X RAY OF HEART

1. X RAY OF HEART Dr R. Ravikumar DMRD,DMRE,DNB, PhD Consultant Radiologist Madras Medical Mission

2. X Ray Chest • PA view • Erect • Maximum Inspiration • Short exposure time (few milliseconds) • Tube to film distance of atleast 6 feet- this minimizes distortion and magnification

3. Traditional views for cardiac evaluation • PA view • Lateral • LAO • RAO with barium contrast in the esophagus

4. How to go about reading Chest X ray? • Check patient details • Rotation: the spinous processes should be equidistant from the medial end of clavicle • Inspiratory film- diaphragm should lie between anterior ends of 5-7 rib space • Penetration- one should just see the lower thoracic vertebral bodies

5. How to go about reading Chest X ray? • Position size and contour of the heart • Tracheal position • Mediastinal contour • Lung markings • Diaphragm and CP angle • Soft tissue • Bone

8. Cardiac contours • Right border: SVC, Right atrium • Left border: Aortic knob, Main or undivided segment of PA, LA, LV. • Aortic knob: In normal people the aortic knob measures <35mm when measured from the lateral border of trachea to lateral border of aortic knob • The right border of the heart should neither project more than 5.0cms from the midline nor exceeded one third of the total diameter of the heart

10. Cardio-thoracic ratio • It is the maximum transverse diameter of the heart divided by the greatest diameter of the thoracic cage • Normal CT ratio- <50% • Pseudo-enlargement of CT ratio- Obesity, ascites, pectus excavatum, straight back syndrome.

11. CT ratio measurement

12. Pulmonary vasculature evaluation • Right descending pulmonary artery <17mm • Distribution of flow- Increase vessels seen in the base in comparison to apex • Central to peripheral- normally vessels taper gradually from central to peripheral. When central more prominent than peripheral it is suggestive of PAH

13. Left atrial enlargement • Double density shadow behind right atrial margin • Upward and posterior displacement of the left main bronchus • Massive enlargement may cause leftward displacement of the descending aorta • Enlargement of LAA causes first straightening and later convexity in the upper left cardiac contour • Posterior displacement of esophagus • Left atrial wall calcification

14. Left atrial enlargement

15. Mitral stenosis • Can have normal Chest X ray findings • Straightening of left heart border • Small aortic knob from decreased cardiac output • “Double density” sign due to LA enlargment • Calcification of mitral valve (not annulus)

16. Mitral stenosis • Cephalization of pulmonary vascular markings • Elevation of left main stem bronchus • Kerley B lines- are horizontal septal lines seen above the costophrenic recess indicating interstitial edema of the septa • Calcification of left atrial wall indicating chronic MS • Dilated pulmonary arteries or calcification of pulmonary arteries due to PAH

17. Mitral stenosis

18. Mitral Regurgitation • LV enlargment • LA enlargment greater than MS • Left atrial appendage dilatation if MR is of rheumatic origin • Interstitial edema and alveolar edema are quite UNCOMMON except in acute MR

19. Combined MS and MR • If the heart is small relative to the degree of pulmonary vasculature and interstitial changes MS is dominant • Large heart and LA with mild changes of pulmonary venous hypertension MR is dominant

20. Left ventricle enlargementPA view • LVH causes rounding of the cardiac apex with downward and lateral displacement without cardiac enlargement • LV dilatation causes increase in transverse diameter and cardiac apex displaced to such an extent that it projects below the diaphragm

21. LVH and LV dilatation LV dilatation LVH

22. Left ventricle enlargmentLateral view • Dilatation increases the posterior convexity of the left ventricular contour which will project behind the edge of the vertical IVC (Rigler’s sign)

23. Cardiac failure • Enlarged CT ratio • Pribronchial cuffing • Lungs appear hazy and less radiolucent than normal • ‘Bats wing’ appearance • Kerley B lines • Pleural effusion • Widening of vascular pedicle (N 48± 5mm)

25. Chest X ray findings and PAWP • Grade 0- Normal PAWP <12mmHg • Grade 1- pulmonary venous HT seen as vascular redistribution PAWP 12-19mmHg • Grade 2- Interstitial edema (Kerley B) PAWP 20-25mmHg • Grade 3- Generalized or perhilar alveolar edema PAWP >25mmHg

26. Right atrial enlargmentPA view • Increased fullness and convexity of the right cardiac contour • Angulation of the junction of the SVC and right atrium • Dilatation of SVC causing superior mediastinal widening • Dilatation of IVC causing an additional border in the right CP angle • Marked isolated RA enlargement causes “Box shaped” heart- Ebstein’s anomaly

27. Right ventricle enlargment • Whole heart rotates to the left around its long axis and displaces the LV posteriorly • Increased convexity of the left upper heart border and elevation of cardiac apex • The rotation also makes the pulmonary trunk appear prominent and the aorta appear relatively small • On lateral view RV is seen extending cranially behind the sternum

28. RV enlargement

29. Valvular location- Aortic valve • On PA view it overlies the spine • On lateral it lies above a line drawn from the junction of the sternum and diaphragm to hilum

30. Valvular location- Mitral valve • On PA view it lies to the left of spine • On lateral it lies below a line drawn from the junction of the sternum and diaphragm to hilum

31. Pericardial calcification

32. Coarctation of aorta Figure of 3 sign

33. Eventeration of diaphragm

34. Pericardial effusion • Symmetrically enlarged cardiac silhoutte • Water bottle configuration

35. Silhoutte sign

37. Hydropneumothorax

41. Bronchiectasis