7. patient is rotated to
the left - heart may
appear enlarged &
pulmonary bay
become prominent
if rotated to the
right –heart size
may be
underestimated &
ascending aorta
prominent
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
8. upper 4 thoracic vertebral bodies should
only just be visible through the cardiac
shadow.
Too clearly visible: film is over penetrated
⇒ may miss low density lesions.
Cannot see them: under penetrated ⇒
lung fields will appear falsely white.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
10. Exposure -amount of x-ray energy that
passes through the patient during the
acquisition of the image.
2 basic parameters:
The amount of energy used for the
exposure (measured in kilovolts [kV]).
The duration of the exposure (measured
in milliampere seconds [mAs]).
standard PA view -125 kV and 3 to 4 mAs .
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
11. Normal Exposure
Shadow of vertebral column is faintly
visible, intervertebral spaces not
clearly visible, and shadow of trachea
is normally visible upto the level of
clavicle as a translucent shadow.
One needs to be able to identify both
costophrenic angles and lung apices
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
12. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
13. obtained with high kilovoltage technique
at maximal inspiration to permit short
exposure times, which freeze cardiac
motion.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
14. A tube-to-film distance of at least 6 feet / 2
metres minimizes distortion and magnification.
At 2 metres focal length
X rays gives maximum resolution
Beam is near parallel without
divergence and distortions.
X ray is taken in deep inspiration to
visualise 10 posterior ribs and 6
anterior ribs.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
16. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
17. X ray PA view in expiration
pseudo cardiomegaly
widening of aorta and prominent PA.
Interstitial markings are accentuated .
Pseudo tracheal deviation
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
18. PA AND AP VIEWS
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
19. PA view preferred for cardiac evaluation:
Heart is placed anteriorly in chest.
Image is without magnification and
gives real cardiac size.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
20. PA VIEW
The edges of the
scapulae are
retracted laterally
with only a small
portion projected
over each lung
lungs are therefore
more easily seen
CTR is clearly well
within the normal
limit of 50%.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
21. AP VIEW
pa
lower quality than
PA images..
The scapulae are
not retracted
laterally and they
remain projected
over each lung.
Acute angle of
ribs
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
22. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
24. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
25. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
26. PA PROJECTION- normal left
mediastinal contour
from superior to inferior
◦ Aortic Knob.
◦ PT
◦ LV Abutting The Diaphragm
Rarely, LAE can be projected between
PT and the LV in the normal heart,
primarily in young females.
Occasionally, the cardiophrenic junction of
the cardiac silhouette is formed by a fat pad.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
28. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
29. In babies and young
children the normal
thymus is a
triangular sail-
shaped structure
with well-defined
borders projecting
from one or both
sides of the
mediastinum
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
30. LATERAL PROJECTION
Superiorly: the anterior
border is formed by the
ascending aorta posterior to
the retrosternal air space.
Normally there is clear 3-5mm
retrosternal space
Inferiorly, RV and RVOT abut
the sternum and blend into
the MPA, which then courses
posteriorly to its bifurcation.
The posterior cardiac contour
is formed by LA superiorly
beneath the carina and the LV
curving inferiorly to the
diaphragm.CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
31. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
32. Retrosternal Filling on the Lateral Chest
Radiograph
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
34. Pectus excavatum :
In PA view results in pseudocardiomegaly
False prominence of MPA
narrow AP diameter in lateral view.
Normal distance between posterior
sternum and vertebral column
10.5 cm –men; 9cm –women
<5 cm pectus excavatum is severe;5-
7cm moderate.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
35. Pectus carinatum:
Best in lateral view.
↑ AP diameter
May be congenital or due to increased
PVR in infants secondary to left to
right shunts.
Barrel shaped chest:
AP and TRANSEVERSE diameters are
equal.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
36. BONY ABNORMALITIES INDICATING
HEART DISEASES
Hypersegmentation of
the sternum (more that
four to five segments)
> 90% of Downs
syndrome and a clue
to ECD or complete
AVCD
Wavy retrosternal
linear opacities
dilated IMA (CoA)
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
40. Premature fusion of sternal segment is usual in
cyanotic CHD
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
41. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
42. CARDIOTHORACIC RATIO (CTR)
Ratio Of The Transverse Cardiac
Diameter (TCD) To The Maximal Internal
Diameter Of The Thorax At The Level Of
The Diaphragm On An Upright PA film
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
43. CARDIOTHORACIC RATIO( CTR)
Normal CTR: 33-50%.
