Cardiac X-ray .pptx

normal and pathological chest xray

1. Cardiac X-ray Dr Seebat masrur D-card resident Cardiology department SZMCH

2. Reading an X-ray

3. Assessment

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

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

6. 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.

7. Importance of inspiratory film Poor inspiratory film Normal inspiratory film

8. Projection Anterior Posterior view Posterior Anterior view

9. 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.

10. Exposure

11. Structures seen in CXR

12. Normal Cardiac Contour

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

14. 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.

15. 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

16. 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.

17. 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

18. 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.

19. 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)

20. 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

21. 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 diminu tion of hilar vessels

22. P lethoric 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

23. Constrictive Pericarditis Straightening of the right border. Pericardial thickening. Pericardial calcification.

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

25. 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

26. Mitral stenosis L eft atrial enlargement - double density sign . U pper zone venous enlargement due to pulmonary venous hypertension. Pulmonary Oedema . Diffuse alveolar haemorrhage . S econdary pulmonary hemosiderosis ( Mottling ) P ulmonary ossification , a late sign. M itral annular calcification .

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

28. M itral V alve C alcification Aortic knuckle with intimal calcification Prominent main pulmonary artery segment Prominent left atrial appendage Calcification in mitral valve Elevated left bronchus – feature of left atrial enlargement Double atrial contour – border of enlarged left atrium (shadow within shadow) Right atrial border shifted to right, suggestive of right atrial enlargement

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

30. Aortic Stenosis R ight mediastinal border occupied by the ascending aorta Left ventricular hypertrophy Aortic Valve calcification The descending aorta is unfolded but of normal caliber

31. Aortic Regurgitation Cardiomegaly Aortic dilatation Widened mediastinum Pulmonary congestion Aortic valve calcification

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

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

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

35. Infundibular PS Concave PA segment RVH

36. Atrial Septal Defect I ncreased pulmonary flow-RPA & MPA dilated Right atrial enlargement Right Ventricular Enlargement Pulmonary Plethora RV type Apex

37. Ventricular Septal Defect N ormal with a small VSD Larger VSDs may show cardiomegaly   L eft A trial E nlargement increased pulmonary vascular markings

38. 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 )  

39. ASD Vs VSD Vs PDA

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

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

42. 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

43. 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

44. 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

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

46. 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.

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

48. D/D of Inferior Rib notching

49. 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

50. Cardiac Device

51. 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

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

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

54. Fracture of a pacemaker lead

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

56. Subcutaneous implantable defibrillator

57. 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

58. 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.

59. CRT-P implantation

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

61. Thank You

62. Measuring Main Pulmonary artery

63. 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

64. Prosthetic Heart Valve

65. Normal Cardiac Contour

66. Normal Cardiac Contour

67. Normal Cardiac Contour

68. Normal Cardiac Contour