BASIC CHEST IMAGING : Focused

on Heart Failure

Sianny Suryawati, dr., Sp.Rad(K)

Radiology Department, Faculty of Medicine
Wijaya Kusuma University
Surabaya - 2021

S
 Introduction

• Chest X-Ray is one of the most frequently requested hospital

investigations.
• It is readily available and inexpensive in comparison to other
imaging studies.
• The basic interpretation is of utmost importance in answering
several clinical questions at hand.
• It is an important tool to complement both history and initial
clinical examination.
 X-rays make up X-radiation, a form of
electromagnetic radiation.
 X-ray wavelengths are shorter than those of UV rays
and typically longer than those of gamma rays.
 It is also referred as Rontgen radiation, after the
German scientist Wilhelm Conrad Roentgen who
discovered these on November 8, 1895.
X-rays can be generated by an X-ray tube, a vacuum tube that uses a high
voltage to accelerate the electrons released by a hot cathode to a high
velocity. The high velocity electrons collide with a metal target, the anode,
creating the X-rays.
IMAGE FORMATION

 High density structure absorb x-

ray (bone)
 Low density structure let the x-
ray pass, more x-ray coming out
under the area (lung)
 More x-ray to film caused darker
image on films or detector
RADIOGRAPHIC DENSITIES ARRANGED FROM LEAST TO
MOST DENSE :
 Air - appears the darkest
 Fat - lighter shade of grey than air
 Soft tissue or fluid - less black than fat
 Calcium - usually contained within bones
 Metal - whitest
(objects of metal density are not normally present in the body)
RADIOGRAPHIC VIEWS
BASIC CHEST X-RAY INTERPRETATION

A. Patient details : name, age, MRN, date

B. Quality
• Image quality influences interpretation
• Quality is influenced by radiographic technique and patient

factors.
• Projection, rotation, inspiration, penetration and artefacts.
Projection
Well centered PA chest X-ray
• Find the medial ends of the
clavicles
• Find the vertebral spinous
processes
• The spinous processes
shoulf be half way between
the medial ends of the
clavicles.
 Degree of Inspiration

 To judge the degree of inspiration, count the number of

ribs above the diaphragm.

 The midpoint of the right hemi-diaphragm should be

between the 5th and 7th ribs anteriorly.

 The anterior end of the 6th rib should be above the

diaphragm as should the posterior end of the 10th rib.

• If more ribs are visible the patient is
hyperinflated
• If fewer it indicates inadequate
inspiration
• Poor inspiration will make the heart
look larger, give appearance of basal
shadowing and cause the trachea to
appear deviated to the right
CHEST X-RAY ANATOMY
 HEART

• The heart lies more to the left of the thoracic cavity.

• The heart is assessed by means of the cardio-thoracic ratio
(CTR).
• CTR = Cardiac width : Thoracic width
• CTR > 50% is abnormal – PA view only
• The left hemidiaphragm should be visible behind the heart.
• The hemidiaphrams do not represent the lowest point of the
lungs.
 APPROACH TO CXR PATHOLOGY

a. The CXR is an important tool to complement both history and initial

clinical examination.
b. Low density structures appear dark(black/radiolucent) and high density
are whitish (opaque).
c. Abnormalities need to be described in detail.
d. Identify the most striking abnormality first. However, once you are
done with this, it is vital to check the rest of the image.
 HEART FAILURE

 Heart failure is a syndrome of cardiac ventricular dysfunction,

where the heart is unable to pump sufficiently to meet the body's
blood flow requirements.

 Myocardial damage due to myocardial infarcts, cardiomyopathy and

myocarditis can cause or aggravate heart failure. Additionally,
valvular disease such as aortic stenosis or mitral regurgitation may
result in heart failure as well. Further causes include conduction
defects, cardiac arrhythmia and infiltrative/matrix disorders.

 Systemic factors that may contribute or exacerbate heart failure

include anemia, hyperthyroidism or hypertension.
 Left ventricular failure

 Left ventricle (LV) failure is the most common and results in

decreased cardiac output and increased pulmonary venous pressure.

 Patients usually report fatigue, dyspnea on exertion, and if severe, at

rest. Orthopnea, paroxysmal nocturnal dyspnea and Cheyne-Stokes
respiration can also be a feature.

 In the lungs LV failure will lead to dilatation of pulmonary vessels,

leakage of fluid into the interstitium and the pleural space and finally
into the alveoli resulting in pulmonary edema.
 Right ventricular failure

 Right ventricle (RV) failure is usually the result of long standing LV

failure or pulmonary disease and causes increased systemic venous
pressure resulting in edema in dependent tissues and abdominal
viscera.
 Symptoms include ankle swelling, fatigue, abdominal
bloating/discomfort and nocturia.
 Evidence of right ventricular failure can manifest as peripheral edema
(if severe extending to thighs and sacrum), ascites, hepatomegaly,
elevated jugular venous pressure (JVP). JVP can be further
accentuated by hepatojugular reflux. Cardiac murmurs may also be
heard, commonly tricuspid regurgitation.
 Increased pulmonary venous pressure is related to the pulmonary
capillary wedge pressure (PCWP) and can be graded into stages,
each with its own radiographic features on the chest film (Table).
 This grading system provides a logical sequence of signs in
congestive heart failure.
 In daily clinical practice however some of these features are not
seen in this sequence and sometimes may not be present at all.
 This can be seen in patients with chronic heart failure, mitral valve
disease and in chronic obstructive lung disease.
 RADIOGRAPHIC
FEATURES OF HEART
FAILURE

