IMAGING MODALITIES

1. Chest X-ray
2. Cor analysis (barium in
esophagus)
3. Echocardiography
4. Computerized Tomography (CT)
5. Magnetic Resonance Imaging
(MRI)
6. Nuclear Medicine
CHEST X-RAY
Erect position.
Full inspiration.
Projection:
PA Posteroanterior
Left lateral
RAO Right anterior oblique
LAO Left anterior oblique
NORMAL CHEST X-RAY

Rib
Lung
Right
pulmonary
artery
Heart
COR ANALYSIS
Barium swallow X-ray photography

Projection:
PA Posteroanterior
Left lateral
RAO Right anterior oblique
LAO Left anterior oblique
PA
LATERAL
RAO
LAO
RA
LV
HEART BORDER - PA
RIGHT

- Right atrium

LEFT
- Arcus aorta
- Left atrium
appendage
- Left venticle
HEART BORDER -
LATERAL (LEFT LATERAL)

ANTERIOR
- Pulmonary artery
- Right ventricle (lower)

POSTERIOR
- Left atrium (upper)
- Left ventricle (lower)
HEART BORDER - RAO
(Vertebra on the right of patient)

ANTERIOR
- Right ventricle

POSTERIOR
- Left atrium
HEART BORDER - LAO
(Vertebra on the left of patient)

ANTERIOR
- Ascending aorta
- Right atrium
appendage
- Right ventricle

POSTERIOR
- Left atrium (upper)
- Left ventricle (lower)
CARDIAC
MEASUREMENT
CARDIOTHORACIC RATIO (CTR)

r+l
_______________
td + td
NORMAL CTR: <
50%
A = 12
_________ = < 0.5
B = 28

A: maximum width heart

B: maximum width
thorax
A

B
HEART CHAMBER
ENLARGEMENT
RV: filling retrosternal clear space (lateral
view).
LV: bulging downward and to the left
(frontal view) and posteroinferiorly (lateral
view).
RA: bulging of the right heart border.
LA: bulging below the pulmonary artery,
double contour right heart border (frontal
view), displacement of the esophagus
(lateral view,barium), lift up left mainstem
bronchus.
RV ENLARGEMENT

Rounded apex (PA) , filling retrosternal clear

space (lateral view).
RV ENLARGEMENT
RV
LV ENLARGEMENT

LV

Bulging downward and to the left (frontal view)

and posteroinferiorly (lateral view).
RA ENLARGEMENT

Bulging of the right heart border,

> 1/3 right hemithorax
LA ENLARGEMENT

Bulging left atrial appendage,

double contour right heart border
LA ENLARGEMENT

Displacement of the esophagus (lateral

view,barium), lift up left mainstem bronchus.
 PULMONARY ARTERY

Right Left
pulmonary pulmonary
artery artery
ANGIOGRAPHY

PULMONARY ARTERY PULMONARY VEIN

PULMONARY
VASCULARITY
TYPE OF DISEASES
1. ASD (Atrial Septal Defect)
2. VSD (Ventricular Septal Defect)
3. PDA (Patent Ductus Arteriosus)
4. TOF (TETRALOGY OF FALLOT)
5. COARCTATION OF AORTA
ASD

RIGHT - SIDED ENLARGEMENT

VASKULER MENINGKAT
ASD

Lateral RAO LAO

VSD

LEFT SIDED ENLARGEMENT

VSD

Kardiomegali sedang, vaskularisasi bertambah,

dilatasi ventrikel kiri dan atrium kiri.
VSD

Atrium kiri membesar, menekan esofagus 1/3 tengah.

 PDA

Kardiomegali, aortic knob membesar, vaskuler pulmo

bertambah, ventrikel kiri dan atrium kiri membesar.
TOF
4 ABNORMALITIES:
- VSD
- Hipertrofi ventrikel kanan
- PS (Pulmonary Stenosis0
- Overriding aorta
Pathognomic: boot-shaped heart
configuration.
Jantung bentuk sepatu = boot-shaped
= coeur en sabot
TOF

Apex bulat terangkat, pinggang jantung dalam,

vaskuler paru berkurang, right sided aorta.
COARCTATIO AORTA

Hipertrofi ventrikel kiri, figure-3 sign (pre &

postsenotic dilatation).
Vaskularisasi paru normal. Rib notching.
RIB NOTCHING
PULMONARY ARTERY
HYPERTENSION

Right
pulmonary
artery
VALVE
ABNORMALITIES
1. Mitral stenosis (MS)
2. Mitral insufficiency (MI)
3. MS + MI
MITRAL STENOSIS
Radiographic findings :
- Initially normal heart size
- Calcified mitral valve
- Left atrial enlargement ( elevation left
main bronchus, double density/contour
the right heart border, posterior
displacement of
esophagus (with barium), enlargement
left atrial appendage.
MITRAL STENOSIS
Advanced cases:
- Left atrium may calcify.
- Right ventricular enlargement (filling
in of
the retrosternal clear space).
- Signs of pulmonary venous
hypertension cephalization and
pulmonary edema.
MS

