Presentation on theme: "Chest X-ray signs of cardiac disease"— Presentation transcript:
1 Chest X-ray signs of cardiac disease A. SwartbooiDiagnostic Radiology, UFS2 March 2012
2 Congenital Heart Disease Numerous clinically important imaging signs in congenital cardiovascular disease.It is important that Radiologists must be able to recognize these signs and must understand their causes in order to provide accurate diagnoses of abnormalities affecting the heart and vessels of the thorax.
3 Congenital Heart Disease Transposition of the Great ArteriesMost common cyanotic congenital heart lesion5%–7% of congenital cardiac malformationsisolated in 90%Transposition of the great arteries is produced by a ventriculoarterial discordance in which the aorta arises from the morphologic right ventricle and the pulmonary artery arises from the morphologic left ventriclePulmonary artery is situated to the right of its normal locationResults in the apparent narrowing of the superior mediastinum on radiographsPatent ASD, VSD, Foramen ovale, systemic collaterals to sustain lifeAtrial border is abnormally convex, and the left atrium commonly is enlarged because of increased pulmonary blood flow.
5 Congenital Heart Disease Total Anomalous Pulmonary Venous ReturnOccurs when the pulmonary veins fail to drain into the left atrium and instead form an aberrant connection with some other cardiovascular structure2% of cardiac malformationsFour types of TAPVR may be definedType I (55%)The anomalous pulmonary veins terminate at the supracardiac level.Typically, four anomalous pulmonary veins converge behind the left atrium and form a common vein, known as the vertical vein, this passes anterior to the left pulmonary artery and the left main bronchus to join the innominate veinLess commonly, drainage to the left brachiocephalic vein, right superior vena cava, or azygos vClassic snowman signType II (30%)Involves a pulmonary venous connection at the cardiac level.Pulmonary veins join either the coronary sinus or the right atrium.
6 Congenital Heart Disease Type III (13%)Involves a connection at the infracardiac or infradiaphragmatic levelPulmonary veins join behind the left atrium to form a common vertical descending vein, which courses anterior to the esophagus and passes through the diaphragm at the esophageal hiatusVertical vein usually joins the portal venous system but occasionally connects directly to the ductus venosus, the hepatic veins, or the inferior vena cava.Type IV (2%)Involves anomalous venous connections at two or more levels.In the most common pattern, the vertical vein drains into the left innominate vein, and the anomalous vein or veins from the right lung drain into either the right atrium or the coronary sinusGenerally associated with other major cardiac lesions.
8 Congenital Heart Disease Partial Anomalous Pulmonary Venous ReturnAnomalous pulmonary vein drains any or all of the lobes of the right lungVein curves outward along the right cardiac border, usually from the middle of the lung to the cardiophrenic angle, and usually empties into the inferior vena cava but also may drain into the portal vein, hepatic vein, or right atriumSize of the vein generally increases as it descends.Characteristic appearance of the vein has led to its comparison to a scimitarFlow through the scimitar vein produces a left-to-right shunt that is usually hemodynamically insignificant.Part of Scimitar syndrome when associated with:Hypoplasia of the right lung with dextroposition of the heart,Hypoplasia of the right pulmonary artery, andAnomalous arterial supply of the right lower lobe from the abdominal aorta
10 Congenital Heart Disease Endocardial Cushion DefectsInterruption of the normal development of the endocardial tissues during gestation which normally forms the lower portion of the atrial septum, the upper portion of the interventricular septum, and the septal leaflets of the mitral valve and the tricuspid valve4% of all cases of congenital heart diseaseGooseneck-shaped deformityCaused by a deficiency of both the conus and sinus portions of the interventricular septum, with narrowing of the left ventricular outflow tract.Characteristic shape by concavity of the interventricular septum below the mitral valve, along with the elongation and narrowing of the left ventricular outflow tract
12 Congenital Heart Disease Tetralogy of Fallot10%–11% of cases of congenital heart diseaseAs a result of single defect, an anterior malalignment of the conal septumComponents:Ventricular septal defectInfundibular pulmonary stenosisOverriding aortaRight ventricular hypertrophy.Heart has the shape of a wooden shoe or bootBlood flow to the lungs is usually reduced
14 Congenital Heart Disease Aortic Coarctation5%–10% of congenital cardiac lesionsProduced by a deformity of the aortic media and intima, which causes a prominent posterior infolding of the aortic lumenOccurs at or near the junction of the aortic arch and the descending thoracic aortaInfolding cause eccentric narrowing of the lumen at the level where the ductus or ligamentum arteriosus inserts anteromediallyResultant luminal narrowing in turn obstructs the flow of blood from the left ventricleClassic radiologic signsFigure-of-three signReverse figure-of-three signRib notching on CXR pathognomonic
15 Aortic Coarctation – Figure of Three, and Reverse Figure of Three The number 3 is formed by dilatation of the left subclavian artery and aorta proximal to the site of coarctation, indentation of the site, and dilatation of the aorta distal to the site. This sign is seen in 50%–66% of adults with aortic coarctation. The reverse figure-of-three sign, a mirror image of the number 3, is observed on the left anterior oblique view during barium esophagography in patients with aortic coarctation (Fig 6e, 6f).
