overall glance at the film

Things to consider:

Position

slight degrees of rotation or obliquity will

substantially affect the cardiac contour and

may alter the apparent size as well

Overview or overall glance at the film

Things to consider:

Inspiration

Should be in full inspiration

In suboptimal inspiration or supine chest

radiographs, the lower lobe markings are

crowded and may obscure the possibility

of early pulmonary edema

Overview or overall glance at the film

Things to consider:

Exposure

underexposure may simulate the

appearance of pulmonary congestion

overexposure may simulate diminished

pulmonary blood flow

Cardiac Position and Situs

Cardiac Positions:

Levocardia: the heart is predominantly in the

left chest, and the cadiac apex points leftward

Dextrocardia: the heart is predominantly in

the right chest, and the cardiac apex points

rightward

Mesocardia: the heart is positioned in the

midline, and the cardiac apex points directly

inferiorly

Cardiac Position and Situs

Cardiac Positions:

Dextroposition (dextroversion): the cardiac

apex points leftward, but the heart is located

predominantly in the right chest (typically due

to extrinsic forces)

Cardiac Position and Situs

Visceroatrial Situs:

“SITUS” refers to the pattern of anatomic

arrangement.

atrial situs is usually concordant with visceral

situs; hence these two are described together

Cardiac Position and Situs

Visceroatrial Situs:

Situs solitus:

the morphologic right atrium is to the right of the

morphologic left atrium

the gastric air bubble is on the left side, and the

liver is on the right

Situs inversus:

the morphologic right atrium is to the left of the

morphologic left atrium

the gastric air bubble is on the right side, and the

liver is on the left

Cardiac Position and Situs

Visceroatrial Situs:

Situs ambiguous:

this term is used when identification of visceroatrial

situs is not possible due to paucity of anatomic

markers

Cardiac Position and Situs

Dextrocardia

Situs solitus

Cardiac Position and Situs

Dextrocardia

Situs inversus

Cardiac Position and Situs

Situs ambiguous

Cardiac Size

Cardio-Thoracic Ratio

divide the widest

transverse diameter of

the heart by the widest

transverse diameter of

the thorax taken at the

inner side of the rib cage

Cardiac Size

Cardio-Thoracic Ratio

normal CT ratio in adults

is ususally 0.5 or less

normal CT ratio in the

newborn is

approximately 0.65

Chamber Enlargement

Right Atrial Enlargement

lateral bulging of the right

heart border

elongation of the right

heart border (length of

right heart border exceeds

50% of the mediastinal

cardiovascular shadow)

Cardiac enlargement

RightAtrial Enlargement

Right cardiac border > 2.5

cm from the lateral aspect

of the thoracic vertebra

and > 5.5 cm from mid

thoracic spine/spinous

process

Chamber Enlargement

Right Ventricular

Enlargement

PA View: Rounding and

upliftment of cardiac apex

Chamber Enlargement

Right Ventricular

Enlargement

PA View: Rounding and

upliftment of cardiac apex

Lateral View:

Retrosternal fullness

(contact of anterior

cardiac border greater

than 1/3 of the sternal

length

Chamber Enlargement

Left Atrial Enlargement

PA view:

Double density

Enlargement of LA

appendage

Upliftment of left mainstem

bronchus

Widening of carinal angle

Chamber Enlargement

Left Atrial Enlargement

Lateral view:

Prominent posterosuperior

cardiac border

Posterior displacement and

upliftment of left mainstem

bronchus

Chamber Enlargement

Left Ventricular

Enlargement

PA View: lateral and

downward displacement

of the cardiac apex

cardiac apex measures

<4 cm from the left

costophrenic sulcus

Chamber Enlargement

Left Ventricular

Enlargement

Lateral view:

posterior displacement of

the posterior inferior border

of the heart

Hoffman-Rigler Sign:

measured 2 cm above the

intersection of the

diaphragm & IVC; (+) if

posterior border extends

more than 1.8 cm of IVC

Pulmonary Vascular Pattern

NORMAL

In normal subjects, pulmonary

vascularity has a predictable

pattern.

Pulmonary arteries are usually

easily visible centrally in the

hila and progressively less so

more peripherally.

The central main right and left

pulmonary arteries are usually

not individually identifiable,

because they lie within the

mediastinum

Pulmonary Vascular Pattern

NORMAL

major arteries

-central, the clearly

distinguishable midsized

pulmonary arteries (third or

fourth order branches) are in

the middle zone

small arteries and arterioles

-normally below the limit of

resolution

-in the outer zone.

visible small and midsized

arteries

-sharp, clearly definable

margins because of the

sharp border between water

density and air density

structures.

