Chest X-ray for evaluation of cardiovascular system

Chest X-ray for evaluation of cardiovascular system

PresenterPraveen Gupta

ModeratorAjith Sir

JIPMERPondicherry

Date31/01/2017

1Chest X-ray for evaluation of crdiovascular system

Introduction2Chest x-ray most common radiographic examination Most difficult to interpretYields anatomic and physiologic informationIt is difficult and impossible to extract all information

Variables determine CXR3Technical factors Milliamperage KilovoltageExposure durationPatient-specific factors Body habitus,Age Physiologic status, Ability to stand and To take and hold a deep breath

Technical Considerations4 Frontal view and lateral viewPosteroanterior (PA) view standing with chest toward the recording medium and back to the x-ray tube Lateral view while standing with the left side toward the film

Portable CXRs Limitations5Obtained with patients supine or semisupine Depth of inspiration decreased Heart appear relatively largerLess optimal visualization of the lungs because they are not expanded.Taken as AP views SID < 6 feetSpace constraints Limited power of portable x-ray machine Longer exposure timeIncreased cardiac and respiratory motion and decreased resolution

Portable CXRs Limitations6Poor resolution Less accurate and usefulGreater radiation dose Most useful for simple mechanical questionPacemaker or implantable cardioverter-defibrillator (ICD) is properly positionedEndotracheal tube in correct locationMediastinum is midlineNot good at providing physiologic or complex anatomic informationImpossible to exclude pneumothorax or pleural effusion.Impossible to evaluate heart size and contour or status of the pulmonary vasculature Should be performed only in limited situations when clearly needed to answer specific questions

NORMAL CHEST RADIOGRAPH7Take systematic approach First assess anatomy Then physiologyFinally pathology.

Normal Chest Radiograph8Heart diameter is normally less than half the transverse diameter of the thorax Heart overlies roughly 75% to the left and 25% to the right of the spine. The mediastinum is narrow superiorly, and normally the descending aorta can be defined from the arch to the dome of the diaphragm on the left The pulmonary hila are seen below the aortic arch, slightly higher on the left than on theright On both frontal and lateral views, the ascending aorta (aortic root) is normally obscured by the main pulmonary artery and both atriaThe location of the pulmonary outflow tract is usually clear on the lateral film

Frontal projection of the heart and great vessels. A, Left and right heart borders in the frontal projection.B, A line drawing in the frontal projection demonstrates the relationship of the cardiac valves, rings, and sulci to the mediastinal borders. A = ascending aorta; AA = aortic arch; Az = azygous vein; LA = left atrial appendage; LB = left lower border of the pulmonary artery; LV = left ventricle; PA = main pulmonary artery; RA = right atrium; RV = right ventricle; S = superior vena cava; SC = subclavian artery.

NORMAL CHEST RADIOGRAPH9Cardiac Chambers and AortaOn the PA view, the right contour of the mediastinum contains the right atrium and the ascending aorta and superior vena cava (SVC)The right ventricle is located partially overlying the left ventricle Left atrium is located just inferior to the left pulmonary hilumConcavity at the level of location of the left atrial (LA) appendageThe left ventricle constitutes the prominent, rounded apex of the heart on the frontal view

Frontal projection of the heart and great vessels. A, Left and right heart borders in the frontal projection. B, A line drawing in the frontal projection demonstrates the relationship of the cardiac valves, rings, and sulci to the mediastinal borders. A = ascending aorta; AA = aortic arch; Az = azygous vein; LA = left atrial appendage; LB = left lower border of the pulmonary artery; LV = left ventricle; PA = main pulmonary artery; RA = right atrium; RV = right ventricle; S = superior vena cava; SC = subclavian artery.Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261

NORMAL CHEST RADIOGRAPH10 On lateral CXR the left main pulmonary artery can be seen coursing superiorly and posteriorly relative to the rightOn both frontal and lateral views, the ascending aorta (aortic root) is normally obscured by the main pulmonary artery and both atriaThe atrium constitutes the upper portion of the posterior contour of the heart on the lateral CXR but cannot normally be separated from the left ventricle The left ventricle constitutes the sloping inferior portion of the mediastinum on the lateral view

Lateral chest radiograph. B, Superimposed anatomic drawing of the cardiac chambers and great vessels. C, Diagram of the lateral projection of the heart showing the position of the cardiac chambers, valve rings, and sulci. Arrows indicate the direction of blood flow. A = aorta; PA = pulmonary artery; RAA = right atrial appendage; RV = right ventricle

