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Chest X-ray signs of cardiac disease

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Title: Chest X-ray signs of cardiac disease


1
Chest X-ray signs of cardiac disease
  • A. Swartbooi
  • Diagnostic Radiology, UFS
  • 2 March 2012

2
Congenital Heart Disease
  • Numerous clinically important imaging signs in
    congenital cardiovascular disease.
  • It is important that Radiologists must be able to
    recognize these signs and must understand their
    causes in order to provide accurate diagnoses of
    abnormalities affecting the heart and vessels of
    the thorax.

3
Congenital Heart Disease
  • Transposition of the Great Arteries
  • Most common cyanotic congenital heart lesion
  • 57 of congenital cardiac malformations
  • isolated in 90
  • Transposition of the great arteries is produced
    by a ventriculoarterial discordance in which the
    aorta arises from the morphologic right ventricle
    and the pulmonary artery arises from the
    morphologic left ventricle
  • Pulmonary artery is situated to the right of its
    normal location
  • Results in the apparent narrowing of the superior
    mediastinum on radiographs
  • Patent ASD, VSD, Foramen ovale, systemic
    collaterals to sustain life
  • Atrial border is abnormally convex, and the left
    atrium commonly is enlarged because of increased
    pulmonary blood flow.

4
TGA EGG ON STRING SIGN
5
Congenital Heart Disease
  • Total Anomalous Pulmonary Venous Return
  • Occurs when the pulmonary veins fail to drain
    into the left atrium and instead form an aberrant
    connection with some other cardiovascular
    structure
  • 2 of cardiac malformations
  • Four types of TAPVR may be defined
  • Type I (55)
  • The anomalous pulmonary veins terminate at the
    supracardiac level.
  • Typically, four anomalous pulmonary veins
    converge behind the left atrium and form a common
    vein, known as the vertical vein, this passes
    anterior to the left pulmonary artery and the
    left main bronchus to join the innominate vein
  • Less commonly, drainage to the left
    brachiocephalic vein, right superior vena cava,
    or azygos v
  • Classic snowman sign
  • Type II (30)
  • Involves a pulmonary venous connection at the
    cardiac level.
  • Pulmonary veins join either the coronary sinus or
    the right atrium.

6
Congenital Heart Disease
  • Type III (13)
  • Involves a connection at the infracardiac or
    infradiaphragmatic level
  • Pulmonary veins join behind the left atrium to
    form a common vertical descending vein, which
    courses anterior to the esophagus and passes
    through the diaphragm at the esophageal hiatus
  • Vertical vein usually joins the portal venous
    system but occasionally connects directly to the
    ductus venosus, the hepatic veins, or the
    inferior vena cava.
  • Type IV (2)
  • Involves anomalous venous connections at two or
    more levels.
  • In the most common pattern, the vertical vein
    drains into the left innominate vein, and the
    anomalous vein or veins from the right lung drain
    into either the right atrium or the coronary
    sinus
  • Generally associated with other major cardiac
    lesions.

7
TAPVR I SNOWMAN SIGN
8
Congenital Heart Disease
  • Partial Anomalous Pulmonary Venous Return
  • Anomalous pulmonary vein drains any or all of the
    lobes of the right lung
  • Vein curves outward along the right cardiac
    border, usually from the middle of the lung to
    the cardiophrenic angle, and usually empties into
    the inferior vena cava but also may drain into
    the portal vein, hepatic vein, or right atrium
  • Size of the vein generally increases as it
    descends.
  • Characteristic appearance of the vein has led to
    its comparison to a scimitar
  • Flow through the scimitar vein produces a
    left-to-right shunt that is usually
    hemodynamically insignificant.
  • Part of Scimitar syndrome when associated with
  • Hypoplasia of the right lung with dextroposition
    of the heart,
  • Hypoplasia of the right pulmonary artery, and
  • Anomalous arterial supply of the right lower lobe
    from the abdominal aorta

9
PAPVR SCIMITAR SIGN
10
Congenital Heart Disease
  • Endocardial Cushion Defects
  • Interruption of the normal development of the
    endocardial tissues during gestation which
    normally forms the lower portion of the atrial
    septum, the upper portion of the interventricular
    septum, and the septal leaflets of the mitral
    valve and the tricuspid valve
  • 4 of all cases of congenital heart disease
  • Gooseneck-shaped deformity
  • Caused by a deficiency of both the conus and
    sinus portions of the interventricular septum,
    with narrowing of the left ventricular outflow
    tract.
  • Characteristic shape by concavity of the
    interventricular septum below the mitral valve,
    along with the elongation and narrowing of the
    left ventricular outflow tract

