CHEST XRAY CARDIAC DISEASE

1. CHEST X-RAY
CARDIAC DISEASE

2. Normal heart
•The heart size is normal – cardiothoracic ratio is less than 50%
•The upper zone vessels are normal – they are smaller than the lower zone
vessels
•The lungs are clear – indicating there is no pulmonary oedema
•The costophrenic angles are well defined (asterisks) – indicating there is no
pleural effusion

3. Pericardial fat pad
•The heart size is normal in this image
•Accurate measurement of the cardiothoracic ratio can be difficult if there is a
pericardial fat pad
•The width of a pericardial fat pad – which may have to be estimated – should
not be included in the measurement of the cardiac size

4. Cardiomegaly - Mild
•Good quality Posterior-Anterior chest X-ray with no rotation
•In this image CTR = 53%
•There are no other signs of heart failure

5. Cardiomegaly
•History of hypertension and angina
•This patient has an enlarged heart
•CTR = 68%

6. Left atrial enlargement
•This image shows massive cardiomegaly (CTR=79%) in a patient with a metallic
mitral valve replacement
•This image shows specific features indicating massive enlargement of the left
atrium (highlighted area)
•1 - Carina splayed to >90°
•2 - Double right heart border
•3 - Left atrial appendage bulging the left heart border

7. Upper zone vascular prominence
•Enlarged heart (CTR = 55%)
•The upper zone vessels are prominent – an indicator of increased pulmonary
venous pressure
•Signs of pulmonary oedema have also developed – septal lines (Kerley B lines)
due to interstitial oedema, and airspace shadowing due to alveolar oedema
•The costophrenic angles are blunt due to bilateral pleural effusions

8. Septal lines - Example 1
•Pulmonary oedema may manifest with evidence of interstitial oedema (septal
lines) or alveolar oedema (airspace shadowing/consolidation)
•Septal lines (also known as ‘Kerley B lines’) appear as horizontal lines which
make contact with the edge of the lung
•Airspace shadowing due to alveolar oedema is also visible )

9. Septal lines - Example 2
•Septal lines represent thickening of the interlobular septa – interstitial tissue
which separates the secondary lobules at the peripheries of the lungs
•Septal lines are a specific sign of interstitial oedema in the context of
suspected left ventricular failure
•Occasionally septal lines are seen in conditions which cause blockage of the
pulmonary lymphatics – such as lymphangitis carcinomatosa or sarcoidosis

10. Septal lines - Example 3
•Septal lines may be very subtle but if present are a clear indicator of
interstitial oedema
•Look carefully at the lung bases near the costophrenic angles whenever heart
failure is suspected clinically
•Septal lines may be present with or without alveolar oedema

11. Alveolar oedema - Bat's wing pattern
•Alveolar oedema is caused by fluid leaking from the interstitial tissues into the
alveoli and small airways, and manifests as airspace shadowing (consolidation)
•In the context of acute pulmonary oedema, alveolar oedema radiates
symmetrically from the hilar regions in a ‘bat's wing’ distribution of airspace
shadowing
•Enlarged heart (CTR 60%) and sternal wires and metallic heart valve
•Blunting of the costophrenic angles is due to pleural effusions

12. Asymmetric bat's wing shadowing
•Bat's wing pulmonary oedema may not be symmetrical
•Note the septal lines on the right (interstitial oedema) and blunting of the
costophrenic angles bilaterally (pleural effusions)
•The oxygen tubing and ECG buttons have not been removed – indicating the
patient is acutely unwell

13. Pulmonary oedema
•Images which show pulmonary oedema are frequently of poor quality
because the patient is too unwell to stand or hold their breath
•This is a common appearance of acute pulmonary oedema
•Remember that bilateral air space shadowing may also be caused by other
disease processes such as infection – it is usually the clinical features that
indicate the diagnosis

14. Non-cardiogenic pulmonary oedema
•This patient had pulmonary oedema secondary to nephrotic syndrome –
albumin was very low
•Note that the heart size is normal (CTR <50%)
•If the heart size is normal, then heart disease may still be the cause of
pulmonary oedema, but non-cardiogenic causes should also be considered
•The converse is also true – if the heart is enlarged, then the cause of
pulmonary oedema is not always cardiac

15. Pleural effusions
•This patient with left ventricular failure has developed pleural effusions
•Note that the heart is enlarged and the upper zone vessels appear prominent –
if these features are absent then other causes of pleural effusions become more
likely

16. Asymmetric pleural effusions
•Pleural effusions caused by heart failure may not be symmetrical
•This patient with heart failure had been nursed lying on their right side before this
X-ray was taken
•Fluid has accumulated in the right pleural space – the right costophrenic angle is
not visible
•No effusion is present in the left pleural space – the left costophrenic angle
remains visible
•The left heart border is not distinct because there is pulmonary oedema of the
adjacent lung