S
 PLAIN RADIOGRAPH

 The accuracy of interpreting chest radiographs regarding

congestive cardiac failure was only around 70% according
to one study.
 Chest X-ray findings include pleural effusions,
cardiomegaly, (enlargement of the cardiac
silhouette),Kerley B lines (horizontal lines in the periphery
of the lower posterior lung fields), upper lobe pulmonary
venous congestion and interstitial edema.
A good mnemonic to remember these principles is ABCDE:

 A - alveolar edema (bat wing opacities)

 B - Kerley B lines

 C - cardiomegaly

 D - dilated upper lobe vessels

 E - pleural effusion
Alveolar edema
 Kerley B lines

Kerley-B lines are seen as peripheral short 1-2 cm horizontal lines near the
costophrenic angles.
These lines run perpendicular to the pleura.
Cardiomegaly
 The cardiothoracic ratio (CTR) is the ratio of the transverse
diameter of the heart to the internal diameter of the chest at its
widest point just above the dome of the diaphragm as measured on
a PA chest film.
 An increased cardiac silhouette is almost always the result of
cardiomegaly, but occasionally it is due to pericardial effusion or
even fat deposition.
 The heart size is considered too large when the CTR is > 50% on a
PA chest x-ray.
 A CTR of > 50% has a sensitivity of 50% for CHF and a
specificity of 75-80%.
 An increase in left ventricular volume of at least 66% is necessary
before it is noticeable on a chest x-ray.
Dilated upper lobe vessels
 In a normal chest film with the patient standing erect, the
pulmonary vessels supplying the upper lung fields are smaller
and fewer in number than those supplying the lung bases.
 The pulmonary vascular bed has a significant reserve capacity
and recruitment may open previously non-perfused vessels
and causes distension of already perfused vessels.
 This results in redistribution of pulmonary blood flow.
 First there is equalisation of blood flow and subsequently
redistribution of flow from the lower to the upper lobes.
 The term redistribution applies to chest x-rays taken in full
inspiration in the erect position.
 In daily clinical practice many chest films are taken in a
supine or semi-erect position and the gravitational difference
between the apex and the lung bases will be less.
 In the supine position, there will be equalisation of blood
flow, which may give the false impression of redistribution.
 In these cases comparison with old fims can be helpful.
Pleural effusion
 Pleural effusion is bilateral in 70% of cases of CHF.
 When unilateral, it is slightly more often on the right side than
on the left side.
 There has to be at least 175 ml of pleural fluid, before it will
be visible on a PA image as a meniscus in the costophrenic
angle.
 On a lateral image effusion of > 75 ml can be visible.
 If pleural effusion is seen on a supine chest film, it means that
there is at least 500 ml present.
 ECHOCARDIOGRAPHY

 Echocardiography is the most common imaging modality

used to evaluate patients with heart failure.
 It is able to provide a semi-quantitative assessment of
heart chamber dimensions, valvular function, ejection
fraction, pericardial effusions and determine the presence
of valvular or wall abnormalities.
Variables near ubiquitously assessed in a complete transthoracic
echocardiograph exam include :
 The systolic function of the left ventricle
 the surrogate measure ejection fraction is the most popular method
 The diastolic function of the left ventricle
 perturbations are often appreciable before the systolic function is affected
 Structure of the left ventricle
 wall thickness and left ventricular end-diastolic internal diameter may yield
a derived mass, the basis of diagnosing remodeling and hypertrophy
 The right ventricular structure and function
 more technically challenging, RV strain lacks parameters to assess to nearly
the same degree as the left ventricl
 COMPUTED TOMOGRAPH

 CT chest may demonstrate the same features as the plain

radiograph but in greater detail and clarity.
 Furthermore, electrocardiograph-gated CT and cardiac CT
angiography may provide estimates of cardiac function and
detailed visualization of various cardiac structures.
 Mediastinal lymph node enlargement may be present in
some cases.
 MAGNETIC RESONANCE IMAGING

 Cardiac MRI (CMR) is able to provide highly accurate ejection

fraction estimates and determine the presence of any structural
abnormalities and is considered by many to be the gold
standard imaging modality.

 Patterns of late gadolinium enhancement can distinguish

between many etiologies of heart failure.
 Treatment and prognosis

 Prognosis is usually poor unless the underlying cause is

reversed. As a result, patients generally gradually deteriorate
with episodes of acute decompensation and ultimately death.
 In addition to treating the underlying cause of heart failure,
management is directed at dietary and lifestyle changes,
medications including ACE inhibitors or beta blockers and if
appropriate, implantable cardioverter-defibrillator (ICD) or
cardiac resynchronisation therapy (CRT)
THANK YOU