DAVID SUTTON PICTURES Only for study purpose

1. ACQUIRED HEART DISEASE I: THE
CHEST RADIOGRAPH
CARDIOVASCULAR SYSTEM
DAVID SUTTON
11

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. Fig. 11.1 The assessment of cardiac enlargement. The cardiac
diameter should be the maximum cardiac diameter (r + I).
The transverse thoracic diameter is measured in various ways;
here it is measured as the maximum internal diameter of the
thorax.

4. • Fig. 11.2 Rheumatic mitral stenosis. This
frontal film shows marked enlargement of the
left atrial appendage (arrow).

5. • Fig. 11.3 Left atrial enlargement. A PA (A) and
penetrated chest film (B) in the same patient. The
double right heart border and splaying of the carina,
due to enlargement of this posterior chamber, is easily
visualised on the penetrated film.

6. • Fig. 11.4 Right atrial enlargement. Right atrial enlargement
is often difficult to detect with only subtle enlargement of the
right heart border present on the PA view.

7. • Fig. 11.5 Selective left ventricular enlargement in aortic incompetence. (A)
Frontal view shows that the left ventricle has enlarged along its long axis,
taking the apex of the heart to the left and downward (white arrow). (B)
Lateral view shows the left ventricle extending behind the line of the
barium-filled oesophagus (arrow).

8. • Fig. 11.6 Gross right ventricular enlargement due to
isolated right ventricular cardiomyopathy. The right
ventricular enlargement occurs on the left heart border
between the left ventricular contour and the pulmonary
outflow tract (A) and is well seen on the lateral film (B).

9. • Fig. 11.7 Normal chest radiograph. In the normal
subject there is a marked difference between the size
of the upper and lower zone vasculature, the lower
zone vessels being much more prominent.

10. • Fig. 11.8 Pulmonary arterial hypertension. The heart has a large triangular
shape with large main and central pulmonary arteries. There is complete
infilling of the pulmonary artery/ventricular concavity on the left heart
border. The pulmonary arteries within the lungs are enlarged but there is
rapid tapering of the vessels as they run towards the periphery.

11. • Fig. 11.9 Pulmonary arterial hypertension. If
the pulmonary artery hyper-tension is severe
and chronic, the pulmonary arteries may
become very large and calcified (arrows).

12. • Fig. 11.10; Pulmonary venous hypertension. There is a mild haziness in
the lower zones with attenuation of the lower zone vessels and
prominence of the upper zone vessels. There is loss of definition of the
heart and mediastinal contours. This is most notable when viewing the
branches of the right pulmonary artery. The difference in density at the
lung bases is due to a right mastectomy.

13. • Fig. 11.11 Kerley B lines are caused by
interstitial fluid and are defined as subpleural
perpendicular lines 1-3 cm in length (A). These
lines often resolve following treatment (B).

14. • Fig. 11.12 Pulmonary plethora due to high-output cardiac failure.
This PA chest radiograph demonstrates pulmonary plethora (A). The
pulmonary vessels are considerably enlarged and also more
tortuous than usual. The central pulmonary arteries are also large.
This patient had a large femoral arteriovenous fistula (arrow) due to
venous surgery 20 years previously. The calcified fistula is evident
on a plain film (B).

15. • Fig. 11.13 Depressed sternum. (A) Frontal view. The heart is displaced to the left.
Its left border is straight and there is a prominence in the position of the main
pulmonary artery. There is an ill-defined shadow to the right of the vertebral
column. The clue to those appearances is given by the visualisation of the
intervertebral discs at the level of the lower thoracic spine where normally they
would disappear. (B) Lateral view. This demonstrates the enormous sternal
depression. This patient was thought to have a normal heart.

16. • Fig. 11.14 Pre- and post-mitral valve replacement. The preoperative film
shows mild cardiac enlargement and pulmonary venous hypertension
with good aeration of both lungs (A). On the mobile AP film (B) on the
second postoperative day there is poor air entry to the chest leading to
basal atelectasis. Small bilateral pleural effusions are also present and the
mitral prosthesis can be identified.

