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PRESENTED BY DR SANDEEP.R

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1 PRESENTED BY DR SANDEEP.R
CARDIAC XRAY PRESENTED BY DR SANDEEP.R

2 Topics discussed 1. BASICS OF CXR 2.STRUCTURES IN ANTERIOR VIEW
3.STRUCTURES IN LATERAL VIEW 4.CHAMBER ENLARGEMENT 5.PULMONARY CIRCULATION 6.CONGENITAL HEART DISEASE 7.PERICARDIAL DISEASE 8.PACEMAKER & ICD 9.CARDIAC CALCIFICATION 10.PROSTHETIC HEART VALVE 11.DISEASES OF AORTA 12. MISCELLENOUS

3 Basics of x-ray TECHNICAL QUALITY
R – ROTATION I -- INSPIRATION P -- PROJECTION E -- EXPOSURE

4 ROTATION The medial ends of both clavicles should be equidistant from the spinous process of the vertebral body projected between the clavicles

5 The increase in blackness of one hemithorax is always on the side to which the patient is rotated, irrespective of whether the CXR has been taken PA or AP

6 DEGREE OF INSPIRATION It is ascertained by counting either the number of visible anterior or posterior ribs Adequate inspiratory effort - six complete anterior or ten posterior ribs are visible Poor inspiratory effort - fewer than six anterior ribs Hyperinflated lung-more than six anterior ribs

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8 IMPORTANCE OF AN INSPIRATORY FILM
POOR INSPIRATORY FILM NORMAL INSPIRATORY FILM 1 3 2 1.MEDIASTINAL WIDENING 2.CMGLY 3.LOWER LOBE PATCHY OPACIFICN

9 Projection of x-ray Projection is defined as the direction of x-ray with relation to the patient If the direction of x-ray projection is from front – AP projection If the direction of x-ray projection is from behind –PA projection

10 AP VIEW PA VIEW

11 Pa view ap view In erect patients Vertebral spines more prominent
Scapulae clear of lungs Clavicles are horizontal In supine patients Vertebral bodies clear Apparent cardiomegaly Scapulae overlap Clavicles are oblique

12 ERECT SUPINE Gas bubble in fundus with a clear air fluid level
Gas bubble in antrum Apparent cardiomegaly

13 EXPOSURE of x-ray Normal exposure - the vertebral bodies should just be visible at the lower part of cardiac shadow Underexposed -If the vertebral bodies are not visible , insufficient number of x-ray photons have passed through the patient to reach the x- ray film Similarly, if the film appears too ‘black’, then too many photons have resulted in overexposure of the x-ray film.

14 OVERPENETRATION UNDERPENETRATION NORMAL

15 Topics discussed 1. BASICS OF CXR 2.STRUCTURES IN ANTERIOR VIEW
3.STRUCTURES IN LATERAL VIEW 4.CHAMBER ENLARGEMENT 5.PULMONARY CIRCULATION 6.CONGENITAL HEART DISEASE 7.PERICARDIAL DISEASE 8.PACEMAKER & ICD 9.CARDIAC CALCIFICATION 10.PROSTHETIC HEART VALVE 11.DISEASES OF AORTA 12. MISCELLENOUS

16 Systematic approach Technical factors
Skeletal abnormalities and hardware Situs: gastric air bubble, cardiac apex, and aortic knob Heart: position, size, and shape Great vessels: position, size, and shape Lung fields and vascularity by zone Search for calcifications

17 STRUCTURES SEEN IN ANTERIOR VIEW

18 Structures in lateral view
AA PT LA RV LV

19 Left upper lobe bronchus
Brachiocephalic vessels Trachea Scapula Manubrium Aorta Right upper lobe bronchus LPA RPA Retrosternal space Left upper lobe bronchus Pulmonary outflow tract Body of sternum LA Confluence of pulmonary veins RV IVC LV Right hemidiaphragm Gastric air bubble Left hemidiaphragm

