1. Chest X-ray Findings in Heart Failure
Stefan Da Silva
Jan 18th 2007

2. Progression of findings
Related to increasing pulmonary capillary pressures.
Common Chest Xray Findings
Increased Heart Size
Cephalization of flow/Vascular Redistribution
Interstitial Edema
Pleural Effusions
Aveolar Edema

3. Case #1 75 yr old male presenting with swelling in legs.
Vitals 37.6, 70 HR, 150/80, 18RR sats 94% RA

5. Increased Heart Size Usually a cardiothoracic ratio of >0.50
Sensitivity 54% - 79% (Knudsen et al., Fonseca et al)
Specificity 78% - 80% (Knudsen et al., Fonseca et al)

7. Dr. W. Roentgen
1895
7 weeks of experiments after he discovered the “x” ray to produce the first image.

8. Case #2
75 yr old male with leg swelling and increasing SOB on exertion
Vitals 37.6, 70 HR, 150/80, RR 18 sats 94% RA

10. Vascular Redistribution
Usually lung bases better perfused than apices and vessels supplying lower lobes are larger than upper lobes.
Perivascular edema develops in lower lobes  compresses vessels  causes equalization of size of vessels between lower lobes and apices.
Upper vessel size > 3mm diameter

11. Vascular Redistribution con’t
Increasing pulmonary capillary pressure causes “cephalization of flow” due to shunting to upper lobe vessels.
Flip xray upside down
Poorly sensitive: 41% (as low as 17% in one study)
Specificity: % (Knudsen et al., Fonseca et al)

13. Case #3
75 yr old male with leg swelling and progressive SOB while at rest
Vitals 37.6, 90 HR, 170/90, RR 25 sats 89% RA

15. Interstitial Edema
(1) septal, producing Kerley lines (i.e., sharp, linear densities of interlobular interstitial edema);
(2) perivascular, producing loss of sharpness of the central and peripheral vessels; and
(3) subpleural, producing spindle-shaped accumulations of fluid between the lung and adjacent pleural surface.

16. Accumulation of fluid leads to
Indistinct hilar vessels
Kerley “B” lines (Kerley “A” lines: same significance but less common and seen more at inner lung fields towards hilum)
Fluid in the interlobar fissures
Peribronchial cuffing
Sensitivity: % (Knudsen et al., Fonseca et al)
Specificity: % (Knudsen et al., Fonseca et al)

20. Case #4
75 yr old male with leg swelling and increasing SOB at rest, diaphoretic.
Vitals 37.6, 100 HR, 180/96, RR 30 sats 85% RA

22. Pleural Effusions
Sensitivity: 1.2% - 25% (Knudsen et al., Fonseca et al)
Specificity: % (Knudsen et al., Fonseca et al)
Again seen with higher pulmonary capillary pressures ( > 25 mg Hg)
Commonly seen with patients with chronic heart failure

24. Case #5
75 yr old male with leg swelling, diaphoresis and marked SOB while at rest
Vitals 37.6, 110 HR, 190/100, RR >30 sats 78% RA

26. Alveolar Edema
Can lead to the “butterfly” or “batwing” appearance commonly described
Sensitivity 1.9% - 6% (Knudsen et al., Fonseca et al)
Specificity: 97 – 99% (Knudsen et al., Fonseca et al)

28. Take home points
1 in 5 pts with acute decompensated heart failure with have no signs of congestion on chest xray (Collins et al.)
Poorly sensitive
Those with chronic heart failure may have subtle findings (Chakko et al.)
Beware of portable chest xrays