11
Endocardial cushion defect - GOOSENECK SIGN
12
Congenital Heart Disease
  • Tetralogy of Fallot
  • 1011 of cases of congenital heart disease
  • As a result of single defect, an anterior
    malalignment of the conal septum
  • Components
  • Ventricular septal defect
  • Infundibular pulmonary stenosis
  • Overriding aorta
  • Right ventricular hypertrophy.
  • Heart has the shape of a wooden shoe or boot
  • Blood flow to the lungs is usually reduced

13
Tetralogy of Fallot BOOT SHAPED SIGN
14
Congenital Heart Disease
  • Aortic Coarctation
  • 510 of congenital cardiac lesions
  • Produced by a deformity of the aortic media and
    intima, which causes a prominent posterior
    infolding of the aortic lumen
  • Occurs at or near the junction of the aortic arch
    and the descending thoracic aorta
  • Infolding cause eccentric narrowing of the lumen
    at the level where the ductus or ligamentum
    arteriosus inserts anteromedially
  • Resultant luminal narrowing in turn obstructs the
    flow of blood from the left ventricle
  • Classic radiologic signs
  • Figure-of-three sign
  • Reverse figure-of-three sign
  • Rib notching on CXR pathognomonic

15
Aortic Coarctation Figure ofThree, and
Reverse Figure of Three
16
Congenital Heart Disease
  • Ebstein Anomaly
  • 0.50.7 of cases of congenital heart disease.
  • Characterized by the downward displacement of the
    septal leaflets and posterior leaflets of the
    tricuspid valve into the inflow portion of the
    right ventricle.
  • Results in the formation of a common right
    ventriculoatrial chamber and causes tricuspid
    regurgitation.
  • Insufficiency of the tricuspid valve leads to
    dilatation of the right ventricular outflow tract
    and all proximal right heart structures,
  • Most consistent imaging feature is right atrial
    enlargement

17
Ebstein Anomaly Box Shaped Heart
18
Useful Approach
  • Clinical
  • Cyanotic vs Acyanotic
  • Thoracic Musculoskeletal Structures
  • prior operations, rib or sternal deformities or
    sternal wire sutures
  • Pulmonary vascularity
  • ? pulmonary arterial circulation versus pulmonary
    venous hypertension
  • Overall Heart Size
  • Assessing CT index

19
Useful Approach
  • Specific Chamber Enlargement
  • LA
  • Right retrocardiac double density
  • Splayed carina, horiz L bronchus
  • Posterior displacement of the left upper lobe
    bronchus
  • Enlarged atrial appendage
  • RA
  • Lateral bulging and elongation of the right heart
    border
  • LV RV
  • PA View ?
  • Lat
  • Great arteries
  • Ascending aorta,
  • Aortic knob,
  • Main pulmonary arterial segment

20
Acquired Heart Disease
  • In the evaluation of acquired heart disease a
    systematic approach is directed toward discerning
    the pertinent findings from the radiograph and,
    for each finding, narrowing the diagnostic
    considerations
  • Cardiac size and chamber enlargement can be
    inferred by evaluation of the chest radiograph.
  • The normal heart will occupy slightly less than
    50 of the transverse dimension of the thorax.

21
Anatomy
22
Anatomy
23
Acquired Heart DiseaseSmall Heart
24
RADIOGRAPHIC FEATURES OF AORTIC STENOSIS
  • Enlargement of the ascending aorta due to
    poststenotic dilatation
  • Mild or no cardiomegaly in compensated stage
  • Substantial cardiomegaly occurs only after
    myocardial failure has ensued
  • No pulmonary venous hypertension or pulmonary
    edema is seen during most of the course of this
    disease
  • Calcification of aortic valve may be discernible
    on radiograph but is more readily shown on CT

25
RADIOGRAPHIC FEATURES OF ARTERIAL HYPERTENSION
  • Enlargement of the thoracic aortaascending,
    arch, and descending aorta
  • Mild or no cardiomegaly until the onset of
    myocardial failure
  • No pulmonary edema or pulmonary venous
    hypertension until the occurrence of diastolic
    dysfunction due to severe left ventricular
    hypertrophy or myocardial failure

26
RADIOGRAPHIC FEATURES OF MITRAL STENOSES
  • Pulmonary venous hypertension or edema is present
  • Pulmonary edema may be observed intermittently
  • Mild cardiomegaly is seen in isolated mitral
    stenoses
  • Enlargement of the left atrium is characteristic
  • Enlargement of the left atrial appendage is
    frequent and suggests a rheumatic etiology
  • Right ventricular enlargement indicates some
    degree of pulmonary arterial hypertension or
    associated tricuspid regurgitation.

