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Thoracic Radiology Wendy Blount, DVM Nacogdoches TX Thoracic Rads - Normal Why is it so difficult to evaluate cardiac and chamber size on radiographs? • Comparing heart size to lung field size doesn’t work – Dogs of different conformation have different ratios of heart size to lung size – Lung field size changes with the breathing cycle – Abdominal fat pushes the diaphragm cranially – Thoracic fat makes lung fields appear smaller • Comparing heart size to vertebral size works better – Vertebral heart score Thoracic Rads - Normal Why is it so difficult to evaluate cardiac and chamber size on radiographs? • Things can make the heart look bigger – – – – Pericardial fat Pericardial effusion Peritoneopericardial diaphragmatic hernia Oblique positioning on VD/DV can make right heart look bigger • MYTH - “increased sternal contact” means right heart enlargement Thoracic Rads - Normal Normal cats change with age • Long axis of the heart is more horizontal in old cats (40%) • Aortic bulge (30%) – Not due to hypertension or hyperthyroidism – At the aortic isthmus – Measurements in young & old cats are the same Thoracic Rads - Normal Vertebral Heart Score • Measure heart long axis 5.0 + 4.8 = 9.8 – carina to the apex • Measure heart short axis – Widest perpendicular to length • • • • Count vertebrae from cranial aspect T4 Add together Dogs – normal 8.5-10.5 Cats – normal 7-8 Thoracic Rads - Normal Heart Chambers – VD/DV • LV 3-6 o’clock • Aorta 12-1 o’clock • RV 5-9 o’clock • MPA 1-2 o’clock • LA has to be really big to see on VD • RA 9-12 o’clock Thoracic Rads - Normal Review of thoracic radiographs • Skeletal – Spine, front limbs, ribs, sternum • Cranial abdomen • Airways, Lung fields • Great vessels – Aorta, pulmonary arteries, cranial & caudal vena cava • Smaller vessels – Internal thoracic arteries, pulmonary lobar a & v, brachiocephalic trunk, left subclavian artery • Cardiac silhouette – Vertebral heart score, bulge • Left Heart Failure? Right Heart Failure? Thoracic Rads - Normal Heart Chambers – Lateral • LA – caudal waist – 12-3 o’clock • LV 2-6 o’clock • Aorta 10-11 o’clock • Raur 9 o’clock (RA not on lateral) • RV 6-9 o’clock • MPA 11-12 o’clock normal – Bulge often 1-2 o’clock Thoracic Rads - Abnormal 6.2 + 5.9 = 12.1 Case #1 – 8 year old neutered male cocker spaniel - coughing • Skeletal • Cranial abdomen – No abnormalities noted • Airways, Lung fields – Mild perihilar edema • Great vessels – enlarged caudal vena cava • Smaller vessels – enlarged pulmonary lobar veins • Cardiac silhouette – Generalized cardiomegaly, enlarged LA Thoracic Rads - Abnormal Case #1 – 8 year old neutered male cocker spaniel - coughing • Left Heart Failure – – – – Mild perihilar edema enlarged pulmonary lobar veins enlarged LA (generalized cardiomegaly) Enlarged LV (elevated trachea) • Right Heart Failure – enlarged caudal vena cava – Generalized cardiomegaly (RV enlargement) – (ascites, pleural effusion) Thoracic Rads - Abnormal Case #1 – 8 year old neutered male cocker spaniel - coughing • Diagnosis by echo - DCM Thoracic Rads - Abnormal Are rads or echo better for detecting congestive heart failure? • radiographs Are rads or echo better for detecting enlarged heart chambers? • echo Thoracic Rads - Abnormal Generalized cardiomegaly (all 4 heart chambers enlarged) Dogs • Dilated Cardiomyopathy • Mitral regurgitation • Tricuspid regurgitation Cats • Dilated cardiomyopathy • anemia Thoracic Rads - Abnormal Pseudocardiomegaly • No significantly enlarged heart chambers • Significantly enlarged cardiac silhouette • Pericardial effusion – – – – Hemorrhage – heart base tumor Right heart failure – modified transudate Infectious pericarditis Idiopathic pericarditis • Peritoneopericardial Diaphragmatic Hernia • Pericardial fat Thoracic Rads - Abnormal Case #2 – 15 month Maine coon cat 5.1 + 3.8 = 8.9 – tachypnea, lethargy • Skeletal & cranial abdomen • Airways, Lung fields – No abnormalities noted • Great vessels – caudal vena cava somewhat enlarged • Smaller vessels – No abnormalities noted • Cardiac silhouette – Generalized cardiomegaly, apex shifted right Thoracic Rads - Abnormal Case #2 – 15 month Maine coon