Trans thoracic diameter is measured by
a line drawing across the thoracic cage
at level of inner border of 9 rib.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
46. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
47. Many newborn children appear to have
cardiomegaly when in fact the thymus is
contributing to the “cardio-thymic
shadow”.
lateral view of CXR can separate this
from true cardiomegaly.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
48. A CTR > 0.5 with a normal heart size
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
49. 1. Hyperinflation changes the
configuration of the heart, making it
appear smaller.
2. Systole or diastole can make up to a
1.5-cm difference in heart size
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
51. RIGHT ATRIAL ENLARGEMENT
Right border more convex and
elongated and forms > 50% of right
cardiac border
Mid vertical line to maximum
convexity in right border is >5 cm in
adults and> 4 cm in children
Right cardiac border > 2.5
cm from the lateral aspect
of the thoracic vertebra.
Right border of heart >3.5cm from
sternal right border
Right atrial border extends beyond 3
ICS
dilatation of SVC & IVC that causes
widening of the right superior
mediastinum
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
52. LAO view-best view to visualise RAE.
upper half of anterior cardiac border is
RA and lower half is RV
When RA enlarges the upper anterior
cardiac border becomes squared giving
a box like appearance.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
54. LEFT ATRIAL ENLARGEMENT
dilation of the left atrial appendage- focal
convexity where there is normally a concavity
between LPA and left border of LV
elevates the left main stem bronchus-widens
the angle of the carina, normal being 45-75
degrees. (splaying of the carina)
marked LA enlargement- double density
(Shadow within shadow)
lateral film= focal, posteriorly directed bulge;
posterior and upward displacement of the left
main stem bronchus
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
55. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
56. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
57. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
58. LEFT ATRIAL ENLARGEMENT
Displacement of thoracic aorta to left
Straightening of left heart border
Distance from right border of LA to left
bronchus >7 cm
Grading of LAE
I=Right border of LA is within RHB
II=Right border of LA matches with RHB
Right border of LA is right to RHB
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
59. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
60. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
61. LEFT VENTRICULAR ENLARGEMENT
PA VIEW:
◦ Left cardiac border gets elongated and becomes
convex resulting in cardiomegaly.
◦ Obtuse cardiophrenic angle
◦ Left cardiac border dips into left dome of diaphragm.
◦ Rounded apical segment: duck back appearance
◦ gastric air bubble is displaced inferiorly (PA view) and
anteroinferiorly (lateral view) .
◦ LV aneurysm - localized cardiac bulge in left cardiac
border.
LATERAL VIEW:
◦ Riglers measurement >17mm
◦ Eyelers ratio >0.42
◦ Obliteration of retrocardiac space
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
62. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
HOFFMAN RIGLERS
SIGN
63. HOFFMAN RIGLERS SIGN
On a lateral chest radiograph, if the
distance between LV border and the
posterior border of IVC exceeds 1.8 cm,
at a level 2 cm above the intersection of
diaphragm and IVC, LV enlargement is
suggested
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
64. EYELERS RATIO Valid when IVC
shadow is absent on
lateral view.
Mark point of junction
where posteroinferior
cardiac border meets
dome as B.
From B draw a
horizontal line to
posterior border of
sternum AB
From B draw another
line to inner border of
rib BC
Ratio of AB/BC is
EYELERS RATIO.
It is 0.42 or less.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
65. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
66. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
67. LV aneurysms, result in a localized bulge that
projects beyond the normal ventricular contour or
an angulation of LV contour
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
68. RIGHT VENTIRCULAR ENLARGEMENT
As RV dilates, it expands superiorly, laterally and
posteriorly
classic signs of RV enlargement are a boot-shaped
heart
In adults it is rare for RV to dilate without LV dilation
seen as an isolated finding in CHD, typically TOF
PA VIEW: cardiac apex moves posteriorly
RV forms left cardiac border resulting in rounded and
elevated apex.
