Chest radiograph in cardiovascular disease

Chest radiograph in cardiovascular diseaseDr. Jayanta Kr. Gogoi

Ideal x-rayProper exposureProper centeringProper labeling

Proper exposureA well penetrated chest X-ray is one where the vertebrae are just visible behind the heart.Over exposure- black lung fieldclear vertebral bodiesUnderexposure- hazy lung field

Proper centeringThe clavicle should be at the same level

Clavicles should be equidistant from the midline.

Proper labelingThe side determinationLabel L or RApex of heart on leftFundal gas shadow on leftRight dome of diaphragm placed higher than leftAortic knuckle on left

*(NOT for dextrocardia with Situs inversus)

How to read a chest x-rayView (PA, AP, lat)ExposureCentralizationPosition of tracheaSkeletal structuresLung fields including blood vessels and pleuraCardiovascular silhouetteCostophrenic and cardiophrenic anglesSoft tissue abnormalitiesFinal diagnosis or conclusion

Describe a normal chest x-rayThis is a PA view of the chest with normal exposure, proper centering and without any apparent bony abnormality. The lung fields are clear with normal bronchovascular markings; cardiovascular silhouette is within normal limit with normal cardiothoracic ratio. Mediastinum, costophrenic and cardiophrenic angles, domes of the diaphragm and soft tissue shows no abnormality.

Skeletal structure abnormalitiesKyphosis, scoliosisCrowding or widely spaced ribsAbsence of clavicleErosion of clavicleRib erosionRib notchingPresence of cervical rib

Skeletal deformityAbsent clavicleScoliosis

Rib notching

MM, Br Ca, HPT

Cervical rib

Lung fieldAccentuated pulmonary arteriesDistension of pulmonary arteriesAccentuation of bronchial patternProminent lymphatic vesselsThickened alveolar septum

Hilar shadowsPA, PV, bronchi, lymph gland, lymphatics, connective tissue.The lung field is divided in three zonesUpper, middle and lowerDo not corresponds with lobes of lung

Lung fields2nd CC

4th CC

Lung fields

Cardiothoracic rationRatio between max diameter of heart to max internal diameter of chest.Normal 1:2

2/3 of cardiacshadow lieson the left.

(a+b)/(c+d)

Borders of heart

Borders of heartRight border:SVCRALeft border:Aortic archPulmonary trunk or LPA (bay)LAALV

Cardiac enlargementLeft atrial enlargementStraightening of the left border of heart.Prominent LAADouble contour of rt border of heart (upper outer border is LA)Widening of carinal anglePosterior displacement of barium filled esophagus (rt lat view)

Double contour of rt border

LA enlargement in MS

LA enlargement AP and Lat view

RA enlargementenlarged, globular heartnarrow vascular pedicle gross enlargement of the right atrial shadow, i.e. increased convexity in the lower half of the right cardiac border

Causes of RAEraised right ventricular pressurespulmonary arterial hypertensioncor pulmonalevalvular diseasetricuspid regurgitationtricuspid stenosisEbstein's anomalyatrial septal defect (ASD)atrial fibrillation (AF)dilated cardiomyopathy

RAE

RV enlargementShifting of apex to the left (up outward)

Increase transverse diameter of heart

Lat view- obliteration of retrosternal space

RVE in PS

RVE and lat view

LV enlargementIncrease transverse diameter (cardiomegaly)Apex shift outward and downward

diaphragmElevation- collapse or fibrosis, ascites, pregnancy, dia. Palsy, abd mass, liver abscessDepression-Emphysema, pneumothorax

Soft tissue abnormalityChest wallCalcified lymph nodesBreast malignancySOL of lung

Chest X-ray in Cardiology

Pulmonary edema (PVH)

descriptionThis is a PA view of the chest with normal exposure, proper centering and without any apparent bony abnormality.Lung fields shows bat-wing appearance of confluent shadows which extends from the hilum to mid and upper zones. Cardiac silhouette is enlarged.No mediastinal shifting, both CP angles are obscured.

