This presentation is almost a complete Pictoral view of Radiograph chest. This presentation will help radiologist in daily reporting. This presentation will help physicians, surgeons, anesthetist and almost all medical professionals in diagnosing commonly presenting cardiac diseases. This will also help all in preparaing TOACS examination.

1. AN APPROACH TO
CARDIAC XRAY
Dr. Muhammad Bin Zulfiqar
PGR IV FCPS Services Institute of Medical Sciences /
Hospital Lahore
radiombz@gmail.com

2. AIMS
Basic Approach to Radiograph Chest
Basic Anatomy
Cardiac Pathologies

3. TOPICS DISCUSSED
 1. BASICS OF CXR
 2.STRUCTURES IN ANTERIOR VIEW
 3.STRUCTURES IN LATERAL VIEW
 4.CHAMBER ENLARGEMENT
 5.PULMONARY CIRCULATION
 6.CONGENITAL HEART DISEASE
 7.PERICARDIAL DISEASE
 8.PACEMAKER & ICD
 9.CARDIAC CALCIFICATION
 10.PROSTHETIC HEART VALVE
 11.DISEASES OF AORTA
 12. MISCELLENOUS

4. BASICS OF X-RAY TECHNICAL QUALITY
R – ROTATION
I -- INSPIRATION
P -- PROJECTION
E -- EXPOSURE

5. ROTATION
The medial ends of both clavicles
should be equidistant from the
spinous process of the vertebral
body projected between the
clavicles

6. The increase in blackness
(radiolucency) of one
hemithorax is always on
the side to which the
patient is rotated,
irrespective of whether the
CXR has been taken PA or
AP

7. DEGREE OF INSPIRATION
It is ascertained by counting either the
number of visible anterior or posterior
ribs
Adequate inspiratory effort – five to
seven complete anterior or ten posterior
ribs are visible
Poor inspiratory effort - fewer than five
anterior ribs
Hyperinflated lung-more than seven
anterior ribs

8. IMPORTANCE OF AN INSPIRATORY FILM
POOR INSPIRATORY FILM NORMAL INSPIRATORY FILM
1
2
3
1. Mediastinal Widening 2.Cardiomegaly 3.Lower lobe patchy opacification

9. PROJECTION OF X-RAY
Projection is defined as the direction of x-ray with
relation to the patient
If the direction of x-ray projection is from front – AP
projection
If the direction of x-ray projection is from behind –PA
projection

10. AP VIEW PA VIEW

11. PA VIEW AP VIEW
In erect patients
Vertebral spines more
prominent
Scapulae clear of lungs
Clavicles are horizontal
In supine patients
Vertebral bodies clear
Apparent cardiomegaly
Scapulae overlap
Clavicles are oblique

12. ERECT SUPINE
 Gas bubble in fundus with a
clear air fluid level
 Gas bubble in antrum
 Apparent cardiomegaly

13. EXPOSURE OF X-RAY
Normal exposure - the vertebral bodies should just be
visible at the lower part of cardiac shadow
Underexposed -If the vertebral bodies are not visible ,
insufficient number of x-ray photons have passed
through the patient to reach the x-ray film
Similarly, if the film appears too ‘black’, then too many
photons have resulted in overexposure of the x-ray film.

14. UNDERPENETRATION NORMAL OVERPENETRATION

15. SYSTEMATIC APPROACH
Technical factors
Skeletal abnormalities and hardware
Situs: gastric air bubble, cardiac apex, and aortic knob
Heart: position, size, and shape
Great vessels: position, size, and shape
Lung fields and vascularity by zone
Search for calcifications

16. STRUCTURES SEEN IN ANTERIOR VIEW

17. STRUCTURES IN LATERAL VIEW
RV
PT
AA
LA
LV

18. Gastric air
bubble
Left upper
lobe
bronchus
IVC
Right
hemidiaphragm
LV
LARV
Pulmonary
outflow
tract
Aorta
Right upper
lobe bronchusRPA
LPA
Confluence
of
pulmonary
veins
Brachiocephalic
vessels Trachea
Left
hemidiaphrag
m

