PRESENTED BY DR SANDEEP.R

CARDIAC XRAY

TOPICS DISCUSSED 1. BASICS OF CXR

2.STRUCTURES IN ANTERIOR VIEW

3.STRUCTURES IN LATERAL VIEW

4.CHAMBER ENLARGEMENT

5.PULMONARY CIRCULATION

6.CONGENITAL HEART DISEASE

7.PERICARDIAL DISEASE

8.PACEMAKER & ICD

9.CARDIAC CALCIFICATION

10.PROSTHETIC HEART VALVE

11.DISEASES OF AORTA

12. MISCELLENOUS

BASICS OF X-RAY TECHNICAL QUALITY

R – ROTATION I -- INSPIRATION P -- PROJECTION E -- EXPOSURE

ROTATION

The medial ends of both clavicles should be equidistant from the spinous process of the vertebral body projected between the clavicles

The increase in blackness of

one hemithorax is always on the side to which the patient is rotated, irrespective of whether the CXR has been taken PA or AP

DEGREE OF INSPIRATION

It is ascertained by counting either the number of visible anterior or posterior ribs

Adequate inspiratory effort - six complete anterior or ten posterior ribs are visible

Poor inspiratory effort - fewer than six anterior ribs

Hyperinflated lung-more than six anterior ribs

IMPORTANCE OF AN INSPIRATORY FILMPOOR INSPIRATORY FILM NORMAL INSPIRATORY FILM

1

23

1.MEDIASTINAL WIDENING 2.CMGLY 3.LOWER LOBE PATCHY OPACIFICN

PROJECTION OF X-RAY

Projection is defined as the direction of x-ray with relation to the patient

If the direction of x-ray projection is from front – AP projection

If the direction of x-ray projection is from behind –PA projection

AP VIEW PA VIEW

PA VIEW AP VIEW In erect patients Vertebral spines

more prominent Scapulae clear of

lungs Clavicles are

horizontal

In supine patients Vertebral bodies clear Apparent

cardiomegaly Scapulae overlap Clavicles are oblique

ERECT SUPINE Gas bubble in

fundus with a clear air fluid level

Gas bubble in antrum Apparent

cardiomegaly

EXPOSURE OF X-RAY

Normal exposure - the vertebral bodies should just be visible at the lower part of cardiac shadow

Underexposed -If the vertebral bodies are not visible , insufficient number of x-ray photons have passed through the patient to reach the x-ray film

Similarly, if the film appears too ‘black’, then too many photons have resulted in overexposure of the x-ray film.

UNDERPENETRATION

NORMAL

OVERPENETRATION

TOPICS DISCUSSED 1. BASICS OF CXR

2 . S T R U C T U R E S I N A N T E R I O R V I E W

3.STRUCTURES IN LATERAL VIEW

4.CHAMBER ENLARGEMENT

5.PULMONARY CIRCULATION

6.CONGENITAL HEART DISEASE

7.PERICARDIAL DISEASE

8.PACEMAKER & ICD

9.CARDIAC CALCIFICATION

10.PROSTHETIC HEART VALVE

11.DISEASES OF AORTA

12. MISCELLENOUS

SYSTEMATIC APPROACH

Technical factors

Skeletal abnormalities and hardware

Situs: gastric air bubble, cardiac apex, and aortic knob

Heart: position, size, and shape

Great vessels: position, size, and shape

Lung fields and vascularity by zone

Search for calcifications

STRUCTURES SEEN IN ANTERIOR VIEW

STRUCTURES IN LATERAL VIEW

RV

PT

AA

LA

LV

Gastric air bubble

Left upper lobe bronchus

IVC

Right hemidiaphragm

LV

LARV

Pulmonary outflow tract

AortaRight upper lobe bronchus

RPALPA

Confluence of pulmonary veins

Brachiocephalic vessels Trachea

Left hemidiaphragm

Sca

pula

Man

ubriu

m

Bod

y of

ste

rnum

Retr

oste

rnal

spac

e

Aortic knob is the junction formed by the arch and descending aorta

MAIN PULMONARY ARTERY

LPA

HOW TO MEASURE MAIN PULMONARY ARTERY

If we draw atangent line from the apex of the leftventricle to theaortic knob(red line) and measure along a perpendicularto that tangentline (yellow line)

The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away fromthe tangent line

