X-RAY OF THE HEART

1. X-ray of The Heart

2. Radiographic Densities
Different tissues in our body
absorb X-rays at different
extent

3. Technical aspects…P-VERB
1. Patient’s details
2. View : PA vs AP or lateral
3. Exposure
4. Rotation
5. Breath: Inspiration or Expiration
Buku Pabduan Kerja Keterampilan Pemeriksaan Foto Thorax Cardiovascular.
2017. Fakultas Kedokteran Unhas. Makassar

4. Patient’s details
• Name
• Age
• Gender
• Date of photo was taken
Buku Panduan Kerja Keterampilan Pemeriksaan Foto Thorax Cardiovascular.
2017. Fakultas Kedokteran Unhas. Makassar

5. 4 major views
1. Posterior-anterior (PA)
2. Anterior-Posterior (AP)
3. Lateral
4. Lateral decubitus

6. PA view
•Standard view for routine Chest x-rays
•Taken in full inspiration

7. AP view
•Patient is too ill to stand or non-cooperative
•Heart at a greater distance from film, appears
enlarged

8. PA vs AP view
PA view AP view
Clavicle Over lung fields Above lungs apex
Scapulae Away from lung fields Over lung fields
Heart Relatively enlarged

9. Lateral view
•Lung lobes, mediastinum & bony thoracic cavity better
visualized
•Useful for lobar pathology, mediastinal masses,
pleural fluid & basal consolidation

10. Lateral decubitus view
•Specialized projection to demonstrate small pleural
effusions or pneumothorax

11. Exposure
•Adequate exposure: Inter-vertebral spaces barely visible through
the heart shadow

12. Rotation

13. Good Inspiration
• 6 anterior ribs visible
•10 posterior ribs visible

14. CRITERIA OF A GOOD X-RAY OF
THE CHEST FROM PA VIEW
PLAIN RADIOGRAPHY OF THE CHEST (CXR)
• The film covers the entire thoracic
cavity from both the lung apex and
the costophrenic sinus.
• Sufficient inspiration when the right
diaphragm is at 9th or 10th rib
posteriorly.
• Symmetrical when the thoracic
vertebral bodies are located in the
middle of the sternoclavicular joint.
• The condition of the photo is
sufficient; only the 3rd-4th thoracic
vertebrae are visible.
Buku Pabduan Kerja Keterampilan Pemeriksaan Foto Thorax
Cardiovascular. 2017. Fakultas Kedokteran Unhas. Makassar

15. Counting Ribs

16. Cardiac Anatomy
Normal: like pear / guava / avocado
Abnormal: typical shape (shoes, oval,
square), the waist of the heart can be
shallow (concave) or straight, or
protruding.
Buku Panduan Kerja Keterampilan Pemeriksaan Foto Thorax
Cardiovascular. 2017. Fakultas Kedokteran Unhas. Makassar

17. Cardiac Anatomy

18. Lateral view

19. Cardio-thoracic Ratio
(PA view)
Normal CT ratio <0.5 Buku Panduan Kerja Keterampilan Pemeriksaan Foto Thorax
Cardiovascular. 2017. Fakultas Kedokteran Unhas. Makassar

20. Right Atrial Enlargement
The right border of
the heart protrudes,
the right transverse
diameter of the heart
divided by the
diameter of the right
hemithorax more than
1/3.
Radswiki, T., Baba, Y. Right atrial enlargement. Reference article,
Radiopaedia.org. (accessed on 24 Aug 2022) https://doi.org/10.53347/rID-12941

21. Left Atrial Enlargement
Double contour on the
right border of the
heart, the left auricle is
prominent, the left
main bronchus is
raised.
Gaillard, F., Murphy, A. Left atrial enlargement. Reference article,
Radiopaedia.org. (accessed on 24 Aug 2022) https://doi.org/10.53347/rID-12944

22. Right Ventricular Enlargement
The heart is widened to
the left with uplifted
cardiac apex
and prominent conus
pulmonalis (PA projection)
and narrowed retrosternal
clear space (left lateral
projection).
Radswiki, T., Bell, D. Right ventricular enlargement. Reference article,
Radiopaedia.org. (accessed on 24 Aug 2022) https://doi.org/10.53347/rID-12942

23. Left Ventricular Enlargement
The heart is widened to
the left with downwards
cardiac apex (PA
projection) and the
retrocardiac clear space
narrows / disappears (left
lateral projection).
Gaillard, F., Weerakkody, Y. Left ventricular enlargement. Reference article,
Radiopaedia.org. (accessed on 24 Aug 2022) https://doi.org/10.53347/rID-12943