16 Congenital Heart Disease Ebstein Anomaly0.5%–0.7% of cases of congenital heart disease.Characterized by the downward displacement of the septal leaflets and posterior leaflets of the tricuspid valve into the inflow portion of the right ventricle.Results in the formation of a common right ventriculoatrial chamber and causes tricuspid regurgitation.Insufficiency of the tricuspid valve leads to dilatation of the right ventricular outflow tract and all proximal right heart structures,Most consistent imaging feature is right atrial enlargement;
18 Useful Approach Clinical Thoracic Musculoskeletal Structures Cyanotic vs AcyanoticThoracic Musculoskeletal Structuresprior operations, rib or sternal deformities or sternal wire suturesPulmonary vascularity⇧ pulmonary arterial circulation versus pulmonary venous hypertensionOverall Heart SizeAssessing CT indexSternal deformities such as pectus may serve as a clue to cardiac lesions associated with it, such as Marfan syndrome and mitral valve prolapse; or perhaps the deformity is responsible for a cardiac murmur or even symptoms caused by cardiac compression. Narrow anteroposterior diameter of the thorax can be caused by a straight thoracic spine (straight-back syndrome) or pectus excavatum. A narrow anteroposterior diameter is defined as a distance between the sternum and the anterior border of the vertebral body that measures less than 8 cm and a ratio of the transverse diameter (determined by frontal view) to the anteroposterior diameter (determined by lateral view) exceeding The anteroposterior diameter is the maximum diameter from the undersurface of the sternum to the anterior border of the vertebral body
19 Useful Approach Specific Chamber Enlargement Great arteries Right retrocardiac double densitySplayed carina, horiz L bronchusPosterior displacement of the left upper lobe bronchusEnlarged atrial appendageRALateral bulging and elongation of the right heart borderLV & RVPA View ⇨LatGreat arteriesAscending aorta,Aortic knob,Main pulmonary arterial segment“Vectors of enlargement” for the left and right ventricles. For left ventricular enlargement (LVE), the vector is directed leftward and caudal. For right ventricular enlargement (RVE), the vector is directed leftward or leftward and slightly cranial.On the lateral view, the posterior border of the heart is displaced posteriorly. The Hoffman-Rigler sign is measured 2.0 cm above the intersection of the diaphragm and the inferior vena cava. A positive measurement for LV enlargement is a posterior border of the heart extending more than 1.8 cm behind the inferior vena caval shadow at this level.On the lateral view, the retrosternal space is encroached upon by the enlarged right ventricle. Right ventricular enlargement is inferred by contact of the right heart border over greater than one third of the sternal length
20 Acquired Heart Disease In the evaluation of acquired heart disease a systematic approach is directed toward discerning the pertinent findings from the radiograph and, for each finding, narrowing the diagnostic considerationsCardiac size and chamber enlargement can be inferred by evaluation of the chest radiograph.The normal heart will occupy slightly less than 50% of the transverse dimension of the thorax.
