CHEST ROENTGENOGRAPHY

PEDIATRIC CARDIOLOGY
JULY 2014
CHEST X RAY - Posteroanterior And Lateral Views
Heart size and Silhouette

Evaluation of cardiac chambers and great arteries

Pulmonary blood flow or pulmonary vascular markings

Systemic apporach : lung parenchyma, spine, bony

thorax, abdominal situs
 HEART SIZE AND SILHOUETTE
HEART SIZE
CARDIOTHORACIC (CT) RATIO :
relating the largest transverse diameter of
the heart to the widest internal diameter of
the chest
(A+ B ) / C
> 0.5 cardiomegaly
Newborn & small infants :
Estimation of cardiac volume by inspecting PA
and lateral views
 Isolated right ventricular enlargement may not be obvious on
a posteroanterior film but is obvious on a lateral film.
In a patient with a flat chest (or narrow anteroposterior
diameter of the chest), a posteroanterior film may
erroneously show cardiomegaly.
An enlarged heart on chest x-ray films more reliably reflects
a volume overload than a pressure overload.
NORMAL CARDIAC SILHOUETTE
 Lateral projection of the cardiac
silhouette is formed anteriorly by the
RV and posteriorly by the LA above
and the LV below
ABNORMAL CARDIAC SILHOUETTE

Left vertical vein, left innominate

vein & dilated SVC snowmans
head

Narrow-waisted & egg-shaped heart

Narrow-waisted due to absence of large
thymus and abnormal relationship of great
arteries
Increased PBF
EVALUATION OF CARDIAC CHAMBERS & GREAT ARTERIES

LA enlargement Mild LA enlargement is best appreciated in lateral projection by posterior protrusion of LA border
May produce double density on posteroanterior view

LV enlargement PA view : apex of heart is farther to the left and downward

Lateral view : lower posterior cardiac border is displaced farther posteriorly and meets IVC line below the
diaphragm level

RA enlargement Most obvious in the posteroanterior projection as an increased prominence of the lower right cardiac silhouette

RV enlargement
Isolated right ventricular enlargement may not be obvious in the posteroanterior projection, and the normal CT ratio
may be maintained because the RV does not make up the cardiac silhouette in the posteroanterior projection.
Right ventricular enlargement is best recognized in the lateral view, in which it is manifest by filling of the retrosternal
space
SIZE OF THE GREAT ARTERIES

Prominent MPA
Post stenotic dilatation
e.c PS

Increased blood flow

through PA e.c ASD, VSD

Increase pressure in PA
e.c PH

Occasional normal
findings in adolescents
especially girls
SIZE OF THE GREAT ARTERIES

Hypoplasia of PA
Tetralogy of
Fallot

Tricuspid atresia
SIZE OF THE GREAT ARTERIES
TOF

Dilatation of Aorta
AS
(as post stenotic dilatation)

PDA

CoA

Marfan syndrome

Systemic hypertension
 PULMONARY VASCULAR MARKINGS
INCREASED PULMONARY BLOOD FLOW
the right and left pas appear enlarged and extend into the lateral third of the lung field,
where they are not usually present
there is increased vascularity to the lung apices where the vessels are normally collapsed
the external diameter of the right pa visible in the right hilus is wider than the internal diameter
of the trachea.
Increased pulmonary blood flow in :
- an acyanotic child represents ASD, VSD, PDA, ECD, PAPVR, or any combination of these.
- a cyanotic infant : TGA, TAPVR, HLHS, Persistent truncus arteriosus or single ventricle
 PULMONARY VASCULAR MARKINGS
DECREASED PULMONARY BLOOD FLOW
the hilum appears small
the remaining lung fields appear black
the vessels appear small and thin
Ischemic lung fields are seen in cyanotic heart diseases with decreased
pulmonary blood flow such as :
- critical stenosis or atresia of the pulmonary or tricuspid valves,
including TOF
 PULMONARY VASCULAR MARKINGS
PULMONARY VENOUS CONGESTION
a hazy and indistinct margin of the pulmonary vasculature
this is caused by pulmonary venous hypertension secondary to left
ventricular failure or obstruction to pulmonary venous drainage
(e.g., mitral stenosis, TAPVR, cor triatriatum).
kerley's b lines are short, transverse strips of increased density best seen in the
costophrenic sulci.
this is caused by engorged lymphatics and interstitial edema of the interlobular
septa secondary to pulmonary venous congestion.
 PULMONARY VASCULAR MARKINGS
NORMAL PULMONARY VASCULATURE
in patients with :
- obstructive lesions such as pulmonary stenosis or aortic stenosis.
Unless the stenosis is extremely severe, pulmonary vascularity
remains normal in pulmonary stenosis
- small left-to-right shunt lesions also show normal pulmonary
vascular markings.
 SYSTEMIC APPROACH
LOCATION OF THE LIVER AND STOMACH GAS BUBBLE
the cardiac apex should be on the same side as the stomach or opposite the hepatic shadow.

SKELETAL ASPECT OF CHEST X-RAY FILM

- Pectus excavatum may flatten the heart in the anteroposterior dimension and cause a
compensatory increase in its transverse diameter, creating the false impression of cardiomegaly.
- Thoracic scoliosis and vertebral abnormalities are frequent in cardiac patients.
- Rib notching is a specific finding of coa in an older child (usually older than 5 years) and
is usually found between the fourth and eighth ribs.
 IDENTIFICATION OF THE AORTA
1. Identification of the descending aorta along the left margin of the spine usually indicates
a left aortic arch; identification along the right margin of the spine indicates a right aortic
arch. right aortic arch is frequently associated with TOF or persistent truncus arteriosus.
2. When the descending aorta is not directly visible, the position of the trachea and esophagus
may help locate the descending aorta. If the trachea and esophagus are located slightly to
the right of the midline, the aorta usually descends normally on the left (i.e., left aortic arch).
In the right aortic arch, the trachea and esophagus are shifted to the left.
3. In a heavily exposed film, the precoarctation and postcoarctation dilatation of the aorta may
be seen as a figure of 3. this may be confirmed by a barium esophagogram with e-shaped
indentation.
 UPPER MEDIASTINUM
1. The thymus is prominent in healthy infants and may give a false impression of cardiomegaly.
It may give the classic sail sign.

2. The thymus shrinks in cyanotic infants or infants under severe stress from CHF .
In TGA, the mediastinal shadow is narrow (narrow waist), partly because of the shrinkage of the
thymus gland. Infants with digeorge syndrome have an absent thymic shadow and a high
incidence of aortic arch anomalies.

3. A snowman figure (or figure-of-8 configuration) is seen in infants, who are usually older than
4 months, with anomalous pulmonary venous return draining into the svc through the left svc
(vertical vein) and the left innominate vein
 PULMONARY PARENCHYMA