CHEST RADIOLOGY

Dr. Hari Soekersi, Sp.Rad.

Posteroanterior Projection1

Lateral Projection2

Right Anterior Oblique Projection3

Left Anterior Oblique Projection4

NORMAL FOUR VIEWS OF THE HEART

1. Right innominate vein2. Superior vena cava3. Right main branch of the pulmonary artery4. Upper and lower lobe veins5. Right atrium6. Tricuspid valve7. Inferior vena cava8. Arch of the aorta

9. Left main branch of the pulmonary artery10. Main pulmonary artery11. Left upper lobe vein12. Appendage of the left atrium13. Mitral valve14. Left ventricle15. Right ventricle

POSTEROANTERIOR PROJECTION

POSTEROANTERIOR PROJECTION

POSTEROANTERIOR PROJECTION

POSTEROANTERIOR PROJECTION

Right Atrium

Superior vena cava

Left Ventricle

Appendage of the left atrium

Pulmonary artery

Aorta

1. Superior vena cava2. Ascending aorta3. Main pulmonary artery4. Right atrium5. Tricuspid valve6. Right ventricle7. Aortic arch8. Left main branch of the pulmonary artery

9. Left atrium10. Mitral valve11. Left ventricle12. Descending aorta13. Inferior vena cava

LATERAL PROJECTION

LATERAL PROJECTION

LATERAL PROJECTION

LATERAL PROJECTION

Right Ventricle

Root of the main pulmonary artery

Left Ventricle

Left Atrium

Because these structures are in contact with mediastinal fat, their margin may be indistinct

1. Anterior wall of the trachea2. Innominate vein3. Anterior border of the superior vena cava4. Superior vena cava5. Right main branch of the pulmonary artery6. Thoracic aorta7. Left atrium8. Right atrium9. Inferior vena cava

10. Left innominate vein11. Arch of the aorta12. Left main branch of the pulmonary artery13. Main stem of the pulmonary artery14. Left main bronchus15. Tricuspid valve16. Mitral valve17. Right ventricle18. Left ventricle

RIGHT ANTERIOR OBLIQUE PROJECTION

RIGHT ANTERIOR OBLIQUE PROJECTION

1. Superior vena cava2. Right main branch of the pulmonary artery3. Ascending aorta4. Main pulmonary artery5. Right atrial appendage6. Tricuspid valve7. Right ventricle8. Left subclavian artery

9. Posterior border of the trachea10. Left main branch of the pulmonary artery11. Left main bronchus12. Left atrium13. Mitral valve14. Left ventricle15. Inferior vena cava

LEFT ANTERIOR OBLIQUE PROJECTION

LEFT ANTERIOR OBLIQUE PROJECTION

ANATOMY OF THE HEART

HISTOLOGY OF THE HEART

2. Myocardium of atrium

1. Endocardium of atrium

3. Annulus fibrosus

4. Mitral valve :a. Endocardiumb. Connective tissue

core

5. Chorda tendina

6. Endocardium of ventricle

7. Myocardium of ventricle

8. Purkinje fibers (conduction fibers)

10. Coronary artery

9. Plate A

11. Coronary sinus

12. Coronary vein with valve

13. Epicardium of atrium

14. Subepicardial connective tissue and fat

15. Perimysial septa with blood vessels

16. Epicardium and subepicardium of ventricle

17. Columnae carneae

18. Apex of papillary muscle

Analyze each case with six steps:

PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE

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34 5

6

Analyze each case with six steps:

PLAIN FILMS DIAGNOSIS OF CARDIAC DISEASE

EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS SURGERY OR OTHER

ABNORMALITIES

IDENTIFICATION OF THE POSITION OF THE STOMACH BUBBLE AND HEPATIC SHADOW TO

DETERMINE BODY SITE

EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION

EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT

EVALUATION OF CARDIAC SIZE AND CONTOUR

EVALUATION OF PULMONARY VASCULARITY

Signs of previous surgery

- periosteal elevation- asymmetry thoracic cage- smaller and slightly deformed rib- resected rib in previous thoracotomy

EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS

SURGERY OR OTHER ABNORMALITIES

1

Congenital heart disease:

- premature fusion of sternum→ cyanotic form- hypersegmentation of sternum → Down’s syndrome

- bulging of sternum → enlarged right ventricle

EVALUATION OF THE THORACIC CAGE FOR SIGN OF PREVIOUS

SURGERY OR OTHER ABNORMALITIES

1

COMPLETE FUSION OF STERNAL SEGMENTS

HYPERSEGMENTATION OF THE STERNUM

ATRIAL SEPTAL DEFECT WITH ENLARGED RIGHT VENTRICLE AND

ANTERIOR BULGING OF THE STERNUM

Abnormal hepatic and stomach position show

abnormalities in position of the viscera congenital

cardiac disease

IDENTIFICATION OF THE POSITION OF THE STOMACH

BUBBLE AND HEPATIC SHADOW TO DETERMINE BODY SITE

2

SITUS SOLITUS WITH DEXTROCARDIA

Stomach bubble is under the left diaphragmLiver is on the rightHeart is on the right with cardiac axis directed to the right

SITUS INVERSUS WITH DEXTROCARDIA

Stomach bubble is under the right diaphragmLiver is on the leftHeart is on the right with cardiac axis directed to the right

ISOLATED LEVOCARDIA OR SITUS AMBIGUS

Stomach bubble is under the right diaphragmLiver is on the leftNormal heart position

DEXTROCARDIA

Dextrocardia :Location of the heart in the right side of the thorax, the apex pointing to the right

Dextroversion :Location of the heart in the right chest, the left ventricle remaining in the normal position on the left with the apex pointing the the left

DEXTROVERSION

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Enlargement of the pulmonary artery segmentProminent pulmonary arterial segment along the left upper cardiac borderIn TGV and truncus arteriosusabnormal position (concave)

Enlargement of the aortaThree portions of the aorta can be evaluated: ascending aorta, aortic arch dan descending aorta.

EVALUATION OF GREAT VESSELS FOR SIZE AND POSITION3

ENLARGEMENT OF PULMONARY ARTERY SEGMENT

TRANSPOSITION OF GREAT VESSELS

TRANSPOSITION OF GREAT VESSELS

TRUNCUS ARTERIOSUS

TRUNCUS ARTERIOSUS

ENLARGEMENT OF THE AORTA

Usually, the ascending aorta does not extend

beyond the right upper mediastinal shadow.Here, there is enlargement of the aorta.

Signs of left atrial enlargementSigns of left ventricular enlargementSigns of right atrial enlargementSigns of right ventricular enlargement

EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT4

Posteroanterior projection1. Displace the barium-filled esophagus below the

carina to the right2. Prominent bulge along the mid-left cardiac border3. A double density along the right cardiac border4. Widening of the angle of the carina >900

Lateral projection1. Posterior displacement of both walls of the

barium-filled esophagus

SIGNS OF LEFT ATRIAL ENLARGEMENT

Left anterior oblique projectionElevate the left mainstem bronchus and obliterates the spaces between the posterior cardicac margin and the left mainstem bronchus

SIGNS OF LEFT ATRIAL ENLARGEMENT

LEFT ATRIAL ENLARGEMENT

Posteroanterior projection1. Left ventricular dilatation produces downward

displacement of the apex toward diaphragm.2. Left ventricular hypertrophy produces a round left

cardiac borderLeft anterior oblique projection

Posterior cardiac margin to overlap the vertebral column

SIGNS OF LEFT VENTRICULAR ENLARGEMENT

LEFT VENTRICULAR DILATATION

LEFT VENTRICULAR HYPERTROPHY

Posteroanterior projectionDifficult increased convexity of the lower right heart

border on PA projection

SIGNS OF RIGHT ATRIAL ENLARGEMENT

RIGHT ATRIAL ENLARGEMENT

SIGNS OF RIGHT VENTRICULAR ENLARGEMENT

Posteroanterior projectionRounding and elevation of the cardiac apexLateral projection