24 RADIOGRAPHIC FEATURES OF AORTIC STENOSIS Enlargement of the ascending aorta due to poststenotic dilatationMild or no cardiomegaly in compensated stageSubstantial cardiomegaly occurs only after myocardial failure has ensuedNo pulmonary venous hypertension or pulmonary edema is seen during most of the course of this diseaseCalcification of aortic valve may be discernible on radiograph but is more readily shown on CTAortic stenosis. Frontal radiograph shows normal cardiac size and normal pulmonary vascularity. The sole abnormality in this 40-year-old subject is enlargement of the ascending aorta (arrows). The posterior aortic arch is normal in size.
25 RADIOGRAPHIC FEATURES OF ARTERIAL HYPERTENSION Enlargement of the thoracic aorta—ascending, arch, and descending aortaMild or no cardiomegaly until the onset of myocardial failureNo pulmonary edema or pulmonary venous hypertension until the occurrence of diastolic dysfunction due to severe left ventricular hypertrophy or myocardial failureSystemic hypertension. Frontal view shows borderline cardiomegaly and prominence of the entire thoracic aorta.
26 RADIOGRAPHIC FEATURES OF MITRAL STENOSES Pulmonary venous hypertension or edema is presentPulmonary edema may be observed intermittentlyMild cardiomegaly is seen in isolated mitral stenosesEnlargement of the left atrium is characteristicEnlargement of the left atrial appendage is frequent and suggests a rheumatic etiologyRight ventricular enlargement indicates some degree of pulmonary arterial hypertension or associated tricuspid regurgitation.Mitral stenosis causing moderate enlargement of the left atrium and appendage. The wall of the appendage is calcified (arrow).
27 RADIOGRAPHIC FEATURES OF MITRAL STENOSES Enlargement of the pulmonary arterial segment is indicative of associated pulmonary arterial hypertensionRight ventricular enlargement in the absence of prominence of the main pulmonary artery suggests associated tricuspid regurgitation. The right atrium is also enlarged with tricuspid regurgitationThe ascending aorta and aortic arch are usually inconspicuous in isolated mitral stenosis. Even slight enlargement of the thoracic aorta raises the question of associated aortic valve diseaseMitral stenosis. Frontal thoracic radiograph demonstrates left atrial and right ventricular enlargement. Left atrial enlargement is indicated by right retrocardiac double density (arrow) on the frontal view. There is pulmonary arterial hypertension as shown by enlargement of the main and central pulmonary arteries. The thoracic aorta is inconspicuous. Right ventricular enlargement is indicated by lateral displacement of the ventricular margin (apex uplifted) on the frontal view.
28 RADIOGRAPHIC FEATURES OF HYPERTROPHIC CARDIOMYOPATHY Normal in most patientsMild cardiomegaly and pulmonary venous hypertension in a minority of patientsLeft atrial enlargement can be caused by associated mitral insufficiency or reduced left ventricular complianceIn the obstructive form (subaortic stenosis), ascending aortic enlargement is infrequentLeft ventricular enlargement may occur in end-stage diseaseNormal cardiac size with left atrial enlargement
29 RADIOGRAPHIC FEATURES OF RESTRICTIVE CARDIOMYOPATHY Pulmonary venous hypertension is typicalPulmonary edema may occur intermittentlyNormal heart size or mild cardiomegaly in most patientsLeft atrial enlargementLeft atrial appendage is typically not enlargedModerate to severe cardiomegaly can ensue in end-stage diseaseRestrictive cardiomyopathy. Frontal (left) and lateral (right) radiographs show interstitial pulmonary edema and left atrial and right ventricular enlargement.
30 RADIOGRAPHIC FEATURES OF ACUTE MYOCARDIAL INFARCTION Normal chest x-ray in about 50% of first acute infarctionsNormal heart size with pulmonary venous hypertension or pulmonary edema in about 50% of first acute infarctionsCardiomegaly is usually indicative of acute infarction in a patient with history of previous infarctionsCardiomegaly may be indicative of ischemic cardiomyopathy
31 RADIOGRAPHIC FEATURES OF ACUTE MYOCARDIAL INFARCTION Signs of complication of acute myocardial infarctionIntractable pulmonary edema may occur with papillary muscle rupture (mitral regurgitation) or ventricular septal rupture (left to right shunt).Enlarged cardiac silhouette may be caused by pericardial effusion.Abnormal cardiac contour may be a sign of true (bulge of the anterolateral or apical regions) or false (bulge of the posterior or diaphragmatic regions) aneurysmsFalse left ventricular aneurysm complicating myocardial infarction. Frontal (left) and lateral (right) radiographs show left retrocardiac density (arrow) on the frontal view and large posterior evagination (arrowheads) of left ventricular contour on the lateral view. Large size and posterior location are characteristics of false aneurysm.