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25 Aortic knob is the junction formed by the arch and descending aorta

26 Main pulmonary artery LPA

27 How to measure main pulmonary artery
If we draw a tangent line from the apex of the left ventricle to the aortic knob(red line) and measure along a perpendicular to that tangent line (yellow line) The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away from the tangent line

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29 Prominent mpa Main pulmonary artery projects more than the tangent
Causes: Increased pressure Increased flow

30 Hypoplastic pa MPA > 15 mm from the tangent Concave PA segment
Causes: TOF 2. TRUNCUS ARTERIOSUS

31 Left atrial appendage L LA ENLARGEMENT HYPERTROPHIED LA APPENDAGE

32 LEFT VENTRICLE

33 cardiomegaly The cardiothoracic ratio should be less than i.e. A+B/C<0.5 A cardiothoracic ratio > 0.5 suggests cardiomegaly in adults A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn A B C

34 CTR is more than 50% but heart is normal
Extracardiac causes of cardiac enlargement Portable AP films Obesity Pregnant Ascites Straight back syndrome Pectus excavatum

35 CTR is less than 50% but heart is abnormal
Obstruction to outflow of the ventricles Ventricular hypertrophy Must look at cardiac contours < 50% ASCENDING AORTA DILATED LV CONTOUR

36 Criteria's for cardiomegaly
Cardiothoracic ratio >0.5 in adults Cardiothoracic ratio >0.6 in newborn Any increase in transcardiac diameter > 2 cm compared to old x-ray In old age and emphysema a transcardiac diameter more than 15.5 cm in males &>12.5 cm in females

37 Chamber enlargement RA enlargement LA enlargement RV enlargement
LV enlargement

38 Criteria for ra enlargement
Rt. Cardiac border becomes more convex > 50% of right border Rt. Atrial border extends >3 intercostal spaces Measurement from mid vertical line to max. convexity in rt. Border>5 cm in adult & >4cm in children Lateral view – fullness in space between sternum and front of upper part of cardiac silhouette

39 Ab > 5cm a b

40 Criteria for la enlargement
Widening of carina( normal degree) Elevation of left bronchus Straightening of left border Double atrial shadow( shadow within shadow) Grade 1 –double cardiac contour Grade2 - LA touches RA border Grade 3 – LA overshoots the Rt. Cardiac border Displaces the descending aorta to the left and esophagus to right seen in barium swallow

41 La enlargement HYPERTROPHIED LA APPENDAGE

42 LEFT ATRIAL ENLARGEMENT
ELEVATION OF LEFT BRONCHUS WIDENING OF CARINA LAA enlargement DOUBLE ATRIAL SHADOW

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44 Elevation of lt. bronchus
Widening of carina Elevation of lt. bronchus Aneurysmal LA Aneurysmal LA – When La enlarges to left and right and approaches within an inch of lateral chest wall

45 LATERAL VIEW-LA ENLARGEMENT
LA pushing the Esophagus posterior

46 LEFT VENTRICULAR ENLARGEMENT
PA view (a)Left cardiac border gets enlarged and becomes more convex resulting in cardiomegaly (b)Lt. cardiac border dips into lt. dome of diaphragm (c) rounded apical segment (d) cardiophrenic angle is obtuse

47 Lateral view (a) Left ventricle enlarges inferiorly and posteriorly
(b)Rigler’s measurement A is >17 mm (c)Rigler,s measurement B is< 7.5 mm (d) Eyeler’s ratio becomes > 0.42

48 RIGLER’S MEASUREMENT Rigler’s A & B used to differentiate left ventricular and right ventricular enlargement Possible only when IVC shadow is present Jn. Of IVC with Lt. Atrium – J point Rigler’s A- from J point along line of IVC draw a line of 2 cm above and mark the point X.

