an approach to cardiac xray dr. muhammad bin zulfiqar

AN APPROACH TO CARDIAC XRAY

Dr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical Sciences / Hospital Lahoreradiombz@gmail.com

AIMS Basic Approach to Radiograph Chest

Basic Anatomy

Cardiac Pathologies

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

BASICS OF X-RAY TECHNICAL QUALITY

R – ROTATION I -- INSPIRATION P -- PROJECTION E -- EXPOSURE

ROTATION

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

The increase in blackness (radiolucency) 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

DEGREE OF INSPIRATION It is ascertained by counting either the

number of visible anterior or posterior ribs

Adequate inspiratory effort – five to seven complete anterior or ten posterior ribs are visible

Poor inspiratory effort - fewer than five anterior ribs

Hyperinflated lung-more than seven anterior ribs

IMPORTANCE OF AN INSPIRATORY FILMPOOR INSPIRATORY FILM NORMAL INSPIRATORY FILM

1

23

1. Mediastinal Widening 2.Cardiomegaly 3.Lower lobe patchy opacification

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

AP VIEW PA VIEW

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

ERECT SUPINE

Gas bubble in fundus with a clear air fluid level

Gas bubble in antrum Apparent cardiomegaly

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.

UNDERPENETRATION NORMAL OVERPENETRATION

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

STRUCTURES SEEN IN ANTERIOR VIEW

STRUCTURES IN LATERAL VIEW

RV

PTAA

LA

LV

Gastric air bubble

Left upper lobe bronchus

IVC

Right hemidiaphragm

LV

LARV

Pulmonary outflow tract

AortaRight upper lobe bronchus

RPA LPA

Confluence of pulmonary veins

Brachiocephalic vessels Trachea

Left hemidiaphragm

ScapulaMan

ubriu

m

Body

of s

tern

umRe

troste

rnal

spac

e

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

MAIN PULMONARY ARTERY

LPA

HOW TO MEASURE MAIN PULMONARY ARTERY

If we draw atangent line from the apex of the leftventricle to theaortic knob(red line) and measure along a perpendicularto that tangentline (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 fromthe tangent line

PROMINENT MPA

Main pulmonary artery projects more than the tangent

Causes:

1. Increased pressure

2. Increased flow

HYPOPLASTIC PA

MPA > 15 mm from the tangent Concave PA segment Causes:

1. TOF

2. TRUNCUS ARTERIOSUS

LEFT ATRIAL APPENDAGE

L

LA ENLARGEMENT

HYPERTROPHIEDLA APPENDAGE

LEFT VENTRICLE

CARDIOMEGALY

The cardiothoracic ratio should be less than 0.55 on PA view. i.e. A+B/C<0.55

A cardiothoracic ratio > 0.55 suggests cardiomegaly in adults

A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn

CTR is more than 50% but heart is normal

Spurious causes of cardiac enlargement Portable AP films Obesity Pregnant Ascites Straight back syndrome Pectus excavatum

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

CRITERIA'S FOR CARDIOMEGALY

Cardiothoracic ratio >0.55 in adults on PA view Cardiothoracic ratio >0.6 in newborn on PA view 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

CHAMBER ENLARGEMENT

RA enlargement LA enlargement RV enlargement LV enlargement

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

CRITERIA FOR LA ENLARGEMENT

Widening of carina( normal 45-75 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

LA ENLARGEMENT HYPERTROPHIEDLA APPENDAGE

LEFT ATRIAL ENLARGEMENT

DOUBLE ATRIAL SHADOW

WIDENING OF CARINA

ELEVATION OF LEFT BRONCHUS

Left atrial appendageenlargement

Widening of carina

Elevation of lt. bronchusAneurysmal LA

Aneurysmal LA – When La enlarges to left and right and approaches within an inch of lateral chest wall

LATERAL VIEW-LA ENLARGEMENT

LA pushing theEsophagus posterior

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

LEFT VENTRICULAR ENLARGEMENT

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

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.