24. Aortic knob is the junction formed by the arch and descending aorta

25. MAIN PULMONARY ARTERY
LPA

26. HOW TO MEASURE MAIN PULMONARY ARTERY
If we draw a
tangent line from the apex
of the left
ventricle to the
aortic knob(red line)
and measure along
a perpendicular
to that tangent
line (yellow line)
The distance between the
tangent and the main
pulmonary artery
(between two small green
arrows) falls in a range
between 0 mm (touching
the tangent line) to as
much as 15 mm away from
the tangent line

28. PROMINENT MPA
Main pulmonary artery projects
more than the tangent
Causes:
1. Increased pressure
2. Increased flow

29. HYPOPLASTIC PA
MPA > 15 mm from the tangent
Concave PA segment
Causes:
1. TOF
2. TRUNCUS ARTERIOSUS

30. LEFT ATRIAL APPENDAGE
L
LA ENLARGEMENT
HYPERTROPHIED
LA APPENDAGE

31. LEFT VENTRICLE

32. CARDIOMEGALY
The cardiothoracic ratio should be less
than 0.55 on PA view. i.e. A+B/C<0.55
 A cardiothoracic ratio > 0.55 suggests
cardiomegaly in adults
A cardiothoracic ratio > 0.6 suggests
cardiomegaly in newborn

33. CTR is more than 50% but heart is normal
Spurious causes of cardiac enlargement
 Portable AP films
 Obesity
 Pregnant
 Ascites
 Straight back syndrome
Pectus excavatum

34.  CTR is less than 50% but heart is
abnormal
Obstruction to outflow of the
ventricles
 Ventricular hypertrophy
Must look at cardiac contours
< 50%
ASCENDING AORTA DILATED LV CONTOUR

35. CRITERIA'S FOR CARDIOMEGALY
Cardiothoracic ratio >0.55 in adults on PA view
Cardiothoracic ratio >0.6 in newborn on PA view
Any increase in transcardiac diameter > 2 cm compared
to old x-ray
In old age and emphysema a transcardiac diameter
more than 15.5 cm in males &>12.5 cm in females

36. CHAMBER ENLARGEMENT
RA enlargement
LA enlargement
RV enlargement
LV enlargement

37. CRITERIA FOR RA ENLARGEMENT
Rt. Cardiac border becomes more
convex > 50% of right border
Rt. Atrial border extends >3
intercostal spaces
Measurement from mid vertical line
to max. convexity in rt. Border>5 cm
in adult & >4cm in children
Lateral view – fullness in space
between sternum and front of
upper part of cardiac silhouette

38. CRITERIA FOR LA ENLARGEMENT
 Widening of carina( normal 45-75 degree)
 Elevation of left bronchus
 Straightening of left border
 Double atrial shadow( shadow within shadow)
 Grade 1 –double cardiac contour
 Grade2 - LA touches RA border
 Grade 3 – LA overshoots the Rt. Cardiac border
 Displaces the descending aorta to the left and esophagus to
right seen in barium swallow

39. LA ENLARGEMENT HYPERTROPHIED
LA APPENDAGE

40. LEFT ATRIAL ENLARGEMENT
DOUBLE ATRIAL SHADOW
WIDENING OF CARINA
ELEVATION OF LEFT
BRONCHUS
Left atrial appendage
enlargement

42. Widening of carina
Elevation of lt.
bronchusAneurysmal LA
Aneurysmal LA – When La enlarges to left and right and approaches within
an inch of lateral chest wall

43. LATERAL VIEW-LA ENLARGEMENT
LA pushing the
Esophagus posterior

44. LEFT VENTRICULAR ENLARGEMENT
 PA view
 (a)Left cardiac border gets enlarged and becomes more convex
resulting in cardiomegaly
 (b)Lt. cardiac border dips into lt. dome of diaphragm
 (c) rounded apical segment
 (d) cardiophrenic angle is obtuse

45. LEFT VENTRICULAR ENLARGEMENT
Lateral view
(a) Left ventricle enlarges inferiorly and posteriorly
(b)Rigler’s measurement A is >17 mm
(c)Rigler,s measurement B is< 7.5 mm
(d) Eyeler’s ratio becomes > 0.42

46. RIGLER’S MEASUREMENT
Rigler’s A & B used to differentiate left
ventricular and right ventricular
enlargement
 Possible only when IVC shadow is
present
Jn. Of IVC with Lt. Atrium – J point
Rigler’s A- from J point along line of IVC
draw a line of 2 cm above and mark the
point X.

