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CARDIAC RADIOLOGY

Chest radiography
mainstay for imaging of the heart
provides the initial evaluation of the heart
Fluoroscopy provides dynamic information.
Echocardiography, angiography, CT scan and MRI are also used.

Size
the cardiothoracic ratio should not exceed 0.5 on a standard posteroanterior (PA)
radiograph or 0.6 on a portable or anteroposterior (AP) examination.
Shape
Various contour effects can offer clues to underlying disease.
Straightening of the left heart border: rheumatic heart disease and mitral stenosis
Water bottle configuration: pericardial effusion or generalized cardiomyopathy
Chamber Enlargement
Left atrial enlargement
distance from the midinferior border of the left mainstem bronchus to the right
lateral border of the left atrial density should be less than 7 cm.
other signs of LA enlargement include splaying of the carinal angle, uplifting of
the left mainstem bronchus, and prominence of the left atrial appendage on PA
view
on lateral views, an enlarged LA will displace the left bronchus posteriorly
(walking man sign)
Causes: acquired (mitral stenosis, mitral regurgitation, left ventricular failure, left
atrial myxoma) or congenital (ventricular septal defect (VSD), patent ductus
arteriosus (PDA)
Right atrial enlargement
prominent atrial bulge too far to the right of the spine (more than 5.5 cm from the
midline on a well-positioned PA radiograph)
elongation of the right atrial convexity to exceed 50% of the mediastinal or
cardiovascular shadow
caused by: tricuspid regurgitation, tricuspid stenosis, atrial septal defect (ASD),
atrial fibrillation (AF), dilated cardiomyopathy
Left ventricular enlargement
elongated left heart border with the apex pointing downward on PA view. (Shmoo
configuration)
prominent rounding of the inferior left heart border
Hoffman- Rigler sign- LV extends more than 1.8 cm posterior to the posterior
border of the IVC at a level 2 cm cephalad to the intersection of the LV and the
IVC. Requires a true lateral view.
Cause: pressure overload (hypertension, aortic stenosis), volume overload
(aortic or mitral regurgitation, wall abnormalities (left ventricular aneurysm,
hypertrophic cardiomyopathy)
Right ventricular enlargement
tend to lift the apex and create a more horizontal vector to the cardiac axis
if the RV fills too much of the retrosternal clear space or climbs more than one
third of the sternal length
Indirect signs such as enlargement of the pulmonary outflow tract or hilar arteries
add confidence
can be the result of pulmonary valve stenosis, pulmonary artery hypertension,
atrial septal defect, tricuspid regurgitation, dilated cardiomyopathy

CONGENITAL HEART DISEASES:


Acyanotic Heart Disease With Increased Pulmonary Vascularity
VSD, ASD, and patent ductus arteriosus (PDA)
As the pressure in the right side of the heart rises, the shunt becomes balanced and
eventually reverses. This phenomenon is referred to as Eisenmenger physiology
and can be seen with any left-to-right shunt.

Ventricular septal defect


most common congenital heart abnormality after bicuspid aortic valve
categorized according to its location within the ventricular septum.
most are perimembranous defects in the portion of the septum near the fusion of
the membranous and muscular portions.
characteristic findings: PA enlargement, increased pulmonary vascularity, and
cardiomegaly that is predominantly left-sided
aorta is small

Atrial septal defect


less common than VSD
ostium secundum defect
most common type
occurs centrally at the foramen ovale
typically, the RA is enlarged, causing prominence of the right cardiac border on the
frontal view
on the lateral view, RV enlargement produces fullness in the retrosternal space
the aorta is rather small

Patent Ductus Arteriosus


ductus arteriosus connects the PA and aorta in fetal life and begins to close
immediately after birth, but in some infants, closure is delayed.
prolonged patency is a common complication of hypoxia in the premature infant
LA, LV, and PA become dilated with active pulmonary vascular engorgement.
enlarged proximal aorta
PDA is easily diagnosed by echocardiography or angiography.
Aortopulmonary window is a rare condition that is very similar to PDA, both
hemodynamically and radiographically.
results from failure of complete division of the primitive truncus arteriosus, which
leaves a communication between the aorta and the PA just above the valves.

Cyanotic Heart Disease With Increased Pulmonary Vascularity


group of complex heart abnormalities whose common feature is the admixture of
oxygenated and deoxygenated blood that is circulated systemically, resulting in
cyanosis

Complete transposition of the great vessels (D-transposition)


most common form of cyanotic congenital heart disease with increased pulmonary
blood flow
the positions of the aorta and PA are reversed
ventricles lie in their normal positions
communications that allow the infant to survive are most commonly a VSD, an ASD,
or PDA.
prognosis is more favorable with associated pulmonary stenosis.
cardiomegaly with an oval configuration develops in the first few days of life
superior mediastinum and base of the heart are narrow because of thymic atrophy
abnormal alignment of the aorta and PA
vascular congestion
on lateral views of the chest, the anteriorly placed aorta causes increased opacity in
the retrosternal region
In L-transposition, ventricular inversion (left to right reversal) accompanies the
transposed positions of the aorta and PA, resulting in functional correction of the
transposition

Total anomalous pulmonary venous return (TAPVR)


condition in which the pulmonary veins, instead of emptying into the LA, return blood
to the right side of the heart via the RA, coronary sinus, or a systemic vein
in all types, the pulmonary veins converge into a single common vein before
emptying into the anomalous site
Type 1
most common form
the abnormal vein empties into a large supracardiac vein
Snowman sign - prominence of the superior mediastinum caused by a large,
inverted U-shaped vessel that empties into the superior vena cava
Type 2
common vein drains into the coronary sinus or directly into the RA
radiographic findings resemble those of the transposition complex of lesions
Type 3
the common vein travels through the esophageal hiatus to empty into the portal
vein or, less commonly, an abdominal systemic vein.
TAPVR types 1 and 2 overload the right side of the heart, causing dilation of the RA,
RV, and PA and engorgement of the pulmonary vessels

Decreased Pulmonary Vascularity


A decreased pulmonary vascular pattern usually indicates a condition in which the
flow through the right side of the heart is obstructed
obstruction can occur anywhere from the tricuspid valve to the PA

Tetralogy of Fallot
most common anomaly to cause diminished pulmonary vascularity
most common cause of cyanotic congenital heart disease
classic components are
(1) VSD
(2) pulmonary stenosis
(3) right ventricular hypertrophy
(4) aorta that overrides the VSD
the degree of pulmonary stenosis is the most critical component of this anomaly
pulmonary vascularity is decreased, with a shallow or concave PA shadow.
Boot shaped heart - right ventricular hypertrophy causes lateral and superior
displacement of the cardiac apex without overall enlargement of the cardiac
silhouette

Normal Pulmonary Vascularity


Congenital cardiac anomalies with normal pulmonary vascularity are predominantly
abnormalities of the cardiac valves and great vessels

Coarctation of the aorta


two distinct forms:
juxtaductal (adult) type
lies at or just distal to the level of the ductus arteriosus,
preductal (infantile) form
generally is a long-segment narrowing
more severe clinical course, frequently developing congestive heart failure
during the first month of life
usually the heart is normal in size; however, eventually some rounding and
prominence of the left cardiac border can develop.
prestenotic and poststenotic dilation of the aorta commonly occurs and is
responsible for the figure-3 sign
progressive collateral circulation develops, usually involving the intercostal arteries.
It is the dilation of these arteries that eventually causes a notching along the inferior
edge of the posterior ribs.

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