32 RADIOGRAPHIC FEATURES OF CONSTRICTIVE PERICARDITIS Pulmonary venous hypertensionNormal heart size or mild cardiomegalyLeft atrial enlargement may be discernibleFlattened cardiac contours are pathognomonic but infrequently observedCalcification of the cardiac margin, especially the atrioventricular and interventricular groovesConstrictive pericarditis. Frontal (left) and lateral (right) radiographs demonstrate pericardial calcification. The calcification involves the atrioventricular (arrows) and the interventricular (arrowheads) grooves.
34 RADIOGRAPHIC FEATURES OF AORTIC REGURGITATION Absence of pulmonary venous hypertension or pulmonary edema until late in the course of this lesionModerate to severe cardiomegalyLeft ventricular enlargementEnlargement of ascending aorta and aortic archAortic regurgitation. Frontal radiograph shows marked cardiomegaly with displacement of the ventricular contour laterally and caudally, indicating left ventricular enlargement. The ascending aorta and the contour of the posterior aortic arch are enlarged. Concavity (broken line) along the upper left cardiac border indicates no right ventricular enlargement.
35 RADIOGRAPHIC FEATURES OF MITRAL REGURGITATION Variable degree of pulmonary venous hypertensive or pulmonary edema (less severe than with mitral stenosis)Moderate to severe cardiomegalyLeft ventricular enlargementLeft atrial enlargementEnlargement of left atrial appendageMitral regurgitation. There is cardiomegaly and marked left atrial enlargement with pulmonary ventricular hypertension. The left atrium is enlarged to the extent that it forms the right heart border on the frontal view (arrows).
36 RADIOGRAPHIC FEATURES OF TRICUSPID REGURGITATION No pulmonary venous hypertension or pulmonary edema (isolated tricuspid regurgitation)Pulmonary venous hypertension or edema indicates associated mitral valve diseaseModerate to severe cardiomegalyRight ventricular enlargementRight atrial enlargementTricuspid regurgitation. The features of this lesion are diminished pulmonary vascularity, marked cardiomegaly, and right atrial and right ventricular enlargement. The severe enlargement of the right-sided chamber produced the “wall-to-wall heart.” The length of the right atrial border exceeds 60% of the height of the mediastinal cardiovascular structures.
37 RADIOGRAPHIC FEATURES OF CONGESTIVE (DILATED) CARDIOMYOPATHY Pulmonary venous hypertension or pulmonary edema may be but is not invariably presentModerate to severe cardiomegalyLeft ventricular enlargementLeft atrial enlargement is infrequently evident but can be caused by mitral regurgitation caused by left ventricular enlargementCongestive dilated cardiomyopathy. Frontal radiograph shows moderate cardiomegaly with biventricular but no discernible left atrial enlargement.
39 RADIOGRAPHIC FEATURES OF PERICARDIAL EFFUSION No pulmonary venous hypertension or pulmonary edemaModerate to severe enlargement of cardiac silhouetteAssociated pleural effusion is not uncommonSpecific features, such as “fat pad” and/or “variable density” signs, are infrequently evidentPericardial perfusion. Varying cardiac density sign caused by transition of density near the margin of the cardiac silhouette (arrows).
40 ENLARGEMENT OF MAIN PULMONARY ARTERY EtiologyPulmonary arterial hypertensionExcess pulmonary blood flow (left to right shunts, chronic high output states)Valvular pulmonic stenosisPulmonary regurgitationCongenital absent pulmonary valve (aneurysmal pulmonary artery)Absence of left pericardiumAneurysm of pulmonary arteryIdiopathic dilatation of pulmonary arteryPulmonary arterial hypertension due to Eisenmenger's complex; the underlying lesion was an atrial septal defect. Frontal view shows the markedly enlarged main (arrow) and right pulmonary arterial segments. There is calcification (arrow) in the pulmonary arteries consistent with a systemic arterial pressure level in the pulmonary circulation.
