1. CHEST RADIOLOGY
Dr. Hari Soekersi, Sp.Rad.

2. NORMAL FOUR VIEWS OF THE HEART1
Posteroanterior Projection 2
Lateral Projection 3
Right Anterior Oblique Projection 4
Left Anterior Oblique Projection

3. POSTEROANTERIOR PROJECTION
Right innominate vein
Left main branch of the pulmonary artery
Superior vena cava
Main pulmonary artery
Right main branch of the pulmonary artery
Left upper lobe vein
Upper and lower lobe veins
Appendage of the left atrium
Right atrium
Mitral valve
Tricuspid valve
Left ventricle
Inferior vena cava
Right ventricle
Arch of the aorta

4. POSTEROANTERIOR PROJECTION

5. POSTEROANTERIOR PROJECTION

6. POSTEROANTERIOR PROJECTION
Aorta
Superior vena cava
Pulmonary artery
Appendage of the left atrium
Right Atrium
Left
Ventricle

7. LATERAL PROJECTION Superior vena cava
Left main branch of the pulmonary artery
Ascending aorta
Left atrium
Main pulmonary artery
Mitral valve
Right atrium
Left ventricle
Tricuspid valve
Descending aorta
Right ventricle
Inferior vena cava
Aortic arch

8. LATERAL PROJECTION

9. LATERAL PROJECTION

10. LATERAL PROJECTION Root of the main pulmonary artery Left Atrium
Right Ventricle
Left Ventricle
Because these structures are in contact with mediastinal fat, their margin may be indistinct

11. RIGHT ANTERIOR OBLIQUE PROJECTION
Anterior wall of the trachea
Left innominate vein
Innominate vein
Arch of the aorta
Anterior border of the superior vena cava
Left main branch of the pulmonary artery
Superior vena cava
Main stem of the pulmonary artery
Right main branch of the pulmonary artery
Left main bronchus
Thoracic aorta
Tricuspid valve
Left atrium
Mitral valve
Right atrium
Right ventricle
Inferior vena cava
Left ventricle

12. RIGHT ANTERIOR OBLIQUE PROJECTION

13. LEFT ANTERIOR OBLIQUE PROJECTION
Superior vena cava
Posterior border of the trachea
Right main branch of the pulmonary artery
Left main branch of the pulmonary artery
Ascending aorta
Left main bronchus
Main pulmonary artery
Left atrium
Right atrial appendage
Mitral valve
Tricuspid valve
Left ventricle
Right ventricle
Inferior vena cava
Left subclavian artery

14. LEFT ANTERIOR OBLIQUE PROJECTION

15. ANATOMY OF THE HEART

16. HISTOLOGY OF THE HEART 10. Coronary artery 1. Endocardium of atrium
2. Myocardium of atrium
1. Endocardium of atrium
3. Annulus fibrosus
4. Mitral valve :
Endocardium
Connective tissue core
5. Chorda tendina
6. Endocardium of ventricle
7. Myocardium of ventricle
8. Purkinje fibers (conduction fibers)
10. Coronary artery
9. Plate A
11. Coronary sinus
12. Coronary vein with valve
13. Epicardium of atrium
14. Subepicardial connective tissue and fat
15. Perimysial septa with blood vessels
16. Epicardium and subepicardium of ventricle
17. Columnae carneae
18. Apex of papillary muscle

17. PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE
Analyze each case with six steps: 6 2 1 5 3 4

18. Analyze each case with six steps:
PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE
Analyze each case with six steps:
EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER ABNORMALITIES
IDENTIFICATION OF THE POSITION OF THE STOMACH BUBBLE AND HEPATIC SHADOW TO DETERMINE BODY SITE
EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION
EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT
EVALUATION OF CARDIAC SIZE AND CONTOUR
EVALUATION OF PULMONARY VASCULARITY

19. 1
EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER ABNORMALITIES
Signs of previous surgery - periosteal elevation - asymmetry thoracic cage - smaller and slightly deformed rib - resected rib in previous thoracotomy

