46
Chest X-Ray in Acute Heart Failure
Laurence Monnier-Cholley
This chapter discusses the consequences of chest
x-ray of acute left heart failure due to left ventric-
ular failure or mitral valve disease. Valuable inter-
pretation of a chest x-ray in such conditions
requires knowledge of the normal appearance of
a chest x-ray and the technical parameters that
may change it to avoid misinterpretation. A better
understanding of the images also requires some
knowledge of the physiopathology of pulmonary
edema.
Normal Chest Radiograph
Under normal conditions, there is a linear increase
in pulmonary blood flow from the apex to the base
of the lung due to gravity, when the chest radio-
graph is performed with the patient in the erect
position. Pulmonary blood flow is equally distrib-
uted throughout the lung when the patient lies in
the supine position. In consequences, one needs
to know the patient position when looking at his
chest radiograph. If the radiograph is taken with
the patient supine or semierect, the position has
to be documented. The presence of an air-fluid
level in the stomach is the landmark of an erect
position.
Cardiac size also depends on technical param-
eters. On a posteroanterior view of the chest,
cardiac size is almost the real-life size, but if the
radiograph is taken with the x-ray beam oriented
in the anteroposterior direction, the size of the
heart is artificially enlarged on the film and may
be mistaken for a cardiomegaly. The degree of
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inspiration–expiration can dramatically change
the appearance of the cardiothoracic (C/T) ratio,
which corresponds to the ratio of the width of the
heart to the width of the thoracic cavity (Fig. 46.1).
Normal C/T is less than 50%. Cardiothoracic ratio
has to be measured at end inspiration (more than
six to seven anterior ribs above the diaphragm) to
be of value (Fig. 46.1). On expiration, cardiomeg-
aly can be erroneously diagnosed (Fig. 46.2). On
the other hand, patients with emphysema often
have cardiac enlargement, although heart size
appears normal due to pulmonary distention.
Typical Aspect and Physiopathology of
Acute Heart Failure
In acute left heart failure, there is a progressive
increase in pulmonary venous pressure. The first
stage of elevation of venous hypertension, when
pulmonary capillary wedge pressure is between
10 and 15 mm Hg, is a uniformization of blood
flow with equalization from bases to apices
accomplished through capillary distention and
recruitment.
For a capillary wedge pressure between 15 and
25 mm Hg, a vascular redistribution of blood flow
to the apices is observed and vessels appear larger
than basal vessels (Figs. 46.3 and 46.4). Modest
elevations in pulmonary venous pressure are
accommodated in this manner without the devel-
opment of pulmonary edema.
At higher filling pressures, fluid begins to cross
the microvascular barrier, and edema can develop.
The interstitial compartment is first involved and
46. Chest X-Ray in Acute Heart Failure
C C
T T
FIGURE 46.1. Posteroanterior chest radiograph taken in the
upright position, at end inspiration. Seven anterior ribs are visual-
ized above the diaphragm (black arrowheads). Cardiothoracic (C/T)
ratio corresponds to the ratio of the width of the heart to the width
of the thoracic cavity.
fluid fills up successively in the interlobular septa
and the peribronchovascular spaces, and reaches
the hila. The radiologic signs are therefore Kerley
lines corresponding to septal thickening (Figs.
46.4 and 46.5), and peribronchovascular and hilar
haziness (Fig. 46.6). Kerley lines include Kerley A
C C
T T
FIGURE 46.2. Same patient as in Figure 46.1 with chest radiograph
taken at end expiration. Four anterior ribs are visualized above the
diaphragm (black arrowheads). C/T should not be measured in
such conditions because it is artificially increased and could errone-
ously lead to the diagnosis of cardiomegaly.
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FIGURE 46.3. Posteroanterior chest radiograph taken in the
upright position showing cardiomegaly, vascular redistribution
(arrow) to the apices, and fairly discrete Kerley B lines
(arrowheads).
lines situated at the apices and Kerley B lines
located at the bases.
If the pressure raises a value above 35 mm Hg,
alveolar pulmonary edema can occur and pro-
duces a bilateral alveolar syndrome in a medullary
distribution, with sparing of the periphery of the
FIGURE 46.4. Posteroanterior chest radiograph in an upright
position showing marked cardiomegaly, vascular redistribution
(arrow), and Kerley B lines (arrowheads).