This document provides an overview of how to read and interpret a cardiac x-ray. It discusses the basics of technical quality including proper rotation, inspiration, projection and exposure. It then examines how to identify normal cardiac contours and sizes as well as various abnormalities like enlargement of the atria or ventricles, pericardial effusions, valvular disorders and congenital heart defects. The document also reviews interpreting pulmonary vascular markings and identifying implanted cardiac devices and prosthetic heart valves on x-ray.

1. Cardiac X-ray
DR SEEBAT MASRUR
D-CARD RESIDENT
CARDIOLOGY DEPARTMENT
SZMCH

2. Reading an X-ray

4. Assessment

5. Basics of X-ray Technical Quality
R-Rotation
I-Inspiration
P-Projection
E-Exposure

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

7. Degree of Inspiration
▪ It is ascertained by counting
either the visible anterior or
posterior ribs.
▪ Adequate inspiratory effort-Five
to seven complete anterior or ten
posterior ribs are visible.
▪ Poor inspiratory effort- Fewer
than five anterior ribs.
▪ Hyperinflated lung-more than
seven anterior ribs.

8. Importance of inspiratory film
Poor inspiratory film Normal inspiratory film

9. Projection
Anterior Posterior view Posterior Anterior view

10. Comparison of anteroposterior (AP) and
posteroanterior (PA) views
▪ Portable AP view shows an
enlarged cardiac silhouette,
indistinct hilar vasculature, and
a widened mediastinum.
▪ PA view of the same patient
obtained 5 hours later after
removal of the central venous
catheter shows the true
normal size of the heart with
no mediastinal widening.

11. Exposure

12. Structures seen in
CXR

13. Normal Cardiac
Contour

14. Heart Size
• Normal CTR:33-50%
• Transthoracic diameter is
measured by a line drawing
across the thoracic cage at
level of inner border of 9th rib.
• Expiratory film will show
Pseudocardiomegaly

15. Right Atrial Enlargement
• Right border more convex and
elongated.
• Midvertebral line to maximum convexity
in right border is >5 cm in adults.
• Right cardiac border > 2.5 cm from the
lateral aspect of the thoracic vertebra.
• Right border of heart >3.5cm from
sternal right border.
• Right atrial border extends beyond 3
ICS.

16. Left Atrial Enlargement
• Widening of the carina(Normal 45-75 degree.
• Straightening of the left border.
• Double atrial shadow(shadow within shadow).
• Grading-
I=Right Border of LA within RHB
II=Right border of LA matches with RHB
III=LA overshoots the RHB
• Elevation of Left Bronchus

17. Left Ventricular enlargement
PA View
▪ Left cardiac border gets enlarged and
becomes more convex resulting in
cardiomegaly.
▪ Left cardiac border dips into left dome
of diaphragm.
▪ Rounded apical segment.
▪ Cardiophrenic angle is obtuse.

18. Right Ventricular Enlargement
▪ RV dilates, it expands superiorly,
laterally and posteriorly.
▪ In adults it is rare for RV to dilate
without LV dilation.
▪ Cardiac apex moves posteriorly as a
result apex becomes rounded and
apex is elevated.
▪ Classical sign is Boot shaped heart

19. Pericardial Effusion
▪ Cardiomegaly directly proportional to
severity of pericardial effusion.
▪ Rounded, globular appearance with no
particular chamber enlargement.
▪ Cardiophrenic angle become more acute.
▪ Oligemic pulmonary vascular markings.
▪ Marked change in cardiac silhouette in
decubitus posture.

