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
7
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
13
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
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
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
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
48. 48
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/