Radiologic Diagnosis of Heart Diseases An Atlas of Cardiac X-rays

PART 1 Radiographic technique The thoracic cage

Dr. Khairy Abdel Dayem

Professor of Cardiology Ain Shams University

Contents
PART 1 Radiographic technique
 Over exposure  Under exposure  Centralization

The thoracic cage

 kyphyoscoliosis  Straight back  Pectus excavatum  Precordial bulge  Rib notching  Effects of previous operations or interventions

PART 2 Pulmonary vasculature

 The normal pulmonary vasculature  Pulmonary congestion  Pulmonary Plethora  Pulmonary Oligemia  Pulmonary embolism and Infarction  Pulmonary Hypertension

PART 3 The Cardiac Shadow Cardiothoracic ratio Pericardial effusion Abnormal densities Pericardial calcifications Calcifications of valves Calcifications of walls of cardiac chambers Calcifications of the aorta Calcifications of coronary arteries Radiology of cardiac chambers in health and disease Normal radiological anatomy of the heart Normal cardiac outline The lateral view Right atrial enlargement Right ventricular enlargement Pulmonary artery dilatation Left atrial enlargement Left ventricular enlargement Diseases of the aorta

PART 4 Radiological features of acquired valvular diseases

 Mitral stenosis  Mitral regurgitation  Aortic stenosis  Aortic regurgitation  Tricuspid valve disease

Heart failure and cardiomyopathies

PART 5 Radiological feature of common congenital cardiac malformations

 The cardiac malpositions  Atrial septal defect  Ventricular septal defect  Patent ductus arteriosus  Pulmonary stenosis  Coarctation of aorta  Fallots tetralogy  Transposition of great arteries  Ebstein Anomaly of the Tricuspid valve  Total anomalous pulmonary venous drainage

Extracardiac structures simulating cardiac disease

Effects of Radiographic Technique on X-ray Interpretation

Certain defects in the way the X-ray was taken may alter the cardiac shadow and/or the lung vasculature. The following are the most common examples:

A. Defects in exposure (Dose of the X-ray)

The X-ray should not be over or under-exposed Proper exposure is essential in order to judge the pulmonary vasculature. Criteria of Over-exposure (Fig. 1): 1. Jet black lung fields. 2. Individual thoracic vertebrae are clearly seen within the cardiac shadow. 3. The junction of each rib with the thoracic vertebrae is well seen within the cardiac shadow.

Fig. (1): Over-exposed X-ray

Errors that may be caused by over-exposure:  Over-diagnosis of pulmonary oligemia Criteria of Under-exposure (Fig. 2): 1. The ribs and the thoracic vertebrae can not be seen at all within the cardiac shadow. 2. Partial veiling of lung fields Errors that may be caused by under-exposure:  Inability to judge pulmonary vasculature.  Over-diagnosis of:     Pulmonary congestion Pulmonary plethora Pulmonary fibrosis Pleural effusion
Fig. (2): Under-exposed X-ray

B. Defects in Centralization
The patient should be centralized, not rotated, standing erect and directly facing the X-ray tube. Criteria for proper centralization: The medial ends of both clavicles should be equidistant from the middle line. This is represented by the spinal processes of the vertebrae. Both clavicles should also be at the same level as in (Fig. 3). This (Fig. 4) shows a non-centralized patient as evidenced by the unequal distance between the medial ends of the clavicles and the spinal processes of the vertebrae. The clavicles are not at the same level.

Fig. (3): Left: Centralized Patient, Right: Uncentralized Patient Note: The unequal space between the medial end of both clavicles and the middle line

Error that may be caused by a non-centralized patient:  Abnormal cardiac configuration without the presence of heart disease.

Abnormalities in the Thoracic Cage that may Affect Interpretation of Cardiac X-ray
Before looking at the cardiac outline, the thoracic cage must be examined carefully for evidence of the following abnormalities:

1. Skeletal

abnormalities

include

kyphosis, scoliosis or kyphoscoliosis. If marked, these skeletal abnormalities may drastically change the configuration of the cardiac shadow as in (Fig. 4). In this X-ray kyphoscoliosis is manifested by: a) Sideway curves of the vertebral column.

Fig. (4): Kyphoscoliosis

b) Intercostal spaces on the right side are much wider than on the left side.

Other skeletal abnormalities that may affect the cardiac size and configuration include: a) Straight back syndrome: straight back causes diminution of the antroposterior thoracic diameter compressing the heart against the spine and causing it to appear enlarged in the PA view, (Fig. 5).

Fig. (5): (Right) Straight back and (Left) Apparent enlargement of the pulmonary artery due to the skeletal deformity

b) Pectus excavatum: the depressed sternum displaces the heart towards the left. The right cardiac border disappears behind the sternum and the cardiac outline is distorted, (Fig. 6).

Fig. (6): Pectus excavatum: Inward displacement of the lower third of the sternum

2. Precordial Bulge
Skeletal abnormalities may result from heart disease. Chronic and early enlargement of the heart may displace the chest wall anteriorly resulting in precordial bulge. This is diagnosed in the lateral view of the X-ray by anterior displacement of the sternum, (Fig. 7).

Fig. (7): Marked enlargement of the heart causing anterior displacement of the sternum and the ribs (Precordial Bulge)

3. Rib Notching
Notching on the lower edges of the fourth to the ninth ribs indicate enlarged intercostal arteries eroding the lower border of the ribs in cases of coarctation of the aorta, (Fig. 8 & 9).

Fig. (8): X-ray of coarctation of aorta showing rib notching starting from the 4th rib. The left border of the heart shows the 3 sign

Fig. (9): Enlarged view of the ribs showing notching of their lower borders

4. Effect of previous Operations or Interventions e.g.

 Open heart surgery is usually done through a median strenotomy incision. The 2 halves of the sternum are approximated by wires as in (Fig. 10).

Fig. (10): Lateral view showing wires that are used to join the two halves of the sternum together