This document provides guidance on evaluating chest x-rays for congenital heart disease. It outlines key aspects to examine such as cardiac size and position, pulmonary vasculature, and abnormalities in specific heart structures. Common errors made in interpretation are also discussed, such as misdiagnosing over- or under-penetration of images. Example x-rays of various congenital heart conditions are provided to demonstrate typical features, including tetralogy of Fallot, transposition of the great vessels, and total anomalous pulmonary venous return.

1. Chest x rays
Dr Virbhan

2. TECHNICAL ASPECT
PROJECTION
ORIENTATION
ROTATION
PENETRATION
DEGREE OF INSPIRATION

3. Reading of chest X-rays in CHD
Is there cardiomegaly?
Cardiothoracic ratio >60% in neonates
> 55% in infants
> 50% in older children/adult

4. Is the situs normal?
The situs as defined by-
Stomach bubble
Liver shadow
Bronchial morphology of more horizontal and
short right bronchus

5. Situs inversus totalis and dextrocardia- rarely
has heart disease
Mesocardia -commonly has c TGA
Left-sided heart in situs inversus- has complex
heart disease.
Apex -dome of diaphragm is lower on the side
of apex.

6. Is there a particular chamber enlargement ?
RA enlargement-
Vertical height compared to height from aortic
arch to SVC-RA junction
lateral 3 spaces criteria
The RV type- upturned apex e.g TOF
LV type of apex -tricuspid atresia

8. Is the cardiac silhouette normal?
L-posed aorta
Enlarged thymus

9. What is the pulmonary blood flow—
increased, decreased or normal?
Increased pulmonary blood flow - more than 5
end-on vessels in the lungs, or more than 3 in
one lung.
The end-on vessels should be more than twice
the size of an accompanying bronchus.
More than 6 vessels could be traced in the
periphery in increased flow states.

10. Decreased flow - when the vessels are thin and
small.
Less than 3 vessels are seen in the periphery
Pulmonary conus and main arteries are not
prominent.

11. Is there PAH? How severe?
In adults NORMAL descending branch of right
pulmonary artery-
9–14 mm in females.
10–15 mm in males.
 In children, the artery size larger than the trachea
indicates enlargement.
 Peripheral pruning—that is sudden taper of PA
branches as it travels to periphery indicates PAH.
 Pruning is seen in functional as well as organic PAH.

12. Is there PVH ? How severe?
PVH is present when the PAWP >12 mm Hg.
Equalization
Cephalization
Perihilar haze
Interstitial edema indicate progressively
increasing PVH.
o Kerley lines generally indicate chronic severe
PVH

13. Is there aortic arch abnormality?
The aortic arch is identified by the impression on
trachea.
A right aortic arch is commonly associated with
VSD.
A right arch and increased blood flow is typically
seen in truncus arteriosus.
An inconspicuous aortic arch could mean double
arch.
Coarctation with arch hypoplasia.

14. Is there pulmonary parenchymal lesion—
Infection
Infarction
Aspiration
Hemorrhage
Collapse

15. Is there asymmetry of findings, e.g.
Decreased vasculature on one side?
This could indicate ipsilateral pulmonary artery
stenosis.
Pulmonary embolism.
Anomalous pulmonary venous drainage
Lung disease.
Is there rib notching? Signs of previous
surgery like rib regeneration?

16. Are there serial changes?
The changes of pulmonary plethora diminish
but in Eisenmenger’s syndrome

17. Spot diagnosis-
Boot-shaped heart- TOF,
Egg on side appearance of TGA without VSD
Figure-of-8 for supracardiac TAPVC
Waterfall sign of a truncus arteriosus
Typical straight right border for tricuspid atresia
Aorta forming the left border in corrected
transposition of great vessels.

18. COMMON ERRORS
Following are the common errors seen in day-
to-day clinical practice:
Spurious cardiomegaly due to expiratory film.
Wrong assessment of lung vasculature due to
over- and underpenetration (underpenetration
increases lung vasculature and vice versa)
Rotation of film leading to wrong
interpretation of cardiac silhouette or hilum.

19. Missing a spinal deformity causing
cardiomegaly, or altered silhouette.
Over-relying on patterns without taking into
account the sensitivity and specificity of a
finding- e.g RA dilatation, type of apex (RV or
LV), egg-on-side pattern for TGA.

20. Misunderstanding PVH for pulmonary plethora
can lead to misclassification of the disease.
Wrong reading of hilar shadows is frequent cause
of errors.
Many a times, dilated PAs have been interpreted
as lymph nodes and patients prescribed
antitubercular treatment.
Not paying enough attention to lungs e.g
infiltration, or military shadows missed or over-
read.

21. Misinterpretation of normal but infrequent
seen structures such as the azygous lobe,
diaphragmatic humps, atypical thymus
shadow, etc.

22. TOF with absent pulmonary valve -Dilated main pulmonary artery
The pulmonary vasculature is not markedly decreased and may be
normal or increased

23. TOF - markedly decreased lung vasculature
and pulmonary bay and right aortic arch

24. TOF and endocarditis. Note the infiltration in the lungs due
to septic emboli from the right-sided vegetations. The boot-
shaped heart and decreased pulmonary blood flow is seen

25. Tricuspid atresia with decreased pulmonary blood flow.
LV type of apex. note the left SVC.

26. Corrected transposition of great vessels. Note the mesocardia, and shadow
of L-posed aorta. Pulmonary artery shadow is not distinctly seen and is
behind the aortic shadow.

27. Note the figure-of-8 shadow and increased pulmonary blood flow from
supracardiac TAPVC that is not obstructed (A thymic shadow can sometime
mimic this, but then the pulmonary blood flow will be normal)

28. Typical sail-like thymic shadow in a normal infant

29. Truncus arteriosus. Note cardiomegaly and increased
pulmonary blood flow. The main pulmonary artery is not in
normal place. Rt PA origin seems high. A right arch would
have made the diagnosis easy but is not present

30. Two examples of transposition with intect septum. Note the variation in TGA
X-rays.

31. Marked cardiomegaly in newborn has few differential diagnoses, Ebstein’s
anomaly in this case

32. Regression of pulmonary artery (PA) pressure and its importance
in neonate.

33. Diffuse cardiomegaly and overpenetrated
film. No comments possible regarding lung
vasculature
Hyperinflated lung in double aortic arch

34. TOF and cardiomegaly due to severe anemia. Cardiomegaly does not
occur in all lesions of “TOF physiology” unless complicated by other
things

35. Typical ground-glass appearance in a neonate from obstructed infracardiac
TAPVC. The angiogram shows the descending vertical vein going below the
diaphragm

36. Increased vasculature in VSD
PAH, peripheral pruning, dilated right
descending PA, and prominent main
PA.

37. Eisenmenger’s syndrome due to ASD, VSD, and PDA . Note the massive
dilatation of pulmonary arteries, cardiomegaly and small aorta shadow in ASD. The
PDA Eisenmenger (right) is remarkable for prominent aorticopulmonary shadow.
Sometimes a ductal calcification may be seen in the area between aorta and dilated
PA. Eisenmenger VSD (middle) shows PAH but neither cardiomegaly nor
prominent aorta

38. Prosthetic Cardiac Valves

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