17. • Fig. 11.15 Post cardiac surgery. The midline sternotomy
sutures are difficult to visualise on the PA film. There are
surgical clips in the anterior mediastinum which have been
used to occlude small side branches of the left internal
mammary artery (arrow), which has being used as a graft.

18. • Fig. 11.16 Cardiac surgery complication. On the PA chest
radiograph (A) the right heart border has an unusual
configuration and on closer inspection a metallic strip can
be visualised (arrows). This soft-tissue opacity is anterior to
the heart and clearly visualised (arrows) on the lateral film
(B). This was a retained swab.

19. • Fig. 11.17 Coronary artery stent. This patient presented with
a cough. On the PA chest radiograph (A), a 3-cm soft-tissue
mass is present due to an adenocarcinoma of the left
bronchus. A stent is seen in the left anterior descending
coronary artery (arrow). The detailed configuration of the
stents clearly seen (arrow) on the magnified view (B).

20. • Fig. 11.18 Prosthetic mitral and aortic valves with biventricular
pacemaker insertion. This treatment for heart failure allows
synchronous contraction of both ventricles. There is one lead with
its tip in the coronary sinus (black arrow) to pace the left ventricle
(A). This position is best visualised on the lateral view (B). The
other lead has its tip in the apex of the right ventricle (white
arrow).

21. • Fig. 11.19 Automatic implantable defibrillator. The electrode
is heavier than a normal pacing electrode with additional
discharge electrodes in the SVC and the right ventricle. The
generator is larger than the current generation pacemaker
generators.

22. • Fig. 11.20 Pneumothorax post pacemaker placement. A single-
chamber pacemaker has been inserted. The tip is in a good
position on both the PA film (A) and lateral film (B) in the apex of
the right ventricle. The lateral film taken within 24 hours of
pacemaker insertion is obtained using a non-standard method
with the arms by the side. There is a large left pneumothorax.

23. • Fig. 11.21 Coronary calcification. Calcification
of the coronary arteries is often best seen on
the lateral view. The calcification of the vessels
is shown well on this magnified view (arrows).

24. • Fig. 11.22 Cardiac failure post myocardial infarction. A previous PA
film obtained before the infarction is normal. Marked cardiomegaly
is seen 2 weeks after a large anterior myocardial infarction,
indicating left ventricular damage. Pulmonary venous hypertension
has also developed.

25. • Fig. 11.23 Post myocardial infarction ventricular septal
defect. This patient developed breathlessness on day 4
after an acute myocardial infarction. The
interventricular septum has ruptured producing left to
right shunting and heart failure. There is engorgement
of the pulmonary vasculature (pulmonary plethora).

26. • Fig. 11.24 Anterior left ventricular aneurysm. There is a
bulge of the anterior border of the left ventricle shown on
both the PA (A) and lateral (B) films (arrows). This patient
suffered a large infarct and has developed an anterior
aneurysm of the left ventricle.

27. • Fig. 11.25 Posterior left ventricular aneurysm. The PA chest
radiograph shows a sharply defined and rounded left heart border
due to the profiling of the margin of the aneurysm (A). The bulge of
the posterior border of the left ventricle due to the aneurysm is
clearly seen on the lateral film (B) (arrows).

28. • Fig. 11.26 Calcification of a left ventricular
aneurysm. In a small number of cases a fine
line of calcification within the aneurysm can
be identified (arrows).

29. • Fig. 11.27 Postmyocardial infarction (Dressler's)
syndrome. Small effusions are seen in both
costophrenic angles, together with ill-defined
basal shadows resembling pulmonary infarcts.

30. • Fig. 11.28 Ischaemic cardiomyopathy. There is
biventricular dilatation of the ventricles producing a
globular large heart in this patient with ischaemic
cardiac failure.

31. • Fig. 11.29 Calcified aortic stenosis. The heart has a slightly
prominent left ventricular contour on the PA chest radiograph and
there is dilatation of the ascending aortic arch (arrow) caused by
the poststenotic dilatation (A). Calcification of the aortic valve
(arrow) is more apparent on the lateral film (B).