PVH stagesStage I Redistributionprominent upper lobe vessels

the pulmonary vessels supplying the upper lung fields are smaller and fewer in number than those supplying the lung bases.35

When there is redistribution of pulmonary blood flow there will be an increased artery-to-bronchus ratio in the upper and middle lobesArtery-to-bronchus ratio

Normally the vessels in the upper lobes are smaller than the accompanying bronchus with a ratio of 0.8536

Stage II - Interstitial edema

When fluid leaks into the peripheral interlobular septa it is seen as Kerley B or septal lines.Kerley-B lines are seen as peripheral short 1-2 cm horizontal lines near the costophrenic angles. These lines run perpendicular to the pleura.

Stage III - Alveolar edema

This stage is characterized by continued fluid leakage into the interstitium, which cannot be compensated by lymphatic drainage. This eventually leads to fluid leakage in the alveoli (alveolar edema) and to leakage into the pleural space (pleural effusion).

Kerley a lINESKerleys C linesKerleys B linesA= ApexB= baseC= centerKerley lines

Pulmonary artery hypertensionMain pulmonary artery usually prominent

Right and left pulmonary arteries large and taper rapidly

Peripheral pulmonary arteries are narrow and inconspicuous

Diffuse oligemia of the lungs

PAH

PAH

Increase Qp (pulmonary flow)Prominent MPA, RDPAPulmonary plethoraVascular markings of lung fields can be traced up to lateral third of it.End-on vessels (3 in rt, or 5 in both)

Cardiac temponadethere can be globular enlargement of the cardiac shadow giving awater bottle configuration

widening of the subcarinal angle without other evidence of left atrial enlargement may be an indirect clue

lateral CXR may showa vertical opaque line (pericardial fluid)separatinga vertical lucent line directly behind sternum (epicardial fat) anteriorly from a similar lucent vertical lucent line (pericardial fat) posteriorly; this is known as theOreo cookie sign

C. temponade

Pacemaker X ray

C X-RAY of CONGENITAL HEART DISEASE

CHD

ASDcan be normal inearly stages +/- when the ASD is small signs of increased pulmonary flow (shunt vascularity) enlarged pulmonary vesselsupper zone vascular prominencevessels visible to the periphery of the filmeventual signs of pulmonary arterial hypertension chamber enlargement right atriumright ventriclenote: left atrium is normal in sizenote: aortic arch is small to normal (narrow pedicle)

CHD 2

CHD

VSDThe chest radiographcan be normal with a small VSD.

Larger VSDs may show cardiomegaly (particularly left atrial enlargement although the right and left ventricle can also be enlarged).

A large VSD may also show features of pulmonary edema, pleural effusion and/orincreased pulmonary vascular markings

Wide pedicle

PDA

PDAChest radiographic features may vary depending on whether it is isolated or associated with other cardiac anomalies and with direction of shunt flow (right to left or left to right).

Can have cardiomegaly (predominantly left atrial and left ventricular enlargement if not complicated). Obscuration of the aortopulmonary window and features of pulmonary oedema may be evident

Wide pedicle

CHD4

TAPVRThe right heart is prominent in TAPVR because of the increased flow volume, but the left atrium remains normal in size. Types I and II result in cardiomegaly.

The supracardiac variant (type I) can classically depict a snowman appearance on a frontal chest radiograph, also known as figure of 8 heart or cottage loaf heart2-3.The dilated vertical vein on the left, brachiocephalic vein on top, and superior vena cava on the right form the head of the snowman; the body of the snowman is formed by the enlarged right atrium

TAPVR57

TOFBoot shaped heart

TOFPlain films may classically show a "boot shaped" heart with an upturned cardiac apex due to right ventricular hypertrophy and concave pulmonary arterial segment. Most infants with TOF however may not show this finding .

Pulmonary oligemia due to decreased pulmonary arterial flow. Right sided aortic arch is seen in 25%.

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