OS 205: Thorax Topic: CARDIAC IMAGING [29 June 2010] 13 September 2010

Outline: I. Introduction: Chest Radiographs II. Plain Film Anatomy A. PA View B. Lateral View C. CT Scan III. Congenital Heart Diseases IV. Valvular Heart Diseases

Exam

Lecturer: Dr. Rogelio I. de Jesus

aorta LA

Main Pulmo. Artery

I. INTRODUCTION: CHEST RADIOGRAPHS

Most commonly requested diagnostic tool Least costly and frequently effective Essential part of cardiac evaluation Information obtained: Heart size and silhouette Enlargement of cardiac chambers Pulmonary blood flow/markings Evaluation involves sequential logical assessment and correlation of both anatomic and physiologic information available on PA and lateral radiographs Patient with fever and cough. Infiltration in R lung based on x-ray. This is probably pneumonia. Patient with chronic cough and weight loss. Both upper lobes of lungs with cavitations. This is probably tuberculosis. Radiologists act as detectives Extract as much info as you can Come up with a specific diagnosis that would fit all findings
LV IVC RV

Figure 2: Normal lateral view showing borders and other visible structures.

C. CT Scan
Axial (most requested) Transverse cuts, as if viewed from the patients feet Your right hand side is the left side of the patient, your left hand side is the right side of the patient Contrast study:
WHITE BLACK GRAY Bones Air-filled structures (e.g. lungs, trachea) Soft tissues (e.g. skeletal muscles, cardiac muscles)

II. PLAIN FILM ANATOMY

A. PA View
trachea

L.Brachiocephalic v. meeting with R.BCv

esophagus
SVC R Pulmo. Artery RA IVC Aortic knob L Pulmo. Artery Main Pulmo. Trunk LV

SVC Figure 1: Normal PA showing the borders and other visible structures.

aorta

Know relative positions of valves, atria, etc. Know which structures are border-forming
RIGHT BORDER Superior vena cava Right atrium Inferior vena cava LEFT BORDER Aortic knob Main pulmonary artery segment Left ventricle

Use the hila as a landmark Pulmonary arteries (PA) and bronchi are at the level of hila Pulmonary veins are below hila Contrast study:
WHITE BLACK Arteries and veins Air-filled structures (e.g. bronchi, trachea)

B. Lateral View
Left atrium (posterosuperior) Left ventricle (posteroinferior) Right ventricle (anteroinferior) Aorta VISIBLE SHADOWS Main pulmonary trunk Inferior vena cava Note: Right atrium is not border-forming in the lateral view! BORDERS

R Pulmo. Artery

L Pulmo. Artery

Note: Pulmonary arteries (left and right) and veins may be mistaken for enlarged lymph nodes in children

Pulmonary arteries branching from main trunk More superior on left side than right

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RA

RV

LV

Figure 3: Dextrocardia and situs solitus.

III. PLAIN FILM INTERPRETATION

Systemic Approach
1. OVERVIEW OR OVERALL GLANCE AT THE FILM Is it adequate or optimal for cardiac evaluation? Erroneous data can lead to misdiagnosis. Position Slight degrees of rotation or obliquity will substantially affect the cardiac contour and may alter the apparent size as well Obliquity can be deceiving and may be seen as a false enlargement Inspiration Should be in full inspiration th th Diaphragm is at the level of the 9 -10 posterior th th aspect or the 5 -6 anterior aspect of the ribs In suboptimal inspiration or supine chest radiographs, the lower lobe markings are crowded and may obscure the possibility of early pulmonary edema Film should not be taken during exhalation or suboptimal inhalation because then the superoinferior diameter decreases and the heart is squeezed The vessels are crowded, which could simulate pulmonary edema Exposure Underexposure appears whiter May simulate pulmonary congestion Overexposure appears blacker (remember: OVERcooked rice is black, nasunog!) May simulate emphysema, diminished pulmonary blood flow or hypopulmovascularity 2. CARDIAC POSITION AND SITUS
CARDIAC POSITION Heart Predominantly in Apex Points Towards Left Left Right Right Midline Down Right Left Typically due to extrinsic forces, rotation of heart

Figure 4: Dextrocardia and situs inversus.

