This document discusses evaluating the cardiovascular system on chest x-rays. It describes the normal appearance and positioning of the heart and major vessels. It then discusses how various cardiovascular abnormalities may appear on chest x-rays, including enlargement of the different cardiac chambers and changes in the pulmonary vasculature seen in conditions like pulmonary edema. It also covers evaluating implanted devices, postoperative changes, and pericardial effusions. The key information is evaluating the size and positioning of the heart and vessels and knowing how different cardiovascular diseases may cause identifiable changes visible on chest x-rays.

1. CHEST X-RAY FOR
EVALUATION OF
CARDIOVASCULAR SYSTEM
MODERATOR
DR.SUKRITI KUMAR
MD
PRESENTER
DR.NABA KUMAR BARMAN
JR1
GROUP DISCUSSION

2. 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
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 the right
On both frontal and lateral views, the ascending
aorta
(aortic root) is normally obscured by the main
pulmonary artery and both atria
.

3. Measuring
the CTR. On a PA chest
radiograph obtained in full
inspiration, if a / b > 50% the
heart is likely to be enlarged1.
(a = maximum transverse
diameter of the heart; b =
maximum internal diameter
of the thorax.

4. 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

5. 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
Chronic obstructive pulmonary
disease, heart appearing small even
in the presence of cardiac
dysfunction

6. 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 xray
showing film taken in obese patient

7. Lungs and Pulmonary Vasculature
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 fourthorder
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
•lower lobe arteries are coloured blue
“because they contain oxygen-poor blood”.
•They have a more vertical orientation,
•while the pulmonary veins run more
horizontally towards the left atrium, which is
located below the level of the main
pulmonary arteries.

8. 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 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.
The lower lobe pulmonary
arteries extend inferiorly from
the hilum.They are described as
little fingers, because each has
the size of a little finger .
•On the right side the little
finger will be visible in 94% of
normal CXRs and on the left
side in 62% of normals.
The aorta and great vessels normally
dilate and become more tortuous and
prominent with increasing age, thereby
leading to widening of the superior
mediastinum

9. Chest radiograph in heart disease
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

10. 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
portion
Vessels larger in the lower part of the lung
and sharply marginated in both the upper
and lower zones
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

11. 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

12. Normal Increased
Flow

13. 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
In Venous Hypertension PCWP usually>17mm ,Upper lobe vessels
equal to or larger than size of lower lobe vessels =Cephalization

14. 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

15. The vascular pedicle is bordered on the
right by the superior vena cava and on the
left by the left subclavian artery origin .
The vascular pedicle is an indicator of the
intravascular volume.
A vascular pedicle width less than 60 mm
on a PA chest radiograph is seen in 90% of
normal chest x-rays.
A vascular pedicle width of more than 85
mm is pathologic in 80% of cases.
5 mm increase in diameter corresponds to
1 liter increase of intravascular fluid.
An increase in width of the vascular pedicle
is accompanied by an increased width of
the azygos vein.
VASCULAR PEDICLE

16. 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
Chest X-ray showing Bat-Wing
appearnce in
a patient with acute congestive
heart failure

18. Cardiac Chambers and Great Vessels
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

20. Cardiac Chambers and Great Vessels
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

21. Cardiac Chambers and Great Vessels
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

22. Cardiac Chambers and Great
Vessels
Right Ventricle
Commonly seen in
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

23. Right Ventricle
On a lateral CXR in normal patients,
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
third in the absence of other it is a reliable
indication of RV enlargement
Common disease：
Mitral valve stenosis
Chronic pulmonary heart
disease
Pulmonary stenosis
Pulmonary hypertension
Fallot’s tetralogy
ASD , VSD

24. Left Atrium
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

25. Left Atrium
 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
Chest radiographs of a 60-year-old woman
with severe
mitral stenosis , Lateral view confirming RV
enlargement with filling in of
the retrosternal airspace. Note also the
marked LA enlargement
Common disease：
mitral lesion
left ventricular failure
congenital heart
diseases：
PDA

26. Left Ventricle
LV enlargement is
characterized
by a prominent,
downward
directed contour of
the apex
Cardiac contour
enlarged
cardiac apex
extending to left
and down
the aorta is
prominent

27. Left Ventricle
Pushing gastric bubble inferiorly
retrocardiac space become
narrowed or
disappeared, esophageal space
disappeaered
Common disease：
high blood pressure
aortic incompetence、
stenosis
mitral incompetence
congenital heart disease：
PDA

28. Aortic Valve and Aorta
On frontal CXR, aortic dilation
as
prominence to the right of the
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

29. Pleura and Pericardium
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
Chest X-ray showing Water bottle
shape heart suggestive of large
pericardial effusion

30. Pleura and Pericardium
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 PA view and Lateral
view only
showing pericardial calcification

31. IMPLANTABLE DEVICES AND OTHER
POSTSURGICAL
FINDINGS
 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

32. Position of prosthetic valve on
chest X-ray
• 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

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

34. IMPLANTABLE DEVICES AND OTHER
POSTSURGICAL
FINDINGS
 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

35. A CHILD PRESENTED WITH
DYSPNEA

37. PERICARDIAL EFFUSION
The CXR appearance of fluid in the pericardial sac is very difficult to
distinguish
from simple chamber enlargement . The distinction is rapidly and
easily made using echocardiogaphy. The following 2 are worth noting:
The pericardial sac normally contains 15–30 ml fluid.
Change in cardiac size or shape only occurs once 250 –500 ml of fluid has
accumulated.
The claim that a pericardial effusion will produce a globular cardiac outline
or a well-defined cardiac contour because of the tamponading effect of the
effusion on cardiac motion is unsound.
Rule of thumb: The single most important sign of an effusion on a CXR is a
rapid alteration in heart size or shape without any changes in the lungs

38. An enlarged cardiac silhouette may be due to chamber enlargement, to
a pericardial effusion, to infl ammation / hypertrophy of the cardiac
musculature…or to
a combination of these possibilities. The CXR appearance of the cardiac
shadow alone
is insensitive in making a distinction between these causes of an enlarged
heart. This is
illustrated: (a) pericardial effusion; (b) ventricular dilatation (i.e. chamber
enlargement
with thin walls); (c) hypertrophy of the myocardium.

39. KNOWN CASE OF
MS AND MR FRONTAL
CHEST XRAY FINDINGS

41. THANK YOU