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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
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