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The Heart Size
C:T RATIO: The simplest way to estimate the heart size.
Measured by relating the widest diameter of the heart to the
widest internal diameter of the chest.
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Postero-Anterior (PA) View
SVC
IVC
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Postero-Anterior (PA) View
RA
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Right Atrial Enlargement
•Increased convexity
of the lower right
heart border
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Postero-Anterior (PA) View
• Right Atrium
In some cases, the length
of right heart border exceeds
50% of the mediastinal
cardiovascular shadow
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Postero-Anterior (PA) View
RV
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Right Ventricle Enlargement
PA View:
•Rounding and
upliftment of cardiac
apex
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Postero-Anterior (PA) View
PA
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Postero-Anterior (PA) View
LA
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Left Atrial Enlargement
PA view:
1. Double density,
(r) cardiac border2. Enlargement of
LA appendage
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Left Atrial Enlargement
PA View:
3. Widening of carinal
angle, >60o
4. Upliftment of left
mainstem
bronchus
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Postero-Anterior (PA) View
LV
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Left Ventricular Enlargement
PA View:
- Round (L) cardiac border
- Lateral, downwarddisplacement of cardiac
apex
-Elongation LV outflowtract
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Postero-Anterior (PA) View
Aorta
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Postero-Anterior (PA) View
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Postero-Anterior (PA) View
• Right border
– Superior vena cava
– Right atrium
– Inferior vena cava
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Postero-Anterior (PA) View
• Right border
– Superior vena cava
– Right atrium
– Inferior vena cava
• Left border
– Aortic knob
– Main pulmonary trunk
– Left ventricle
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Postero-Anterior (PA) View
• Pulmonary Arteries
– Right
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Postero-Anterior (PA) View
Pulmonary Arteries
Right
Left
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Postero-Anterior (PA) View
• Pulmonary Arteries
– Right
– Left
• Pulmonary VeinsLA
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Lateral View
RA
SVC
IVC
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Lateral View
RV
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Right Ventricle
Lateral View• Retrosternal
fullness• R heart
border greater than
1/3 of the retro
sternal length
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Lateral View
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Lateral View
LA
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Left Atrial Enlargement
Lateral view:
- LA fills the upper partof the retro cardiacfree space.
- Barium filledesophagus displaced
posteriorly
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Lateral View
LV
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Lateral View
Aorta
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Lateral View
– Left Ventricle
– Hoffman Rigler Sign
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Left Ventricle Enlargement
Lateral View
• Posterior displacement
posterior border
of the heart
*Hoffman-Rigler Sign:
measured 2 cm above the intersection
of the diaphragm and IVC.(+) posterior border of the LV extends
more than 1.8 cm of IVC
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Lateral View
– Left atrium
– Left ventricle
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Lateral View
– Left atrium
– Left ventricle
– Right ventricle
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Lateral View
• Aorta
• Main Pulmonary Artery
• Inferior vena cava
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Lateral View
• Pulmonary Arteries
– Left
– Right
• Pulmonary Veins
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Teleradiography, 4
1. PA
2. Upright
3. Deep inspiration
4. Tube-filmdistance
of 6 feet
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Areas to be inspected
• Lungs
• Mediastinum –
including the heart and
the great vessels• Trachea and central
bronchi
• DiaphragmD
H
S
A
T
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Areas to be inspected
• Bony thorax
• Soft tissues of the
thorax and neck
• Sub diaphragmatic upperabdominal structures
S
S
AR
C
CP
V
PR
PIS
CP
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S
H
D
A
V
R
RS
RS
T
Areas to be inspected / LAT
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Lung Zones
• Inner zone / inner third -large main trunk vessels
• Middle zone - intermediate
sized vessels
• Peripheral - vessels less than
