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Thoracic Radiology Wendy Blount, DVM Nacogdoches TX Thoracic Rads - Normal Review of thoracic radiographs - Steps • 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 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 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 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 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 Thoracic Rads - Normal Why is it so difficult to evaluate cardiac and chamber size on radiographs? • Things can make the heart look bigger Thoracic Rads - Normal Why is it so difficult to evaluate cardiac and chamber size on radiographs? • Things can make the heart look bigger 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 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 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 Thoracic Rads - Normal Thoracic Rads - Normal Normal cats change with age • Long axis of the heart is more horizontal in old cats (40%) • Aortic bulge develops (30%) – Not due to hypertension or hyperthyroidism – At the aortic isthmus – Cardiac measurements in young & old cats are the same, despite these conformational changes in the thorax Thoracic Rads - Normal Vertebral Heart Score 5.0 + 4.8 = 9.8 Thoracic Rads - Normal Vertebral Heart Score • Measure heart long axis – 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 - Left LV - Left Ventricle AV - Aortic Valve AA - Ascending Aorta DA - Descending Aorta Thoracic Rads - Normal Heart Chambers – VD/DV - Left LV - Left Ventricle AV - Aortic Valve AA - Ascending Aorta DA - Descending Aorta LA – Left Atrium Thoracic Rads - Normal Heart Chambers – VD/DV - Left Thoracic Rads - Normal Heart Chambers – VD/DV - Right PV Right Ventricle Pulmonic Valve Main Pulmonary Artery Right Pulmonary Artery Left Pulmonary Artery Thoracic Rads - Normal Heart Chambers – VD/DV - Right Thoracic Rads - Normal Heart Chambers – VD/DV – Clock Face • Aorta 12-1 o’clock • LV 3-6 o’clock Thoracic Rads - Normal Heart Chambers – VD/DV – Clock Face • Aorta 12-1 o’clock • MPA 1-2 o’clock • LV 3-6 o’clock • RV 7-9 o’clock Thoracic Rads - Normal Heart Chambers – VD/DV – Clock Face • Aorta 12-1 o’clock • MPA 1-2 o’clock • LV 3-6 o’clock • RV 7-9 o’clock • LA has to be really big to see on VD Thoracic Rads - Normal Heart Chambers – VD/DV – Clock Face • Aorta 12-1 o’clock • MPA 1-2 o’clock • LV 3-6 o’clock • RV 7-9 o’clock • LA has to be really big to see on VD • RA 9-12 o’clock Thoracic Rads - Normal Heart Chambers – Lateral – Left • • • • • • • LA – Left Atrium MV – Mitral Valve LV – Left Ventricle AV – Aortic Valve SV – Sinus of Valsalva AAo – Ascending Aorta BCT – Brachiocephalic Trunk • LS – Left Subclavian a. Thoracic Rads - Normal Heart Chambers – Lateral – Right • • • • RA – Right Atrium Raur – R Auricle RV – Right Ventricle MPA – Pulmonary a. Thoracic Rads - Normal Heart Chambers – Lateral – Right • • • • • • • • RA – Right Atrium Raur – R Auricle RV – Right Ventricle MPA – Pulmonary a. RVOT – RV Outflow PV – Pulmonic Valve RPA – R Pulmonary a. LPA – L Pulmonary a. Thoracic Rads - Normal Heart Chambers – Lateral – Clock Face •LA (caudal waist) – 12-3 o’clock •LV - 2-6 o’clock Thoracic Rads - Normal Heart Chambers – Lateral – Clock Face •LA (caudal waist) – 12-3 o’clock •LV - 2-6 o’clock •RV - 6-9 o’clock •MPA – 10-11 o’clock – bulge at 1-2 o’clock Thoracic Rads - Normal Heart Chambers – Lateral – Clock Face •LA (caudal waist) – 12-3 o’clock •CdVC – 2 o’clock •LV - 2-6 o’clock •RV - 6-9 o’clock •Raur – 9 o‘clock •RA not easily seen on the lateral view •CrVC – 10 o’clock •MPA – 10-11 o’clock – bulge at 1-2 o’clock Thoracic Rads - Abnormal Case #1 – 8 year old neutered male cocker spaniel – coughing Thoracic Rads - Abnormal 6.2 + 5.9 = 12.1 Case #1 – 8 year old neutered male cocker spaniel – coughing Thoracic Rads - Abnormal 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 • 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 Thoracic Rads - Abnormal Case #1 – 8 year old neutered male cocker spaniel – coughing Thoracic Rads - Abnormal Case #1 – 8 year old neutered male cocker spaniel – coughing Thoracic Rads - Abnormal Case #1 – 8 year old neutered male cocker spaniel - coughing • Left Congestive Heart Failure – – – – Mild perihilar edema enlarged pulmonary lobar veins enlarged LA (generalized cardiomegaly) Enlarged LV (elevated trachea) • Right Congestive 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 Thoracic Rads - Abnormal Pseudocardiomegaly • No significantly enlarged heart chambers • Significantly enlarged cardiac silhouette • Pericardial effusion – – – – Hemorrhage – HBT or ruptured LA 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 Thoracic Rads - Abnormal Case #2 – 15 month Maine coon cat – 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 • 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 Case #3 – 5 year old Maltese • honking cough • holosystolic murmur loudest L apex Thoracic Rads - Abnormal 6.0 + 7.1 = 13.1 Case #3 – 5 year old Maltese • honking cough • holosystolic murmur loudest L apex Thoracic Rads - Abnormal Case #3 – 5 year old Maltese • continuous murmur is heard loudest at the left