Download Chest X-ray Interpretation

Chest X-ray
signs of cardiac disease
A. Swartbooi
Diagnostic Radiology, UFS
2 March 2012
Congenital Heart Disease
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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.
Congenital Heart Disease
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Transposition of the Great Arteries
– Most common cyanotic congenital heart lesion
– 5%–7% of congenital cardiac malformations
– isolated in 90%
– Transposition of the great arteries is produced by a ventriculoarterial
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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.
TGA –
EGG ON STRING SIGN
Congenital Heart Disease
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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
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Type I (55%)
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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%)
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Involves a pulmonary venous connection at the cardiac level.
Pulmonary veins join either the coronary sinus or the right atrium.
Congenital Heart Disease
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Type III (13%)
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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.
TAPVR I –
SNOWMAN SIGN
Congenital Heart Disease
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Partial Anomalous Pulmonary Venous Return
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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:
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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
PAPVR –
SCIMITAR SIGN
Congenital Heart Disease
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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
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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
Endocardial cushion defect GOOSENECK SIGN
Congenital Heart Disease
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Tetralogy of Fallot
– 10%–11% 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
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Tetralogy of Fallot –
BOOT SHAPED SIGN
Congenital Heart Disease
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Aortic Coarctation
– 5%–10% of congenital cardiac lesions
– Produced by a deformity of the aortic media and intima, which causes a
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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
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Figure-of-three sign
Reverse figure-of-three sign
Rib notching on CXR pathognomonic
Aortic Coarctation –
Figure of
Three, and Reverse Figure of Three
Congenital Heart Disease
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Ebstein Anomaly
– 0.5%–0.7% 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;
Ebstein Anomaly –
Box Shaped Heart
Useful Approach
Clinical
A.
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Cyanotic vs Acyanotic
Thoracic Musculoskeletal
Structures
1.
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prior operations, rib or
sternal deformities or
sternal wire sutures
Pulmonary vascularity
2.
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⇧ pulmonary arterial
circulation versus
pulmonary venous
hypertension
Overall Heart Size
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Assessing CT index
Useful Approach
Specific Chamber Enlargement
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Right retrocardiac double density
Splayed carina, horiz L bronchus
Posterior displacement of the left
upper lobe bronchus
Enlarged atrial appendage
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RA
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Great arteries
– Ascending aorta,
LA
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5.
Lateral bulging and elongation of the
right heart border
LV & RV
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PA View
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Lat
⇨
– Aortic knob,
– Main pulmonary arterial
segment
Acquired Heart Disease
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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.
Anatomy
Anatomy
Acquired Heart Disease
Small Heart
RADIOGRAPHIC FEATURES OF
AORTIC STENOSIS
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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
RADIOGRAPHIC FEATURES OF
ARTERIAL HYPERTENSION
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Enlargement of the thoracic aorta—
ascending, 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
RADIOGRAPHIC FEATURES OF
MITRAL STENOSES
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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.
RADIOGRAPHIC FEATURES OF
MITRAL STENOSES
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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
RADIOGRAPHIC FEATURES OF
HYPERTROPHIC CARDIOMYOPATHY
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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
RADIOGRAPHIC FEATURES OF
RESTRICTIVE CARDIOMYOPATHY
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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
RADIOGRAPHIC FEATURES OF ACUTE
MYOCARDIAL INFARCTION
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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
RADIOGRAPHIC FEATURES OF ACUTE
MYOCARDIAL INFARCTION
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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
RADIOGRAPHIC FEATURES OF
CONSTRICTIVE PERICARDITIS
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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
Acquired Heart Disease
Large Heart
RADIOGRAPHIC FEATURES OF
AORTIC REGURGITATION
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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
RADIOGRAPHIC FEATURES OF
MITRAL REGURGITATION
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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
RADIOGRAPHIC FEATURES OF
TRICUSPID REGURGITATION
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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
RADIOGRAPHIC FEATURES OF
CONGESTIVE (DILATED)
CARDIOMYOPATHY
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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
Congestive Heart Failure
RADIOGRAPHIC FEATURES OF
PERICARDIAL EFFUSION
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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
ENLARGEMENT OF MAIN PULMONARY
ARTERY
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Etiology
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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
Cardiac Calcification
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Ascending aortic calcification
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Mitral annular calcification
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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
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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.
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).
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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).
Cardiac Calcification
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Coronary arterial calcification
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Left ventricular mural calcification
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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
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Coronary arterial calcification is frequently observed by fluoroscopy or CT.
It must be both dense and extensive to be recognized on the thoracic radiograph.
Indicative of constrictive pericarditis.
Located usually in the interventricular or atrioventricular grooves of the heart.
Unusual sites
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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.
Cardiac Calcification
Reference
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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; 27:1323–1334
http://radiologymasterclass.co.uk/tutorials/chest/chest_path
ology/chest_pathology_page8.html(last accessed 22/02/12)
Acquired Heart Disease
Approach
Cardiac Valvular Lesions
Signpost
Signpost
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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.
Cardiac Size
ENLARGEMENT OF THE MIDDLE
SEGMENT OF LEFT HEART BORDER
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Etiology
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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
EVAGINATION OF LEFT LOWER
HEART BORDER
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Etiology
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Ventricular aneurysm
Ventricular tumor
Pericardial cyst, diverticulum or tumor
Left ventricular diverticulum
Mediastinal or lung tumor
Pericardial fat pad
ENLARGEMENT OF RIGHT HEART
AND BORDER
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Etiology
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Right atrial enlargement
Pericardial fat pad
Eventration or hernia of diaphragm
Pericardial cyst or diverticulum
Pericardial tumor
Cardiac tumor
Diaphragmatic tumor
Mediastinal tumor