PROMINENT MPA Main pulmonary

artery projects more than the tangent

Causes:1. Increased

pressure2. Increased flow

HYPOPLASTIC PA MPA > 15 mm from

the tangent

Concave PA segment

Causes:1. TOF

2. TRUNCUS ARTERIOSUS

LEFT ATRIAL APPENDAGE

L

LA ENLARGEMENT

HYPERTROPHIEDLA APPENDAGE

LEFT VENTRICLE

CARDIOMEGALY The cardiothoracic

ratio should be less than 0.5. i.e. A+B/C<0.5

A cardiothoracic ratio > 0.5 suggests cardiomegaly in adults

A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn

A

B

C

CTR is more than 50% but heart is normal

Extracardiac causes of cardiac enlargement Portable AP films Obesity Pregnant Ascites Straight back syndrome Pectus excavatum

CTR is less than 50% but heart is abnormal

Obstruction to outflow of the ventricles

Ventricular hypertrophy

Must look at cardiac contours

< 50%

ASCENDINGAORTA DILATED

LV CONTOUR

CRITERIA'S FOR CARDIOMEGALY

Cardiothoracic ratio >0.5 in adults

Cardiothoracic ratio >0.6 in newborn

Any increase in transcardiac diameter > 2 cm compared to old x-ray

In old age and emphysema a transcardiac diameter more than 15.5 cm in males &>12.5 cm in females

CHAMBER ENLARGEMENT

RA enlargement LA enlargement RV enlargement LV enlargement

CRITERIA FOR RA ENLARGEMENT

Rt. Cardiac border becomes more convex > 50% of right border

Rt. Atrial border extends >3 intercostal spaces

Measurement from mid vertical line to max. convexity in rt. Border>5 cm in adult & >4cm in children

Lateral view – fullness in space between sternum and front of upper part of cardiac silhouette

a b

Ab > 5cm

CRITERIA FOR LA ENLARGEMENT

Widening of carina( normal 45-75 degree) Elevation of left bronchus Straightening of left border Double atrial shadow( shadow within shadow)

Grade 1 –double cardiac contour Grade2 - LA touches RA border Grade 3 – LA overshoots the Rt. Cardiac border

Displaces the descending aorta to the left and esophagus to right seen in barium swallow

LA ENLARGEMENT

HYPERTROPHIEDLA APPENDAGE

LEFT ATRIAL ENLARGEMENT

DOUBLE ATRIAL SHADOW

WIDENING OF CARINA

ELEVATION OF LEFT BRONCHUS

LAA enlargement

Widening of carina

Elevation of lt. bronchusAneurysmal LA

Aneurysmal LA – When La enlarges to left and right and approaches within an inch of lateral chest wall

LATERAL VIEW-LA ENLARGEMENT

LA pushing theEsophagus posterior

LEFT VENTRICULAR ENLARGEMENT

PA view

(a)Left cardiac border gets enlarged and becomes more convex resulting in cardiomegaly

(b)Lt. cardiac border dips into lt. dome of diaphragm

(c) rounded apical segment

(d) cardiophrenic angle is obtuse

Lateral view

(a) Left ventricle enlarges inferiorly and posteriorly

(b)Rigler’s measurement A is >17 mm

(c)Rigler,s measurement B is< 7.5 mm (d) Eyeler’s ratio becomes > 0.42

RIGLER’S MEASUREMENT

Rigler’s A & B used to differentiate left ventricular and right ventricular enlargement

Possible only when IVC shadow is present

Jn. Of IVC with Lt. Atrium – J point

Rigler’s A- from J point along line of IVC draw a line of 2 cm above and mark the point X.

Draw a horizontal line from pt. A to posterior Cardiac border and mark that pt. y

Distance between points x & y is Rigler’s measurement A

NORMAL<17 mm

Rigler’s B-from the pt. J drop a perpendicular line to the dome and this distance is Rigler’s measurement B

NORMAL>7.5 mm

When LV enlarges, Posterior cardiac border gets

displaced posteriorly & IVC shadow gets included in cardiac shadow, without getting displaced posteriorly

Rigler’s measurement A >17 mm in lt. ventricular enlargement

EYELER’S RATIO To differentiate lt. & rt.

Ventricular enlargement

Valid when IVC shadow is absent or cannot be visualised

Mark the pt. of jn. where postero inferior cardiac border meets the dome as B

From this pt. B draw a horizontal line to the posterior border of sternum-AB

From pt.B - draw another horizontal line posteriorly to the inner border of the rib-BC

Ratio of AB/BC is Eyeler’s ratio < 0.42

LA Oblique view There is a retrocardiac

space( prevertebral)

(a)Mild lt. Ventricular enlargement-obliteration of retrocardiac space

(b) mod. Lt.ventricular enlargement-cardiac shadow overlaps vertebral column

(c)Marked Lt.ventricular enlargement-cardiac shadow overshoots vertebral column

Chest X ray shows left ventricular enlargement. Left heart border is displaced leftward, inferior and

posteriorly. Rounding of the cardiac apex.