20. 1
EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER ABNORMALITIES
Congenital heart disease: - premature fusion of sternum→ cyanotic form - hypersegmentation of sternum → Down’s syndrome - bulging of sternum → enlarged right ventricle

21. COMPLETE FUSION OF
STERNAL SEGMENTS

22. HYPERSEGMENTATION OF THE STERNUM

23. ATRIAL SEPTAL DEFECT WITH ENLARGED RIGHT VENTRICLE AND ANTERIOR BULGING OF THE STERNUM

24. 2
IDENTIFICATION OF THE POSITION OF THE STOMACH BUBBLE AND HEPATIC SHADOW TO DETERMINE BODY SITE
Abnormal hepatic and stomach position show abnormalities in position of the viscera  congenital cardiac disease

25. SITUS SOLITUS WITH DEXTROCARDIA
Stomach bubble is under the left diaphragm
Liver is on the right
Heart is on the right with cardiac axis directed to the right

26. SITUS INVERSUS WITH DEXTROCARDIA
Stomach bubble is under the right diaphragm
Liver is on the left
Heart is on the right with cardiac axis directed to the right

27. ISOLATED LEVOCARDIA OR SITUS AMBIGUS
Stomach bubble is under the right diaphragm
Liver is on the left
Normal heart position

28. ? ? ? DEXTROCARDIA DEXTROVERSION Dextrocardia :
Location of the heart in the right side of the thorax, the apex pointing to the right
Dextroversion :
Location of the heart in the right chest, the left ventricle remaining in the normal position on the left with the apex pointing the the left

29. EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION3
EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION
Enlargement of the pulmonary artery segment Prominent pulmonary arterial segment along the left upper cardiac border In TGV and truncus arteriosusabnormal position (concave) Enlargement of the aorta Three portions of the aorta can be evaluated: ascending aorta, aortic arch dan descending aorta.

30. ENLARGEMENT OF PULMONARY ARTERY SEGMENT

31. TRANSPOSITION OF GREAT VESSELS

32. TRANSPOSITION OF GREAT VESSELS

33. TRUNCUS ARTERIOSUS

34. TRUNCUS ARTERIOSUS

35. ENLARGEMENT OF THE AORTA
Usually, the ascending aorta does not extend beyond the right upper mediastinal shadow.
Here, there is enlargement of the aorta.

36. EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT4
EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT
Signs of left atrial enlargement Signs of left ventricular enlargement Signs of right atrial enlargement Signs of right ventricular enlargement

37. SIGNS OF LEFT ATRIAL ENLARGEMENT
Posteroanterior projection
Displace the barium-filled esophagus below the carina to the right
Prominent bulge along the mid-left cardiac border
A double density along the right cardiac border
Widening of the angle of the carina >900
Lateral projection
Posterior displacement of both walls of the barium-filled esophagus

38. SIGNS OF LEFT ATRIAL ENLARGEMENT
Left anterior oblique projection Elevate the left mainstem bronchus and obliterates the spaces between the posterior cardicac margin and the left mainstem bronchus

39. LEFT ATRIAL ENLARGEMENT

40. SIGNS OF LEFT VENTRICULAR ENLARGEMENT
Posteroanterior projection
Left ventricular dilatation produces downward displacement of the apex toward diaphragm.
Left ventricular hypertrophy produces a round left cardiac border
Left anterior oblique projection
Posterior cardiac margin to overlap the vertebral column

41. LEFT VENTRICULAR DILATATION

42. LEFT VENTRICULAR HYPERTROPHY

43. SIGNS OF RIGHT ATRIAL ENLARGEMENT
Posteroanterior projection
Difficult  increased convexity of the lower right heart border on PA projection

44. RIGHT ATRIAL ENLARGEMENT

45. SIGNS OF RIGHT VENTRICULAR ENLARGEMENT
Posteroanterior projection
Rounding and elevation of the cardiac apex
Lateral projection
Retrosternal space is obliterated
Left anterior oblique projection
Increased convexity of the anterior cardiac border