cat – tachypnea, lethargy • Heart Failure?? – Probably not • Diagnosis – Echo showed dilation of LV and RV – Flea Anemia (PCV 10%) Thoracic Rads - Abnormal 6.0 + 7.1 = 13.1 Case #3 – 5 year old Maltese – honking cough • Skeletal & cranial abdomen & small vessels – No abnormalities noted • Airways, Lung fields – Elevated trachea, compression of left bronchus – Focal pulmonary edema • Great vessels – Bulge at 1:30 on VD • Cardiac silhouette – Generalized cardiomegaly, apex shifted right, LA enl Thoracic Rads - Abnormal Case #3 – 5 year old Maltese • holosystolic murmur loudest L apex • continuous murmur is heard loudest at the left axilla • Left Heart Failure – pulmonary edema, LA enl, tracheal elevation • Airway Cough – compression of left bronchus and trachea • Bulge at 1:30 on VD, apex shifted right – cardiomegaly (R or L or both?) Thoracic Rads - Abnormal Case #3 – 5 year old Maltese • Diagnosis by echo - PDA – Right heart normal LISTEN TO THE LEFT ARMPIT!! When the left heart is markedly enlarged, right heart size can be difficult to evaluate Thoracic Rads - Abnormal Case #4 – 12 year old Mini Poodle - holosystolic murmur L apex • Skeletal, cranial abdomen, airways, Lung fields, Great vessels, small vessels – No abnormalities noted • Cardiac silhouette – VHS high if you include LA – VHS normal if you exclude LA – Huge LA • No signs of congestive heart failure Thoracic Rads - Abnormal Case #4 – 12 year old Mini Poodle - holosystolic murmur L apex • Diagnosis – Mitral regurgitation • Treatment – None needed • Monitoring – Chest rads every 6 months – Sooner if respiratory rate while sleeping >40 Thoracic Rads - Abnormal Case #4 – 12 year old Mini Poodle - holosystolic murmur L apex You can have a Huge LA and even LV without CHF CHF is rarely present without enlarged LA Thoracic Rads - Abnormal Case #5 – 4 year old DSH 4 + 3.5 = 7.5 - Murmur heard on annual – left sternum • Skeletal, cranial abdomen, Lung fields, airways, Great vessels, small vessels – No abnormalities noted • Cardiac silhouette – VHS normal – Enlarged LA on VD • No signs of congestive heart failure Diagnosis by echo - HCM Thoracic Rads - Abnormal Case #5 – 4 year old DSH - Murmur heard on annual – left sternum LA is seen more easily on the VD in cats • LA sits more cranial in the cat LA is seen more easily on lateral in dogs VHS usually does not include LA in cats • Other chambers need to be enlarged to perceive cardiomegaly on the lateral in cats Thoracic Rads - Abnormal Case #6 – 10 year old mixed dog - Gagging up white foamy fluid, mitral murmur • Skeletal, Cranial abdomen, Great vessels – No abnormalities • Airways, Lung fields – Elevated trachea, compressed left bronchus – Perihilar edema • Smaller vessels – enlarged pulmonary lobar veins • Cardiac silhouette – VHS 11.5, generalized cardiomegaly, enlarged LA Thoracic Rads - Abnormal Case #6 – 10 year old mixed dog - Gagging up white foamy fluid, mitral murmur • Left Heart Failure • Echo diagnosis – severe mitral regurgitation Thoracic Rads - Abnormal Case #7 – 1 yr old Golden Retriever - Episodes of collapse with exercise • Skeletal, Cranial abdomen, Airways, Lung fields, small vessels – No abnormalities • Cardiac silhouette – VHS 9.5, aortic bulge on lateral, enlarged LA • No signs of congestive heart failure • Echo diagnosis – severe SAS Thoracic Rads - Abnormal Case #7 – 12 yr old Mixed Terrier - Chronic cough and cyanosis • Skeletal, Cranial abdomen, Vessels – No abnormalities • Airways, Lung fields – Pronounced airway pattern • Cardiac silhouette – VHS 10-10.5, RV enlargement, apex shifted L • No heart failure Thoracic Rads - Abnormal Case #7 – 12 yr old Mixed Terrier - Chronic cough and cyanosis • Echo diagnosis – RV thickening – Pulmonary hypertension • Clinical Diagnosis – Severe chronic pulmonary disease Thoracic Rads - Abnormal Case #7 – 12 yr old Mixed Terrier - Chronic cough and cyanosis What does it mean when the apex is shifted right? – LV enlargement or generalized cardiomegaly What does it mean when the apex is shifted left? – RV enlargement Thoracic Rads - Abnormal Case #7 – 12 yr old Mixed Terrier - Chronic cough and cyanosis RV enlargement must be moderate to severe to see on rads RA enlargement