Chest X – Ray : Heart Failure Dr.Juan A.Venter Dept.Imaging Sciences Universitas Hospital

Causes:PVH/Pulmonary Oedema Left Ventricular Failiure Left Ventricular Outflow Obstruction Mitral Valve Disease Left Atrial Myxoma Fibrosing Mediastinitis Pulmonary Venous Occlusive Disease

Non Cardiogenic Pulmonary Oedema – Normal Cardiothoracic Index Aspiration ,Near Drowning ARDS Hepatorenal Failiure Post thoracocenthesis – Rapid Lung Expansion Drugs : Aspirin,Nutrofurantoin,Opiates,Cytokines PS:Early post MI phase – acute decrease in miocardial compliance

Right Atrial Enlargement PA CXR: Prominent round superior border with SVC > 5,5 cm from midline to most lateral RA margin > 2,5 cm from right vertebral margin

Right Ventricular enlargement PA CXR: Upturned cadiac apex Lateral CXR: > 1/3 contact distance from cadiophrenic sulcus to sternal angle

Left Atrial Enlargement PA CXR: Retrocardiac double density >75 % splaying of carina with horizontal orientation of left mainstem bronchus Enlarged left convex left atrial appendage > 7 cm from LMB to right LA border. Lateral CXR: Posterior displacement of Ba filled oesophagus

Left Ventricle Enlargement PA CXR: Downturned cardiac apex with leftward displacement Left diaphragmatic inversion Lateral CXR: Posterior cardiac margin > 1,8 cm posterior to IVC meassured 2 cm above intersection of right hemidiaphragm with IVC.(Hofman-Rigler rule)

Cardiac vs Non Cardiac Oedema Signs Cardiac Renal /Fluid Overload ARDS CARDIOMEGALY (uremic pericarditis) VASCULAR REDISTRIBUTION Balanced WIDENED VASCULAR PEDICLE KERLEY LINES PERIBRONCHIAL CUFFING AIRSPACE OPACIFICATION Basal Central Diffuse PLEURAL EFFUSIONS Very Common Common

Congestive Cardiac Failiure

Stages of CCF Stage 1 PCWP 13-18 mmHg Redistribution Stage 2 Interstitial Oedema Stage 3 PCWP > 25 mmHg Alveolar Oedema

Redistribution/Cephalization

Redistribution

Interstitial Oedema

Interstitial Oedema

Interstitial Oedema

Alveolar Oedema

Alveolar Oedema

Gravity dependent density differences

Cardiothoracic Index

Pleural Effusion

Vascular Pedicle Width: < 60 mm, > 85mm , 5mm = 1l

VPW – Serial CXR

Azygos Vein Width : Erect > 10 mm , Supine > 15 mm , Serial X Rays > 3mm,Not depending on in - or expiration

Right Ventricular Failiure

References 1.www.radiology assistant.nl – accessed 27/02/2012 2.Primer of Diagnostic Imaging – Fourth Edition 3.Radiology Review Manual – 6 th Edition