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Cardiac Imaging • This term is used when identification of

Cardiac Position and Sinus

visceroatrial situs is not possible due to
Cardiac Positions
paucity of anatomic markers
• Levocardia: the heart is predominantly in the
left chest, the cardiac apex points leftward
• Dextrocardia: the heart is predominantly in
the right chest, and the cardiac apex points • Dextrocardia
• Sinus solitus
• Mesocardia: the heart is positioned in the
midline, and the cardiac apex points directly
• Dextroposition (dextroversion): the cardia
apex points leftward, but the heart is located
predominantly in the right chest (typically due
to extrinsic forces)

Visceroatrial Situs
• Dextrocardia
• “SITUS” refers to the pattern of anatomic
• Sinus inversus

• Atrial situs is usually concordant with visceral

situs; hence, these two are described together

• Situs solitus
• Situs
o The morphologic right atrium is to the Ambiguous
right of the morphologic left atrium

o The gastric air bubbles is on the left

side and the liver on the right

In Dextrocardia, gastric
bubbles is on the right
Cardiac Size
• Cardio-Thoracic Ratio: divide the widest
transverse diameter of the heart by the widest
transverse diameter of the thorax taken at the
inner side of the rib cage

• Situs inversus

o The morphologic right atrium is to the

left of the morphologic left atrium
o The gastric air bubbles is on the right Enlargement
side, and the liver is on the left
• Right Atrial Enlargement
o lateral bulging of the
• Situs ambiguous right heart border
o elongation of the
right heart border
(length of right heart
border exceeds 50%
of the mediastinal

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• Right Ventricular Enlargement
o PA View: o Lateral View:
Rounding and - Prominent posterosuperior
upliftment of cardiac border
cardiac apex - Posterior displacement and
upliftment of left mainstem

o Lateral View:
(contact of
anterior cardiac
border greater
than 1/3 of the • Left Ventricular Enlargement
sternal length) o PA view:
lateral and
of the cardiac

• Left Atrial
o PA view:
Double density o Lateral View:
- Posterior

o PA view:
displacement of the posterior
Enlargement inferior border of the heart
of LA

- Hoffman-Rigler Sign:
measured 2 cm above the
intersection of the diaphragm &
IVC; (+) if posterior border
extends more than 1.8 cm of IVC

o PA view: Pulmonary Vascular Pattern

Upliftment of
left mainstem

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Venous Congestion

Comparison of Normal and Increased Increased Arterial Blood Flow

Kerley’s B lines

Lateral View

Perihalar Haziness

Comparison of Normal and Decreased

Peribronchial Cuffing

Lateral View

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Redistribution Equalization

o Prominent
o Diminutive

Redistribution Cephalization

Non-cyanotic • Main pulmonary

• ASD (RAE and RVE)
o Normal
• VSD (both ventricles
may be enlarged
and LA)
Interstitial Edema • PDA (LVE & LAE)
• AV canal defect

o Prominent

o concave

Conditions wherein pulmonary artery is concave:

• Transposition of great arteries
The Great Arteries • Pulmonary atresia
• Aorta
o Normal Congenital Heart Diseases

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• Anatomic malformation of VSD:
the heart and or its
vessels, which occurs
during the intrauterine

Radiologic Interpretation of congenital heart disease

1. Cyanotic or acyanotic
2. Vascularity: normal, increased, or decreased Patent Ductus Arteriosus
• Increased vascularity

•• Normal or enlarged
cardiac size
• Chamber prominence:
• Left ventricle
• Left atrium
• dTGA
• Enlarged main
• TAPVR without
and central
Decreased obstruction
Normal Vascularity pulmonary
Vascularity • PTA
• Prominent aortic • Single ventricle
knob • DORV without pulmo
• TOF • Coarctation of the Atrial Septal Defect stenosis
• Ebstein’s aorta • Increased vascularity
anomaly • Aortic stenosis • Cardiomegaly
• Severe pulmo • Pulmonary stenosis • Chamber prominence:
stenosis o Right atrium
• Pulmo Atresia o Right ventricle
• Tricuspid atresia • Enlarged main and
with pulmo central pulmonary
stenosis arteries
• DORV with pulmo • Small aortic knob
Increased Venous
Transposition of the Great Arteries (d-TGA)
• Increased vascularity
• Cardiomegaly

Hypoplastic left • Cardiac silhouette:
heart o “Egg on its
• Pulmonary vein side”
stenosis o “Apple on a
• TAPVR with stem”
Ventricular Septal obstruction
Defect • Narrow vascular pedicle
• Increased vascularity
• Normal or enlarged
cardiac size
• Chamber prominence:
o Either or both
Patent Truncus Arteriosus
• Increased vascularity
o Left atrium
• Pulmonary venous
• Enlarged main and
congestion or edema
central pulmonary
is frequent in Type 1
• Cardiomegaly
• Normal or small aorta
• Chamber prominence

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o Either or both ventricles • Post-stenotic dilatation of the main pulmonary
o Left atrium artery
• Concave main pulmonary artery segment
(Prominent in Type 1)

Total Anomalous Pulmonary Venous Return Ebstein’s Anomaly

• Increased vascularity • Decreased
• Cardiomegaly vascularity
• Chamber prominence • Marked
o Right atrium cardiomegaly
o Right ventricle • Right atrial
• Enlarged systemic vein prominence
into which drainage • “Balloon-“ or
• Type 1 (Supracardiac)
o left-sided
vertical vein connects pulmo venous
confluence to the left innominate vein,
right SVC or azygos vein
o “Snowman appearance”
• Type III (Infracardiac)
o Connection is Aortic Stenosis
below the • Normal vascularity
diaphragm to
the portal vein,
• Cardiomegaly
ductus venousus • Left ventricular
or hepatic vein prominence
o Pulmonary • Dilated ascending
edema aorta
o Normal sized

o Prominence of the right atrium and

often the right ventricle

Tetralogy of Fallot
• Depressed
• Normal or enlarged
Coarctation of the Aorta
cardiac size
• Normal vascularity
• Right ventricular
prominence • Cardiomegaly
• Concave main • Left ventricular
pulmonary artery prominence
segment • “3” sign
• Prominent aorta
• Right aortic arch
(in 20-25%)
• Boot-shaped

Mitral Stenosis
• Normal to slightly enlarged
Pulmonary Stenosis heart
• Normal to decreased • Chamber prominence:
vascularity o Left atrium
• Normal or enlarged o Right ventricle
cardiac size • Equalization or
• Right ventricular cephalization of
prominence pulmonary blood flow
• Prominent main
pulmonary artery segment

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• Small aorta

Mitral Regurgitation
• Cardiomegaly
• Chamber prominence
o Left atrium (MR >
o Left ventricle
• Pulmonary venous
congestion (MR < MS)
• Small aorta

Aortic Stenosis
• Normal-sized heart or
mild cardiomegaly
• Left ventricular
• +/- pulmonary venous
• Dilated ascending

Aortic Regurgitation
• Cardiomegaly
• Left ventricular
• Dilated ascending
aorta and aortic
• Normal pulmonay

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