The Chest X-ray

• Still common• In patient• Portable imaging

• ‘Morning Portables’• Pre-op• Post-op• Out patient

• Still effective but possibly overused

http://cdn.lifeinthefastlane.com/wp-content/uploads/2012/08/CXR-AP.jpghttp://lifeinthefastlane.com/investigations/cxr-normal/

Right AtriumRight Ventricle

Right Ventricle

Left Ventricle Left VentricleLeft Atrium

Left Atrium

The Chambers

The Pulmonary and Aortic Vessels

Main Pulmonary ArteryRDPA Main Pulmonary ArteryLDPA

Aortic Arch Aortic Arch

Descending Aorta Descending Aorta

This Lecture

• Pulmonary Hypertension• Ventricular Septal Defect• Mitral Stenosis vs Mitral Regurgitation• Aortic Stenosis

Pulmonary HTN

• Increase in pulmonary vascular resistance

• Mean pulmonary artery pressure (PAP) >25mmHg at rest• At least 30 mmHg during exercise• Mean pulmonary wedge pressure < 15mmHg

Causes

• Group 1• Idiopathic• Pulmonary Arterial Hypertension

• Group 2• Left Heart Disease• Pulmonary Venous Hypertension

• Group 3• Hypoxemia• COPD

• Group 4• Group 5

Clinical Indications

• Dyspnea on exertion

• Dizziness

• Syncope

• Angina

Radiographic Indicators

• Prominent main pulmonary artery• Convex shadow along the left cardiac border (PA)

• Right ventricle enlargement• Increased cardiac border in contact with anterior chest wall

(Lat)

• Right descending pulmonary enlargement• Transverse diameter is greater than 16mm

• Pruning of peripheral pulmonary vessels• Abrupt tapering of distal pulmonary vessels with loss of side

branches

• Pleural effusion/Pulmonary Edema

Case courtesy of Dr Frank Gaillard, Radiopaedia.org

Prominent Main Pulmonary Artery and Trunk

Enlarged RDPA

Pleural Effusion

http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=100743&ti=311759&searchkey=

Enlarged Right Ventricle

Enlarged Pulmonary Trunk

Miniati et al. Accuracy of chest radiography in predicting pulmonary hypertension:A case-control study. M. Miniati et al. / Thrombosis Research 133 (2014) 345–351

http://www.vcuthoracicimaging.com/Historyanswer.aspx?qid=40&fid=1

Ventricular Septal Defect

• Holes in the ventricular septum• Conoventricular• Perimembranous• Inlet• Muscular

• Most common congenital cardiac malformation• Up to 50% in congenitally malformed hearts

Causes

• Can exist in isolation

• Or existing with other malformations:• Tetralogy of Fallot• Double outlet right ventricle• Transposition• Univentricular hearts

Clinical Indications

• Dependent on size• May be asymptomatic• May be cyanotic

• Retardation of growth• Pulmonary HTN• Pulmonary edema• Wheezing• Tachypnea

Radiographic Indicators

• Cardiomegaly• Can be difficult to diagnose due to the thymus

• Increased pulmonary vascular markings

Normal

http://www.scielo.br/scielo.php?pid=S0100-39842006000600012&script=sci_arttext&tlng=en

Ventricular Septal Defect

http://radiopaedia.org/articles/ventricular-septal-defect-1

Normal Cardiomegaly

RADIOLOGIC CLINICS OF NORTH AMERICAVOLUME 37 * NUMBER 6 * NOVEMBER 1999

Ventricular Septal Defect

http://radiopaedia.org/cases/ventricular-septal-defect

Case courtesy of Dr Frank Gaillard, Radiopaedia.org

Spicer et al. Orphanet Journal of Rare Diseases (2014) 9:144

Tetralogy of Fallot

http://radiopaedia.org/cases/tetralogy-of-fallot-1">Tetralogy of Fallot

Ventricular Septal Defect

Right Ventricular outflow track obstruction

Overriding Aorta

Right Ventricular Hypertrophy

Let’s Think What Happens

Mitral Stenosis

• Leaflet thickening resulting in narrowing of the mitral valve.

• Causes• Rheumatic Fever

• Common in developing countries• Degenerative

• Common in developed countries

Healthy Mitral Valve Mitral Valve Stenosis

Fish Mouth Appearance

Mitral Regurgitation

• Systolic retrograde flow from the left ventricle into the left atrium.