difficult to appreciate on rads unless severe (cause) – TR Lifting of the apex off the sternum on lateral view means RV enlargement Thoracic Rads - Abnormal 3.75 / 1 = 3.75 Measuring RV enlargement on Lateral View of the Thorax 1. Measure heart long axis • Carina to apex 2. Measure heart short axis • Widest point perpendicular to long axis 3. Short Axis - Divide Cranial part by Caudal part • Cranial is <2.5x Caudal in normal dogs • (Cr >2.5x Cd) means RV enlargement Thoracic Rads - Abnormal Case #8 – 10 month old English Pointer Ejection murmur loudest at left heart base • Skeletal, Cranial Abdomen, Airways, Lung fields, small vessels – normal • Great vessels – pulmonary artery enlarged • No signs of Congestive Heart Failure Thoracic Rads - Abnormal Case #8 – 10 month old English Pointer Ejection murmur loudest at left heart base • Causes of enlarged MPA (dogs) – PS – PDA – Pulmonary hypertension (lobar aa also enlarged) • MPA enlargement – Not easily seen on lateral in dogs – not readily seen in cats • This case – echo diagnosis – PS – RV thickening Thoracic Rads - Abnormal Case #9 – 6 month old poodle with murmur found on physical exam Causes of enlarged pulmonary lobar arteries -Caudal lobar aa should be same width as a rib -cranial lobar aa 0.75x 3rd or 4th rib • PDA – Pulmonary lobar veins enlarged also – Called “pulmonary overcirculation” • Pulmonary hypertension • Heartworm Disease Thoracic Rads - Abnormal Case #10 – 5 yr old DSH cat tachypnea Causes of enlarged Caudal vena cava -size varies with respiratory cycle -only severe enlargement is reliably detected -maximum width < length T5 or T6 • Right heart failure Thoracic Rads - Abnormal Case #11 – 2 yr old DSH cat tachypnea • Left Heart Failure • Right Heart failure • Echo diagnosis – hypertrophic cardiomyopathy Thoracic Rads - Abnormal Case #12 – 6 yr old Westie ADR • Clinical diagnosis – severe dehydration • Causes of microcardia – Severe dehydration – Addison’s Disease – Pneumothorax (heart lifted off the sternum) Thoracic Rads - Review Left Heart Failure • Pulmonary edema • Pleural effusion in cats • Pulmonary lobar veins much larger than arteries • Enlarged LA – Not a sign of heart failure per se – But LHF is rarely present without LA enlargement • + Enlarged LV – Tracheal elevation – Cardiomegaly (increased VHS) Thoracic Rads - Review Right Heart Failure • Pleural effusion – Can obscure evaluation of the heart, lungs and great vessels • Enlarged caudal vena cava • Ascites – Modified transudate • Often concurrent with left heart failure – Generalized cardiomegaly (increased VHS) Thoracic Rads - Review Chronic Bronchitis • Increased or mineralized airway pattern • Peribronchiolar infiltrates – May progress to bronchopneumonia – Interstitial pattern – Alveolar pattern (air bronchograms) if severe • Signs of pulmonary hypertension – Enlarged pulmonary artery and lobar aa • No signs of heart failure Thoracic Rads - Review Patent Ductus Arteriosus -left to right shunt (aorta to MPA) -volume expansion • + Enlarged pulmonary artery • + Pulmonary overcirculation – Enlarged pulmonary lobar aa & vv • Enlarged descending aorta • Enlarged LV – Tracheal elevation – Increased VHS • Enlarged LA – + compression left bronchus • + pulmonary edema Thoracic Rads - Review Sub-Aortic Stenosis -pressure overload left side • + Enlarged LV – Increased VHS – Not as marked as volume overload • Enlarged ascending aorta • Left Heart Failure due to aortic insufficiency is rare Thoracic Rads - Review Pulmonic Stenosis -pressure overload right side • + Enlarged RV – Not as marked as volume overload • Enlarged MPA • Right Heart Failure due to pulmonic insufficiency is rare Thoracic Rads - Review Ventricular Septal Defect -left to right shunt (LV to RV) -volume expansion • + RV enlargement • + Pulmonary overcirculation – Enlarged pulmonary lobar aa & vv • Enlarged LV – Tracheal elevation – Increased VHS • Enlarged LA – + compression left bronchus • + pulmonary edema Thoracic Rads - Review Atrial Septal Defect -left to right shunt (LA to RA) -lower pressure differential, so no significant volume expansion • + RV enlargement • + RA enlargement – Enlarged pulmonary lobar aa & vv • Heart failure is rare (handout)