47. Draw a horizontal line from pt. A to posterior
Cardiac border and mark that pt. y
Distance between points x & y is Rigler’s
measurement A
NORMAL<17 mm
Rigler’s B-from the pt. J drop a perpendicular
line to the dome and this distance is Rigler’s
measurement B
NORMAL>7.5 mm
RIGLER’S MEASUREMENT

48. When LV enlarges,
Posterior cardiac border gets displaced
posteriorly & IVC shadow gets included in
cardiac shadow, without getting displaced
posteriorly
 Rigler’s measurement A >17 mm in lt.
ventricular enlargement
RIGLER’S MEASUREMENT

49. EYELER’S RATIO
To differentiate lt. & rt. Ventricular
enlargement
 Valid when IVC shadow is absent or cannot
be visualised
Mark the point of jn. where postero inferior
cardiac border meets the dome as B
 From this point B draw a horizontal line to
the posterior border of sternum-AB

50. From pt.B - draw another horizontal line
posteriorly to the inner border of the rib-
BC
Ratio of AB/BC is Eyeler’s ratio < 0.42
EYELER’S RATIO

51. LA Oblique view
 There is a retrocardiac space( prevertebral)
(a)Mild lt. Ventricular enlargement-obliteration
of retrocardiac space
(b) mod. Lt.ventricular enlargement-cardiac
shadow overlaps vertebral column
(c)Marked Lt.ventricular enlargement-cardiac
shadow overshoots vertebral column

52. Chest X ray shows left ventricular
enlargement.
Left heart border is displaced
leftward, inferior and posteriorly.
Rounding of the cardiac apex.

53. RV ENLARGEMENT
PA VIEW
Cardiophrenic angle is acute
Clockwise rotation of heart causes RV to form
the middle portion of the left heart border.
RIGHT LATERAL VIEW
Obliteration of retrosternal spac

54. RV ENLARGEMENT
LEFT LATERAL VIEW
Rigler’s measurement will be17mm or less
Rigler’s measurement will be 7.5mm or more
Eyeler’s ratio is 0.42 or less

55. PERICARDIAL EFFUSION
Narrow vascular pedicle
Cardiomegaly directly proportional to severity of pericardial
effusion
This shadow has a rounded, globular appearance with no
particular chamber enlargement
Cardiophrenic angle become more and more acute
Oligaemic pulmonary vascular markings
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

56. Narrow vascular pedicle
Acute
cardiophre
nic angle
‘Water bottle’
appearence
Pulmonary
oligaemia

57. DILATED CARDIOMYOPATHY VS
PERICARDIAL EFFUSION
Chambers can be identified
Cardiophrenic angle is obtuse
Increased pulmonary venous hypertension
No change in cardiac silhouette in decubitus
Vascular pedicle is dilated or normal
Fluoro shows cardiac pulsation

58. CONSTRICTIVE PERICARDITIS
1.Straightening of the right
border
2.Pericardial thickening > 4
mm
3.Pericardial calcification (50%
cases)
4.Dilatation of SVC and
azygous vein
Pericardial calcification

59. CONGENITAL ABSENCE OF PERICARDIUM
Focal bulge in area of main pulmonary
artery
 Sharply marginated
 Absent right cardiac border
 Increased distance between sternum
and heart due to absence of sterno
pericardial ligament

60. PULMONARY VASCULARITY
1.RDPA<17MM
NORMAL PULMONARY CIRCULATION – 3 FEATURES

61. PULMONARY VASCULARITY

62. PULMONARY VENOUS HYPERTENSION

63. PULMONARY VENOUS HYPERTENSION
LARRY ELLIOT’S CLASSIFICATION OF PVH
RADIOGRAPHIC
GRADE OF PVH
ACUTE DISEASE
PCWP
CHRONIC DISEASE
PCWP
1 13-17 MMHG 13-17 MMHG
2 18-25 MMHG 18-30 MMHG
3 >25 MMHG >30 MM HG
4 HEMOSIDEROSIS
AND OSSIFICATION
LONG STANDING
PVH