RV ENLARGEMENT

PA VIEW

Cardiophrenic angle is acute

Clockwise rotation of heart causes RV to form the middle portion of the left heart border.

RIGHT LATERAL VIEWObliteration of retrosternal space

LEFT LATERAL VIEWRigler’s measurement will be17mm or lessRigler’s measurement will be 7.5mm or moreEyeler’s ratio is 0.42 or less

PERICARDIAL EFFUSION Narrow vascular pedicle

Cardiomegaly directly proportional to severity of pericardial effusion

This shadow has a rounded, globular appearance with no particular chamber enlargement

Cardiophrenic angle become more and more acute

Oligaemic pulmonary vascular markings

Marked change in cardiac silhouette in decubitus posture

‘Epicardial fat pad sign’- anterior pericardial strip bordered

by epicardial fat post. and mediastinal fat ant.>2mm

Narrow vascular pedicle

Acute cardiophrenic angle

‘Water bottle’appearence

Pulmonary oligaemia

DILATED CARDIOMYOPATHY VS PERICARDIAL EFFUSION

Chambers can be identified

Cardiophrenic angle is obtuse

Increased pulmonary venous hypertension

No change in cardiac silhouette in decubitus

Vascular pedicle is dilated or normal

Fluoro shows cardiac pulsation

CONSTRICTIVE PERICARDITIS

Pericardial calcification

1.Straightening of the right border

2.Pericardial thickening > 4 mm

3.Pericardial calcification (50% cases)

4.Dilatation of SVC and azygous vein

CONGENITAL ABSENCE OF PERICARDIUM

Focal bulge in area of main pulmonary artery

Sharply marginated

Absent right cardiac border

Increased distance between sternum and heart due to absence of sterno pericardial

ligament

PULMONARY VASCULARITY

1.RDPA<17MM

NORMAL PULMONARY CIRCULATION – 3 FEATURES

PULMONARY VENOUS HYPERTENSION

PULMONARY VENOUS HYPERTENSION

LARRY ELLIOT’S CLASSIFICATION OF PVH

RADIOGRAPHIC GRADE OF PVH

ACUTE DISEASE

PCWP

CHRONIC DISEASE

PCWP

1 13-17 MMHG 13-17 MMHG

2 18-25 MMHG 18-30 MMHG

3 >25 MMHG >30 MM HG

4 HEMOSIDEROSIS AND OSSIFICATION

LONG STANDING PVH

GRADE 0 -PCWP< 12 MM HG Upper lobe pulmonary veins are less prominent than

lower lobe veins

GRADE 1- PCWP 13-17MMHG

Redistribution of blood flow with cephalization-’ANTLER SIGN’

1) increased resistance to flow due to interstitial odema

2) alveolar hypoxia in lower lobes causes reflex vasoconstriction

3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex

GRADE 2- PCWP 18-25mm hg

Interstitial edema Peribronchial cuffing Kerley A,B,C lines Interlobular effusion Pleural effusion Hilar haze

Peribronchialcuffing

KERLEY A LINES

Distended lymphatic channels within edematous septa coursing from peripheral lymphatics to central hilar nodes

Towards the hilum

Less specific for Pulmonary venous hypertension

KERLEY A LINES

KERLEY B LINES

Horizontal lines 1-3 mm thick Perpendicular to pleural

surface

Towards the costophrenic angle

Accumulation of fluid in interlobular septa and lymphatics

Highly specific for PVH

KERLEY B

KERLEY C LINES

Crisscross lines seen between A &B

GRADE 3 – pcwp > 25mm hg

Alveolar odema

B/l diffuse patchy

cotton wool opacities

PULMONARY CIRCULATION

Pulmonary plethora – features

Enlargement of central pulmonary artery , lobar and segmental artery

Prominent nodular vascular shadows in frontal CXR- shunt vessels that course ventral to dorsal

Upper & lower lobe vessels prominent

RPDA > 17mm

Right descending pulmonary artery> tracheal diameter Ratio of RPDA to diameter of trachea > 1

Plethora seen if shunt size >2:1

PLETHORA

Pulmonary oligaemia Decreased flow proximal to orgin of main pulmonary

artery

Small pulmonary artery

Empty pulmonary bay

Pulmonary vessels small

Lung hypertranslucent

Lateral view shows diminution of hilar vessels

OLIGAEMIA

Empty pulmonary bay

Pruning High pressure left to right shunts are associated with

obliterative changes in the smaller pulmonary arteries & arterioles

Large main & large central pulmonary arteries taper down rapidly to very small vessels