Retrosternal space is obliteratedLeft anterior oblique projection

Increased convexity of the anterior cardiac border

RIGHT VENTRICULAR ENLARGEMENT

Index of cardiac enlargement is the cardiothoracic ratio.In infants: 0.55In adults : 0.45The lateral and oblique views must be considered

EVALUATION OF CARDIAC SIZE AND CONTOUR5

CARDIOTHORACIC RATIO

(Cardiac width / Thoracic cage width) x 100%

In normal the pulmonary vascular marking taper gradually toward the periphery of the lung fields, and more prominent in the lower lung fields.The vessels in the right hillum is larger than in the left

EVALUATION OF PULMONARY VASCULARITY6

1. Normal pulmonary vascularity2. Increased pulmonary vascularity due to increased

pulmonary blood flow.- the peripheral arteries are sharply outlined and dilated and distributed equally to both the upper and lower lobes.- ex. VSD, PDA, truncus arteriosus, transposition of the great vessels.

SIX DIFFERENT VASCULAR PATTERNS ARE RECOGNIZED

3. Decreased pulmonary vascularity due to right-to-left shunts.- small pulmonary arterial segment- reduced diameter of the hilar pulmonary arteries- ex. Tetralogy of Fallot, tricuspid atresia,

pulmonary stenosis

4. Pulmonary venous congestion- occurs in condition that causes increased resistance distal to pulmonary capillaries- fluid accumulates in the interstitial tissues and Kerley B lines- ex. Mitral stenosis, acute left ventricular failure are common causes.

5. Bronchial collateral

6. A bizarre pattern of pulmonary vascularity- different vascular pattern in each lung

• Five factors influence the distribution of pulmonary blood flow.

• Interstitial osmotic and alveolar pressures remain constant throughout the lung

• Hydrostatic, pulmonary arterial and pulmonary venous pressures, diminish from base to apex because of gravitational effects.

• In left-sided cardiac failure, the increased pulmonary venous pressure resulting from the elevated left ventricular end-diastolic pressure

PULMONARY VASCULARITY IN LEFT-SIDED FAILURE

• The transudation of fluid into the pulmonary interstitium causes an increase in the interstitial pressure

• The earliest radiographic manifestation on left-sided cardiac failure is:1. An indistinctness of the vascular markings caused

by the increased interstitial fluids.2. The hilar vessels become enlarged and indistinct.3. The increased interstitial fluid can be seen as

‘peribronchial cuffing’.

• Later, ‘cephalization’ occurs. The vascular markings are prominent in the upper lobes owing to the constriction of the lower lobe vessels and redistribution of flow to the upper lobes.

• Pleural effusion occurs late• Transudation of fluid into the alveoli leads to pulmonar

edema. This appears in a perihilar location (‘butterfly wings’ or ‘bat wings’).

• Kerley B lines, due to fluid in the lobular septum.

Several non-cardiac causes as differential diagnosis of pulmonary edema:1. Uremia. Increased capillary permeability.2. Fluid overload. Decreased plasma osmotic pressure.3. Neurogenic. Altered capillary permeability or capillary pressure.4. Hypoproteinemia. Decreased plasma osmotic pressure.5. Transfusion and allergic reactions. Altered capillary

permeability.6. Inhalation of toxic gases. Altered capillary permeability

CEPHALIZATION

KERLEY B

KERLEY A, B, & C

• Kerley A : white arrow• Kerley B : white arrow head• Kerley C : black arrow head

EDEMA PARU INTERSTITIAL

EDEMA PARU ALVEOLAR

PULMONARY VASCULARITY IN PULMONARY HYPERTENSION

• Pulmonal artery segment dilatation• Right ventricular enlargement• Reduced bronchovascular marking

