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 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

21. LVH and LV dilatation
LV dilatation
LVH

22. 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)

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 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

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