In this PPT you will be able to read chest x ray in evaluation of cardiovascular problems

1. Chest x ray
Chest x ray in Heart and vessels
conditions
Dr ananya Goswami

6. CT RATIO
• Ratio Of The Transverse Cardiac
Diameter (TCD) To The Maximal Internal
Diameter Of The Thorax At The Level Of
The Diaphragm On An Upright PA film

7. CT RATIO
• Normal CTR: 33-50%.
• Trans thoracic diameter is measured by
a line drawing across the thoracic cage
at level of inner border of 9 rib.

8. HEART SIZE

10. CT RATIO>0.5
• Pectus excavatum
• Absence of pericardium
• Large pericardial fat
• Obesity
• Poor inspiration
• Supine films
• AP FILM

11. CT RATIO >0.5
• Systole or diastole can make up to a
1.5-cm difference in heart size

12. HEART AND CHAMBERS
CHAMBERS

13. RIGHT ATRIAL ENLARGEMENT
• Right border more convex and
elongated and forms > 50% of right
cardiac border
• Mid vertical line to maximum
convexity in right border is >5 cm in
adults and> 4 cm in children
. 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
• Dilatation of SVC & IVC that causes
widening of the right superior
mediastinum

14. LAO view-best view to visualise RAE.
 upper half of anterior cardiac border is RA
and lower half isRV
 When RA enlarges the upper anterior
cardiac border becomes squared giving a
box like appearance.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS

15. Isolated RAE

16. LEFT ATRIAL ENLARGEMENT
 dilation of the left atrial appendage- focal
convexity where there is normally a concavity
between LPA and left border of LV
 elevates the left main stem bronchus-widens
the angle of the carina, normal being 45- 75
degrees . (splaying of the carina)
 marked LA enlargement- double density
(Shadow within shadow)
 lateral film= focal, posteriorly directed bulge;
posterior and upward displacement of the left
main stem bronchus

20. LEFT ATRIAL
ENLARGEMENT




Displacement of thoracic aorta to left
Straightening of left heartborder
Distance from right border of LA to left
bronchus >7 cm
Grading of LAE
 I=Right border of LA is withinRHB
 II=Right border of LA matches with RHB
 Right border of LA is right to RHB

21. CHEST X RAY IN DIAGNOSIS OF CARDIA C CONDITIONS

23. LEFT VENTRICULAR
ENLARGEMENT
 PAVIEW:
◦ Left cardiac border gets elongated and becomes
convex resulting in cardiomegaly.
◦ Obtuse cardiophrenic angle
◦ Left cardiac border dips into left dome of diaphragm.
◦ Rounded apical segment: duck back appearance
◦ gastric air bubble is displaced inferiorly (PAview) and
anteroinferiorly (lateral view) .
◦ LV aneurysm - localized cardiac bulge in left cardiac
border.
LATERAL VIEW:
◦ Riglers measurement >17mm
◦ Eyelers ratio >0.42
◦ Obliteration of retrocardiacspace

24. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
HOFFMAN RIGLERS
SIGN

25. HOFFMAN
RIGLERS SIGN

• On a lateral chest radiograph, if the distance
between LVborder and the posterior border of IVC
exceeds 1.8 cm, at a level 2 cm above the
intersection of diaphragm and IVC, LVenlargement is
suggested

26. EYELERS
RATIO
Valid when IVC
shadow is absent on
lateral view.
Mar k point of junction
where posteroinferior
cardiac border meets
dome as B.
From B draw a
horizontal line to
posterior border of
sternum AB
From B draw another
line to inner border of
rib BC
Ratio of AB/BC i
s
EYELERS RATIO.
 I t is 0.42 or less.

29.  LV aneurysms, result in a localized bulge that projects
beyond the normal ventricular contour or an
angulation of LVcontour

30. RIGHT VENTIRCULAR
ENLARGEMENT






As RV dilates, it expands superiorly, laterally and
posteriorly
classic signs of RV enlargement are a boot-shaped
heart
In adults it is rare for RV to dilate without LV dilation
seen as an isolated finding in CHD, typically TOF
PAVIEW: cardiac apex moves posteriorly
 RV forms left cardiac border resulting in rounded and
elevated apex.
LATERAL VIEW:
 Obliteration of retrosternal space. contact of anterior
cardiac border greater than 1/3 of the sternallength
 Riglers ratio A <17mm
 Eyelers ratio:<0.42
 Isolated RV enlargement is unusual;More typically, there is
assoC
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and PT

31.  MCC of increased retrosternal soft tissue -
previous median sternotomy.

32. RIGHT VENTRICULAR
ENLARGEMENT

34. RV Apex
No cardiomegaly
TOF
Valvula
r PS
ES
DORV.
VSD.PS
Cardiomegaly
d- TGA
DORV.
VSD.
ASD
Eisenm
enger
Late
PPH
TAPVC ASD

36. CHEST X RAY IN DIAGNOSIS OF CARDIAC CO

37. 