20. Pneumopericardium
PA chest radiograph shows lucent
bands of air outlining the right and left
cardiac borders. A radiodense band
outlining the pneumopericardium
represents the thickening visceral
pericardium (arrows)

21. Dilated cardiomyopathy Vs Pericardial Effusion
▪ Chambers can be identified in CMP
▪ Cardiophrenic angle is obtuse in CMP
▪ Increased pulmonary venous hypertension seen in CMP
▪ No change in cardiac silhouette in decubitus om CMP
▪ Vascular pedicle is dilated or normal in CMP

22. Oligemic Lung Field
▪ Decreased flow proximal to origin of
main pulmonary artery
▪ Small pulmonary artery
▪ Empty pulmonary bay
▪ Pulmonary vessels small
▪ Lung hypertranslucent
▪ Lateral view shows diminution of hilar
vessels

23. Plethoric lung fields
▪ Enlargement of central pulmonary
artery, lobar and segmental artery
▪ Prominent nodular vascular shadows
in frontal CXR-shunt vessels that
course ventral to dorsal
▪ Upper and lower lobe vessels
prominent

24. Constrictive Pericarditis
▪ Straightening of the right border.
▪ Pericardial thickening.
▪ Pericardial calcification.

25. Congestive cardiac failure (CCF)
▪ Upper Lobe Pulmonary venous
diversion(Stag Antler sign)
▪ Cardiomegaly
▪ Septal Kerley Lines
▪ Air Space opacification
▪ Pulmonary Interstitial oedema
▪ Pleural Effusion

26. Septal Kerley Lines
▪ Kerley A lines: Horizontal Linear Shadows towards hilum
▪ Kerley B lines: Horizontal and linear towards cosophrenic angle
▪ Kerley C lines: Crisscross between A and B

27. Mitral stenosis
▪ Left atrial enlargement-double density sign.
▪ Upper zone venous enlargement due to
pulmonary venous hypertension.
▪ Pulmonary Oedema.
▪ Diffuse alveolar haemorrhage.
▪ Secondary pulmonary
hemosiderosis(Mottling)
▪ Pulmonary ossification, a late sign.
▪ Mitral annular calcification.

28. Mitral stenosis
▪ Septal Kerley Lines
▪ Straightening of Left Heart border
▪ Widening of Carina

29. Mitral Valve Calcification
1.Aortic knuckle with intimal calcification
2.Prominent main pulmonary artery segment
3.Prominent left atrial appendage
4.Calcification in mitral valve
5.Elevated left bronchus – feature of left atrial
enlargement
6.Double atrial contour – border of enlarged left atrium
(shadow within shadow)
7.Right atrial border shifted to right, suggestive of right
atrial enlargement

30. Mitral regurgitation
▪ LA enlargement
▪ LV Enlargement
▪ Pulmonary venous hypertension
▪ features of congestive heart
failure may also be present

31. Aortic Stenosis
▪ Right mediastinal border occupied by
the ascending aorta
▪ Left ventricular hypertrophy
▪ Aortic Valve calcification
▪ The descending aorta is unfolded but
of normal caliber

32. Aortic Regurgitation
▪ Cardiomegaly
▪ Aortic dilatation
▪ Widened mediastinum
▪ Pulmonary congestion
▪ Aortic valve calcification

33. PROSTHETIC VALVE
▪ A caged ball prosthesis with four struts
facing and to the apex suggestive of
mitral prosthetic valve.

34. PROSTHETIC VALVE
X-ray chest PA view showing a prosthetic
aortic valve within the lower portion of
the cardiac silhouette overlapping the
spine.

35. Valvular PS
▪ No obvious cardiomegaly
▪ Enlarged PA
▪ Dilated left pulmonary artery
▪ Decreased pulmonary vasculature

36. Infundibular PS
▪ Concave PA segment
▪ RVH

37. Atrial Septal Defect
▪ Increased pulmonary flow-RPA & MPA
dilated
▪ Right atrial enlargement
▪ Right Ventricular Enlargement
▪ Pulmonary Plethora
▪ RV type Apex

38. Ventricular Septal Defect
▪ Normal with a small VSD
▪ Larger VSDs may show
cardiomegaly
▪ Left Atrial Enlargement
▪ increased pulmonary vascular
markings