49 Draw a horizontal line from pt
Draw a horizontal line from pt. A to posterior Cardiac border and mark that pt. y Distance between points x & y is Rigler’s measurement A NORMAL<17 mm Rigler’s B-from the pt. J drop a perpendicular line to the dome and this distance is Rigler’s measurement B NORMAL>7.5 mm

50 When LV enlarges, Posterior cardiac border gets displaced posteriorly & IVC shadow gets included in cardiac shadow, without getting displaced posteriorly Rigler’s measurement A >17 mm in lt. ventricular enlargement

51 EYELER’S RATIO To differentiate lt. & rt. Ventricular enlargement
Valid when IVC shadow is absent or cannot be visualised Mark the pt. of jn. where postero inferior cardiac border meets the dome as B From this pt. B draw a horizontal line to the posterior border of sternum-AB

52 Ratio of AB/BC is Eyeler’s ratio < 0.42
From pt.B - draw another horizontal line posteriorly to the inner border of the rib-BC Ratio of AB/BC is Eyeler’s ratio < 0.42

53 There is a retrocardiac space( prevertebral)
LA Oblique view There is a retrocardiac space( prevertebral) (a)Mild lt. Ventricular enlargement-obliteration of retrocardiac space (b) mod. Lt.ventricular enlargement-cardiac shadow overlaps vertebral column (c)Marked Lt.ventricular enlargement-cardiac shadow overshoots vertebral column

54 Left heart border is displaced leftward, inferior and posteriorly.
Chest X ray shows left ventricular enlargement. Left heart border is displaced leftward, inferior and posteriorly. Rounding of the cardiac apex.

55 RV ENLARGEMENT RIGHT LATERAL VIEW LEFT LATERAL VIEW PA VIEW
Cardiophrenic angle is acute Clockwise rotation of heart causes RV to form the middle portion of the left heart border. RIGHT LATERAL VIEW Obliteration of retrosternal space LEFT LATERAL VIEW Rigler’s measurement will be17mm or less Rigler’s measurement will be 7.5mm or more Eyeler’s ratio is 0.42 or less

56 PERICARDIAL EFFUSION Narrow vascular pedicle
Cardiomegaly directly proportional to severity of pericardial effusion This shadow has a rounded, globular appearance with no particular chamber enlargement Cardiophrenic angle become more and more acute Oligaemic pulmonary vascular markings Marked change in cardiac silhouette in decubitus posture ‘Epicardial fat pad sign’- anterior pericardial strip bordered by epicardial fat post. and mediastinal fat ant.>2mm

57 Narrow vascular pedicle
Pulmonary oligaemia Narrow vascular pedicle ‘Water bottle’ appearence Acute cardiophrenic angle

58 DILATED CARDIOMYOPATHY VS PERICARDIAL EFFUSION
Chambers can be identified Cardiophrenic angle is obtuse Increased pulmonary venous hypertension No change in cardiac silhouette in decubitus Vascular pedicle is dilated or normal Fluoro shows cardiac pulsation

59 Constrictive pericarditis
1.Straightening of the right border 2.Pericardial thickening > 4 mm 3.Pericardial calcification (50% cases) 4.Dilatation of SVC and azygous vein Pericardial calcification

60 CONGENITAL ABSENCE OF PERICARDIUM
Focal bulge in area of main pulmonary artery Sharply marginated Absent right cardiac border Increased distance between sternum and heart due to absence of sterno pericardial ligament

61 PULMONARY VASCULARITY
NORMAL PULMONARY CIRCULATION – 3 FEATURES 1.RDPA<17MM

62

63 PULMONARY VENOUS HYPERTENSION

64 PULMONARY VENOUS HYPERTENSION
LARRY ELLIOT’S CLASSIFICATION OF PVH RADIOGRAPHIC GRADE OF PVH ACUTE DISEASE PCWP CHRONIC DISEASE 1 13-17 MMHG 2 18-25 MMHG 18-30 MMHG 3 >25 MMHG >30 MM HG 4 HEMOSIDEROSIS AND OSSIFICATION LONG STANDING PVH

