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Chest xray for evaluation of cardiovascular system

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In this ppt i am describing how to approach for chest X-ray in a patient with cardiovascular disorder

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Chest xray for evaluation of cardiovascular system

  1. 1. Chest X-ray for evaluation of cardiovascular system Presenter Praveen Gupta Moderator Ajith Sir JIPMER Pondicherry Date 31/01/2017 1 Chest X-ray for evaluation of crdiovascular system
  2. 2. Introduction 2  Chest x-ray most common radiographic examination  Most difficult to interpret  Yields anatomic and physiologic information  It is difficult and impossible to extract all information
  3. 3. Variables determine CXR 3 Technical factors  Milliamperage  Kilovoltage  Exposure duration Patient-specific factors  Body habitus,  Age  Physiologic status,  Ability to stand and  To take and hold a deep breath
  4. 4. Technical Considerations 4  Frontal view and lateral view  Posteroanterior (PA) view standing with chest toward the recording medium and back to the x-ray tube  Lateral view while standing with the left side toward the film
  5. 5. Portable CXRs Limitations 5  Obtained with patients supine or semisupine  Depth of inspiration decreased  Heart appear relatively larger  Less optimal visualization of the lungs because they are not expanded.  Taken as AP views  SID < 6 feet  Space constraints  Limited power of portable x-ray machine  Longer exposure time  Increased cardiac and respiratory motion and decreased resolution
  6. 6. Portable CXRs Limitations 6  Poor resolution  Less accurate and useful  Greater radiation dose  Most useful for simple mechanical question  Pacemaker or implantable cardioverter-defibrillator (ICD) is properly positioned  Endotracheal tube in correct location  Mediastinum is midline  Not good at providing physiologic or complex anatomic information  Impossible to exclude pneumothorax or pleural effusion.  Impossible to evaluate heart size and contour or status of the pulmonary vasculature  Should be performed only in limited situations when clearly needed to answer specific questions
  7. 7. NORMAL CHEST RADIOGRAPH 7  Take systematic approach  First assess anatomy  Then physiology  Finally pathology.
  8. 8. Normal Chest Radiograph 8  Heart diameter is normally less than half the transverse diameter of the thorax  Heart overlies roughly 75% to the left and 25% to the right of the spine.  The mediastinum is narrow superiorly, and normally the descending aorta can be defined from the arch to the dome of the diaphragm on the left  The pulmonary hila are seen below the aortic arch, slightly higher on the left than on theright  On both frontal and lateral views, the ascending aorta (aortic root) is normally obscured by the main pulmonary artery and both atria  The location of the pulmonary outflow tract is usually clear on the lateral film Frontal projection of the heart and great vessels. A, Left and right heart borders in the frontal projection. B, A line drawing in the frontal projection demonstrates the relationship of the cardiac valves, rings, and sulci to the mediastinal borders. A = ascending aorta; AA = aortic arch; Az = azygous vein; LA = left atrial appendage; LB = left lower border of the pulmonary artery; LV = left ventricle; PA = main pulmonary artery; RA = right atrium; RV = right ventricle; S = superior vena cava; SC = subclavian artery.
  9. 9. NORMAL CHEST RADIOGRAPH 9  Cardiac Chambers and Aorta  On the PA view, the right contour of the mediastinum contains the right atrium and the ascending aorta and superior vena cava (SVC)  The right ventricle is located partially overlying the left ventricle  Left atrium is located just inferior to the left pulmonary hilum  Concavity at the level of location of the left atrial (LA) appendage  The left ventricle constitutes the prominent, rounded apex of the heart on the frontal view Frontal projection of the heart and great vessels. A, Left and right heart borders in the frontal projection. B, A line drawing in the frontal projection demonstrates the relationship of the cardiac valves, rings, and sulci to the mediastinal borders. A = ascending aorta; AA = aortic arch; Az = azygous vein; LA = left atrial appendage; LB = left lower border of the pulmonary artery; LV = left ventricle; PA = main pulmonary artery; RA = right atrium; RV = right ventricle; S = superior vena cava; SC = subclavian artery. Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261
  10. 10. NORMAL CHEST RADIOGRAPH 10  On lateral CXR the left main pulmonary artery can be seen coursing superiorly and posteriorly relative to the right  On both frontal and lateral views, the ascending aorta (aortic root) is normally obscured by the main pulmonary artery and both atria  The atrium constitutes the upper portion of the posterior contour of the heart on the lateral CXR but cannot normally be separated from the left ventricle  The left ventricle constitutes the sloping inferior portion of the mediastinum on the lateral view Lateral chest radiograph. B, Superimposed anatomic drawing of the cardiac chambers and great vessels. C, Diagram of the lateral projection of the heart showing the position of the cardiac chambers, valve rings, and sulci. Arrows indicate the direction of blood flow. A = aorta; PA = pulmonary artery; RAA = right atrial appendage; RV = right ventricle