Double
contour
right heart
border
RHEUMATOID MITRAL
STENOSIS
LA ENLARGEMENT

Left atrium
MITRAL
INSUFFICIENCY
Radiologic findings:
- Left atrial enlargement (all cases).
- Left ventricular enlargement .
- Mild to moderate pulmonary venous
hypertension.
- No mitral valve calcify.
MITRAL
INSUFFICIENCY

LA

LA
LV
MS + MI
Esophagus

LA
CARDIOMYOPATHY

A group of heart
diseases due to primary
heart muscle pathology.
1. DILATED
CARDIOMYOPATHI
Most common (90%)
Causes: alcohol, viral infection.
Clinical sign: CHF ( right or left-
sided )
Radiographic finding: global
cardiomegaly, predominant LV.
2. HYPERTROPHIC
CARDIOMYOPATHY
Most commonly familial or
pressure overload.
The heart muscle thicken but,
the heart may not dilate.
Radiographic finding: 50% a
normal chest.
Cross-sectional imaging:
abnormal thickness of the
myocardium
3.RESTRICTIVE
CARDIOMYOPATHY
Rarest cardiomyopathy.
Causes: stiffen the myocardium
(amyloidosis and sarcoidosis).
Chest radiograph:
- normal cardiac size with
- pulmonary -venous
congestion.
HEART FAILURE
The hearts inability:
1.To supply the bodys demands
for oxygen and nutrients
2.To remove of wastes

Causes:
- ischemic damage to the
myocardium
- hypertensive heart disease.
HEART FAILURE
Right heart failure:
systemic venous
congestion
Left heart failure
pulmonary venous
congestion
pulmonary edema
CONGESTIVE HEART FAILURE

CHEST X-RAY - PA
PULMONARY OEDEMA
PULMONARY OEDEMA
HYPERTENSIVE HEART
DISEASE
1. Cardiomegali
2. LV enlargement
3. Prominent
aortic knob
4. Elongated
descending
aorta
HYPERTENSIVE HEART
FAILURE
A form of congestive heart
failure.
Cause : the high systemic blood
pressure
Chest radiograph: severe left
ventricular hypertrophy
/dilatation cardiac
enlargement.
PULMONARY
PHLETORA
HEART FAILURE:
- Cardiomegali
- Vessels enlarged
- Enlargement
pulmonary artery
PULMONARY VENOUS
HYPERTENSION
Radiographic findings:
Distended the upper lobe veins upper
lobe venous diversion or cephalization.
Interstitial pulmonary oedema: fluid
accumulation in the lung interstitium.
Appearance of interstitial lines (Kerley A
& B lines),
KERLEY LINES
Represent thickening of interlobular septa..
Kerley A line: 4 cm in length, upper and mid
portions of the lung, deep septal lines,
radiate from the hila into the central
portions of the lungs.
Kerley B lines: 1 cm or less, interlobular
septal lines, in the lower zones peripherally,
and parallel to each other, right angles to
the pleural surface.
Kerley C lines: overlapping Kerley B lines
(the term is no longer used).
KERLEY B LINES
PULMONARY VENOUS
HYPERTENSION
CAUSES PULMONARY VENOUS
HYPERTENSION
1. Left ventricular outflow obstruction:
aortic coarctation, aortic stenosis,
hypoplastic left heart
2. Left ventricular failure
3. Mitral valve disease
4. Left atrial myxoma
5. Fibrosing mediastinitis
6. Pulmonary veno-occlusive disease
PULMONARY ARTERIAL
HYPERTENSION
Radiographic findings:
Cardiac enlargement (right atrial and
ventricular).
Enlargement central pulmonary arteries
inverted coma
Tapering of peripheral arterial branches
peripheral pruning.
Calcification central pulmonary arteries
due to atheroma (long standing).
 PULMONARY ARTERIAL
HYPERTENSION

MPA

RPA
PULMONARY ARTERY
HYPERTENSION

Right
pulmonary
artery
CAUSES PULMONARY ARTERY
HYPERTENSION

1. Chronic lung disease: COPD, interstitial

pneumonia
2. Pulmonary embolic disease
3. Pulmonary venous hypertension
4. Intracardiac shunts (left-to-right or
bidirectional)
5. Pulmonary arteritides
6. Idiopathic
REFERENCES
1.Daffner RH. Clinical Radiology. The essentials. 2nd
ed. Maryland: Lippincott Williams & Wilkins, 1999.
2. Sutton D. Textbook of Radiology and Imaging. 7th
ed. Vol. 1. London: Churchill Livingstone, 2003.
3. Gunderman RB. Essential Radiology. 2nd ed. New
York: Thieme, 2006.
4. Goodman LR. Felsons Principles of chest
Roentgenology. 3nd 3d. Philadelphis: Saunders,
2007.
5. Adam A, Dixon AK. eds. Grainger & Allisons
Diagnostic Radiology. 5th ed. Vol. 1. London:
Churchill Livingstone, 2008.