64. GRADE 0 -PCWP< 12 MM HG
 Upper lobe pulmonary veins are less prominent than lower lobe veins
GRADE 1- PCWP 13-17MMHG
Redistribution of blood flow with cephalization-’ANTLER SIGN’
 1) increased resistance to flow due to interstitial odema
 2) alveolar hypoxia in lower lobes causes reflex vasoconstriction
 3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex
PULMONARY VENOUS HYPERTENSION

65. GRADE 2- PCWP 18-25mm hg
 Interstitial edema
 Peribronchial cuffing
 Kerley A,B,C lines
 Interlobular effusion
 Pleural effusion
 Hilar haze
Peribronchial cuffing
PULMONARY VENOUS HYPERTENSION

66. KERLEY A LINES
Distended lymphatic channels within
edematous septa coursing from
peripheral lymphatics to central hilar
nodes
 Towards the hilum
 Less specific for Pulmonary venous
hypertension
KERLEY A LINES

67. KERLEY B LINES
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
KERLEY B

68. Crisscross lines seen between A &B
GRADE 3 – pcwp > 25mm hg
Alveolar odema
Bilateral diffuse patchy
cotton wool opacities
KERLEY C LINES

70. Pulmonary circulation
Pulmonary plethora – features
 Enlargement of central pulmonary artery , lobar and segmental
artery
 Prominent nodular vascular shadows in frontal CXR- shunt vessels
that course ventral to dorsal
 Upper & lower lobe vessels prominent
 RPDA > 17mm
 Right descending pulmonary artery> tracheal diameter Ratio of
RPDA to diameter of trachea > 1
 Plethora seen if shunt size >2:1

71. PLETHORA

72. Decreased flow proximal to orgin of main pulmonary artery
Small pulmonary artery
Empty pulmonary bay
Pulmonary vessels small
Lung hypertranslucent
Lateral view shows diminution of hilar vessels
Pulmonary oligaemia

73. OLIGAEMIA
Empty pulmonary bay

74. High pressure left to right shunts are associated with
obliterative changes in the smaller pulmonary arteries &
arterioles
Large main & large central pulmonary arteries taper down
rapidly to very small vessels
Seen in Eisenmenger’s syndrome
Precapillary PAH
Pruning

75. PRUNING

76. PULMONARY EMBOLISM
Hamptons hump
Wedge opacity
Westermark sign
Hampton’s hump
Fleischner’s sign- prominent central
pulmonary artery
Palla’s sign-dilated rt. Descending
pulmonary artery
Chang’s sign – dilatation and abrupt
change in calibre of the rt. Descending
PA

77. VALVULAR HEART DISEASE MITRAL STENOSIS
Small aortic knob from decreased cardiac
output
Features of left atrial enlargement
Right atrial enlargement from tricuspid
insufficiency
Pulmonary venous hypertension
Enlarged MPA
Calcified mitral valve

78. Mitral regurgitation
LA enlargement
LV enlargement
Pulmonary venous hypertension

79. Ascending aorta dilated
Left ventricular hypertrophy
Aortic valve calcification
AORTIC STENOSIS

80. Dilated ascending aorta
LV enlargement
AORTIC REGURGITATION

81. No obvious cardiomegaly
Enlarged PA
Dilated left pulmonary artery
Normal to decreased pulmonary
vasculature
VALVULAR PS

82. Concave PA segment
RVH
Infundibular Pulmonary
stenosis

83. MPA DILATED
RPA DILATED
RV APEX
PULMONARY
PLETHORAASD
CONGENITAL HEART DISEASE

84. HOW TO DIFFERENTIATE ASD VSD PDA

85. MPA
DILATED
RPA
DILATED
LV APEX
PLETHORA
VSD

86. Linear or railroad track
calcification at site of ductus may
be seen in adults with PDA
PROMINENT
MPA
LV APEX
PLETHORA
AORTIC KNOB
PDA