Mild PAH Severe PAH

1. Decrease bronchovascular marking

a) Acyanotic1. Pulmonary Stenosis (PS)

b) Cyanotica) Tetralogy Fallotb) Trilogy Fallotc) Atresia Pulmonald) Atresia Tricuspide) Ebstein Anomaly

CONGENITAL HEART DISEASE

2. Increase bronchovascular marking

a) Acyanotic1. Atrial septal defect (ASD)2. Ventricle septal defect (VSD)3. Right atrioventricular anomaly4. Patent ductus arteriosus (PDA)5. Partial Anomalous Pulmonary

Venous Return (PAPVR)

b) Cyanotic1. Total Anomalous Pulmonary

Venous Return (TAPVR)2. Truncus Arteriosus3. Transposition of the Great Vessels

(TGV)

PULMONARY STENOSIS

PULMONARY STENOSIS

Pulmonary stenosis make right ventricular resistancy increased, causing radiographic feature:• Right ventricular enlargement• Rounding and elevation of the cardiac apex• Bulging of pulmonary trunc• Bronkhovascular marking decreased

TETRALOGY FALLOT

TETRALOGY FALLOT

The malformation has four components:Right ventricular hypertrophy, Overriding aorta, Pulmonary stenosis, and Ventricular septal defectRadiographic features:• Right ventricular enlargement• Boot shape contour• Pulmonary artery segment concave• Right sided aortic arch• Pulmonary vascularity decreased

EBSTEIN ANOMALY

EBSTEIN ANOMALY

• Atrial septal defect• Displace tricuspid valveRadiographic feature:• Vary • Widening of right heart border• Rounded heart (cardiomegali all chamber)• Bronchovascular marking decreased

ATRESIA PULMONAL

ATRESIA PULMONAL

Radiographic feature:• Cardiomegali with oval heart contour• Bronchovascular marking decreased

ATRESIA TRICUSPID

ATRESIA TRICUSPID

• ~ Atresia pulmonal• Cardiomegali with oval heart contour• Pulmonary vascularity decreased

ATRIAL SEPTAL DEFECT

ATRIAL SEPTAL DEFECT

The feature related to how large the defect and the complication on the pulmonary vascularityRadiographic feature:• Right atrial enlargement, widening right heart border• Right ventricular enlargement, rounded and

elevation of the cardiac apex• Prominent conus pulmonalis, with widening of hillum• Bronchovascular marking increased• Signs of pulmonary hypertension

VENTRICULAR SEPTAL DEFECT

VENTRICULAR SEPTAL DEFECT

Radiographic feature:

• Small defect (Maladie de Roger)• Heart is not enlarged• Normal pulmonary vascularization

• Mild • Heart is enlarged to the left (left ventricle hypertrophy)• Apex downward to the diaphragm.• Right ventricle has not enlarged.• Left atrium dilated• Increase pulmonary vascularization.

VENTRICULAR SEPTAL DEFECT

Radiographic feature:• Moderate – Severe

• Right ventricle dilatation and hypertrophy.• Left atrium dilatation.• Widening of the pulmonary artery and its branches• Normal right atrium.• Left ventricle hypertrophy.• Small aorta.

• Pulmonary hypertension• Right ventricle is enlarged.• Pulmonary artery is widening with prominent of conus pulmonalis.• Normal left atrium.• Small aorta.• Decrease peripheral pulmonary vasculature.• Pulmonary emphysematous

PATENT DUCTUS ARTERIOSUS

PATENT DUCTUS ARTERIOSUS

• Small defect– Normal

• Moderate– Normal or mild enlargement of descendent aorta and

aortic arch.– Prominent of conus pulmonary.– Widening of the pulmonary artery and its branches.– Left atrial enlargement.– Right and left ventricle enlargement.

PATENT DUCTUS ARTERIOSUS

• Severe (pulmonary hypertension)– Enlarge central pulmonary vasculature.– Decrease peripheral pulmonary vasculature.– Prominent conus pulmonalis.– Widening of the ascendent aorta with prominent

aortic knob.– Normal left atrium.

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