Seen in Eisenmenger’s syndrome Precapillary PAH

PRUNING

PULMONARY EMBOLISM

Westermark sign Hampton’s hump Fleischner’s sign-

prominent central pulmonary artery

Palla’s sign-dilated rt. Descending pulmonary artery

Chang’s sign – dilatation and abrupt change in calibre of the rt. Descending PAHamptons hump

Wedge opacity

VALVULAR HEART DISEASE

MITRAL STENOSIS

Small aortic knob from decreased cardiac output

Features of left atrial enlargement

Right atrial enlargement from tricuspid insufficiency

Pulmonary venous hypertension

Enlarged MPA Calcified mitral valve

Mitral regurgitation

LA enlargement

LV enlargement

Pulmonary venous hypertension

Ascending aorta dilated

Left ventricular hypertrophy

Aortic valve calcification

AORTIC STENOSIS

Dilated ascending aorta

LV enlargement

AORTIC REGURGITATION

No obvious cardiomegaly

Enlarged PA

Dilated left pulmonary artery

Normal to decreased pulmonary vasculature

VALVULAR PS

Concave PA segment

RVH

INFUNDIBULAR PS

CONGENITAL HEART DISEASE ASD

MPA DILATED

RV APEX

RPA DILATED

PULMONARY PLETHORA

HOW TO DIFFERENTIATE ASD VSD PDA

DISEASE LEFT ATRIUM

AORTA

ASD

VSD

PDA

VSD

MPA DILATED

RPADILATED

LV APEX

PLETHORA

PDA

Linear or railroad track calcification at site of ductus may be seen in adults with PDA

PROMINENT MPA

LV APEX

PLETHORA

AORTIC KNOB

COARCTATION OF AORTA

“FIGURE OF 3” in CXR “REVERSE 3” or “E sign” in Barium meal

SUBCLAVIANARTERY DILATION

COARCTATION

POSTSTENOTICAORTICDILATION

RIBNOTCHING

DD OF INFERIOR RIB NOTCHING 1)Aortic obstruction- Takayasu arteritis Coarctation of aorta

2) Subclavian artery obstruction –Classic BT shunt

Takayasu arteritis

3)Chronic Svc obstruction

4)Intercostal Av fistula

5)Neurofibromatosis

CYANOTIC CHD

Cyanosis With Decreased Vascularity

Tetralogy of Fallot

Truncus-type IV

Tricuspid atresia

Transposition of great arteries

Ebstein’s anomaly

Cyanosis With Increased Vascularity

Truncus types I, II, III

TAPVC

Tricuspid atresia

Transposition

Single ventricle

CYANOTIC CHDTOF‘Cour en sabot’

Due to1)Rv apex

2)Underfilled LV

3)Concave pulmonary artery

4)Pulmonary oligaemia

TGA ‘Egg on string’ 1)Narrow pedicle

2)Rt. Border RA

3)Lt. border LV

4)Increased vascularity

5)Hypoplastic thymus

TAPVC (supracardiac) ‘figure of 8’ “snowman”

Rt border-SVC

Upper border-left innominate

Left border-left vertical vein

Body of snowman-RA

PAPVC(Scimitar sign)

The scimitar sign is produced by an anomalous pulmonary vein that drains any or all of the lobes of the right lung.

Scimitar vein empties into the inferior vena cava

EBSTEIN ‘Box shaped’heart

Enlarged RA

Hypoplastic pulmonary trunk

Decreased vascularity

TRUNCUS ARTERIOSUS LV apex

Rt pulmonary artery has a superior orgin (20%)

‘waterfall sign’

‘Hilar comma sign’

Associated right aortic arch (33%)

Concave PA segment

ELEVATED RIGHT HILUM

Eisenmenger’s syndrome

PACEMAKER

BIVENTRICULAR PACING

RA LEADRV LEAD

PACEMAKER PROBLEMS

LEAD FRACTURE

DISPLACED RA LEADDISPLACED RV LEAD

ICD

CARDIAC CALCIFICATIONS A) Valvular – Mitral , aortic valve B)Pericardial – constrictive pericarditis