39. Patent Ductus Arteriosus
▪ Marked cardiomegaly with dilatation
of the main pulmonary artery.
▪ Bilateral pulmonary plethora.
▪ Filling up of the angle between the
aortic arch and the pulmonary
artery(Most specific sign)

40. ASD Vs VSD Vs PDA

41. Tetralogy of Fallot
▪ RV Apex
▪ Underfilled LV
▪ Concave pulmonary artery
▪ Pulmonary Oligemia

42. Transposition of Great vessels
▪ Egg on string
▪ Narrow pedicle
▪ Increased pulmonary vasculature
▪ Ascending aorta occupies the left
border of the cardiac silhouette.

43. Total anomalous pulmonary venous return
▪ Figure of 8 or Snow-man
appearance
▪ Nonobstructive
supracardiac TAPVC to left
innominate vein
▪ This diagnostic sign is
usually not present in first
few months of life

44. Partial anomalous pulmonary venous return
▪ The Scimitar Sign is produced by an
anomalous pulmonary vein that drains
any or all the lobes of the right lung.
▪ Scimitar vein empty into the IVC

45. Epstein's anomaly
• A large globular heart with a narrow
waist due to enlargement of the right
atrium
• A box-shaped heart can be seen
sometimes
• Pulmonary vasculature can be either
normal or reduced

46. Truncus Arteriosus
▪ LV apex
▪ Right pulmonary artery has a
superior origin(20%)
▪ Right aortic arch
▪ Concave PA segment

47. Eisenmenger syndrome
• Cardiomegaly
• Right ventricular or biventricular
enlargement
• Right atrial or biatrial
enlargement
• Pulmonary vascular plethora
• In severe disease, a normal-sized
heart with diminished pulmonary
vasculature may be seen.

48. Coarctation of Aorta
▪ Figure of 3 sign:Contour
abnormality of the aorta
▪ Inferior Rib notching: Resler sign

49. D/D of Inferior Rib notching

50. Aortic Aneurysm
▪ Frontal chest radiograph
shows a curvilinear
calcification (arrow)
projecting over the aortic
knob, located medial and
parallel to the lateral
contour of the aortic knob

51. Cardiac Device

52. Dual lead cardiac pacemaker
A dual chamber pacemaker. The atrial lead
usually curves upward in a "J " to reach the
atrial appendage. The right ventricular lead
(ideally) ends in the ventricular apex to the
left of the spine

53. Biventricular pacemaker
▪ A biventricular pacemaker with its
three wires in appropriate positions:
• right ventricle
• right atrium
• coronary sinus pacing the left ventricle

54. What is the problem???
▪ Right atrial lead is not in the
expected position.

55. Fracture of a
pacemaker lead

56. Perforation of the heart
▪ The tip of the ventricular lead lies outside
of the cardiac silhouette.

57. Subcutaneous
implantable
defibrillator

58. IMPLANTABLE CARDIOVERTER
DEFIBRILLATOR
Device is seen in the left
infraclavicular area. Two high voltage
shocking coils are seen, one in the
superior vena cava and another in the
right ventricle. Two pacing electrodes
are seen beyond the right ventricular
high voltage coil

59. CRT defibrillator device
Cardiac resynchronization therapy (CRT)
device in situ (right atrial, right
ventricular and coronary sinus leads).
An insulated right ventricular lead
indicates that this is a CRT defibrillator
device.

60. CRT-P implantation

61. Reference
▪ Braunwald's Heart Disease.
▪ Radiology in medical practice by Dr ABM Abdullah.
▪ www.radiopaedia.org
▪ Chest X-Ray Made Easy, International Edition

62. Thank You

63. Measuring Main Pulmonary artery

65. Pruning-Attenuation of peripheral pulmonary
vascular markings
▪ 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

66. Prosthetic Heart Valve

67. Normal Cardiac Contour

68. Normal Cardiac Contour

69. Normal Cardiac Contour

70. Normal Cardiac Contour