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

RIGLER’S MEASUREMENT

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

RIGLER’S MEASUREMENT

EYELER’S RATIO

To differentiate lt. & rt. Ventricular enlargement

Valid when IVC shadow is absent or cannot be visualised

Mark the point of jn. where postero inferior cardiac border meets the dome as B

From this point B draw a horizontal line to the posterior border of sternum-AB

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

EYELER’S RATIO

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

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

RV ENLARGEMENT

PA VIEW

Cardiophrenic angle is acuteClockwise rotation of heart causes RV to form the

middle portion of the left heart border.

RIGHT LATERAL VIEWObliteration of retrosternal spac

RV ENLARGEMENT

LEFT LATERAL VIEWRigler’s measurement will be17mm or less

Rigler’s measurement will be 7.5mm or more

Eyeler’s ratio is 0.42 or less

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

Narrow vascular pedicle

Acute cardiophrenic angle

‘Water bottle’appearence

Pulmonary oligaemia

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

CONSTRICTIVE PERICARDITIS

1.Straightening of the right border2.Pericardial thickening > 4 mm3.Pericardial calcification (50% cases)4.Dilatation of SVC and azygous vein

Pericardial calcification

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

PULMONARY VASCULARITY

1.RDPA<17MM

NORMAL PULMONARY CIRCULATION – 3 FEATURES

PULMONARY VASCULARITY

PULMONARY VENOUS HYPERTENSION

PULMONARY VENOUS HYPERTENSION LARRY ELLIOT’S CLASSIFICATION OF PVH

RADIOGRAPHIC GRADE OF PVH

ACUTE DISEASE

PCWP

CHRONIC DISEASE

PCWP

1 13-17 MMHG 13-17 MMHG

2 18-25 MMHG 18-30 MMHG

3 >25 MMHG >30 MM HG

4 HEMOSIDEROSIS AND OSSIFICATION

LONG STANDING PVH

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

PULMONARY VENOUS HYPERTENSION

GRADE 2- PCWP 18-25mm hg

Interstitial edema Peribronchial cuffing Kerley A,B,C lines Interlobular effusion Pleural effusion Hilar haze

Peribronchial cuffing

PULMONARY VENOUS HYPERTENSION

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

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

Crisscross lines seen between A &B

GRADE 3 – pcwp > 25mm hg

Alveolar odema

Bilateral diffuse patchy

cotton wool opacities

KERLEY C LINES

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

PLETHORA

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

Pulmonary oligaemia

OLIGAEMIA

Empty pulmonary bay

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

Pruning

PRUNING

PULMONARY EMBOLISM

Hamptons humpWedge opacity

Westermark signHampton’s humpFleischner’s sign- prominent central pulmonary arteryPalla’s sign-dilated rt. Descending pulmonary arteryChang’s sign – dilatation and abrupt change in calibre of the rt. Descending PA

VALVULAR HEART DISEASE MITRAL STENOSIS

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 regurgitation

LA enlargementLV enlargementPulmonary venous hypertension

Ascending aorta dilated Left ventricular hypertrophy Aortic valve calcification

AORTIC STENOSIS

Dilated ascending aorta LV enlargement

AORTIC REGURGITATION

No obvious cardiomegaly Enlarged PA Dilated left pulmonary artery Normal to decreased pulmonary

vasculature

VALVULAR PS

Concave PA segment RVH

Infundibular Pulmonary stenosis

MPA DILATED

RPA DILATED

RV APEX

PULMONARY PLETHORAASD

CONGENITAL HEART DISEASE

HOW TO DIFFERENTIATE ASD VSD PDA

MPA DILATED

RPADILATED

LV APEX

PLETHORA

VSD

Linear or railroad track calcification at site of ductus may be seen in adults with PDA PROMINENT