46. RIGHT VENTRICULAR ENLARGEMENT

47. EVALUATION OF CARDIAC SIZE AND CONTOUR5
EVALUATION OF CARDIAC SIZE AND CONTOUR
Index of cardiac enlargement is the cardiothoracic ratio. In infants: 0.55 In adults : 0.45 The lateral and oblique views must be considered

48. (Cardiac width / Thoracic cage width) x 100%
CARDIOTHORACIC RATIO
(Cardiac width / Thoracic cage width) x 100%

49. EVALUATION OF PULMONARY VASCULARITY6
EVALUATION OF PULMONARY VASCULARITY
In normal  the pulmonary vascular marking taper gradually toward the periphery of the lung fields, and more prominent in the lower lung fields. The vessels in the right hillum is larger than in the left

50. SIX DIFFERENT VASCULAR PATTERNS ARE RECOGNIZED
Normal pulmonary vascularity
Increased pulmonary vascularity due to increased pulmonary blood flow.
- the peripheral arteries are sharply outlined and dilated and distributed equally to both the upper and lower lobes.
- ex. VSD, PDA, truncus arteriosus, transposition of the great vessels.

51. 3. Decreased pulmonary vascularity due to right-to-left shunts
3. Decreased pulmonary vascularity due to right-to-left shunts. - small pulmonary arterial segment - reduced diameter of the hilar pulmonary arteries - ex. Tetralogy of Fallot, tricuspid atresia, pulmonary stenosis

52. Pulmonary venous congestion
- occurs in condition that causes increased resistance distal to pulmonary capillaries
- fluid accumulates in the interstitial tissues and Kerley B lines
- ex. Mitral stenosis, acute left ventricular failure are common causes.

53. Bronchial collateral
A bizarre pattern of pulmonary vascularity
- different vascular pattern in each lung

54. PULMONARY VASCULARITY IN LEFT-SIDED FAILURE
Five factors influence the distribution of pulmonary blood flow.
Interstitial osmotic and alveolar pressures remain constant throughout the lung
Hydrostatic, pulmonary arterial and pulmonary venous pressures, diminish from base to apex because of gravitational effects.
In left-sided cardiac failure, the increased pulmonary venous pressure resulting from the elevated left ventricular end-diastolic pressure

55. The transudation of fluid into the pulmonary interstitium causes an increase in the interstitial pressure
The earliest radiographic manifestation on left-sided cardiac failure is:
An indistinctness of the vascular markings caused by the increased interstitial fluids.
The hilar vessels become enlarged and indistinct.
The increased interstitial fluid can be seen as ‘peribronchial cuffing’.

56. Later, ‘cephalization’ occurs
Later, ‘cephalization’ occurs. The vascular markings are prominent in the upper lobes owing to the constriction of the lower lobe vessels and redistribution of flow to the upper lobes.
Pleural effusion occurs late
Transudation of fluid into the alveoli leads to pulmonar edema. This appears in a perihilar location (‘butterfly wings’ or ‘bat wings’).
Kerley B lines, due to fluid in the lobular septum.

57. Several non-cardiac causes as differential diagnosis of pulmonary edema:
Uremia. Increased capillary permeability.
Fluid overload. Decreased plasma osmotic pressure.
Neurogenic. Altered capillary permeability or capillary pressure.
Hypoproteinemia. Decreased plasma osmotic pressure.
Transfusion and allergic reactions. Altered capillary permeability.
Inhalation of toxic gases. Altered capillary permeability

58. CEPHALIZATION

59. KERLEY B

60. KERLEY A, B, & C
Kerley A : white arrow
Kerley B : white arrow head
Kerley C : black arrow head

61. EDEMA PARU INTERSTITIAL

62. EDEMA PARU ALVEOLAR

63. PULMONARY VASCULARITY IN PULMONARY HYPERTENSION
Mild PAH
Severe PAH
Pulmonal artery segment dilatation
Right ventricular enlargement
Reduced bronchovascular marking