Figure 5: Situs ambiguous.

3. Cardiac size Is heart enlarged or not? 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

Levocardia Dextrocardia Mesocardia Dextroposition (dextroversion)

Figure 6: Cardio-thoracic ratio

Situs refers to the pattern of anatomic arrangement Atrial situs is usually concordant with visceral situs; hence, these two are described together
VISCEROATRIAL SITUS Atrium

Normal CT ratio in adults is usually 0.5 or less Normal CT ratio in the newborn is approximately 0.65 Normal CT ratio for children is between 0.5 and 0.65 (~0.6) 4. CHAMBER ENLARGEMENT
RIGHT ATRIAL ENLARGEMENT Lateral bulging Elongation (length exceeds 50% of the mediastinal cardiovascular shadow, midway between the line at the root of the great vessels and the line at the cardiophrenic sulcus)

Viscera Gastric air bubble Morphologic RA is to the Situs Solitus on left side right of the morphologic LA Liver is on the right Gastric air bubble Morphologic RA is to the Situs Inversus on right side left of the morphologic LA Liver is on the left Situs Identification of situs not possible due to paucity of Ambiguous anatomic markers (spleen and liver unidentifiable) Note: Situs solitus is the normal condition.

Right Heart Border

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Figure 7: RA enlargement RIGHT VENTRICULAR ENLARGEMENT (BUDDING BREAST) Rounding Upliftment and lateral discplacement of apex Retrosternal fullness (contact of anterior cardiac border greater than 1/3 of the sterna length), Lateral View which may lead to false positive of LV enlargement since there is no more room for growth of the RV PA View

LEFT VENTRICULAR ENLARGEMENT (SAGGING BREAST OR HEAVY HEART) Lateral and inferior displacement of the apex PA View (which is normally border-forming) Posterior displacement of the posteroinferior border of the heart Hoffman-Rigler sign: measured 2cm above the Lateral View intersection of diaphragm and IVC; (+) if posterior border extends >1.8 cm of IVC Retrocardiac fullness Note: RV enlargement may be confused to be LV enlargement because heart is pushed back

Figure 8: RV enlargement PA view (left) and lateral view (right) LEFT ATRIAL ENLARGEMENT Double density on right border due to superposition of LA (denser) and RA Enlargement of LA appendage seen inferior to the left main bronchus (recall that the left border is formed by only three bulges) PA View Upliftment of the left mainstem bronchus Widening of the carinal angle (normal is 70-90) due to the left mainstem bronchus being pushed upwards (sometimes not widened when the right bronchus is very much vertically oriented) Prominent posterosuperior cardiac border (recall that the LA is most posterosuperior chamber) Lateral View Posterior displacement and upliftment of the left mainstem bronchus Note: Easiest to evaluate of all the chambers. Inc. carinal angle L bronchus uplifted LA appendage Double density

Figure 10: LV enlargement PA view (top) and lateral view (bottom)

5. PULMONARY VASCULAR PATTERN Start with lungsit can help in assessment

NORMAL VASCULARITY From inner lung zones (medial) to outer lung zones (peripheral) Periphery must be relatively clearer/avascular From lung base (inferior) to apex (superior) Lower lobes are better perfused due to gravity Vessels in lower lobes have greater caliber

Tapering

Figure 11: Normal vascularity

Hypervascularity (increased vascularity) May be seen as an overall increase in vessel caliber However, medial to lateral and inferior to superior taperings are maintained (e.g. in shunt anomalies)

Figure 9: LA enlargement PA view (top) and lateral view (bottom).