  11. 11. NORMAL CHEST RADIOGRAPH 11  Heart appears white and lungs relatively black  A fat pad surrounds apex of the heart  Cardiac motion is usually sufficient to cause minor haziness of the silhouette.  If portion of the heart border does not move (as with left ventricular [LV] aneurysm) the border unusually sharp  The aortic arch is visible because the aorta courses posteriorly and surrounded by air  Most of the descending aorta is also visible Chest X-ray showing Left ventricle aneurysm
  12. 12. Lungs and Pulmonary Vasculature 12  Lung size varies as a function of inspiratory effort, age, body habitus, water content, and intrinsic pathologic processes.  Lung distensibility decreases with age, appear progressively smaller as patients age  With increasing LVEDP as in heart failure, or increasing LA pressure, as in mitral stenosis expansion on a CXR is lessened  Chronic obstructive pulmonary disease, heart appearing small even in the presence of cardiac dysfunction Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no- 261 A, B, PA and lateral digital chest radiographs with different windows and leveling. A, With a pulmonary window and level, the lung fields, including the pulmonary vasculature, are well visualized but the mediastinal structures are not well defined. Note also flattening of the diaphragms and increased lung lucency, indicative of chronic obstructive pulmonary disease. B, Rewindowed, the mediastinal structures are now well seen and show a dilated, calcified aortic root and descending thoracic aorta. Pulmonary vascularity cannot be defined in these images
  13. 13. Lungs and Pulmonary Vasculature 13  Pulmonary arteries visible centrally in the hila and less so more peripherally  Main right and left pulmonary arteries difficult to quantify  If the lung is thought of in three zones, the major arteries are central; the clearly distinguishable midsized pulmonary arteries (third- and fourth- order branches) are in the middle zone; and the small arteries and arterioles, which are normally below the limit of resolution, are in the outer zone
  14. 14. Lungs and Pulmonary Vasculature 14  Visible small and midsized arteries (midzone) have sharp, clearly definable margins  Arteries in the lower zone are larger than those in the upper zone  The angles that the lungs make with the diaphragm are normally sharp and clearly seen  The contour that the inferior vena cava (IVC) makes with the heart is clearly seen on the lateral CXR  IVC lies on the right of the mediastinum and posterior to the contour of the heart. Normal chest X-ray PA view
  15. 15. Lungs and Pulmonary Vasculature 15  If the patient is placed laterally with the left side against the film, the right is relatively slightly magnified in comparison to the left  The aorta and great vessels normally dilate and become more tortuous and prominent with increasing age, thereby leading to widening of the superior mediastinum  Heart appears larger because of decreasing lung compliance in old age although unless true cardiac disease is present, its diameter remains less than half the transverse diameter of the chest on a PA view Normal lateral chest X-ray
  16. 16. Lungs and Pulmonary Vasculature 16  Patients who are obese may not be able to fully expand their lungs, thus making a normal heart appear slightly larger  In patients with pectus excavatum the heart may appear enlarged on the frontal view Left side showing x-ray taken in thin individual and right chest x- ray showing film taken in obese patient
  17. 17. Chest radiograph in heart disease 17  First step is to define which type of CXR study is being evaluated—PA and lateral, PA alone, or an AP view  The next step is to determine whether previous CXRs are available for comparison  Look at areas that are easily ignored  Such areas include thoracic spine, neck (for masses and tracheal position), costophrenic angles, lung apices, retrocardiac space, and retrosternal space  Evaluate the lung fields next  Search for infiltrates or masses, even when primary concern is cardiovascular abnormalities Normal chest X-ray
  18. 18. Chest radiograph in heart disease 18  Size of the cardiac silhouette ,its position, and the location of the ascending and descending aorta  Site and position of the stomach  Define pulmonary vascularity by looking at the middle zone of the lungs (i.e., the third of the lungs between the hilar region and the peripheral region laterally) and comparing a region in the upper portion of the lungs with a region in the lower portion, at equal distances from the hilum  Vessels larger in the lower part of the lung and sharply marginated in both the upper and lower zones Normal chest X-ray
