Medicine

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. 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. 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. 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. 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. 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. NORMAL CHEST RADIOGRAPH
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 Take systematic approach
 First assess anatomy
 Then physiology
 Finally pathology.

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. 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. 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. 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. 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. Lungs and Pulmonary Vasculature
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 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. 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. 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. 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. 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. 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. 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. 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. Increased Flow
Normal
21

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. 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. Venous Hypertension
RDPA usually
> 17 mm
Upper lobe
vessels equal
to or larger
than size of
lower lobe
vessels =
Cephalization
24

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Position of prosthetic valve on chest X-ray
44
Aortic valve
is above the
red line and
mitral valve
lies below
this line

45. How to determine the position of prosthetic valve
45

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. 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

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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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