Narrow vascular pedicle
Cardiomegaly directly proportional to severity of pericardial
effusion
rounded, globular appearance with no particular chamber
enlargement
Cardiophrenic angle become more and more acute
Oligaemia
Marked change in cardiac silhouette in decubitus posture
‘Epicardial fat pad sign’- anterior pericardial strip bordered by
epicardial fat post. and mediastinal fat ant.>2mm
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS

39. Prominent superior mediastinum




LSVC
TAPVC
L-TGA
THYMIC SHADOW

40. LEFT MEDIASTINAL
OUTLINE


bulge just above the cardiophrenic
angle- MI or ventricular aneurysm.
Bulge at the cardiophrenic angle
 pericardial cysts
 prominent fat pads
 adenopathy.

41. LEFT MEDIASTINAL OUTLINE
 AORTIC KNOB:
 prominent knob -ectasia, aneurysm or
hypertension.
 Notching or ‘figure of 3” sign-coarctation.

42. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
LEFT AORTIC ARCH
RIGHT AORTIC ARCH

43. RIGHT AORTIC ARCH

46. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS

47. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS

48. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS

50.  MAIN PASEGMENT:







post stenotic dilatation.
PAH
left-to-right shunts.
pericardial defects.
Severe concavity suggests right-to-left
shunts.
PR
Absent Pulmonary Valve syndrome
 PAH-both RPA& LPA (cf PS ); peripheral
pulmonary vascular pruning

51. Causes of Large Central
Pulmonary Arteries

52. VASCULAR
PEDICLE

53. PULMONARY
VASCULATURE
patient standing erect
Vessels supplying the upper lungs are one third to
one quarter the size of those in the lower
lungs
Vessels are smaller and fewer in upper lungs
increasing gradient of perfusion per unit volume of lung
tissue from apex to base
Patient supine
flow per unit volume of lung becomes equal between
apex and base
vessel sizes and numbers tend to equalize

54. 

central main right and left pulmonary
arteries are usually not individually
identifiable, because they lie within the
mediastinum
normally become too small to be seen
near the pleura

55. 1. major arteries –central
2. clearly distinguishable
midsized pulmonary
arteries (third or fourth
order branches) -middle
zone
3. small arteries and
arterioles -normally below
the limit of resolution -in
the outer zone.

57. REDISTRIBUTION
OF FLOW






placing the patient supine
Failure to expose the film at full inspiration
pulmonary venous hypertension, pulmonary
arterial hypertension increased RV cardiac
output
pulmonary parenchymal destruction

61. 



uniformly distributed vascular markings with absence of the normal lower
lobe vascular predominance
Increased RDPA size (> 16 mm in male and >14 mm in female)
PAbranch that is larger than its accompanying bronchus (best noted
in the right parahilar area )
Prominent MPA and proximal PA
Presence of pulmonary arterial vascular markings in lateral one third
of lungfields
Dipping below diaphragm
End on view of PAs-3(unilateral)-5(bilateral)
If the ratio of RDPA to trachea is more than 1 in a child < 12 years
Hilar Haze in lateral film




 Artery to vein ratio > 1.3:1 in upper lobe

62. 



Prominent vascularity -only if Qp-to-Qs ratio is
>1.5:1
overt cardiac enlargement implies a shunt
>2. 5: 1.
unilateral plethora –BT shunt and in
unilateral MAPCA
Asymmetry in lung vascularity
1) Glenn surgery
2) PAbranch stenosis
3) absent RPA or LPA

63. Mimics of shunt
vascularity

64. PULMONARY VENOUS
HYPERTENSION
 prominent upper lung vessels, both arteries
and veins.
 As pulmonary venous hypertension increases to
25 mm Hg, there is increased transudation of
plasma
 It results in the radiographic appearance o
f
septal lines (Kerley lines), which are due to
fluid within the interlobular septa.
 classic alveolar edema -pressure > 30 mm Hg.
CHEST X RAY IN DIAGNOSIS
OF CARDIAC CONDITIONS