17. Pericardial effusion
•This image shows some of the features of heart failure
•1 - Upper zone vascular prominence
•2 - Airspace shadowing (alveolar oedema)
•3 - Septal lines (interstitial oedema)
•4 - Pleural effusion
•The heart is also enlarged and has a globular (rounded) appearance due to a
pericardial effusion (fluid accumulation within the pericardial sac)

18. Post-surgical pericardial effusion
•This patient has had recent cardiac surgery
•The heart is enlarged but there are no other signs of heart failure
•Whenever the heart appears globular, it could be due to a pericardial effusion –
the diagnosis can be confirmed using ultrasound (echocardiogram)

19. Malignant pericardial effusion
•Pericardial effusions may not be due to heart disease
•This patient with metastatic disease (primary colon cancer) has an enlarged and
globular-shaped heart due to a malignant pericardial effusion (fluid and
cancerous cells within the pericardium)
•There are also numerous small lung nodules (pulmonary metastases) and
bilateral pleural effusions (malignant effusions)

20. Left ventricular aneurysm
•Aneurysms of the left ventricle are an uncommon complication of previous
myocardial infarction
•They may calcify and appear as a smooth eggshell-like line near the left
heart border

21. Pericardial calcification
•Increased density – due to calcification of the pericardium – follows the
contour of the heart
•Pericardial calcification is an uncommon feature seen on a chest X-ray which
is associated with constrictive pericarditis – in this case caused by previous
tuberculosis infection

22. Mitral valve calcification
•Calcification of the mitral valve is common in elderly patients – occasionally this
is heavy enough to be seen on a chest X-ray
•Mitral valve calcification is often asymptomatic but may be associated with
arrhythmias or mitral valve incompetence

23. Atrial septal defect
•The pulmonary artery is large relative to the aortic knuckle
•This combination is associated with increased pulmonary blood flow (left to
right shunt)
•An atrial septal defect was confirmed on echocardiogram
•This adult patient had mild shortness of breath and a subtle systolic murmur

24. Patent ductus arteriosus
•The pulmonary artery is large relative to the aortic knuckle
•The features are very similar to those seen in the image above
•Echocardiogram showed that this patient had a patent ductus arteriosus (PDA)
•PDA is usually discovered in early childhood but can be asymptomatic until
adulthood

25. Congenital heart disease - post-surgery
•This patient had undergone corrective surgery for tetralogy of Fallot (TOF)
many years previously
•The X-ray can be considered ‘normal’ for this patient even though the
pulmonary arteries are enlarged and there is also a right-sided aorta – a
common associated anatomical variant in patients with TOF
•The appearances of a chest X-ray can be confusing following surgery for
correction of congenital anomalies – reference to the surgical history is required

26. Pacemaker
•Cardiac pacemakers are a frequently encountered artifact seen on chest X-rays
•There are many different designs of pacemaker which may have one or two
leads placed in the right heart chambers
•The pulse generator (battery pack) is usually implanted in the retro-pectoral
space on the left side of the anterior chest wall

27. Pneumothorax following pacemaker
insertion
•After pacemaker insertion a chest X-ray is used to check for a pneumothorax

28. Implantable cardioverter defibrillator
•Implantable cardioverter defibrillators (ICDs) have a similar appearance to
pacemakers
•The ventricular lead has two thicker segments – these are the shocking
electrodes which automatically defibrillate the heart if an arrhythmia is detected
•The proximal shocking electrode is located in the superior vena cava and left
brachiocephalic vein
•The distal shocking electrode is located in the right ventricle

29. Cardiac surgery artifact
•Surgical artifacts such as sternotomy wires and metallic heart valves are
common artifacts seen on chest X-rays
•This patient also has a single chamber pacemaker
•Note the signs of heart failure – large heart, prominent upper zone vessels and
pulmonary oedema

30. CABG clips
•Patients who have had coronary artery bypass grafts (CABG) will often have
visible metallic vascular clips seen on their post-operative chest X-ray
•These clips are placed to prevent flow through the branches of the internal
mammary arteries which are used to form the coronary artery bypass

31. Prosthetic heart valves
•This patient had previously undergone mitral and aortic valve replacement
surgery – see the metallic heart valve artifact
•New signs of heart failure are evident – large heart, prominent upper zone
vessels, septal lines (Kerley B lines), and pleural effusions

32. Coronary artery stent
•Coronary stents may be visible on chest X-rays

33. ECG buttons
•Following a 12 lead ECG (electrocardiogram) this patient’s ECG buttons remain
stuck to the skin of the chest wall and were not noticed by the radiographer at the
time of this chest X-ray
•If appropriate, artifacts should be removed from the chest wall prior to taking a
chest X-ray
•Sometimes a patient is too unwell for these to be removed – as in many of the
other images in this gallery

34. Other medical artifacts
•This X-ray was acquired to verify the position of the temporary pacing wire –
the only internal artifact visible in this image
•Very sick patients frequently have a large number of lines, tubes and other
artifacts projected over the chest X-ray
•It is often not appropriate for these to be removed prior to acquisition of a chest
X-ray
•If you cannot identify an artifact on a chest X-ray then its identity can be
checked by examining the patient or checking the notes