41 Cardiac Calcification Ascending aortic calcificationMost frequently observed on the right anterolateral margin of the ascending aorta in elderly individuals, especially in the presence of aortic valve disease.In the past, it was considered to be a characteristic of syphilitic aortitis.Mitral annular calcificationDense C-shaped calcification in the region of the mitral valve.It may be a causative factor of mitral regurgitation.It is frequently observed in apparently normal elderly patients.Aortic annular calcificationA circular calcification in the region of the aortic valve.Extension of this calcification into the region of the conducting system can produce complete heart failure.Valvular calcification (aortic and mitral).Calcification of the aortic valve of sufficient density and extent to be visualized on the radiograph is nearly always associated with hemodynamically important aortic stenosis (gradient more than 50 mm Hg).
42 Cardiac Calcification Coronary arterial calcificationCoronary arterial calcification is frequently observed by fluoroscopy or CT.It must be both dense and extensive to be recognized on the thoracic radiograph.Left ventricular mural calcificationMost frequently located in the anterolateral or apical regions of the left ventricle and marks the site of a transmural MI or aneurysm.Pericardial calcificationIndicative of constrictive pericarditis.Located usually in the interventricular or atrioventricular grooves of the heart.Unusual sitesIntracardiac tumor (left atrial myxoma),Pericardial tumor (dermoid), orHealed granulomas (myocardial tuberculoma).An extremely rare process of the left ventricle, Loeffler's eosinophilic fibroplasia, can cause calcification of the left ventricular wall.
43 Cardiac Calcification Mitral annular calcification. Frontal (left) and lateral (middle) views and CT scan (right) show a C-shaped calcification (arrows) in the mitral annulus.
44 ReferenceThoracic Imaging: Pulmonary and Cardiovascular Radiology, 1st Edition; Webb, Richard W.; Higgins, Charles B. pageGrainger & Allison's Diagnostic Radiology, 5th ed; pageClassic Imaging Signs of Congenital Cardiovascular Abnormalities, RadioGraphics 2007; 27:1323–1334accessed 22/02/12)
47 SignpostAortic stenosis with calcification in 43-year-old man. Frontal radiograph (left) shows a nearly normal appearance except for enlargement of the ascending aorta. Lateral view (right) demonstrates heavy calcification (arrow) of the aortic valve.
48 SignpostIf no signposts are present, then the diagnosis is unlikely to be a valvular lesion.The absence of signposts should direct attention to a disease directly afflicting the myocardium or pericardium, such as acute MI, hypertrophic cardiomyopathy, restrictive cardiomyopathy, and constrictive pericardial disease.However, even these latter diseases sometimes induce left atrial enlargement, as stated above.
50 ENLARGEMENT OF THE MIDDLE SEGMENT OF LEFT HEART BORDER EtiologyDilated left atrial appendage (rheumatic mitral valve disease)Partial absence of left pericardiumEnlargement of right ventricular outlet region such as occurs with left-to-right shuntsAsymmetric form of hypertrophic cardiomyopathy (minority of cases)Levo transposition of the great arteriesJuxtaposition of atrial appendages (rare anomaly usually associated with tricuspid atresia)Left ventricular aneurysmCardiac tumorAneurysm or pseudoaneurysm of left circumflex coronary arteryPericardial cyst or tumorMediastinal tumor
51 EVAGINATION OF LEFT LOWER HEART BORDER EtiologyVentricular aneurysmVentricular tumorPericardial cyst, diverticulum or tumorLeft ventricular diverticulumMediastinal or lung tumorPericardial fat pad
52 ENLARGEMENT OF RIGHT HEART AND BORDER EtiologyRight atrial enlargementPericardial fat padEventration or hernia of diaphragmPericardial cyst or diverticulumPericardial tumorCardiac tumorDiaphragmatic tumorMediastinal tumor