65. PULMONARY VENOUS HYPERTENSION LARRY
ELLIOTS CLASSIFICATION
X RAY FINDINGS PCWP
NORMA
L
vascular pattern is
normal
<8 mm-10
Hg,
STAGE
1
CEPHALISATION (Deer Antler
sign)
10-12MM
HG
STAGE
2
INTERSTITIAL EDEMA
(PERIVASCULAR PERIBROCHIAL
AND SUBPLEURAL
EFFUSION),KERLEY LINES
12 to 18 mm
Hg
STAGE
3
INTRA ALVEOLAR EDEMA BILATERAL
PATCHY
COTTON WOOL OPACITIES -Perihilar “bat
wing” appearance
1.Diagnostic phage lag :12
hours 2.Therapeutic phase
lag-2 days
>18 to 20 mm
Hg

66. CHEST X RAY IN DIAGNOSIS
OF CARDIAC CONDITIONS

67.  extensive pulmonary fibrosis or multiple bullae=
vascular pattern is abnormal at baseline, and as
PCWP increases, it does not change in
predictable ways a
 chronic heart failure, there are chronic changes
in the pulmonary vascular pattern that do not
correlate with the changes that occur in patients
with normal LV pressure at baseline
CHEST X RAY IN DIAGNOSIS
OF CARDIAC CONDITIONS

68.  Kerley A lines :horizontal linear shadows
towards hilum
 Kerley B lines: horizontal and linear towards
costophrenic angle
 Kerley C lines: crisscross between A and B.
CHEST X RAY IN DIAGNOSIS
OF CARDIAC CONDITIONS

69. CHEST X RAY IN DIAGNOSIS
OF CARDIAC CONDITIONS

70. CHEST X RAY IN DIAGNOSIS
OF CARDIAC CONDITIONS

71. DECREASED PULMONARY
BLOOD FLOW


All the linear shadows in the
normal lung fields are due to
pulmonary vasculature.
Small pulmonary artery
 Empty pulmonary bay
 Pulmonary vessels small
 Lung hypertranslucent
 Lateral view shows diminution of
hilarvessels

72.  Small-caliber pulmonary vessels with
relatively hyperlucent lungs and a small
heart are evidence of a marked decrease in
the circulating blood volume (e.g., in
Addison disease, hemorrhage).

73. 



Distended lymphatic channels
within edematous septa
from peripheral lymphatics to
central hilar nodes
Towards the hilum
Less specific

74. 





Horizontal lines
1-3 mm thick
Perpendicular to pleural surface
Towards the costophrenic angle
Accumulation of fluid in interlobular
septa and lymphatics
Highly specific for PVH
DIAGNOSIS OF CARDIAC CONDITIONS
CHEST X RAY IN

75. CARDIAC MALPOSITION






If the stomach bubble cannot be seen →
aerophagia
(deliberate inhalation in adults or from sucking an empty
bottle in infants)
transverse liver implies visceral heterotaxy but does not
distinguish right from left isomerism
The inferior margin of a transverse liver is horizontal
Bilateral symmetry implied by a transverse liver
demands bilateral symmetry of thebronchi.
Bilateral morphologic right bronchi = right isomerism
bilateral morphologic left bronchi = left isomerism

79. SITUS
SOLITUS

80. COMPLETE SITUS
INVERSUS
Situs inversus is missed if the film is inadvertently read in a reversed
position because it then appears correct except for the L and R
designations that are on the
wrong sideCH.ESTX RAY IN DIAGNOSIS OF CARDIAC CONDITIONS

81. SITUS SOLITUS WITH
DEXTROCARDIA

82. SITUS INVERSUS WITH
LEVOCARDIA





The stomach (S) is on
the right
And the liver (L) is on
the left,
The heart (apex) is to the left
of midline.
The left hemidiaphragm is
lower than the right
hemidiaphragm because the
cardiac apex is on the left.
The descending thoracic
aorta (dao) is on
the right (concordant
for situs inversus), but the
position of the ascending
aorta (aao) indicates a
discordant d-
bulboventricular loop

85. A-liver is transverse
stomach (S) is on the right
heart is midline, but the base to apex axis points to the left
B- liver is transverse
base to apex axis points to the right
heart is to the right of midline
ground-glass appearance -TAPVC

86. RIGHT ISOMERISM




• transverse l iver = visceral
heterotaxy but not its type
• position of the stomach is
variable (right, left, or occasionally
central)
•heart can be either to the
right or left of midline
• symmetric bronchi is right type -
Overpenetrated f i lms or
tomographic scans

87. LEST ISOMERISM






• transverse liver
•heart is usually left- sided
•stomach tends to be on the side opposite the
descending aorta
•IVC interruption with azygous continuation -
frontal projection
•Absence of IVC shadow in the lateral projection is not a
reliable sign of interruption because azygos continuation
may create the impression of a normal uninterrupted IVC
•lung f ields - ↑ PBF ( L-to-R shunts occur with no
RVOTO)