87. • “FIGURE OF 3” in CXR
• “REVERSE 3” or “E sign” in Barium
meal
COARCTATION OF AORTA

88. DD OF INFERIOR RIB NOTCHING
1)Aortic obstruction- Takayasu arteritis
Coarctation of aorta
2) Subclavian artery obstruction –Classic BT shunt
Takayasu arteritis
3)Chronic Svc obstruction
4)Intercostal Av fistula
5)Neurofibromatosis

89.  Cyanosis With Decreased
Vascularity
Tetralogy of Fallot
Truncus-type IV
Tricuspid atresia
Transposition of great arteries
Ebstein’s anomaly
 Cyanosis With Increased
Vascularity
Truncus types I, II, III
TAPVC
Tricuspid atresia
Transposition
Single ventricle
Cyanotic Congenital Heart Disease

90. CYANOTIC CHD—TOF
• Rv apex
• Underfilled LV
• Concave pulmonary artery
• Pulmonary oligaemia

91.  ‘Egg on string’
 1)Narrow pedicle
 2)Rt. Border RA
 3)Lt. border LV
 4)Increased vascularity
 5)Hypoplastic thymus
CYANOTIC CHD—TGA

92. ‘figure of 8’ “snowman”
Rt border-SVC
Upper border-left innominate
Left border-left vertical vein
Body of snowman-RA
CYANOTIC CHD—TAPVC (supracardiac)

93. The scimitar sign is produced
by an anomalous pulmonary
vein that drains any or all of
the lobes of the right lung.
 Scimitar vein empties into the
inferior vena cava
CYANOTIC CHD—PAPVC(Scimitar sign)

94. ‘Box shaped heart
Enlarged RA
Hypoplastic pulmonary trunk
 Decreased vascularity
CYANOTIC CHD—EBSTEIN

95. LV apex
Rt pulmonary artery has a superior
orgin (20%)
‘waterfall sign’
‘Hilar comma sign’
Associated right aortic arch (33%)
Concave PA segment
ELEVATED
RIGHT HILUM
CYANOTIC CHD—TRUNCUS ARTERIOSUS

96. CYANOTIC CHD
Eisenmenger’s syndrome
• Chest xray show dilation of central
pulmonary arteries and pruning of peripheral
pulmonary arteries, right ventricular and
atrial enlargement. Left heart would return
to normal size.
• Left to right shunts such as atrial septal
defect, ventricular septal defect and patent
ductus arteriosus, cause increased
pulmonary blood flow. With time, high
pulmonary vascular resistance will
develop, ultimately causing right to left
shunt.

97. PACEMAKER

98. BIVENTRICULAR PACING

99. RA LEADRV LEAD

100. PACEMAKER PROBLEMS
LEAD FRACTURE
DISPLACED RA LEAD
DISPLACED RV LEAD

101. ICD

102. A) Valvular – Mitral , aortic valve
B) Pericardial – constrictive pericarditis
C) Myocardial – left atrial wall, LV aneurysm
D) Endocardial – Endomyocardial fibrosis
E) Intraluminal – La thrombus , La myxoma , Lv thrombus
F) Vascular – aortic calcification , coronary artery
CARDIAC CALCIFICATIONS

103. CARDIAC CALCIFICATION
MITRAL VALVE
CALCIFICATION

104. MYOCARDIAL CALCIFICATION
CALCIFIED LV APICAL
ANEURYSM

105. CONSTICTIVE PERICARDITIS
CALCIFIED PERICARDIUM

106. PERICARDIAL VS MYOCARDIAL CALCIFICATION
PERICARDIAL
 SEEN IN BOTH SIDES OF HEART MOST
COMMONLY IN AV GROOVE
 DIFFUSE CALCIFICATION AROUND THE
HEART
 CALCIFICATION IS CHUNKY & UGLY
MYOCARDIAL
 SEEN IN ONLY LEFT SIDE
 MOST COMMON SITE IS ANT.
WALL
 LOCALIZED TO THE LEFT
 CALCIFICATION IS FINE &
CURVILINEAR