LATERAL VIEW:
Obliteration of retrosternal space. contact of anterior
cardiac border greater than 1/3 of the sternal length
Riglers ratio A <17mm
Eyelers ratio:<0.42
Isolated RV enlargement is unusual;More typically, there
is associated prominence of RA and PTCHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
69. MCC of increased retrosternal soft
tissue -previous median sternotomy.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
73. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
74. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
75. Narrow vascular pedicle
Cardiomegaly directly proportional to severity of pericardial
effusion
rounded, globular appearance with no particular chamber
enlargement
Cardiophrenic angle become more and more acute
Oligaemia
Marked change in cardiac silhouette in decubitus posture
‘Epicardial fat pad sign’- anterior pericardial strip bordered
by epicardial fat post. and mediastinal fat ant.>2mm
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
76. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
78. LEFT MEDIASTINAL OUTLINE
bulge just above the cardiophrenic
angle- MI or ventricular aneurysm.
Bulge at the cardiophrenic angle
pericardial cysts
prominent fat pads
adenopathy.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
79. LEFT MEDIASTINAL OUTLINE
AORTIC KNOB:
prominent knob -ectasia, aneurysm or
hypertension.
Notching or ‘figure of 3” sign -coarctation.
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
80. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
LEFT AORTIC ARCH
RIGHT AORTIC ARCH
91. PULMONARY VASCULATURE
patient standing erect
Vessels supplying the upper lungs are one third to
one quarter the size of those in the lower
lungs
Vessels are smaller and fewer in upper lungs
increasing gradient of perfusion per unit volume of
lung tissue from apex to base
Patient supine
flow per unit volume of lung becomes equal between
apex and base
vessel sizes and numbers tend to equalize
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
92. central main right and left pulmonary
arteries are usually not individually
identifiable, because they lie within the
mediastinum
normally become too small to be seen
near the pleura
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
93. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
1. major arteries –central
2. clearly distinguishable
midsized pulmonary
arteries (third or fourth
order branches) -middle
zone
3. small arteries and
arterioles -normally below
the limit of resolution -in
the outer zone.
94. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
95. REDISTRIBUTION OF FLOW
placing the patient supine
Failure to expose the film at full inspiration
pulmonary venous hypertension,
pulmonary arterial hypertension
increased RV cardiac output
pulmonary parenchymal destruction
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
96. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
97. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
98. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
99. uniformly distributed vascular markings with absence of the normal
lower lobe vascular predominance
Increased RDPA size (> 16 mm in male and >14 mm in female)
PA branch that is larger than its accompanying bronchus (best
noted in the right parahilar area)
Prominent MPA and proximal PA
Presence of pulmonary arterial vascular markings in lateral one
third of lung fields
Dipping below diaphragm
End on view of PAs -3(unilateral)-5(bilateral)
If the ratio of RDPA to trachea is more than 1 in a child < 12 years
Hilar Haze in lateral film
Artery to vein ratio > 1.3:1 in upper lobe
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
100. Prominent vascularity -only if Qp-to-Qs ratio
is >1.5:1
overt cardiac enlargement implies a shunt
>2.5:1.
unilateral plethora –BT shunt and in
unilateral MAPCA
Asymmetry in lung vascularity
1) Glenn surgery
2) PA branch stenosis
3) absent RPA or LPA
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
101. Mimics of shunt vascularity
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
102. PULMONARY VENOUS HYPERTENSION
prominent upper lung vessels, both arteries
and veins.
As pulmonary venous hypertension increases
to 25 mm Hg, there is increased transudation
of plasma
It results in the radiographic appearance of
septal lines (Kerley lines), which are due to
fluid within the interlobular septa.
classic alveolar edema -pressure > 30 mm Hg.