65 GRADE 0 -PCWP< 12 MM HG Upper lobe pulmonary veins are less prominent than lower lobe veins GRADE 1- PCWP 13-17MMHG Redistribution of blood flow with cephalization-’ANTLER SIGN’ 1) increased resistance to flow due to interstitial odema 2) alveolar hypoxia in lower lobes causes reflex vasoconstriction 3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex

66 Peribronchial cuffing Kerley A,B,C lines Interlobular effusion
GRADE 2- PCWP 18-25mm hg Interstitial edema Peribronchial cuffing Kerley A,B,C lines Interlobular effusion Pleural effusion Hilar haze Peribronchial cuffing

67 KERLEY A LINES Distended lymphatic channels within edematous septa coursing from peripheral lymphatics to central hilar nodes Towards the hilum Less specific for Pulmonary venous hypertension KERLEY A LINES

68 KERLEY B LINES Horizontal lines 1-3 mm thick
Perpendicular to pleural surface Towards the costophrenic angle Accumulation of fluid in interlobular septa and lymphatics Highly specific for PVH KERLEY B

69 KERLEY C LINES Crisscross lines seen between A &B GRADE 3 – pcwp > 25mm hg Alveolar odema B/l diffuse patchy cotton wool opacities

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71 Pulmonary circulation
Pulmonary plethora – features Enlargement of central pulmonary artery , lobar and segmental artery Prominent nodular vascular shadows in frontal CXR- shunt vessels that course ventral to dorsal Upper & lower lobe vessels prominent RPDA > 17mm Right descending pulmonary artery> tracheal diameter Ratio of RPDA to diameter of trachea > 1 Plethora seen if shunt size >2:1

72 plethora

73 Pulmonary oligaemia Decreased flow proximal to orgin of main pulmonary artery Small pulmonary artery Empty pulmonary bay Pulmonary vessels small Lung hypertranslucent Lateral view shows diminution of hilar vessels

74 oligaemia Empty pulmonary bay

75 Pruning High pressure left to right shunts are associated with obliterative changes in the smaller pulmonary arteries & arterioles Large main & large central pulmonary arteries taper down rapidly to very small vessels Seen in Eisenmenger’s syndrome Precapillary PAH

76 PRUNING

77 PULMONARY EMBOLISM Westermark sign Hampton’s hump
Fleischner’s sign- prominent central pulmonary artery Palla’s sign-dilated rt. Descending pulmonary artery Chang’s sign – dilatation and abrupt change in calibre of the rt. Descending PA Hamptons hump Wedge opacity

78 VALVULAR HEART DISEASE
Small aortic knob from decreased cardiac output Features of left atrial enlargement Right atrial enlargement from tricuspid insufficiency Pulmonary venous hypertension Enlarged MPA Calcified mitral valve MITRAL STENOSIS

79 Mitral regurgitation LA enlargement LV enlargement
Pulmonary venous hypertension

80 Ascending aorta dilated Left ventricular hypertrophy
AORTIC STENOSIS Ascending aorta dilated Left ventricular hypertrophy Aortic valve calcification

81 Dilated ascending aorta
AORTIC REGURGITATION Dilated ascending aorta LV enlargement

82 No obvious cardiomegaly
VALVULAR PS No obvious cardiomegaly Enlarged PA Dilated left pulmonary artery Normal to decreased pulmonary vasculature

83 INFUNDIBULAR PS Concave PA segment RVH

84 CONGENITAL HEART DISEASE
ASD PULMONARY PLETHORA MPA DILATED RPA DILATED RV APEX

85 How to differentiate asd vsd pda
DISEASE LEFT ATRIUM AORTA ASD VSD PDA

86 VSD PLETHORA MPA DILATED RPA DILATED LV APEX

87 PDA Linear or railroad track calcification at site of ductus may be seen in adults with PDA AORTIC KNOB PROMINENT MPA PLETHORA LV APEX