MPA

LV APEX

PLETHORA

AORTIC KNOB

PDA

• “FIGURE OF 3” in CXR• “REVERSE 3” or “E sign” in Barium

meal

COARCTATION OF AORTA

DD OF INFERIOR RIB NOTCHING

1)Aortic obstruction- Takayasu arteritis Coarctation of aorta2) Subclavian artery obstruction –Classic BT shunt Takayasu arteritis3)Chronic Svc obstruction4)Intercostal Av fistula5)Neurofibromatosis

Cyanosis With Decreased Vascularity

Tetralogy of Fallot

Truncus-type IV

Tricuspid atresia

Transposition of great arteries

Ebstein’s anomaly

Cyanosis With Increased Vascularity

Truncus types I, II, III

TAPVC

Tricuspid atresia

Transposition

Single ventricle

Cyanotic Congenital Heart Disease

CYANOTIC CHD—TOF

• Rv apex• Underfilled LV• Concave pulmonary artery• Pulmonary oligaemia

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

CYANOTIC CHD—TGA

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

CYANOTIC CHD—TAPVC (supracardiac)

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

CYANOTIC CHD—PAPVC(Scimitar sign)

‘Box shaped heart Enlarged RA Hypoplastic pulmonary trunk Decreased vascularity

CYANOTIC CHD—EBSTEIN

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

CYANOTIC CHD—TRUNCUS ARTERIOSUS

CYANOTIC CHDEisenmenger’s syndrome

• Chest xray show dilation of central pulmonary arteries and pruning of peripheral pulmonary arteries, right ventricular and atrial enlargement. Left heart would return to normal size.

• Left to right shunts such as atrial septal defect, ventricular septal defect and patent ductus arteriosus, cause increased pulmonary blood flow. With time, high pulmonary vascular resistance will develop, ultimately causing right to left shunt.

PACEMAKER

BIVENTRICULAR PACING

RA LEADRV LEAD

PACEMAKER PROBLEMS

LEAD FRACTURE

DISPLACED RA LEADDISPLACED RV LEAD

ICD

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

CARDIAC CALCIFICATIONS

CARDIAC CALCIFICATION

MITRAL VALVE CALCIFICATION

MYOCARDIAL CALCIFICATION

CALCIFIED LV APICAL ANEURYSM

CONSTICTIVE PERICARDITIS

CALCIFIED PERICARDIUM

PERICARDIAL VS MYOCARDIAL CALCIFICATION

PERICARDIAL 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

GIANT LA CALCIFICATION

ATRIAL MYXOMA

TILTING DISK VALVE

PROSTHETIC HEART VALVE

STARR EDWARD BALL VALVE

STARR EDWARD PROSTHETIC VALVE

MITRAL PROSTHESIS

ST. JUDE VALVE

Aneurysm of ascending &Descending aorta

Diseases of aorta

Egg shell sign

Aortic dissection

MISCELLENOUS X-RAYS

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

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

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

CERVICAL AORTIC ARCH

Left sided cervical aortic arch Aortic knob at apex of lung Descend on the left

CERVICAL AORTIC ARCH

SITUS INVERSUS WITH DEXTROCARDIA SITUS INVERSUS WITH LEVOCARDIA

DEXTROCARDIA

HYDROPNEUMOPERICARDIUM

PDA CLIP

BIBLIOGRAPHY(1)Jefferson K, Rees S. Clinical cardiac radiology, 2nd edition Butterworths; 1980. (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;9:208-18.  (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

QUIZ

QUIZ

EBSTEIN’S ANOMALY

8 YR OLD ACYANOTIC CHILD

ATRIAL SEPTAL DEFECT

25 YR OLD LADY WITH DYSPNOEA

MITRAL STENOSIS

65 YR OLD MAN WITH DYSPNOEA

PERICARDIAL EFFUSION

35 YR OLD ACYANOTIC FEMALE

ASD WITH PAH

RT AORTIC ARCH WITH RT DESCENDING AORTA

4 MO CYANOTIC CHILD

TAPVC SUPRACARDIAC

3 MO CYANOTIC CHILD

D-TGA

8 YR OLD ACYANOTIC CHILD

VSD