CHEST X RAY IN DIAGNOSIS OF
CARDIAC CONDITIONS
103. PULMONARY VENOUS HYPERTENSION
LARRY ELLIOTS CLASSIFICATION
X RAY FINDINGS PCWP
NORMAL vascular pattern is normal <8 mm -10 Hg,
STAGE 1 CEPHALISATION (Deer Antler sign) 10-12MM HG
STAGE 2 INTERSTITIAL EDEMA (PERIVASCULAR
PERIBROCHIAL AND SUBPLEURAL
EFFUSION),KERLEY LINES
12 to 18 mm Hg
STAGE 3 INTRA ALVEOLAR EDEMA BILATERAL PATCHY
COTTON WOOL OPACITIES -Perihilar “bat wing”
appearance
1.Diagnostic phage lag :12 hours
2.Therapeutic phase lag-2 days
>18 to 20 mm Hg
104. CHEST X RAY IN DIAGNOSIS OF
CARDIAC CONDITIONS
105. extensive pulmonary fibrosis or multiple
bullae= vascular pattern is abnormal at
baseline, and as PCWP increases, it does not
change in predictable ways a
chronic heart failure, there are chronic
changes in the pulmonary vascular pattern
that do not correlate with the changes that
occur in patients with normal LV pressure at
baseline
CHEST X RAY IN DIAGNOSIS OF
CARDIAC CONDITIONS
106. Kerley A lines :horizontal linear shadows
towards hilum
Kerley B lines: horizontal and linear towards
costophrenic angle
Kerley C lines: crisscross between A and B.
CHEST X RAY IN DIAGNOSIS OF
CARDIAC CONDITIONS
107. CHEST X RAY IN DIAGNOSIS OF
CARDIAC CONDITIONS
108. CHEST X RAY IN DIAGNOSIS OF
CARDIAC CONDITIONS
109. Decreased Pulmonary Blood Flow
All the linear shadows in the
normal lung fields are due to
pulmonary vasculature.
Small pulmonary artery
Empty pulmonary bay
Pulmonary vessels small
Lung hypertranslucent
Lateral view shows diminution
of hilar vessels
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
110. Small-caliber pulmonary vessels with
relatively hyperlucent lungs and a small
heart are evidence of a marked
decrease in the circulating blood volume
(e.g., in Addison disease, hemorrhage).
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
111. Distended lymphatic channels
within edematous septa
from peripheral lymphatics to
central hilar nodes
Towards the hilum
Less specific
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
112. Horizontal lines
1-3 mm thick
Perpendicular to pleural surface
Towards the costophrenic angle
Accumulation of fluid in interlobular
septa and lymphatics
Highly specific for PVH
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
113. CARDIAC MALPOSITION
If the stomach bubble cannot be seen aerophagia→
(deliberate inhalation in adults or from sucking an
empty bottle in infants)
transverse liver implies visceral heterotaxy but does
not distinguish right from left isomerism
The inferior margin of a transverse liver is horizontal
Bilateral symmetry implied by a transverse liver
demands bilateral symmetry of the bronchi.
Bilateral morphologic right bronchi = right isomerism
bilateral morphologic left bronchi = left isomerism
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
114. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
115. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
116. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
118. COMPLETE SITUS INVERSUS
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
Situs inversus is missed if the film is inadvertently read in a reversed position
because it then appears correct except for the L and R designations that are on the
wrong side .
119. SITUS SOLITUS WITH DEXTROCARDIA
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
120. SITUS INVERSUS WITH LEVOCARDIA
The stomach (S) is on
the right
And the liver (L) is on
the left,
The heart (apex) is to the left
of midline.
The left hemidiaphragm is
lower than the right
hemidiaphragm because the
cardiac apex is on the left.
The descending thoracic
aorta (dao) is on
the right (concordant
for situs inversus), but the
position of the ascending
aorta (aao) indicates a
discordant d-
bulboventricular loop
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
121. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
122. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
123. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
A-liver is transverse
stomach (S) is on the right
heart is midline, but the base to apex axis points to the left
B- liver is transverse
base to apex axis points to the right
heart is to the right of midline
ground-glass appearance -TAPVC
124. RIGHT ISOMERISM
transverse liver = visceral heterotaxy but not its
type
position of the stomach is variable (right, left, or
occasionally central)
heart can be either to the right or left of
midline
symmetric bronchi is right type -Overpenetrated
films or tomographic scans
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
125. LEST ISOMERISM
• transverse liver
•heart is usually left-sided
•stomach tends to be on the side opposite the
descending aorta
• IVC interruption with azygous continuation -
frontal projection
•Absence of IVC shadow in the lateral projection is not
a reliable sign of interruption because azygos
continuation may create the impression of a normal
uninterrupted IVC
•lung fields - PBF↑ ( L-to-R shunts occur with no
RVOTO)
CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
126. CHEST X RAY IN DIAGNOSIS OF CARDIAC CONDITIONS