32. • Fig. 11.30 Gross left ventricular dilatation from chronic
aortic incompetence. (A) The axis of the heart is elongated
to the left with rounding of the apex. There is slight
prominence of the ascending aorta (black arrow). (B) The
body of the left ventricle (white arrow) can be seen bulging
behind the line of the right atrium (black arrow).

33. • Fig. 11.31 Left atrial dilatation in mitral stenosis. The
grossly enlarged left atrium (arrows) extends beyond
the right heart border. Note that the border of the right
atrium can be identified where it is joined by the IVC
coming up through the diaphragm.

34. • Fig. 11.32 Mitral stenosis with a normal size heart. In the early
years of this chronic disease there is often a normal heart size with
only subtle signs of left atrial enlargement being evident. The left
atrial appendage is prominent and there is pulmonary venous
hypertension.

35. • Fig. 11.34 Calcification in the mitral ring. In this lateral
view the calcified mitral valve ring (arrows) appears as
a characteristic C-shape; it may take a J -shape.

36. • Fig. 11.33 (A, B) Calcified mitral valve in
rheumatic mitral stenosis. The calcification is
best seen in the lateral view (arrow).

37. • Fig. 11.35 Pulmonary haemosiderosis secondary to longstanding mitral
valve disease. The fine granular background pattern to the lung is typical
of haemosiderosis. In addition, note changes suggestive of mitral valve
disease: straightening of the left heart border and some upper-lobe blood
diversion.

38. • Fig. 11.36 Longstanding severe mitral regurgitation due to
mitral valve prolapse. There is prominence of the left
ventricular contour and subtle evidence of left atrial
enlargement. There is also pulmonary venous hypertension.

39. • Fig. 11.37 Acute non-rheumatic mitral regurgitation. (A) Frontal view
in the acute phase. The heart size is virtually normal, even in the
presence of high left atrial pressure as evidenced by the preferential
dilatation of the upper-lobe vessels and interstitial oedema. (B) Frontal
film 2 weeks later. This shows clearing of the oedema though upper-
lobe blood diversion can still be seen.

40. • Fig. 11.38 Tricuspid stenosis. (A) The right heart
border has bulged to the right and its radius of
curvature has increased. (B) In the lateral view, the
gap between the front of the heart and the sternum is
filled in.

41. • Fig. 11.39 Pericardial effusion. A chest film taken 6 months previously
was normal. (A) Frontal chest film. The heart silhouette has dramatically
increased in size. There is an ill-defined bulge (arrow) above the cardiac
apex. The lungs show no features of cardiac failure, which might be
expected if this were a dilated heart. (B) Lateral chest film. Epicardial fat is
clearly identified (arrows), displaced away from the edge of the cardiac
silhouette and indicating the presence of a pericardial effusion.

42. • Fig. 11.40 Pericardial effusion. The first film in a patient who has had a
left mastectomy for a carcinoma of the breast demonstrates a normal
heart (A). However, during the course of treatment the patient became
breathless and a follow-up film (B) shows marked enlargement of the
cardiac silhouette as a result of a malignant pericardial effusion. A right-
sided pleural effusion has also developed.

43. • Fig. 11.41 Constrictive pericarditis with calcification of the
pericardium. Often with constrictive pericarditis there is
straightening of the right heart border and roughening of the
cardiac outline as a result of pleuropericardial thickening.
Calcification often has a characteristic distribution involving the
anterior and lateral aspects of the heart as shown on the PA (A) and
lateral films (B) (arrows).

44. • Fig. 11.42 Cardiac fat pad. There is a low-density soft-
tissue opacity adjacent to the right heart border (arrow).
The triangular nature of the lesion with the characteristic
position suggests the diagnosis of a pericardial fat pad.

45. • Fig. 11.43 Pericardial cyst. (A) Frontal chest radiograph, there is a
sharply defined abnormal shadow in the right pericardiophrenic
angle. (B) Lateral view. This is seen to lie anteriorly, and is one of
the characteristic sites for a pericardial cyst.