1 mm in diameter
Pulmonary Vascular Pattern
Normal
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Pulmonary Vascular Pattern
NORMAL
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Pulmonary Vascular Pattern
NORMAL
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NORMAL
Pulmonary Vascular Pattern
INCREASED
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NORMAL
Pulmonary Vascular Pattern
INCREASED
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NORMAL
Pulmonary Vascular Pattern
DECREASED
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NORMAL
Pulmonary Vascular Pattern
DECREASED
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NORMAL
Pulmonary Vascular Pattern
VENOUS
CONGESTION
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Pulmonary Vascular Pattern
VENOUS
CONGESTION
INCREASED
ARTERIAL
BLOOD FLOW
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Pulmonary Vascular Pattern
VENOUS
CONGESTION
Interstitial Edema
Kerley B Lines
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Pulmonary Vascular Pattern
VENOUS
CONGESTION
Interstitial Edema
Kerley B LinesKerley A Lines
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MITRAL STENOSIS
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MITRAL STENOSIS
• Normal to slightlyenlarged heart
• > LA >Lung >RV
• Pulmonary venousHPN
– Equalization
– Reversal/Cephalization
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Mitral Stenosis
• PA: Prominent MPAS and branches; constriction of
arteries in mid and peripheral lung zones
• Small aorta
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Severe MS
• Pulmonary arterial
hypertension, RV
• Pulmonary
hemosiderosis,
ossified densities, LL
• Calcification, LA wall,
laminated clot,
thrombus
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Kerley B in MS
Short, horizontal dense
lines, interstitial edemaand dilatation of the
lymphatics, lower lung
fields
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MITRAL REGURGITATION
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MITRAL REGURGITATION
• Cardiomegaly/Big Heart• Chamber Prominence:
– LA (MR>MS)
– LV
• Pulmonary venous HPN
(MR
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AORTIC STENOSIS
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AORTIC STENOSIS
• Normal-sized heart,
mild cardiomegaly
• LV• +/- Pulmonary venous
hypertension
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AORTIC STENOSIS
• Dilated
ascending aorta
• +/- Aortic valve
calcification
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AORTIC REGURGITATION
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AORTIC REGURGITATION
• Cardiomegaly
• LV
• Dilated ascendingaorta and aortic arch
(LV outflow tract)
• Normal pulmonary
vascularity
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AORTIC REGURGITATION
• LV enlargement
• Apex extends below the
dome of the (L) hemi
diaphragm• Aorta – ascending, dilated
• Aortic knob – often
prominent
• ‘Cor bovinum’
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Combined Aortic Valve Disease
• Difficult to ascertain
the prominent valve
lesion
• In cardiac failure, signsof pulmonary
congestion develop
with relative MI, LA
enlargement
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TRICUSPID VALVE DISEASE
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TRICUSPID VALVE DISEASE
• RA enlargement; Elongated (R) cardiac border; +/-
SVC or IVC prominence
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Congestive Heart FailureFour Reliable Signs
l Kerley B lines
l Pleural effusions
l Fluid in the fissures
l Peribronchial cuffing
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Kerley B Lines
Four Reliable Signs of CHF
Short (1 -2 cm)
white lines at the
lung bases,
perpendicular to
the pleural surface
representing
distendedinterlobular septa
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Pleural Effusions
Four Reliable Signs of CHF
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Fluid in the fissures
Four Reliable Signs of CHF
Fluid in the minor
fissure. The fissures
may be seen normally
but they should be
about as thin as a line
drawn with a
sharpened pencil.
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Peribronchial cuffing
Four Reliable Signs of CHF
Fluid in the walls of
the bronchi make
them visible and
produce numerous
“doughnut” densities
throughout theperiphery of the lung.
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63 yr old man with chest pain
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•Widened mediastinum
•Left pleural effusion
• Chest pain
Should make you think
of an aortic dissection
63 yr old man with chest pain
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63 yr old man with chest pain
Linear lucency
in the contrast-
filleddescending
aorta is the
intimal flap of an
aortic dissection
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Classification of Dissecting Aneurysms
Stanford classification
•Widened mediastinum• Left pleural effusion
• Chest pain