PHOTO READING STATION

SPV Advisor:

dr. Indrastuti Normahayu, Sp. Rad (K)

dr. A. Bayhaqi N. A., Sp. Rad (K)

PPDS:
dr. YAF – dr. MEL – dr. TIA – dr. NIA
Patient History
L/MALE/ 10 Y.O/11211022

Patient condition:
Sianotic (+)
Saturation 66%

With echocardiogram result in 2020:

Atresia pulmonal + CAVSD complete atrioventricular septal defects
+ MAPCA? Major Aorto Pulmonary Collateral Arteries
ADVICE: Cardiac Catheter (Waiting for schedule)

Working Diagnosis
CONGENITAL HEART FAILURE + SUSP PNEUMONIA
 Clinical question

The patient already diagnose with Congenital

heart Failure from Echocardiogram.

The Clinician want to check whether low

saturation because the patient also has
pneumonia or not
 what to look for in imaging?

Pulmonary evaluation to see if there are signs of infection or not

Cardiac evaluation to assess whether its accordance with congenital heart disease or not
In Our Case
 CONCLUSION

• There is no sign of pneumonia

• Cardiomegaly (RVH, RAE) may still be CHD right to left shunt

Relevant positive finding
 RAE In Our Case LVE

right atrial margin is

more than 5.5 cm
from the midline
RVH
Further Examination
Thank You
 Cardiovascular Shunt
Cardiovascular (cardiac) shunts are abnormal connections between the pulmonary and systemic
circulations. Most commonly they are the result of congenital heart disease.

Left-to-right shunt Right-to-left shunt

In a left-to-right shunt oxygenated blood flows directly from the systemic circulation In a right-to-left shunt deoxygenated blood flows directly from the
to the pulmonary circulation, which results in decreased tissue oxygenation pulmonary circulation to the systemic circulation, decreasing tissue
through reduced cardiac output. Causes include: oxygenation by reducing the oxygen content of systemic arterial blood.
•  cardiac Causes include:
• ventricular septal defect (VSD) cardiac
• atrial septal defect (ASD) • tetralogy of Fallot
• atrioventricular septal defect • pulmonary atresia
• patent ductus arteriosus (PDA) • double outlet right ventricle
• Gerbode defect • transposition of the great arteries
• vascular pulmonary shunts • truncus arteriosus
• total/partial anomalous pulmonary venous return (TAPVR/PAPVR) • Eisenmenger syndrome
vascular pulmonary shunts
Circular shunt • pulmonary arteriovenous malformations
In most left-to-right or right-to-left cardiovascular shunts, shunted blood • hepatopulmonary syndrome
returns to the same chamber after traversing a capillary bed (either parenchymal intrapulmonary shunts
pulmonary or peripheral), if this does not occur then the term 'circular • atelectasis
shunt' can be employed. Such shunts are generally present in complex • pneumonia
congenital heart defects. • bronchoalveolar carcinoma
 CHD

CHD
CHD
Acyanoti
Cyanotic
c

Decreased vascular Increased vascular Outflow tract

Left-to-right shunt
markings markings obstruction

Tetralogi Anomali Transposisi

TAPVR ASD VSD Coarcatio Aortic valve
of Fallot Ebstein Arteri Besar aorta stenosis

Atresia Pulmonic
Single Truncus PDA
Tricuspi valve
Ventricle Arteriosus stenosis
d
Cardiac Chamber Enlargement

Cardiac chamber
enlargement can be recognized
by cardiac contour changes, new
or different interfaces with
adjacent lung, and/or
displacement of adjacent
mediastinal structures:
1. right atrial enlargement
2. right ventricular hypertrophy
3. left atrial enlargement
4. left ventricular hypertrophy
RAE

Features are non-specific but include 2,3:

• enlarged, globular heart
• narrow vascular pedicle
• gross enlargement of the right atrial shadow, i.e.
increased convexity in the lower half of the right
cardiac border
• right atrial convexity is more than 50% of
the cardiovascular height
• right atrial margin is more than 5.5 cm
from the midline
 LAE

LAE

 Direct visualization of the enlarged atrium includes:

 Double density sign
• when the right side of the left atrium pushes into the adjacent lung, and becomes visible
superimposed or even beyond the normal right heart border (known as atrial escape) 
• a similar appearance can be caused by the right superior pulmonary vein in patients without
atrial enlargement 4
 Oblique measurement of greater than 7cm 5,6
• measured from midpoint of left main bronchus to the right border of the left atrium (this
requires a double density sign of course)
• thought to be the most reliable sign on chest radiography
 convex left atrial appendage (third mogul sign): normally the left heart border just below the
pulmonary outflow track should be flat or slightly concave
 LAE
Indirect signs include:

 splaying of the carina, with the increase of the tracheal bifurcation angle to over 90 degrees
• this refers to both the interbronchial angle (i.e. angle formed by the central axis of the left and right main

bronchi) and the subcarinal angle 1-3

• both are inaccurate and dependent on radiographer technique, inspiration and body habitus 2
• the mean and range of both measurements vary widely in normal individuals 2,3
• interbronchial angle: normal mean 67-77° (range 34-109°) 

• subcarinal angle: normal mean 62-73° (range 34-90°)

 posterior displacement of the left mainstem bronchus on the lateral radiograph

• right and left bronchi, therefore, do not overlap, but rather form an upside down 'V', sometimes referred to

as the walking man sign 5

 superior displacement of the left mainstem bronchus on frontal view

 posterior displacement of a barium-filled esophagus or nasogastric tube

 LVH RVH

Features that may be visible on a chest radiograph Frontal view demonstrates:

include:
• left ventricular dilatation: left heart border is
displaced leftward, inferiorly and posteriorly
• left ventricular hypertrophy: may show rounding
of the cardiac apex
• Shmoo sign
• rounded left heart border
• uplifted cardiac apex
Lateral view demonstrates:
• filling of the retrosternal space
• rotation of the heart posteriorly
Thank You