  19. 19. Chest radiograph in heart disease 19  In normal individuals, vessels taper and bifurcate and are difficult to define in the outer third of the lung  They normally become too small to be seen near the pleura
  20. 20. Chest radiograph in heart disease 20  When PA flow is increased, as in patients with a high-output state (e.g., pregnancy, severe anemia as in sickle cell disease, hyperthyroidism) or left-to-right shunt the pulmonary vessels are more prominent than usual in the periphery of the lung  They are uniformly enlarged and can be traced almost to the pleura, but their margins remain clear All of blood vessels everywhere in lung are bigger than normal RDPA Usually >17 mm
  21. 21. Increased FlowNormal 21
  22. 22. Increased flow Distribution of flow is maintained as in normal Lower lobe vessels bigger than upper lobe Gradual tapering from central to peripheral 22
  23. 23. Chest radiograph in heart disease 23 In patients with elevated pulmonary venous pressure, the vessel borders become hazy, the lower zone vessels constrict, and the upper zone vessels enlarge; vessels become visible farther toward the pleura, in the outer third of the lungs
  24. 24. Venous Hypertension RDPA usually > 17 mm Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization 24
  25. 25. Rapid cutoff in size of peripheral vessels relative to size of central vessels Central vessels appear too large for size of peripheral vessels which come from them = Pruning Pulmonary Arterial Hypertension 25
  26. 26. Chest radiograph in heart disease 26  With increasing LVEDP or LA pressure pulmonary edema develops  Pulmonary edema cause the classic perihilar “bat wing” appearance  With chronic heart failure normal pulmonary vascular pattern or moderate rather than marked redistribution  In the setting of an acute, large transmural myocardial infarction (MI) heart is usually minimally or mildly enlarged despite a marked increase in LVEDP  If the pulmonary edema is independent of LV dysfunction, however, as may occur at a high altitude or following cerebral trauma, the size of the heart may remain normal Chest X-ray showing Bat-Wing appearnce in a patient with acute congestive heart failure
  27. 27. Cardiac Chambers and Great Vessels 27  Individual chambers should be examined  In acquired valvular disease and in many types of congenital heart disease, however, individual chamber enlargement is present and crucial to CXR (and often clinical) diagnosis
  28. 28. Cardiac Chambers and Great Vessels 28 Right Atrium  Right atrial enlargement is never isolated except in the presence of congenital tricuspid atresia or the Ebstein anomaly  Both are rare  X-ray appearance:  PA:inferior segment of right border of heart extending to right , bulge, high bulge point
  29. 29. Cardiac Chambers and Great Vessels 29 Right Atrium  Right atrial enlargement  Lateral :the right atrial curvature at least half as long as the anterior border of heart,bulge  The right atrial contour blends with that of the SVC, right main pulmonary artery, and right ventricle.  Thus it is almost impossible to define in adults, and it is pointless to try
  30. 30. Cardiac Chambers and Great Vessels 30 Right Ventricle  Commonly seen in tetralogy of Fallot  Signs of RV enlargement are, boot-shaped heart and filling of the retrosternal airspace  The former is caused by transverse displacement of the apex of the right ventricle as it dilates Chest X-ray in a patient with TOF suggestive of boot shaped heart in PA view
  31. 31. Cardiac Chambers and Great Vessels 31 Right Ventricle  On a lateral CXR in normal patients, the soft tissue density is confined to less than one third the distance from the suprasternal notch to the tip of the xiphoid  If the soft tissue fills in by more than one third in the absence of other it is a reliable indication of RV enlargement Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261 The lateral view confirms marked RV (arrow) and LA (small arrows) enlargement. Note filling in of the retrosternal airspace.
  32. 32. Left Atrium 32  First dilation of the LA appendage, seen as a focal convexity where there is normally a concavity between the left main pulmonary artery and the left border of the left ventricle on the frontal view  Elevatation of the left main stem bronchus,  Widening of the angle of carina  Focal bowing of the middle to low thoracic aorta toward left  Double density on the frontal view Chest X-ray in a 17 year old male with severe rheumatic mitral valve stenosis showing dilated LA appendage, widening of anlge of carina, double density due to left atrial enlargement JIPMER hospital, CTVS Department
  33. 33. Left Atrium 33  On the lateral CXR, LA enlargement appears as a focal, posteriorly directed bulge  In mitral stenosis the left atrium dilates than right ventricle dilated. The left ventricle remains normal Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261 FIGURE 15-10 Chest radiographs of a 60-year-old woman with severe mitral stenosis B, Lateral view confirming RV enlargement with filling in of the retrosternal airspace. Note also the marked LA enlargement (arrows).