24. Mitral Stenosis
• Convexity or straightening of the left
atrial appendage just below the main
pulmonary artery (along left heart
border)
• Double density
• Elevation of the left main bronchus
Weerakkody, Y., Sharma, R. Mitral valve stenosis. Reference article,
Radiopaedia.org. (accessed on 24 Aug 2022) https://doi.org/10.53347/rID-18253

25. Pericardial Effusion
• Greater than 200 mL of
pericardial fluid is usually
required to become
radiographically visible.
Radiographic signs
include:
• Globular heart shadow
• “Water bottle” sign
Gaillard, F., Moore, C. Pericardial effusion. Reference article, Radiopaedia.org.
(accessed on 25 Aug 2022) https://doi.org/10.53347/rID-7729

26. Tetralogy of Fallot
• Chest radiographs may
classically show a boot
shaped heart with an
upturned cardiac apex
due to right ventricular
hypertrophy and concave
pulmonary arterial
segment.
• Pulmonary oligemia
occurs due to decreased
pulmonary arterial flow. Weerakkody, Y., Sharma, R. Tetralogy of Fallot. Reference article,
Radiopaedia.org. (accessed on 25 Aug 2022) https://doi.org/10.53347/rID-7356

27. Transposition of Great Arteries
• Cardiomegaly with cardiac
contours classically described
as appearing like an egg on
string. There is often an
apparent narrowing of the
superior mediastinum as the
result of the aortic and
pulmonary arterial
configuration, i.e. parallel in
D-loop transposition, with the
main pulmonary artery
posterior to the aorta.
Weerakkody, Y., Carroll, D. Transposition of the great arteries. Reference article,
Radiopaedia.org. (accessed on 25 Aug 2022) https://doi.org/10.53347/rID-7367

28. Aorta
- Normal (A1 + A2) < 4 cm or A1 distance
between 3.5 – 4 cm or a distance of <3.5
cm measured from the left lateral edge
of the trachea.
- Aortic dilatation; (A1+A2) > 4 cm, or
aortic knob protruding (A1 > 4 cm)
- Aorta elongation; if the upper border of
the aorta to the middle of the ends of
the clavicles < 2 cm or < 1 cm from the
lower limits of the ends of the clavicles.
Buku Panduan Kerja Keterampilan Pemeriksaan Foto Thorax
Cardiovascular. 2017. Fakultas Kedokteran Unhas. Makassar

29. Hilar
• Position: Left hilum is slightly
higher than the right hilum
• Shape: Concave
• Size: Similar on both sides
• Density: Almost same on both
sides

30. Pulmonary Hypertension
• Enlarged pulmonary arteries
 >16 mm right descending
pulmonary artery
• Prominent pulmonary outflow
tract
• Pruning of peripheral
pulmonary vessels
• Right ventricular hypertrophy
Buku Panduan Kerja Keterampilan Pemeriksaan Foto Thorax
Cardiovascular. 2017. Fakultas Kedokteran Unhas. Makassar

31. Pulmonary Edema
1. Vascular Redistribution
Early manifestationsion heart failure
include upper zone redistribution
(cephalization) of vessels (green
arrows) and cardiomegaly is present
Lilly LS. 2016. Pathophysiology of Heart Disease Sixth
Edition. Wolters Kluwer.

32. Pulmonary Edema
2. Interstitial edema
• Kerley B lines
• Fluid leakage into the
peribronchial interstitium as a
the increased pressure in the
When fluid leaks into the
interlobular septa it is seen as
or septal lines.
Lilly LS. 2016. Pathophysiology of Heart Disease Sixth
Edition. Wolters Kluwer.

33. Pulmonary Edema
2. Interstitial edema
• Peribronchial cuffing and perihilar
haze
• When fluid leaks into the
peribronchovascular interstitium
it is seen as thickening of the
bronchial walls (peribronchial
cuffing) and as loss of definition
of these vessels (perihilar haze).
Lilly LS. 2016. Pathophysiology of Heart Disease Sixth
Edition. Wolters Kluwer.

34. Pulmonary Edema
3. Alveolar edema
• Bat-wing appearance
• Air bronchogram
Air bronchograms (blue
arrows) occur when the
radiolucent bronchial tree is
contrasted with opaque
edematous tissue.
Lilly LS. 2016. Pathophysiology of Heart Disease Sixth
Edition. Wolters Kluwer.

35. Diaphragm

36. Pleural Effusion
• Blunting of the costophrenic angle
• Blunting of the cardiophrenic angle
• Fluid within the horizontal or oblique
fissures eventually a meniscus sign will
be seen
Jones, J., Lustosa, L. Pleural effusion. Reference article,
Radiopaedia.org. (accessed on 25 Aug 2022)
https://doi.org/10.53347/rID-6159