107. GIANT LA CALCIFICATION

108. ATRIAL MYXOMA

109. TILTING DISK VALVE
PROSTHETIC HEART VALVE

110. STARR EDWARD BALL VALVE

111. STARR EDWARD PROSTHETIC VALVE
MITRAL
PROSTHESIS

112. ST. JUDE VALVE

113. Aneurysm of ascending &
Descending aorta
Diseases of aorta

114. Egg shell sign
Aortic dissection

115. MISCELLENOUS X-RAYS
LEFT SVC
 Occurs in less than 0.5% of people
 Failure of regression of L common
and Ant. Cardinal veins
 Drains left jugular and left subclavian
vein
 Most patients also have right sided
SVC
 Drains into dilated coronary sinus
LEFT SVC

116. RIGHT AORTIC ARCH
 Leftward displacement of barium filled
esophagus
Rt. Indentation of trachea
 Aortic knob is absent from left side
 Aorta descends on right
Associated with TOF
Truncus arteriosus

117. AORTIC NIPPLE
Left superior intercostal vein
 Seen in 5% of cases
To be differentiated from a mass
Also called pseudo dissection
It drains into hemiazygous vein
Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis

118. CERVICAL AORTIC ARCH
Left sided cervical aortic arch
Aortic knob at apex of lung
Descend on the left
CERVICAL AORTIC ARCH

119. SITUS INVERSUS WITH DEXTROCARDIA SITUS INVERSUS WITH LEVOCARDIA

120. DEXTROCARDIA

121. HYDROPNEUMOPERICARDIUM

122. PDA CLIP

123. BIBLIOGRAPHY
(1)Jefferson K, Rees S. Clinical cardiac radiology, 2nd edition Butterworths; 1980.
(2) Lipton MJ. Plain film diagnosis of heart disease: cardiac enlargement. Contemporary Diagnostic Radiology 1988;11:1-6.
(3) Boxt LM, Reagon K, Katz J. Normal plain film examination of the heart and great arteries in the adult. J Thorac Imaging
1994;9:208-18.
(4)Murray G. Baron,Wendy M. Book .Congenital heart disease in the adult.North American Clinics of Radiology 2004;3
(5) Ramesh M. Gowda,Lawrence M. Boxt. Calcifications of the heart.North American Clinics of Radiology 2004;4
(6) Martin J. Lipton, Lawrence M. Boxt. How to approach cardiac diagnosis from the chest radiograph.North American Clinics
Of Radiology 2004;5
(7) Murray G. Baron .PLAIN FILM DIAGNOSIS OF COMMON CARDIAC ANOMALIES IN THE ADULT.North American Clinics Of
Radiology 2004;6
(8) Radiology imaging – sutton 6th edition
(9) Pediatric cardiology- Perloff’s clinical recognition of congenital heart disease
(10)Radiology of congenital heart disease-Amplatz
(11)Grainger & Allisons- diagnostic radiology vol1 , 4th edition
(12)Cardiac Xrays- v.Chockalingam
(13)Braunwald heart diseases 9th edition
(14) Emma C. Ferguson,Rajesh Krishnamurthy,Sandra A. A.Oldham. Classic Imaging Signs
of Congenital Cardiovascular Abnormalities; RadioGraphics 2007; 27:1323–1334
(15)www.learningradiology.com

124. QUIZ

125. QUIZ

126. EBSTEIN’S ANOMALY

127. 8 YR OLD ACYANOTIC CHILD

128. ATRIAL SEPTAL DEFECT

129. 25 YR OLD LADY WITH DYSPNOEA

130. MITRAL STENOSIS

131. 65 YR OLD MAN WITH DYSPNOEA

132. PERICARDIAL EFFUSION

133. 35 YR OLD ACYANOTIC FEMALE

134. ASD WITH PAH

136. RT AORTIC ARCH WITH RT DESCENDING AORTA

137. 4 MO CYANOTIC CHILD

138. TAPVC SUPRACARDIAC

139. 3 MO CYANOTIC CHILD

140. D-TGA

141. 8 YR OLD ACYANOTIC CHILD

142. VSD