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

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

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

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

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

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

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.

CT ratio measurement

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

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

Left atrial enlargement

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)

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

Mitral stenosis

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

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

Left ventricle enlargement PA 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

LVH and LV dilatation LV dilatation LVH

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

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)

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

Right atrial enlargment PA 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

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

RV enlargement

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

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

Pericardial calcification

Coarctation of aorta Figure of 3 sign

Eventeration of diaphragm

Pericardial effusion Symmetrically enlarged cardiac silhoutte Water bottle configuration

Silhoutte sign

Hydropneumothorax

Bronchiectasis