64. CONGENITAL HEART DISEASE
Decrease bronchovascular marking
Acyanotic
Pulmonary Stenosis (PS)
Cyanotic
Tetralogy Fallot
Trilogy Fallot
Atresia Pulmonal
Atresia Tricuspid
Ebstein Anomaly
Increase bronchovascular marking
Acyanotic
Atrial septal defect (ASD)
Ventricle septal defect (VSD)
Right atrioventricular anomaly
Patent ductus arteriosus (PDA)
Partial Anomalous Pulmonary Venous Return (PAPVR)
Cyanotic
Total Anomalous Pulmonary Venous Return (TAPVR)
Truncus Arteriosus
Transposition of the Great Vessels (TGV)

65. PULMONARY STENOSIS

66. PULMONARY STENOSIS
Pulmonary stenosis make right ventricular resistancy increased, causing radiographic feature:
Right ventricular enlargement
Rounding and elevation of the cardiac apex
Bulging of pulmonary trunc
Bronkhovascular marking decreased

67. TETRALOGY FALLOT

68. TETRALOGY FALLOT The malformation has four components:
Right ventricular hypertrophy, Overriding aorta, Pulmonary stenosis, and Ventricular septal defect
Radiographic features:
Right ventricular enlargement
Boot shape contour
Pulmonary artery segment concave
Right sided aortic arch
Pulmonary vascularity decreased

69. EBSTEIN ANOMALY

70. EBSTEIN ANOMALY Atrial septal defect Displace tricuspid valve
Radiographic feature:
Vary
Widening of right heart border
Rounded heart (cardiomegali all chamber)
Bronchovascular marking decreased

71. ATRESIA PULMONAL

72. ATRESIA PULMONAL Radiographic feature:
Cardiomegali with oval heart contour
Bronchovascular marking decreased

73. ATRESIA TRICUSPID

74. ATRESIA TRICUSPID ~ Atresia pulmonal
Cardiomegali with oval heart contour
Pulmonary vascularity decreased

75. ATRIAL SEPTAL DEFECT

76. ATRIAL SEPTAL DEFECT
The feature related to how large the defect and the complication on the pulmonary vascularity
Radiographic feature:
Right atrial enlargement, widening right heart border
Right ventricular enlargement, rounded and elevation of the cardiac apex
Prominent conus pulmonalis, with widening of hillum
Bronchovascular marking increased
Signs of pulmonary hypertension

77. VENTRICULAR SEPTAL DEFECT

78. VENTRICULAR SEPTAL DEFECT
Radiographic feature:
Small defect (Maladie de Roger)
Heart is not enlarged
Normal pulmonary vascularization
Mild
Heart is enlarged to the left (left ventricle hypertrophy)
Apex downward to the diaphragm.
Right ventricle has not enlarged.
Left atrium dilated
Increase pulmonary vascularization.

79. VENTRICULAR SEPTAL DEFECT
Radiographic feature:
Moderate – Severe
Right ventricle dilatation and hypertrophy.
Left atrium dilatation.
Widening of the pulmonary artery and its branches
Normal right atrium.
Left ventricle hypertrophy.
Small aorta.
Pulmonary hypertension
Right ventricle is enlarged.
Pulmonary artery is widening with prominent of conus pulmonalis.
Normal left atrium.
Decrease peripheral pulmonary vasculature.
Pulmonary emphysematous

80. PATENT DUCTUS ARTERIOSUS

81. PATENT DUCTUS ARTERIOSUS
Small defect
Normal
Moderate
Normal or mild enlargement of descendent aorta and aortic arch.
Prominent of conus pulmonary.
Widening of the pulmonary artery and its branches.
Left atrial enlargement.
Right and left ventricle enlargement.

82. PATENT DUCTUS ARTERIOSUS
Severe (pulmonary hypertension)
Enlarge central pulmonary vasculature.
Decrease peripheral pulmonary vasculature.
Prominent conus pulmonalis.
Widening of the ascendent aorta with prominent aortic knob.
Normal left atrium.

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