Figure 12: Hypervascularity (lateral view in powerpoint)

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 Hypovascularity (decreased vascular pattern) Do not confuse with overexposed films, in which everything is black. In hypovascularity, only the lungs are black. (black is larger than white in relation to pulmonary artery (white) and bronchus (black)) Found in cardiac patients of decreased pulmonary blood flow (presence of obstruction)

Fuzzy and blurred (as opposed to a normal radiographic image, where vessels are distinct)

Figure 16: Perihilar haziness

Peribronchial cuffing Thick bronchioles (normal lining is hair strand-thick) Sign of pulmonary congestion

Figure 13: Hypovascularity (lateral view in powerpoint)

Venous congestion Increased caliber of the vessels Cephalization of pulmonary blood flow (vessels in upper lobes are thicker than in lower lobes) Normal tapering from medial to lateral Do not confuse with increased arterial blood flow (e.g. atrial septal defect), which is congenital. Venous congestion is valvular or acquired (e.g. mitral stenosis)
Notes: 1. The terms hypervascular, hypovascular, and normovascular are used for congenital diseases. a. Vessels/arteries/arterioles (white) and bronchioles (black) go together and are normally seen 1:1 in terms of size b. In hypervascularity, the vessels are larger than the bronchioles c. In hypovascularity, the vessels are smaller than the bronchioles 2. The terms cephalization, congestion, and equalization are used for valvular diseases. Figure 17: Peribronchial cuffing REDISTRIBUTION Caliber of vessels in upper lobe is equal to that of the lower lobe vessels Caliber of vessels in the upper lobe is greater than that of the lower lobe vessels As seen in venous congestion

Equalization Cephalization

Interstitial edema Prominent horizontal lines (Kerleys B lines) Kerleys A lines: diagonal lines usually in upper lobes Kerleys C lines: tangled blood vessels with cobweb-like appearance (facing you) All Kerleys lines (A, B, and C) are indicative of interstitial edema Alveolar edema Fluid or blood in alveoli Cotton-like appearance

Figure 14: Venous congestion

Kerleys B lines Horizontal lines seen in the periphery Periphery should be relatively avascular (in normal patients) Indicative of fluid in the interlobular septa, as seen in interstitial edema
Figure 18: Alveolar edema

Figure 15: Kerleys B-lines

6. THE GREAT ARTERIES/VESSELS Are they in normal position? Are they of normal size? Aorta: normal, prominent, or diminutive (not seen)? Main pulmonary artery (seen above left main bronchus): normal, prominent (dilated), or concave (small, waistline is seen)? The aorta and main pulmonary artery are for outflow. Thus, whatever is happening in the ventricle(s) is reflected in these great vessels.

Perihilar haziness

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 If uncorrected, leads to pulmonary hypertension as one ages Lungs vasoconstrict to counter too much blood flowRV hypertrophies (pressure overload)shunt is reversedblood going into systemic circulation is mixed cyanosis (EISENMENGERIZATION)

Figure 19: Prominent aorta

Figure 21: Diagram of VSD

Inc. vascularity

Figure 20: Concave main pulmonary artery

Chamber prominence

7. ANCILLARY FINDINGS (ribs, soft tissues, chest, etc.) Calcifications Rib notching due to coarctation of the aorta Stenotic valves Bone deformities Others
Figure 22: Radiographic findings in VSD

IV. CONGENITAL HEART DISEASE

(See appendix for diagram of congenital heart diseases.) Anatomic malformation of the heart and or its vessels Occurs during intrauterine development Incidence: 8/1000 live births (most common congenital malformation) 13% will have more than one cardiac defect 25% will have associated non-cardiac deformity Etiology is unknown or is multifactorial: Hereditary Chromosomal abnormality Maternal infection Teratogenic drugs Maternal factors Environmental RADIOLOGIC INTERPRETATION OF CONGENITAL HEART DISEASE 1. Cyanotic or Non-cyanotic? 2. Vascularity (hypervascular, hypovascular, cephalic, congested) 3. Specific chamber enlargement 4. Great Vessels (know which vessels are enlarged) 5. Ancillary findings VENTRICULAR SEPTAL DEFECT (VSD) There is abnormal communication between LV and RV Some of the blood flows from LV to RV oxygenated blood mixes with deoxygenated blood lungs (oxygenation of blood) left side of heart some go to systemic circulation, some go to right side of heart Left to right shunt going to pulmonary circulation results in extra burden of volume Acyanotic (oxygenated blood supplies systemic circulation) Radiographic findings: Increased vascularity due to increase in blood volume towards the right side Enlargement of main and central pulmonary arteries Enlargement of left ventricle due to strain on LV(also in left atrium, but less noticeable) Enlargement of right ventricle, but only in a large defect (shunting of blood in both systole and diastole) Aorta is small or normal TOTAL ANOMALOUS PULMONARY VENOUS RETURN (TAPVR)
FLOW OF OXYGENATED BLOOD lungs pulmonary veins LA LV aorta systemic circulation lungs right side of heart (oxygenated blood does not drain into the left side of the heartnot compatible with life)