C) Myocardial – left atrial wall, LV aneurysm

D)Endocardial – Endomyocardial fibrosis

E) Intraluminal – La thrombus , La myxoma , Lv thrombus

F) Vascular – aortic calcification , coronary artery

CARDIAC CALCIFICATION

MITRAL VALVE CALCIFICATION

MYOCARDIAL CALCIFICATION

CALCIFIED LV APICAL ANEURYSM

CONSTICTIVE PERICARDITIS

CALCIFIED PERICARDIUM

PERICARDIAL VS MYOCARDIAL CALCIFICATION

PERICARDIAL SEEN IN BOTH SIDES

OF HEART MOST COMMONLY IN AV GROOVE

DIFFUSE CALCIFICATION AROUND THE HEART

CALCIFICATION IS CHUNKY & UGLY

MYOCARDIAL SEEN IN ONLY LEFT SIDE MOST COMMON SITE IS

ANT. WALL

LOCALIZED TO THE LEFT

CALCIFICATION IS FINE & CURVILINEAR

GIANT LA CALCIFICATION

ATRIAL MYXOMA

PROSTHETIC HEART VALVE

TILTING DISK VALVE

TILTING DISK VALVE

STARR EDWARD BALL VALVE

MITRAL STAREDWARD

STARR EDWARD PROSTHETIC VALVE

MITRAL PROSTHESIS

ST. JUDE VALVE

ST.JUDEMITRAL PROSTHETIC

DISEASES OF AORTA

Aneurysm of ascending &Descending aorta

AORTIC DISSECTION

Egg shell sign

MISCELLENOUS X-RAYS

Occurs in less than 0.5% of people

Failure of regression of L common and Ant. Cardinal veins

Drains left jugular and left subclavian vein

Most patients also have right sided SVC

Drains into dilated coronary sinus

LEFT SVC

LEFT SVC

RIGHT AORTIC ARCH

Leftward displacement of barium filled esophagus

Rt. Indentation of trachea

Aortic knob is absent from left side

Aorta descends on right

Associated with TOF

Truncus arteriosus

RT . AORTIC ARCH

AORTIC NIPPLE

Left superior intercostal vein

Seen in 5% of cases

To be differentiated from a mass

Also called pseudo dissection

It drains into hemiazygous vein

Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis

CERVICAL AORTIC ARCH

Left sided cervical aortic arch

Aortic knob at apex of lung

Descend on the left

CERVICAL AORTIC ARCH

SITUS INVERSUS WITH DEXTROCARDIASITUS INVERSUS WITH LEVOCARDIA

DEXTROCARDIA HYDROPNEUMOPERICARDIUM

PDA CLIP

BIBLIOGRAPHY(1)Jefferson K, Rees S. Clinical cardiac radiology, 2nd edition Butterworths; 1980.

(2) Lipton MJ. Plain film diagnosis of heart disease: cardiac enlargement. Contemporary Diagnostic Radiology 1988;11:1-6.  

(3) Boxt LM, Reagon K, Katz J. Normal plain film examination of the heart and great arteries in the adult. J Thorac Imaging 1994;9:208-18.  

(4)Murray G. Baron,Wendy M. Book .Congenital heart disease in the adult.North American Clinics of Radiology 2004;3

(5) Ramesh M. Gowda,Lawrence M. Boxt. Calcifications of the heart.North American Clinics of Radiology 2004;4

(6) Martin J. Lipton, Lawrence M. Boxt. How to approach cardiac diagnosis from the chest radiograph.North American Clinics Of Radiology 2004;5

(7) Murray G. Baron .PLAIN FILM DIAGNOSIS OF COMMON CARDIAC ANOMALIES IN THE ADULT.North American Clinics Of Radiology 2004;6

(8) Radiology imaging – sutton 6th edition

(9) Pediatric cardiology- Perloff’s clinical recognition of congenital heart disease

(10)Radiology of congenital heart disease-Amplatz

(11)Grainger & Allisons- diagnostic radiology vol1 , 4th edition

(12)Cardiac Xrays- v.Chockalingam

(13)Braunwald heart diseases 9th edition(14) Emma C. Ferguson,Rajesh Krishnamurthy,Sandra A. A.Oldham. Classic Imaging Signs of Congenital Cardiovascular Abnormalities; RadioGraphics 2007; 27:1323–1334(15)www.learningradiology.com

QUIZ

EBSTEIN’S ANOMALY

8 YR OLD ACYANOTIC CHILD

ATRIAL SEPTAL DEFECT

25 YR OLD LADY WITH DYSPNOEA

MITRAL STENOSIS

65 YR OLD MAN WITH DYSPNOEA

PERICARDIAL EFFUSION

35 YR OLD ACYANOTIC FEMALE

ASD WITH PAH

IDENTIFY THE ABNORMALITY

SITUS INVERSUS WITH

DEXTROCARDIA

IDENTIFY THE ABNORMALITY

RT AORTIC ARCH WITH RT DESCENDING AORTA

4 MO CYANOTIC CHILD

TAPVC SUPRACARDIAC

3 MO CYANOTIC CHILD

D-TGA

8 YR OLD ACYANOTIC CHILD

VSD