46. • Fig. 11.44 A congenital pericardial defect. An isolated
pericardial defect is usually left sided (arrows) and can
allow prolapse of the left atrium beyond the normal
left heart contour.

47. • Fig. 11.45 Pericardial cysts. The outline of the
left ventricle has an undulating appearance
(arrows); this was due to the presence of
multiple pericardial cysts, which were
tuberculous in origin.

48. • Fig. 11.46 Hydatid pericardial disease.
Multiple large cysts (arrows) distort the
cardiac outline.

49. • Fig. 11.47 Left atrial myxoma. The chest X-ray
shows selective enlargement of the left atrium;
the left atrial appendage is also enlarged.

50. • Fig. 11.48 Aortic dissection. There is unfolding of the aorta
on this PA film in a patient who presented with severe back
pain. There is a double density within the aortic arch that is
unusual but suggests the possibility of a false lumen. A type
A dissection was diagnosed on CT (black/white arrows).

51. • Fig. 11.49 Traumatic aortic
rupture. This patient was
involved in a high speed road
traffic accident. The film
demonstrates several
important features of a
transected aorta. There is a
widened mediastinum. This is
nonspecific finding, but a
mediastinal width of greater
than 8 cm or a mediastinum to
chest ratio of greater than
0.25 are highly suggestive of a
large mediastinal haematoma
associated with this diagnosis.
There is a left pleural effusion
producing hazy opacification
in this supine patient. There is
also poor definition of the
lateral border of the
descending aorta.

52. • Fig. 11.50 Calcified saccular aneurysm of the
aortic arch. Both the PA (A) and lateral films (B)
demonstrate the large saccular aneurysm of the
aortic arch (arrow). The aneurysm has calcified.

53. • Fig. 11.51 Aortic stab wound. The supine view shows
marked widening of the mediastinum indicating
haemorrhage. There is also an increase in density in
the left hemithorax, due to the presence of a left-sided
pleural effusion.

54. • Fig. 11.52 Aneurysm of the ascending and descending
aorta. This PA film demonstrates marked dilatation of
the ascending aorta consistent with a large aneurysm,
in a patient with atheromatous disease.

55. • Fig. 11.53 Aneurysm of the descending aorta. The
descending aorta has become dilated and tortuous
with a marked increase in size (arrows). These changes
are often well visualised on both PA (A) and lateral (B)
films.

56. • Fig. 11.54 Expanding aortic aneurysm. These serial PA films of a patient
with Marfan's disease demonstrate expansion of the ascending aorta as an
aneurysm develops. The initial film shows mild prominence of the
ascending aorta, unusual in a young adult male (A). The second film taken 2
years later shows obvious increase in prominence of the ascending aorta
(arrow) as the aortic root has expanded (B).

57. • Fig. 11.55 Aortic incompetence due to syphilitic aortic root
aneurysm. (A) Frontal view, showing left ventricular dilatation
extending to the left and only a slight prominence in the
position of the ascending aorta, with a barely visible rim of
calcium. (B) Lateral view, showing a large saccular aortic root
aneurysm clearly outlined by calcification.

58. • Fig. 11.56 Acute massive pulmonary embolism. (A) Frontal chest film
(portable). The right lung and the left upper zone are hypertransradiant
due to oligaemia, and there is overperfusion of the left mid and lower
zones. (B) Pulmonary arteriogram, same patient. The leading edge of an
embolus is seen impacted in the right pulmonary artery, producing virtually
complete obstruction. Another embolus is seen in the supply to the left
upper lobe which is also impaired. Only the left lower lobe fills adequately
with contrast medium.

59. • Fig. 11.57 Pulmonary arteriovenous malformations. (A) Frontal chest film.
Abnormal pulmonary shadows, typically elongated, can be identified in the
right mid zone. (B) Pulmonary arteriogram. The pulmonary arteriovenous
malformations in the right mid zone, associated with premature venous
filling, can be identified. Additional abnormal pulmonary vessels are clearly
visible in the right upper zone and throughout the left lung.