88 COARCTATION OF AORTA “FIGURE OF 3” in CXR “REVERSE 3” or “E sign” in
Barium meal SUBCLAVIAN ARTERY DILATION COARCTATION POSTSTENOTIC AORTIC DILATION RIB NOTCHING

89 DD OF INFERIOR RIB NOTCHING
1)Aortic obstruction- Takayasu arteritis Coarctation of aorta 2) Subclavian artery obstruction –Classic BT shunt Takayasu arteritis 3)Chronic Svc obstruction 4)Intercostal Av fistula 5)Neurofibromatosis

90 Cyanotic chd Cyanosis With Decreased Vascularity
Cyanosis With Increased Vascularity Truncus types I, II, III TAPVC Tricuspid atresia Transposition Single ventricle Cyanosis With Decreased Vascularity Tetralogy of Fallot Truncus-type IV Tricuspid atresia Transposition of great arteries Ebstein’s anomaly

91 CYANOTIC CHD TOF ‘Cour en sabot’ Due to 1)Rv apex 2)Underfilled LV
3)Concave pulmonary artery 4)Pulmonary oligaemia

92 TGA ‘Egg on string’ 1)Narrow pedicle 2)Rt. Border RA 3)Lt. border LV
4)Increased vascularity 5)Hypoplastic thymus

93 TAPVC (supracardiac) ‘figure of 8’ “snowman” Rt border-SVC
Upper border-left innominate Left border-left vertical vein Body of snowman-RA

94 PAPVC(Scimitar sign) The scimitar sign is produced by an anomalous pulmonary vein that drains any or all of the lobes of the right lung. Scimitar vein empties into the inferior vena cava

95 EBSTEIN ‘Box shaped’heart Enlarged RA Hypoplastic pulmonary trunk
Decreased vascularity

96 Rt pulmonary artery has a superior orgin (20%)
TRUNCUS ARTERIOSUS LV apex Rt pulmonary artery has a superior orgin (20%) ‘waterfall sign’ ‘Hilar comma sign’ Associated right aortic arch (33%) Concave PA segment ELEVATED RIGHT HILUM

97 Eisenmenger’s syndrome

98 PACEMAKER

99 BIVENTRICULAR PACING

100 RA LEAD RV LEAD

101 PACEMAKER PROBLEMS LEAD FRACTURE DISPLACED RV LEAD DISPLACED RA LEAD

102 ICD

103 CARDIAC CALCIFICATIONS
A) Valvular – Mitral , aortic valve B)Pericardial – constrictive pericarditis C) Myocardial – left atrial wall, LV aneurysm D)Endocardial – Endomyocardial fibrosis E) Intraluminal – La thrombus , La myxoma , Lv thrombus F) Vascular – aortic calcification , coronary artery

104 CARDIAC CALCIFICATION
MITRAL VALVE CALCIFICATION

105 Myocardial calcification
CALCIFIED LV APICAL ANEURYSM

106 CONSTICTIVE PERICARDITIS
CALCIFIED PERICARDIUM

107 Pericardial vs myocardial calcification
SEEN IN BOTH SIDES OF HEART MOST COMMONLY IN AV GROOVE DIFFUSE CALCIFICATION AROUND THE HEART CALCIFICATION IS CHUNKY & UGLY MYOCARDIAL SEEN IN ONLY LEFT SIDE MOST COMMON SITE IS ANT. WALL LOCALIZED TO THE LEFT CALCIFICATION IS FINE & CURVILINEAR