• Causes• Non-Ischemic

• Degenerative• Endocarditis• Rheumatic

• Ischemic

http://www.vetmed.ucdavis.edu/vmth/small_animal/cardio_kittleson/cases/case9/figures.htm

Healthy Mitral Valve

http://nethealthbook.com/cardiovascular-disease/heart-disease/mitral-valve-disease/

Mitral Valve Prolapse

Clinical Indicators

• Dyspnea

• Exercise Intolerance

• Long Murmur

• Pulmonary HTN

Radiographic Indicators

• Left atrial enlargement• Double Density• Splayed Carina

• Decreased aortic knob

LALV

RVRA

LA

LVRVRA

Double Density and Splayed Carina

http://radiopaedia.org/articles/mitral-valve-regurgitation

http://www.learningradiology.com/lectures/cardiaclectures/valvularlesions2012/Valvular%20Lesions%20of%20the%20Heart/Valvular%20Lesions%20of%20the%20Heart.html

http://radiologyinthai.blogspot.com/2010_06_01_archive.html

http://static.wikidoc.org/3/3a/Left-atrial-enlargement-002.jpg

Aortic Stenosis

• Narrowing of the aortic valve.

• Causes:• Age (Calcific AS, Senile)

• Similar to atherosclerosis• Rheumatic Valve • Congenital

Normal Aortic ValveCalcific Aortic Stenosis

http://www.slideshare.net/drranjithmp/echo-assessment-of-aortic-stenosis

Clinical Indicators

• Angina

• Syncope

• Heart Failure

Radiographic Indicators

• Aortic Valve Calcification

• Prominent Ascending Aorta

• Left Ventricular Enlargement

http://www.learningradiology.com/archives2011/COW%20480-aortic%20stenosis/ascorrect.htm

Ascending aorta projects farther than right atrium

Normal Descending Aorta

Calcified Aortic Valve

http://www.learningradiology.com/archives04/COW%20118-Aortic%20Stenosis/ascorrect.htm

Where are those valves?

A

M

http://web.stanford.edu/dept/radiology/radiologysite/site141.html

AM

Aortic Valve

Mitral Valve

Reference• Barbosa E, Gupta N, Torgian D, Gefter W. (2012). Current Role of imaging in the diagnosis and management of pulmonary

hypertension. American Journal of Roentgenology. 198, 1320-1331

• Batson G, Urquhart W, Sideris D. (1972). Radiologic Features in Aortic Stenosis. Clinical Radiology. 23, 140-144

• Carabello, Blase. (2013). Introduction to aortic stenosis. Circulation Research . , 113, 179-185.

• Carabello, B & Paulus W. (2009) Aortic Stenosis. The Lancet., 373, 956-966

• Chandrashekhar Y, Westaby S, Narula J. Mitral Stenosis. (2009). The Lancet., 374, 1271-1283

• Coussement, Alain & Gooding Charles. (1973). Objective Radiographic Assessment of Pulmonary Vascularity in Children. Radiology. 109, 649-654

• Delnevo A, Tritella S, Carbonaro L, Bobrechova O, Leo G, Sardanelli F. (2012). The use of bedside radiography at a university hospital. Data on a two-week period. Euopean Journal of Radiology. 81, 260-263

• Enriquez-Sarano, M, Akins C, Vahanian, A. (2009). Mitral Regurgitation. The Lancet., 373, 1382-1394

• Matthay R, Schwarz M, Ellis J, Steele P, Siebert P, Durrance J, Levin D.. (1981). Pulmonary Artery Hypertension in Chronic Obstructive Pulmonary Disease: Determination by Chest Radiography. Investigative Radiology. 16, 95-100

• Miniati M, Monti S, Airo E, Pancani R, Formichi B, Bauleo C, Marini C. (2014). Accuracy of chest radiography in predicting pulmonary hypertension: A case-control study. Thrombosis Research. 133, 345-351

• Palazzeti V, Gasparri E, Gambini C, Sollazzo S, Saric S, Salvolini L, Giovagnoni A. (2013). Chest radiography in intensive care: an irreplaceable survey? Radiologia Medica. 118, 744-751

• Sethi R. (2010). An Approach to Assessing the Chest Radiograph. British Journal of Hospital Medicine. 71(11), 172-17

• Shah, Sanjiv.. (2012) Pulmonary Hypertension. Journal of American Medical Association. 308(13), 1366-1374

• Spicer D, Hsu H, Co-Vu J, Anderson R, Fricker F. Ventricular Septal Defect. (2014). Orphanet Journal of Rare Diseases. 9(144), 1-16

• Strife Janet & Sze, Raymond. (1999). Radiographic Evaluation of the Neonate with Congenital Heart Disease. Radiologc Clinics of North America. 37(6), 1093-1107

• Tumkosit M, Yingyong N, Mahayosnond A, Choo K, Goo H. (2012). Accuracy of chest radiography for evaluating significantly abnormal pulmonary vascularity in children with congenital heart disease. International Journal of Cardiovascular Imaging. 28, 69-75

• Zarco, P. (2003). Aortic stenosis. European Heart Journal. , 24, 133-135.