27
RADIOGRAPHIC FEATURES OF MITRAL STENOSES
  • Enlargement of the pulmonary arterial segment is
    indicative of associated pulmonary arterial
    hypertension
  • Right ventricular enlargement in the absence of
    prominence of the main pulmonary artery suggests
    associated tricuspid regurgitation. The right
    atrium is also enlarged with tricuspid
    regurgitation
  • The ascending aorta and aortic arch are usually
    inconspicuous in isolated mitral stenosis. Even
    slight enlargement of the thoracic aorta raises
    the question of associated aortic valve disease

28
RADIOGRAPHIC FEATURES OF HYPERTROPHIC
CARDIOMYOPATHY
  • Normal in most patients
  • Mild cardiomegaly and pulmonary venous
    hypertension in a minority of patients
  • Left atrial enlargement can be caused by
    associated mitral insufficiency or reduced left
    ventricular compliance
  • In the obstructive form (subaortic stenosis),
    ascending aortic enlargement is infrequent
  • Left ventricular enlargement may occur in
    end-stage disease

29
RADIOGRAPHIC FEATURES OF RESTRICTIVE
CARDIOMYOPATHY
  • Pulmonary venous hypertension is typical
  • Pulmonary edema may occur intermittently
  • Normal heart size or mild cardiomegaly in most
    patients
  • Left atrial enlargement
  • Left atrial appendage is typically not enlarged
  • Moderate to severe cardiomegaly can ensue in
    end-stage disease

30
RADIOGRAPHIC FEATURES OF ACUTE MYOCARDIAL
INFARCTION
  • Normal chest x-ray in about 50 of first acute
    infarctions
  • Normal heart size with pulmonary venous
    hypertension or pulmonary edema in about 50 of
    first acute infarctions
  • Cardiomegaly is usually indicative of acute
    infarction in a patient with history of previous
    infarctions
  • Cardiomegaly may be indicative of ischemic
    cardiomyopathy

31
RADIOGRAPHIC FEATURES OF ACUTE MYOCARDIAL
INFARCTION
  • Signs of complication of acute myocardial
    infarction
  • Intractable pulmonary edema may occur with
    papillary muscle rupture (mitral regurgitation)
    or ventricular septal rupture (left to right
    shunt).
  • Enlarged cardiac silhouette may be caused by
    pericardial effusion.
  • Abnormal cardiac contour may be a sign of true
    (bulge of the anterolateral or apical regions) or
    false (bulge of the posterior or diaphragmatic
    regions) aneurysms

32
RADIOGRAPHIC FEATURES OF CONSTRICTIVE PERICARDITIS
  • Pulmonary venous hypertension
  • Normal heart size or mild cardiomegaly
  • Left atrial enlargement may be discernible
  • Flattened cardiac contours are pathognomonic but
    infrequently observed
  • Calcification of the cardiac margin, especially
    the atrioventricular and interventricular grooves

33
Acquired Heart DiseaseLarge Heart
34
RADIOGRAPHIC FEATURES OF AORTIC REGURGITATION
  • Absence of pulmonary venous hypertension or
    pulmonary edema until late in the course of this
    lesion
  • Moderate to severe cardiomegaly
  • Left ventricular enlargement
  • Enlargement of ascending aorta and aortic arch

35
RADIOGRAPHIC FEATURES OF MITRAL REGURGITATION
  • Variable degree of pulmonary venous hypertensive
    or pulmonary edema (less severe than with mitral
    stenosis)
  • Moderate to severe cardiomegaly
  • Left ventricular enlargement
  • Left atrial enlargement
  • Enlargement of left atrial appendage

36
RADIOGRAPHIC FEATURES OF TRICUSPID REGURGITATION
  • No pulmonary venous hypertension or pulmonary
    edema (isolated tricuspid regurgitation)
  • Pulmonary venous hypertension or edema indicates
    associated mitral valve disease
  • Moderate to severe cardiomegaly
  • Right ventricular enlargement
  • Right atrial enlargement

37
RADIOGRAPHIC FEATURES OF CONGESTIVE (DILATED)
CARDIOMYOPATHY
  • Pulmonary venous hypertension or pulmonary edema
    may be but is not invariably present
  • Moderate to severe cardiomegaly
  • Left ventricular enlargement
  • Left atrial enlargement is infrequently evident
    but can be caused by mitral regurgitation caused
    by left ventricular enlargement

38
Congestive Heart Failure
39
RADIOGRAPHIC FEATURES OF PERICARDIAL EFFUSION
  • No pulmonary venous hypertension or pulmonary
    edema
  • Moderate to severe enlargement of cardiac
    silhouette
  • Associated pleural effusion is not uncommon
  • Specific features, such as fat pad and/or
    variable density signs, are infrequently
    evident