108 GIANT LA CALCIFICATION

109 ATRIAL MYXOMA

110 PROSTHETIC HEART VALVE
TILTING DISK VALVE

111 TILTING DISK VALVE

112 STARR EDWARD BALL VALVE
MITRAL STAR EDWARD

113 STARR EDWARD PROSTHETIC VALVE
MITRAL PROSTHESIS

114 ST. JUDE VALVE ST.JUDE MITRAL PROSTHETIC

115 Diseases of aorta Aneurysm of ascending & Descending aorta

116 Aortic dissection Egg shell sign

117 MISCELLENOUS X-RAYS Occurs in less than 0.5% of people
LEFT SVC Occurs in less than 0.5% of people Failure of regression of L common and Ant. Cardinal veins Drains left jugular and left subclavian vein Most patients also have right sided SVC Drains into dilated coronary sinus LEFT SVC

118 Right aortic arch Leftward displacement of barium filled esophagus
Rt. Indentation of trachea Aortic knob is absent from left side Aorta descends on right Associated with TOF Truncus arteriosus RT . AORTIC ARCH

119 Left superior intercostal vein Seen in 5% of cases
aortic nipple Left superior intercostal vein Seen in 5% of cases To be differentiated from a mass Also called pseudo dissection It drains into hemiazygous vein Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis

120 CERVICAL AORTIC ARCH Left sided cervical aortic arch
Aortic knob at apex of lung Descend on the left

121 SITUS INVERSUS WITH DEXTROCARDIA
SITUS INVERSUS WITH LEVOCARDIA

122 DEXTROCARDIA HYDROPNEUMOPERICARDIUM

123 PDA CLIP

124 BIBLiOGRAPHY (1)Jefferson K, Rees S. Clinical cardiac radiology, 2nd edition Butterworths; (2) Lipton MJ. Plain film diagnosis of heart disease: cardiac enlargement. Contemporary Diagnostic Radiology 1988;11:1-6. (3) Boxt LM, Reagon K, Katz J. Normal plain film examination of the heart and great arteries in the adult. J Thorac Imaging 1994;9: (4)Murray G. Baron,Wendy M. Book .Congenital heart disease in the adult.North American Clinics of Radiology 2004;3 (5) Ramesh M. Gowda,Lawrence M. Boxt. Calcifications of the heart.North American Clinics of Radiology 2004;4 (6) Martin J. Lipton, Lawrence M. Boxt. How to approach cardiac diagnosis from the chest radiograph.North American Clinics Of Radiology 2004;5 (7) Murray G. Baron .PLAIN FILM DIAGNOSIS OF COMMON CARDIAC ANOMALIES IN THE ADULT.North American Clinics Of Radiology 2004;6 (8) Radiology imaging – sutton 6th edition (9) Pediatric cardiology- Perloff’s clinical recognition of congenital heart disease (10)Radiology of congenital heart disease-Amplatz (11)Grainger & Allisons- diagnostic radiology vol1 , 4th edition (12)Cardiac Xrays- v.Chockalingam (13)Braunwald heart diseases 9th edition (14) Emma C. Ferguson,Rajesh Krishnamurthy,Sandra A. A.Oldham. Classic Imaging Signs of Congenital Cardiovascular Abnormalities; RadioGraphics 2007; 27:1323–1334 (15)www.learningradiology.com

125 quiz

126 EBSTEIN’S ANOMALY

127 8 YR OLD ACYANOTIC CHILD

128 ATRIAL SEPTAL DEFECT

129 25 YR OLD LADY WITH DYSPNOEA

130 MITRAL STENOSIS

131 65 YR OLD MAN WITH DYSPNOEA

132 PERICARDIAL EFFUSION

133 35 YR OLD ACYANOTIC FEMALE

134 ASD WITH PAH

135 IDENTIFY THE ABNORMALITY

136 SITUS INVERSUS WITH DEXTROCARDIA

137 IDENTIFY THE ABNORMALITY

138 RT AORTIC ARCH WITH RT DESCENDING AORTA

139 4 MO CYANOTIC CHILD

140 TAPVC SUPRACARDIAC

141 3 MO CYANOTIC CHILD

142 D-TGA

143 8 YR OLD ACYANOTIC CHILD

144 VSD


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