axilla • Left Heart Failure – pulmonary edema, LA enl, tracheal elevation • Airway Cough – enlarged LA – compression of left bronchus and trachea • Bulge at 1:30 on VD, apex shifted right – cardiomegaly (R or L or both?) Thoracic Rads - Abnormal Heart Chambers – VD/DV – Clock Face • Aorta 12-1 o’clock • MPA 1-2 o’clock • LV 3-6 o’clock • RV 7-9 o’clock • LA has to be really big to see on VD • RA 9-12 o’clock 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 on radiographs 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 – Cough suppressants • 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 Thoracic Rads - Abnormal 3 Most Common Causes of L Heart Enlargement 1. MR 2. PDA 3. SAS Thoracic Rads - Abnormal Case #5 – 4 year old DSH 4 + 3.5 = 7.5 - Murmur heard on annual – left sternum Thoracic Rads - Abnormal Case #5 – 4 year old DSH - 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 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 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 & enlarged LA on lateral • No signs of congestive heart failure • Echo diagnosis – severe SAS Thoracic Rads - Abnormal Loss of Cranial Waste 1. Dilated Aortic Arch • SAS • PDA • Tetralogy of Fallot 2. Enlarged RAuricle • TR • Heartworm Disease 3. Heart Base Tumor (RA, Aortic Body) • HSA, chemodectoma, myxosarcoma Thoracic Rads - Abnormal Case #7 – 12 yr old Mixed Terrier - Chronic cough and cyanosis 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 – Suspect 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 Thoracic Rads - Abnormal 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 heart base on left side Thoracic Rads - Abnormal Case #8 – 10 month old English Pointer Ejection murmur loudest at heart base on left side • 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 heart base on left • Causes of enlarged MPA (dogs) – PS (RPA, LPA, lobar aa/vv not enlarged) – PDA (lungs overcirculated – lobar aa and vv enlarged, but not tortuous) – Pulmonary hypertension (RPA, LPA lobar aa enlarged) • MPA enlargement – Not easily seen on lateral in dogs – not readily seen in cats • This case – echo diagnosis – PS – need spectral Doppler to measure gradient across – RV thickening Thoracic Rads - Abnormal LPA, RPA, lobar aa enlarged and tortuous •Pulmonary Hypertension 1. HW Disease 2. Primary PH 3. Chronic Respiratory Disease Thoracic Rads - Abnormal Case #9 – 6 month old poodle with murmur found on physical exam Thoracic Rads - Abnormal Case #9 – 6 month old poodle with murmur found on physical exam Dx – PDA with no CHF Measuring pulmonary lobar arteries 1.Caudal lobar aa should be same width as a rib – Seen best on the VD/DV view 2.cranial lobar aa 0.75x 3rd or 4th rib – Seen best on the lateral view Thoracic Rads - Abnormal Case #9 – 6 month old poodle with murmur found on physical exam Dx – PDA with no CHF Measuring pulmonary lobar arteries 1.Caudal lobar aa should be same width as a rib – Seen best on the VD/DV view 2.cranial lobar aa 0.75x 3rd or 4th rib – Seen best on the lateral view Thoracic Rads - Abnormal Case #10 – 5 yr old DSH cat Tachypnea Thoracic Rads - Abnormal Case #10 – 5 yr old DSH cat tachypnea • Ascites in the cranial abdomen • Perihilar edema • HUGE Caudal Vena Cava • Enlarged pulmonary lobar veins • Elevated trachea (LV enlargement) • Enlarged Lauricle on VD • Marked generalized cardiomegaly (VHS 10.5) Thoracic Rads - Abnormal Case #10 – 5 yr old DSH cat Tachypnea Enlarged Caudal vena cava -size varies with respiratory cycle -only severe enlargement is reliably detected -maximum width < length T5 or T6 Causes • Right heart failure • Mass obstructing Caudal Vena Cava – Thrombus, tumor Thoracic Rads - Abnormal Case #10 – 5 yr old DSH cat Tachypnea Thoracic Rads - Abnormal Case #11 – 2 yr old DSH cat Tachypnea Thoracic Rads - Abnormal Case #11 – 2 yr old DSH cat Tachypnea • VHS 8.75 • Left Heart Failure – Patchy pulmonary edema (caudal) – Enlarged pulmonary lobar vv • Right Heart failure – Pleural effusion • Echo diagnosis – hypertrophic cardiomyopathy Thoracic Rads - Abnormal Case #12 – 6 yr old Westie ADR Thoracic Rads - Abnormal Case #12 – 6 yr old Westie ADR VHS 8.5 (low normal) • Clinical diagnosis – severe dehydration • Causes of microcardia – Severe dehydration – Addison’s Disease – Pneumothorax (heart lifted off the sternum) • Should also see collapsed lung lobes Thoracic Rads - Review Left Heart Failure • Pulmonary edema (alveolar if severe) • Pleural effusion in cats • Pulmonary lobar veins much larger than arteries • Enlarged LA + compression of L bronchus – 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) • RHF alone: – HWDz, Chaga's Disease, pericardial disease 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 on rads – Increased VHS – Not as marked as volume overload • Enlarged ascending aorta • Left Heart Failure due to aortic insufficiency is rare • Death more often due to arrhythmia Thoracic Rads - Review Pulmonic Stenosis -pressure overload right side • + Enlarged RV on rads – Not as marked as volume overload • Enlarged MPA • Right Heart Failure due to pulmonic insufficiency is rare • Death more often due to arrhythmia 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)