40
ENLARGEMENT OF MAIN PULMONARY ARTERY
  • Etiology
  • Pulmonary arterial hypertension
  • Excess pulmonary blood flow (left to right
    shunts, chronic high output states)
  • Valvular pulmonic stenosis
  • Pulmonary regurgitation
  • Congenital absent pulmonary valve (aneurysmal
    pulmonary artery)
  • Absence of left pericardium
  • Aneurysm of pulmonary artery
  • Idiopathic dilatation of pulmonary artery

41
Cardiac Calcification
  • Ascending aortic calcification
  • Most frequently observed on the right
    anterolateral margin of the ascending aorta in
    elderly individuals, especially in the presence
    of aortic valve disease.
  • In the past, it was considered to be a
    characteristic of syphilitic aortitis.
  • Mitral annular calcification
  • Dense C-shaped calcification in the region of the
    mitral valve.
  • It may be a causative factor of mitral
    regurgitation.
  • It is frequently observed in apparently normal
    elderly patients.
  • Aortic annular calcification
  • A circular calcification in the region of the
    aortic valve.
  • Extension of this calcification into the region
    of the conducting system can produce complete
    heart failure.
  • Valvular calcification (aortic and mitral).
  • Calcification of the aortic valve of sufficient
    density and extent to be visualized on the
    radiograph is nearly always associated with
    hemodynamically important aortic stenosis
    (gradient more than 50 mm Hg).

42
Cardiac Calcification
  • Coronary arterial calcification
  • Coronary arterial calcification is frequently
    observed by fluoroscopy or CT.
  • It must be both dense and extensive to be
    recognized on the thoracic radiograph.
  • Left ventricular mural calcification
  • Most frequently located in the anterolateral or
    apical regions of the left ventricle and marks
    the site of a transmural MI or aneurysm.
  • Pericardial calcification
  • Indicative of constrictive pericarditis.
  • Located usually in the interventricular or
    atrioventricular grooves of the heart.
  • Unusual sites
  • Intracardiac tumor (left atrial myxoma),
  • Pericardial tumor (dermoid), or
  • Healed granulomas (myocardial tuberculoma).
  • An extremely rare process of the left ventricle,
    Loeffler's eosinophilic fibroplasia, can cause
    calcification of the left ventricular wall.

43
Cardiac Calcification
44
Reference
  • Thoracic Imaging Pulmonary and Cardiovascular
    Radiology, 1st Edition Webb, Richard W.
    Higgins, Charles B. page 655-702.
  • Grainger Allison's Diagnostic Radiology, 5th
    ed page 450-526
  • Classic Imaging Signs of Congenital
    Cardiovascular Abnormalities, RadioGraphics 2007
    2713231334
  • http//radiologymasterclass.co.uk/tutorials/chest/
    chest_pathology/chest_pathology_page8.html(last
    accessed 22/02/12)

45
Acquired Heart DiseaseApproach
46
Cardiac Valvular Lesions
47
Signpost
48
Signpost
  • If no signposts are present, then the diagnosis
    is unlikely to be a valvular lesion.
  • The absence of signposts should direct attention
    to a disease directly afflicting the myocardium
    or pericardium, such as acute MI, hypertrophic
    cardiomyopathy, restrictive cardiomyopathy, and
    constrictive pericardial disease.
  • However, even these latter diseases sometimes
    induce left atrial enlargement, as stated above.

49
Cardiac Size
50
ENLARGEMENT OF THE MIDDLE SEGMENT OF LEFT HEART
BORDER
  • Etiology
  • Dilated left atrial appendage (rheumatic mitral
    valve disease)
  • Partial absence of left pericardium
  • Enlargement of right ventricular outlet region
    such as occurs with left-to-right shunts
  • Asymmetric form of hypertrophic cardiomyopathy
    (minority of cases)
  • Levo transposition of the great arteries
  • Juxtaposition of atrial appendages (rare anomaly
    usually associated with tricuspid atresia)
  • Left ventricular aneurysm
  • Cardiac tumor
  • Aneurysm or pseudoaneurysm of left circumflex
    coronary artery
  • Pericardial cyst or tumor
  • Mediastinal tumor

51
EVAGINATION OF LEFT LOWER HEART BORDER
  • Etiology
  • Ventricular aneurysm
  • Ventricular tumor
  • Pericardial cyst, diverticulum or tumor
  • Left ventricular diverticulum
  • Mediastinal or lung tumor
  • Pericardial fat pad

52
ENLARGEMENT OF RIGHT HEART AND BORDER
  • Etiology
  • Right atrial enlargement
  • Pericardial fat pad
  • Eventration or hernia of diaphragm
  • Pericardial cyst or diverticulum
  • Pericardial tumor
  • Cardiac tumor
  • Diaphragmatic tumor
  • Mediastinal tumor
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