NORMAL CHEST RADIOGRAPH11Heart appears white and lungs relatively black A fat pad surrounds apex of the heartCardiac motion is usually sufficient to cause minor haziness of the silhouette. If portion of the heart border does not move (as with left ventricular [LV] aneurysm) the border unusually sharp The aortic arch is visible because the aorta courses posteriorly and surrounded by airMost of the descending aorta is also visible

Chest X-ray showing Left ventricle aneurysm

Lungs and Pulmonary Vasculature12Lung size varies as a function of inspiratory effort, age, body habitus, water content, and intrinsic pathologic processes. Lung distensibility decreases with age, appear progressively smaller as patients ageWith increasing LVEDP as in heart failure, or increasing LA pressure, as in mitral stenosis expansion on a CXR is lessened Chronic obstructive pulmonary disease, heart appearing small even in the presence of cardiac dysfunction

Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261A, B, PA and lateral digital chest radiographs with different windows and leveling. A, With a pulmonary window and level, the lung fields, includingthe pulmonary vasculature, are well visualized but the mediastinal structures are not well defined. Note also flattening of the diaphragms and increased lung lucency,indicative of chronic obstructive pulmonary disease. B, Rewindowed, the mediastinal structures are now well seen and show a dilated, calcified aortic root and descendingthoracic aorta. Pulmonary vascularity cannot be defined in these images

Lungs and Pulmonary Vasculature13Pulmonary arteries visible centrally in the hila and less so more peripherally Main right and left pulmonary arteries difficult to quantifyIf the lung is thought of in three zones, the major arteries are central; the clearly distinguishable midsized pulmonary arteries (third- and fourth-order branches) are in the middle zone; and the small arteries and arterioles, which are normally below the limit of resolution, are in the outer zone

Lungs and Pulmonary Vasculature14Visible small and midsized arteries (midzone) have sharp, clearly definable marginsArteries in the lower zone are larger than those in the upper zone The angles that the lungs make with the diaphragm are normally sharp and clearly seenThe contour that the inferior vena cava (IVC) makes with the heart is clearly seen on the lateral CXR IVC lies on the right of the mediastinum and posterior to the contour of the heart.

Normal chest X-ray PA view

Lungs and Pulmonary Vasculature15If the patient is placed laterally with the left side against the film, the right is relatively slightly magnified in comparison to the leftThe aorta and great vessels normally dilate and become more tortuous and prominent with increasing age, thereby leading to widening of the superior mediastinum Heart appears larger because of decreasing lung compliance in old age although unless true cardiac disease is present, its diameter remains less than half the transverse diameter of the chest on a PA view

Normal lateral chest X-ray

Lungs and Pulmonary Vasculature16Patients who are obese may not be able to fully expand their lungs, thus making a normal heart appear slightly largerIn patients with pectus excavatum the heart may appear enlarged on the frontal view

Left side showing x-ray taken in thin individual and right chest x-ray showing film taken in obese patient

Chest radiograph in heart disease

17First step is to define which type of CXR study is being evaluatedPA and lateral, PA alone, or an AP viewThe next step is to determine whether previous CXRs are available for comparisonLook at areas that are easily ignoredSuch areas include thoracic spine, neck (for masses and tracheal position), costophrenic angles, lung apices, retrocardiac space, and retrosternal spaceEvaluate the lung fields next Search for infiltrates or masses, even when primary concern is cardiovascular abnormalities

Normal chest X-ray

Chest radiograph in heart disease18Size of the cardiac silhouette ,its position, and the location of the ascending and descending aortaSite and position of the stomach Define pulmonary vascularity by looking at the middle zone of the lungs (i.e., the third of the lungs between the hilar region and the peripheral region laterally) and comparing a region in the upper portion of the lungs with a region in the lower portion, at equal distances from the hilumVessels larger in the lower part of the lung and sharply marginated in both the upper and lower zones

Normal chest X-ray

Chest radiograph in heart disease19In normal individuals, vessels taper and bifurcate and are difficult to define in the outer third of the lung They normally become too small to be seen near the pleura

Chest radiograph in heart disease20When PA flow is increased, as in patients with a high-output state (e.g., pregnancy, severe anemia as in sickle cell disease, hyperthyroidism) or left-to-right shunt the pulmonary vessels are more prominent than usual in the periphery of the lung They are uniformly enlarged and can be traced almost to the pleura, but their margins remain clear