Normal Circulation TAPVR

ASD (obligatory shunt between atria) is needed to survive This condition leads to cyanosis Radiographic findings: vascularity ( blood volume to right side of heart) Cardiomegaly Chamber prominence (right side of the heart) Enlarged systemic vein into which drainage occurs Pulmonary arteries dilated
Inc. vascularity

cardiomegaly

Type I (Supracardiac) Connection above heart; tangle of vessels above heart Left-sided vertical vein connects pulmonary venous confluence to left innominate vein, right SVC or azygos vein Snowman appearance

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Figure 23: Supracardiac TAPVR

Type II (Cardiac) Connections to the RA or coronary sinus Radiographic findings mimic ASD but cyanotic

TETRALOGY OF FALLOT (TOF) Pulmonary stenosis Narrowing of the right ventricular outflow tract Blood has difficulty going to the lungs Blood from RA goes to RV but has difficulty going through the pulmonary valve chooses an alternate route Ventricular septal defect Alternative route chosen since there is pulmonary stenosis Pressure in RV increases and deoxygenated blood is shunted from the RV to the LV, bypassing the lungs Less blood goes into the pulmonary circulation, resulting in decreased vascularity Right ventricular hypertrophy Due to difficulty in propelling the blood to the lungs Overriding aorta Prominent aorta overrides VSD Blood going into the aorta is mixed, leading to cyanosis Radiologic findings: Vascularity Normal or enlarged cardiac size RV prominence Concave main pulmonary artery segment Prominent aorta (right sided aortic arch in 20-25%) Small pulmonary artery

Figure 24: Cardiac TAPVR

Type III (Infracardiac) Connection is below the diaphragm, to the portal vein, ductus venosus or hepatic vein Radiographic findings: Normal sized heart Prominence of the right atrium & less often the right ventricle (due to right side involvement) Dilated pulmonary artery Pulmonary edema (most prone to edema)
Overriding aorta RA prominence

Figure 27: TOF

Concave MPA

Dec. vascularity RV

Figure 25: Infracardiac TAPVR. Radiographic findings on right.

Mixed type Various connections to the right side of the heart

Figure 28: TOF radiologic findings

Remember: Volume overload leads to dilation Pressure overload leads to hypertrophy

Figure 26: Mixed TAPVR

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V. VALVULAR HEART DISEASES

May be congenital or acquired Pathophysiology and clinical manifestations similar in both Almost all acquired valvular heart diseases are rheumatic in origin
Prominent MPA

equalization

Prominent LA

MITRAL VALVE STENOSIS (MITRAL STENOSIS)

Prominent RV

Figure 30: Mitral stenosis (PA view)

Prominent LA

Figure 29: Mitral valve stenosis.

Narrowing of the mitral valve, so it cannot open properly Blood flow to the left ventricle (and to the systemic circulation) is obstructed Radiologic findings: Normal to slightly enlarged heart Chamber prominence: LA (due to pressure build-up), RV (pulmonary vasculature congestion) Equalization or cephalization of pulmonary blood flow Prominent main pulmonary artery segment Small aorta RA wont be affected unless tricuspid valve has a problem

Prominent RV

Figure 31: Mitral stenosis (lateral view)

Ria: Nakakapagod mag-aral. Mas gusto ko mag-edit ng trans, k. Dear USERS, kung mabasa niyo to, kung ako maka Top 10 na score sa exam na to alam niyo na. Hahahaha!

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