Pulmonary Vascular Pattern

NORMAL

NORMAL

Pulmonary Vascular Pattern

INCREASED

NORMAL INCREASED

Pulmonary Vascular Pattern

NORMAL

Pulmonary Vascular Pattern

DECREASED

NORMAL

Pulmonary Vascular Pattern

DECREASED

NORMAL

Pulmonary Vascular Pattern

VENOUS

CONGESTION

Pulmonary Vascular Pattern

VENOUS

CONGESTION

INCREASED

ARTERIAL

BLOOD FLOW

Pulmonary Vascular Pattern

VENOUS

CONGESTION

Kerley’s B lines

Pulmonary Vascular Pattern

VENOUS

CONGESTION

Perihilar Haziness

Pulmonary Vascular Pattern

VENOUS

CONGESTION

Peribronchial Cuffing

Pulmonary Vascular Pattern

VENOUS

CONGESTION

Redistribution:

equalization

Pulmonary Vascular Pattern

Redistribution:

cephalization

VENOUS

CONGESTION

Pulmonary Vascular Pattern

Redistribution:

cephalization

Pulmonary Vascular Pattern

VENOUS

CONGESTIONInterstitial Edema

Kerley B Lines

Pulmonary Vascular Pattern

VENOUS

CONGESTIONInterstitial Edema

Kerley B LinesKerley A Lines

Pulmonary Vascular Pattern

VENOUS

CONGESTION

Alveolar Edema

PCWP VASCULAR PATTERN

<8 mmHg Normal

10-12 mmHg Lower zones appear equal in diameter to or

smaller than the upper zone vessels

12-18 mmHg Vessel borders become progressively hazier

because of increasing extravasation of fluid into

the interstitium – Kerley B lines (horizontal,

pleura based, peripheral linear densities)

>18-20 mmHg (acute) Pulmonary edema occurs, with interstitial fluid

present in sufficient amounts to cause a perihilar

bat wing appearance

The Great Arteries

Are they in normal position?

Are they of normal size?

The Great Arteries

Aorta

normal

prominent

diminutive

Main pulmonary

artery

normal

prominent

concave

The Great Arteries

Aorta

normal

prominent

diminutive

Main pulmonary

artery

normal

prominent

concave

The Great Arteries

Aorta

normal

prominent

diminutive

Main pulmonary

artery

normal

prominent

concave

The Great Arteries

Aorta

normal

prominent

diminutive

Main pulmonary

artery

normal

prominent

concave

The Great Arteries

Aorta

normal

prominent

diminutive

Main pulmonary

artery

normal

prominent

concave

Sample Cases

Compiled from the Specialty Board

of Adult Cardiology Exam

Chest X-ray exercises

normal

normal

TOF- Ventricle enlarged, apex slightly elevated – RV

Trachea displaced to left – aorta on right side. Vascular pattern decreased

TOF - previous syst pulmo shunt. Pulmo vasc normal.

Right sided aortic arch.

TOF

Hypovascular lung

Concave MPA

Prominent aorta

RVH

Transposition – decreased vasc pattern, heart

slightly enlarged, very narrow vascular pedicle.

Ebstein anomaly – massively enlarged heart,

huge left sided structures. Extension of the RA to R (RAE)

Total anomalous pulmonary venous return –figure of 8 deformity or snaoman heart, large veins forming a

convexity on either side of mediastinum

Patial anomalous venous return – scimitar

syndrome. Hypervascularity and large vessel paralleling the

border of the right side of hear and extending below diapragm –

anomalous PV

PAPVR – Hypoplastic right lung

PAPVR

PDA – slightly enlarged heart, some minor decrease in

vascular pattern. Large aortic knob

PDA hypervascular, prominent Ao, prominent MPA, LVH

ASD – RV, PA enlargement. Increased PBF. Lateral-

anterior bowing of sternum indicative of hyperventilation – L to

R shunt

ASD – Hypervascular, Dilated MPA, Dimunitive aorta, RVH, RAE

Pulmonic stenosis – great enlargement

of the PA large hilar vessels on left – represent postenotic

dilatation

PS VALVAR

Hypovascular

Dilated MPA

RVH

Transposition of great vessels – slight convexity of

the left upper border due to ascending aorta. No

aortic shadow on right.

Coarctation of the aorta – heart slightly enlarged 2 to LVH.

Ao unremarkable.

Rib notching – scalloping of inferior surfaces of ribs with

sclerosis

Coarctation of the aorta – LVH, ascending aorta

somwhat prominent. Descending aorta with indentation with

postenotic dilatation. L subclavian artery enlarged on L superior

mediastinum.

Pseudocoarctation of the aorta – transverse aortic

arch is high, very broad convexity of the aorta to

the left, below the arch

Mitral stenosis – LA enlargement. LA appendage

projecting on the L below PA. Right sided double density

MS – cephalization, Normal aorta, Dilated MPA, LAE, RAE, RVH,

MS PULMO CONGESTION, LAE, RAE, DILATED MPA

MS MR CEPHALIZATION, DILATED MPA, LAE,

LVH, RVE

LA wall calcification – dense calcification outlining

LA. Either in the wall or thrombus that lines the

chamber.

Mitral regurgitation – enlargement of both left sided

chambers. Dilated LA appendage. Double density.

Aortic stenosis – heart slightly enlarged, rounding of apex 2

LVH. Ascending Ao enlargement. Densely calcified valve.

Aortic insufficiency – LV dilatation

AI

Normal vascularity

Dilated aorta

LVH

LV aneurysm – LV dilatation, congested pulmonary

vascular marking (Kerly B lines).

3 weeks after- with bulge along LV border.

Calcified myocardial infarct – curvilinear

calcification extending most of the way around the

apex

Pericardial effusion – grossly enlarged cardiac silhoutte, After

pericardial tap and air injection – with note of pericardial

calcification

Aortic aneurysm

PULMONARY EDEMA