All of blood vessels everywhere in lung are bigger than normalRDPA Usually >17 mm

Increased Flow

Normal 21

Increased flow

Distribution of flow is maintained as in normal Lower lobe vessels bigger than upper lobeGradual tapering from central to peripheral

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Chest radiograph in heart disease23 In patients with elevated pulmonary venous pressure, the vessel borders become hazy, the lower zone vessels constrict, and the upper zone vessels enlarge; vessels become visible farther toward the pleura, in the outer third of the lungs

Venous Hypertension

RDPA usually > 17 mm

Upper lobe vessels equal to or larger than size of lower lobe vessels = Cephalization

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Rapid cutoff in size of peripheral vessels relative to size of central vessels

Central vessels appear too large for size of peripheral vessels which come from them = Pruning

31Pulmonary Arterial Hypertension 25

Chest radiograph in heart disease26With increasing LVEDP or LA pressure pulmonary edema developsPulmonary edema cause the classic perihilar bat wing appearanceWith chronic heart failure normal pulmonary vascular pattern or moderate rather than marked redistributionIn the setting of an acute, large transmural myocardial infarction (MI) heart is usually minimally or mildly enlarged despite a marked increase in LVEDP If the pulmonary edema is independent of LV dysfunction, however, as may occur at a high altitude or following cerebral trauma, the size of the heart may remain normal

Chest X-ray showing Bat-Wing appearnce in a patient with acute congestive heart failure

Cardiac Chambers and Great Vessels27Individual chambers should be examined In acquired valvular disease and in many types of congenital heart disease, however, individual chamber enlargement is present and crucial to CXR (and often clinical) diagnosis

Cardiac Chambers and Great Vessels28 Right AtriumRight atrial enlargement is never isolated except in the presence of congenital tricuspid atresia or the Ebstein anomaly Both are rareX-ray appearancePAinferior segment of right border of heart extending to right , bulge, high bulge point

Cardiac Chambers and Great Vessels29 Right AtriumRight atrial enlargementLateral the right atrial curvature at least half as long as the anterior border of heartbulgeThe right atrial contour blends with that of the SVC, right main pulmonary artery, and right ventricle. Thus it is almost impossible to define in adults, and it is pointless to try

Cardiac Chambers and Great Vessels30 Right VentricleCommonly seen in tetralogy of FallotSigns of RV enlargement are, boot-shaped heart and filling of the retrosternal airspace The former is caused by transverse displacement of the apex of the right ventricle as it dilates

Chest X-ray in a patient with TOF suggestive of boot shaped heart in PA view

Cardiac Chambers and Great Vessels31 Right VentricleOn a lateral CXR in normal patients, the soft tissue density is confined to less than one third the distance from the suprasternal notch to the tip of the xiphoid If the soft tissue fills in by more than one third in the absence of other it is a reliable indication of RV enlargement

Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261The lateral view confirms marked RV (arrow) and LA (small arrows) enlargement. Note filling in of theretrosternal airspace.

Left Atrium32First dilation of the LA appendage, seen as a focal convexity where there is normally a concavity between the left main pulmonary artery and the left border of the left ventricle on the frontal view Elevatation of the left main stem bronchus,Widening of the angle of carina Focal bowing of the middle to low thoracic aorta toward left Double density on the frontal view

Chest X-ray in a 17 year old male with severe rheumatic mitral valve stenosis showing dilated LA appendage, widening of anlge of carina, double density due to left atrial enlargementJIPMER hospital, CTVS Department

Left Atrium33On the lateral CXR, LA enlargement appears as a focal, posteriorly directed bulgeIn mitral stenosis the left atrium dilates than right ventricle dilated. The left ventricle remains normal

Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261FIGURE 15-10 Chest radiographs of a 60-year-old woman with severe mitral stenosis B, Lateral view confirming RV enlargement with filling in of the retrosternal airspace. Note also the marked LA enlargement (arrows).

Left Ventricle34LV enlargement is characterized by a prominent, downward directed contour of the apexCardiac contour enlargedMitral regurgitation, with increased volume in the left atrium and ventricle, both dilate

JIPMER hospital, CTVS DepartmentChest X-ray in a patient with severe rheumatic mitral regurgitation showing dilated left ventricle with dilated left atrium

Left Ventricle35Lateral CXR, posterior bulge, below the level of the mitral annulus Pushing gastric bubble inferiorly

Lateral view. Note enlargement of the left ventricle, which is extending below the diaphragm and compressing thegastric bubble (arrowheads).

Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261

Left Ventricle36Focal LV enlargement in adults is a common manifestation of aortic insufficiency (often with aortic root dilation) or mitral regurgitation (with LA dilation)

X-ray of 46 year old male who was known case of dilated ascending aorta with severe aortic regurgitation showing isolated enlargement of left ventricle along with shadow on the right side of the mediastinum suggestive of dilated ascending aorta, patient later underwent David repair with aortic valve repairJIPMER hospital, CTVS Department

Pulmonary Arteries37Dilation is seen as a prominent left hilum on the frontal view and a prominent pulmonary outflow tract on the lateral view

Chest X-ray in a patient with ASD with eissenmenger syndrome showing dilated pulmonary artery bayJIPMER hospital, Cardiology Department

Pulmonary Arteries38 Chest X-ray in a patient with VSD with Moderate Pulmonary artery hypertension showing dilated pulmonary artery bay

JIPMER hospital, Cardiology Department

Aortic Valve and Aorta39On frontal CXR, aortic dilation seen as prominence to the right of the middle mediastinum Prominence in the anterior mediastinum on the lateral view, posterior to the pulmonary outflow tract Aortic valve calcification pathognomonic for aortic valve disease, difficult to see on a CXR

Chest X-ray of a 46 year old male who was known case of dilated ascending aorta with severe aortic regurgitation showing isolated enlargement of left ventricle along with shadow on the right side of the mediastinum suggestive of dilated ascending aorta, patient later underwent David repair with aortic valve repairJIPMER hospital, CTVS Department

Pleura and Pericardium40The pericardium is rarely distinctly definable on a CXR In two situations it can be seen: calcification or, in the presence of a large effusion. With a large pericardial effusion, the visceral and parietal pericardial layers separatePleural calcification pathognomonic for asbestos exposure It is associated with a high risk for malignant mesothelioma

Chest X-ray showing Water bottle shape heart suggestive of large pericardial effusion

Pleura and Pericardium41Pericardial calcification is usually thin and linear and follows the contour of the pericardium, and it is often seen only on one view

Chest X-ray PV view and Lateral view only showing pericardial calcification

IMPLANTABLE DEVICES AND OTHER POSTSURGICAL FINDINGS42 CXR following surgery or other percutaneous interventions Prosthetic valves, pacemakers and ICDs Intra-aortic counterpulsation balloons and ventricular assist devicesChanges after surgery, such as the presence of clips on the side branches of the saphenous veins used for CABG as well as retrosternal blurring and effusions

JIPMER hospital, CTVS DepartmentChest X-ray in a patient with severe aortic regurgitation with severe mitral regurgitation who underwent double valve replacment with TTK Chitra valve

Position of prosthetic valve on chest X-ray43Location of the cardiac valves is best determined on the lateral radiograph Line drawn on the lateral radiograph from the carina to the cardiac apexPulmonic and aortic valves generally sit above this line and the tricuspid and mitral valves sit below this line

Position of prosthetic valve on chest X-ray44 Aortic valve is above the red line and mitral valve lies below this line

How to determine the position of prosthetic valve45

IMPLANTABLE DEVICES AND OTHER POSTSURGICAL FINDINGS46Whether the leads are intact and the second is the position of the tips There are two leads, the tips should generally be in the anterolateral wall of the right atrium and the apex of the right ventricleIf the leads are not positioned in this way, the reasons should be carefully determinedMalpositioned because of error or anatomic variants (e.g., a persistent left SVC that empties into the coronary sinus and then the right atrium)

Chest X-ray showing pacemaker and its lead position

CONCLUSION

47CXRs provide a wealth of physiologic and anatomic informationPlay role in the evaluation and management of patients with cardiovascular disordersRadiation dose in obtaining radiographs should always be considered Portable CXRs used infrequently because information is limited and may be misleadingStandard 6-foot frontal and lateral CXRs, are clinically useful If evaluated carefully by systematic approach and compared with previous CXRs, it is hard to overstate their importance

48Reference Braunwald 10 th edition,Chapter 15, The Chest Radiograph in Cardiovascular Disease Page no-261Thank to Department of Cardiology and CTVS deparment JIPMER hospital, Pondicherry for providing me chest x-ray for this ppthttp://www.slideshare.net/

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