  34. 34. Left Ventricle 34  LV enlargement is characterized by a prominent, downward directed contour of the apex  Cardiac contour enlarged  Mitral regurgitation, with increased volume in the left atrium and ventricle, both dilate JIPMER hospital, CTVS Department Chest X-ray in a patient with severe rheumatic mitral regurgitation showing dilated left ventricle with dilated left atrium
  35. 35. Left Ventricle 35  Lateral CXR, posterior bulge, below the level of the mitral annulus  Pushing gastric bubble inferiorly Lateral view. Note enlargement of the left ventricle, which is extending below the diaphragm and compressing the gastric bubble (arrowheads). Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no- 261
  36. 36. Left Ventricle 36  Focal LV enlargement in adults is a common manifestation of aortic insufficiency (often with aortic root dilation) or mitral regurgitation (with LA dilation) X-ray of 46 year old male who was known case of dilated ascending aorta with severe aortic regurgitation showing isolated enlargement of left ventricle along with shadow on the right side of the mediastinum suggestive of dilated ascending aorta, patient later underwent David repair with aortic valve repair JIPMER hospital, CTVS Department
  37. 37. Pulmonary Arteries 37  Dilation is seen as a prominent left hilum on the frontal view and a prominent pulmonary outflow tract on the lateral view Chest X-ray in a patient with ASD with eissenmenger syndrome showing dilated pulmonary artery bay JIPMER hospital, Cardiology Department
  38. 38. Pulmonary Arteries 38 Chest X-ray in a patient with VSD with Moderate Pulmonary artery hypertension showing dilated pulmonary artery bay JIPMER hospital, Cardiology Department
  39. 39. Aortic Valve and Aorta 39  On frontal CXR, aortic dilation seen as prominence to the right of the middle mediastinum  Prominence in the anterior mediastinum on the lateral view, posterior to the pulmonary outflow tract  Aortic valve calcification pathognomonic for aortic valve disease, difficult to see on a CXR Chest X-ray of a 46 year old male who was known case of dilated ascending aorta with severe aortic regurgitation showing isolated enlargement of left ventricle along with shadow on the right side of the mediastinum suggestive of dilated ascending aorta, patient later underwent David repair with aortic valve repair JIPMER hospital, CTVS Department
  40. 40. Pleura and Pericardium 40  The pericardium is rarely distinctly definable on a CXR  In two situations it can be seen: calcification or, in the presence of a large effusion.  With a large pericardial effusion, the visceral and parietal pericardial layers separate  Pleural calcification pathognomonic for asbestos exposure  It is associated with a high risk for malignant mesothelioma Chest X-ray showing Water bottle shape heart suggestive of large pericardial effusion
  41. 41. Pleura and Pericardium 41 Pericardial calcification is usually thin and linear and follows the contour of the pericardium, and it is often seen only on one view Chest X-ray PV view and Lateral view only showing pericardial calcification
  42. 42. IMPLANTABLE DEVICES AND OTHER POSTSURGICAL FINDINGS 42  CXR following surgery or other percutaneous interventions  Prosthetic valves, pacemakers and ICDs  Intra-aortic counterpulsation balloons and ventricular assist devices  Changes after surgery, such as the presence of clips on the side branches of the saphenous veins used for CABG as well as retrosternal blurring and effusions JIPMER hospital, CTVS Department Chest X-ray in a patient with severe aortic regurgitation with severe mitral regurgitation who underwent double valve replacment with TTK Chitra valve
  43. 43. Position of prosthetic valve on chest X-ray 43 • Location of the cardiac valves is best determined on the lateral radiograph • Line drawn on the lateral radiograph from the carina to the cardiac apex • Pulmonic and aortic valves generally sit above this line and the tricuspid and mitral valves sit below this line
  44. 44. Position of prosthetic valve on chest X-ray 44 Aortic valve is above the red line and mitral valve lies below this line
  45. 45. How to determine the position of prosthetic valve 45
  46. 46. IMPLANTABLE DEVICES AND OTHER POSTSURGICAL FINDINGS 46  Whether the leads are intact and the second is the position of the tips  There are two leads, the tips should generally be in the anterolateral wall of the right atrium and the apex of the right ventricle  If the leads are not positioned in this way, the reasons should be carefully determined  Malpositioned because of error or anatomic variants (e.g., a persistent left SVC that empties into the coronary sinus and then the right atrium) Chest X-ray showing pacemaker and its lead position
  47. 47. CONCLUSION 47  CXRs provide a wealth of physiologic and anatomic information  Play role in the evaluation and management of patients with cardiovascular disorders  Radiation dose in obtaining radiographs should always be considered  Portable CXRs used infrequently because information is limited and may be misleading  Standard 6-foot frontal and lateral CXRs, are clinically useful  If evaluated carefully by systematic approach and compared with previous CXRs, it is hard to overstate their importance
  48. 48. 48 Reference  Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no- 261  Thank to Department of Cardiology and CTVS deparment JIPMER hospital, Pondicherry for providing me chest x-ray for this ppt  http://www.slideshare.net/
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