chest xray in cardiology dept. from practical point of view

1. Chest radiograph in
cardiovascular disease
Dr. Jayanta Kr. Gogoi

2. Ideal x-ray
 Proper exposure
 Proper centering
 Proper labeling

3. Proper exposure
 A well penetrated chest X-ray is one
where the vertebrae are just visible
behind the heart.
 Over exposure- black lung field
clear vertebral bodies
 Underexposure- hazy lung field

4. Proper centering
 The clavicle should be at the same level
 Clavicles should be equidistant from
the midline.

5. Proper labeling
 The side determination
◦ Label L or R
◦ Apex of heart on left
◦ Fundal gas shadow on left
◦ Right dome of diaphragm placed higher
than left
◦ Aortic knuckle on left
*(NOT for dextrocardia with Situs inversus)

6. How to read a chest x-ray
 View (PA, AP, lat)
 Exposure
 Centralization
 Position of trachea
 Skeletal structures
 Lung fields including blood vessels and pleura
 Cardiovascular silhouette
 Costophrenic and cardiophrenic angles
 Soft tissue abnormalities
 Final diagnosis or conclusion

7. Describe a normal chest x-ray
 This 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.

8. Skeletal structure abnormalities
 Kyphosis, scoliosis
 Crowding or widely spaced ribs
 Absence of clavicle
 Erosion of clavicle
 Rib erosion
 Rib notching
 Presence of cervical rib

9. Skeletal
deformity
Absent clavicle Scoliosis

10. RIB NOTCHING  MM, Br Ca, HPT

11. CERVICAL RIB

12. Lung field
 Accentuated pulmonary arteries
 Distension of pulmonary arteries
 Accentuation of bronchial pattern
 Prominent lymphatic vessels
 Thickened alveolar septum

13. Hilar shadows
 PA, PV, bronchi, lymph gland,
lymphatics, connective tissue.
 The lung field is divided in three zones
◦ Upper, middle and lower
◦ Do not corresponds with lobes of lung

14. Lung fields
 2nd CC
 4th CC

15. LUNG FIELDS

16. Cardiothoracic ration
 Ratio between max diameter of heart to
max internal diameter of chest.
 Normal ≤ 1:2
 2/3 of cardiac
shadow lies
on the left.
 (a+b)/(c+d)

17. Borders of heart

18. BORDERS OF HEART
 Right border:
◦ SVC
◦ RA
 Left border:
◦ Aortic arch
◦ Pulmonary trunk
or LPA (bay)
◦ LAA
◦ LV

19. Cardiac enlargement
 Left atrial enlargement
◦ Straightening of the left border of heart.
◦ Prominent LAA
◦ Double contour of rt border of heart (upper
outer border is LA)
◦ Widening of carinal angle
◦ Posterior displacement of barium filled
esophagus (rt lat view)

20. Double contour of rt border

21. LA enlargement in MS

22. LA enlargement AP and Lat view

23. RA enlargement
 enlarged, globular heart
 narrow vascular pedicle
 gross enlargement of the right atrial
shadow, i.e. increased convexity in the
lower half of the right cardiac border

24. Causes of RAE
 raised right ventricular pressures
◦ pulmonary arterial hypertension
◦ cor pulmonale
 valvular disease
◦ tricuspid regurgitation
◦ tricuspid stenosis
◦ Ebstein's anomaly
 atrial septal defect (ASD)
 atrial fibrillation (AF)
 dilated cardiomyopathy

25. RAE

26. RV enlargement
 Shifting of apex to the left (up outward)
 Increase transverse diameter of heart
 Lat view- obliteration of retrosternal
space

27. RVE in PS

28. RVE and lat view

29. LV enlargement
 Increase transverse diameter
(cardiomegaly)
 Apex shift outward and downward

30. diaphragm
 Elevation-
◦ collapse or fibrosis, ascites, pregnancy, dia.
Palsy, abd mass, liver abscess
 Depression-
◦ Emphysema, pneumothorax

31. Soft tissue abnormality
 Chest wall
 Calcified lymph nodes
 Breast malignancy
 SOL of lung

32. Chest X-ray in Cardiology

33. Pulmonary edema (PVH)

34. description
 This 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.

35. PVH stages
 Stage I – Redistribution
◦ prominent upper lobe vessels

36.  When there is redistribution of pulmonary blood flow
there will be an increased artery-to-bronchus ratio in the
upper and middle lobes
Artery-to-bronchus ratio

37. 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.

38. 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).

39. KERLEY A LINES
Kerley’s C lines
Kerley’s B lines
A= Apex
B= base
C= center
Kerley lines

40. Pulmonary artery hypertension
 Main 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

41. PAH

43. Increase Qp (pulmonary flow)
 Prominent MPA, RDPA
 Pulmonary plethora
◦ Vascular markings of lung fields can be
traced up to lateral third of it.
 End-on vessels (3 in rt, or 5 in both)

44. Cardiac temponade
 there can be globular enlargement of the cardiac
shadow giving a water bottle configuration
 widening of the subcarinal angle without other
evidence of left atrial enlargement may be an
indirect clue
 lateral CXR may show a vertical opaque line
(pericardial fluid) separating a vertical lucent line
directly behind sternum (epicardial fat) anteriorly
from a similar lucent vertical lucent line (pericardial
fat) posteriorly; this is known as the Oreo cookie
sign

45.  C. temponade

46.  Pacemaker
X ray

47. C X-RAY of CONGENITAL HEART DISEASE

48. CHD

49. ASD
 can be normal in early stages +/- when the ASD is
small signs of increased pulmonary flow (shunt
vascularity) enlarged pulmonary vessels
 upper zone vascular prominence
 vessels visible to the periphery of the film
 eventual signs of pulmonary arterial hypertension
 chamber enlargement right atrium
 right ventricle
 note: left atrium is normal in size
 note: aortic arch is small to normal (narrow pedicle)

50. CHD 2

51. CHD

52. VSD
 The chest radiograph can 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/or increased pulmonary
vascular markings
 Wide pedicle

53. PDA

54. PDA
 Chest 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

55. CHD4

56. TAPVR
 The 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 heart 2-3.
 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

58. TOF
 Boot
shaped
heart

59. TOF
 Plain 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%.

61. THANK YOU..