William Herring, M.D.

2002

The ABCs of
Heart Disease
In Slide Show mode, to advance slides, press spacebar
or click left mouse button

William Herring, M.D.

Albert Einstein Medical Center
Philadelphia, PA

2000

With Acknowledgement
For Its Creation to
Bernard J. Ostrum, M.D.

2000

What It Is
An

approach
For congenital or acquired heart
disease in adults
Asking systematic set of questions
Answers based on certain
fundamental observations
Visible on frontal chest x-ray alone

Cardio-thoracic
Ratio

One of the easiest

observations to make is
something you already
know: the cardio-thoracic
ratio which is the widest
diameter of the heart
compared to the widest
internal diameter of the rib
cage

<50%

Sometimes, CTR is more than 50%

But Heart is Normal

Extracardiac

causes of
cardiac enlargement
Portable AP films
Obesity
Pregnant
Ascites
Straight back syndrome
Pectus excavatum

>50%

Here is a heart that is larger than 50% of the cardiothoracic ratio, but it is still a normal heart.
This is because there is an extracardiac cause for the apparent cardiomegaly. On the lateral
film, the arrows point to the inward displacement of the lower sternum in a pectus excavatum
deformity.

Sometimes, CTR is less than 50%

But Heart is Abnormal

Obstruction

ventricles

Ventricular

Must

to outflow of the
hypertrophy

look at cardiac contours

<50%

Here is an example of a heart which is less than 50% of the CTR

in which the heart is still abnormal. This is recognizable because
there is an abnormal contour to the heart (yellow arrows).

The Cardiac Contours

Aortic knob
Ascending Aorta

Double density
of LA enlargement
Right atrium

Main pulmonary
artery
Indentation for
LA
Left ventricle

There are 7 contours to the heart in the

frontal projection in this system.

The Cardiac Contours

Aortic knob
Ascending Aorta

Double density
of LA enlargement
Right atrium

Main pulmonary
artery
Indentation for
LA
Left ventricle

But only the top five are really important

in making a diagnosis.

Ascending Aorta
Low density,
almost straight
edge
represents size
of ascending
aorta

Ascending Aorta

Small

Prominent

Double density of left atrial

enlargement
Indentation
where double
density of left
atrial
enlargement will
appear

Even though we are on the right side of the heart, we can

see left atrial enlargement. Normally the left atrium sits
right in the middle of the heart posteriorly and does not
form a normal border on the frontal film.

Left atrium
sits in middle of
heart
posteriorly

Left atrium
forms no border
of normal heart
in PA view

LV

RA

This inset from a CT scan of the chest

shows how RA and LV obscure LA from
forming a heart border on the frontal film.

LA

When the LA enlarges, it will do something on the left

side of the heart well talk about in a minute. And it may
produce a double-density on the right side of the heart.

Double
Density
of left atrial
enlargement

Two shadows,
the yellow
arrow pointing
to the LA and
the red arrow
to the RA
overlap each
other where
the
indentation
between the
ascending
aorta and right
heart border
meet

RA
LA

The last bump on the right side is the right atrium. Since
there is no disease in an adult that causes isolated
enlargement of the RA, well consider the RA together
with the RV later.

Right atrium
not important
contour in
adults

Aortic Knob
The first bump on
the left-side is the
aortic arch. We can
measure the knob
from the lateral
border of air in the
trachea to the
edge of the aortic
knob.

Aortic knob
should
measure
< 35mm

Aortic Knob
42mm

Enlarged with:

Increased pressure

Increased flow

Changes in aortic wall

Main
Pulmonary
Artery
Important

The next bump down is the

main pulmonary artery and is
the keystone of this system.

Finding the
Main
Pulmonary
Artery

Finding the
Main
Pulmonary
Artery
Adjacent to left
pulmonary artery

We can measure the 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

0 mm

15 mm

Ao
Ao

Main
Pulmonary
Artery

Main
Pulmonary
Artery
LV
LV

Main pulmonary
artery ranges from
0 mm15mm
from tangent line

Two Major Classifications

The

main pulmonary artery (MPA) projects

beyond the tangent line
The main pulmonary artery is more than 15 mm
away from the tangent line
Because

the MPA is small or absent

Because the tangent line is being pushed away from
the MPA

Main
pulmonary
artery
projects
beyond
tangent
Increased
pressure
Increased flow

Main pulmonary
artery is more
than 15 mm
from tangent
Small pulmonary
artery
Truncus arteriosus
Tetralogy of Fallot

27

Main pulmonary
artery is more
than 15 mm
from tangent
Left ventricle
and/or aortic
knob push the
tangent away
Common

29

To
recapitulate:

0 - 15 mm

Left atrial enlargement

Concavity where L
atrium will appear on
left side when
enlarged

Left atrial enlargement

Straightening of the
left heart border
Left atrium
may enlarge
without
producing
double
density

In the example on the

right, not only is the
left atrium enlarged,
but the left atrial
appendage is too. So
there is a convexity
outward where there
is normally a
concavity inward.

Main
Pulmonary
Artery
Left
Atrial
Appendage

Left ventricle

Left Ventricle

Which Ventricle is Enlarged?

The best way to determine which

ventricle is enlarged is to look at
the corresponding outflow tract for
each ventricle

Which Ventricle is Enlarged?

If Heart Is Enlarged,
And Main Pulmonary
Artery is Big
>50%

Then Right Ventricle is

Enlarged

Which Ventricle is Enlarged?

If Heart Is Enlarged,
And Aorta is Big
>50%

Then Left Ventricle

is Enlarged

Which ventricle is enlarged?

The

best way to determine

which ventricle is enlarged is to
look at the corresponding
outflow tract for each ventricle
Aorta
MPA

for the LV

for the RV

Which Ventricle is Enlarged?

Once one ventricle is enlarged,

its impossible to tell if other ventricle
is also enlarged

The Cardiac Contours

Aortic knob
Ascending Aorta

Double density
of LA enlargement
Right atrium

Main pulmonary
artery
Indentation for
LA
Left ventricle

The Cardiac Contours

Aortic knob
Ascending Aorta

Double density
of LA enlargement
Right atrium

Main pulmonary
artery
Indentation for
LA
Left ventricle

The Pulmonary
Vasculature

Five States of the Pulmonary

Vasculature
Normal
Pulmonary

venous hypertension
Pulmonary arterial hypertension
Increased flow
Decreased flow

What Were Going to Evaluate

Right

Descending Pulmonary
Artery
Distribution of flow in the lungs
Upper

versus lower lobes

Central versus peripheral

What to Evaluate
2
1
2
3

1. Right Descending Pulmonary Artery

Right
Descending
Pulmonary
Artery
Serves right
middle and
lower lobes

1. Right Descending Pulmonary Artery

Diameter can
be measured
(before
bifurcation)

RDPA
< 17 mm

Normally, the
right
descending
pulmonary
artery should
not be more
than 17mm in
diameter

2. Normal Distribution of Flow

Upper Versus Lower Lobes

In erect position,
blood flow to
bases > than flow
to apices

Size of
vessels at
bases is
normally
> than size
of vessels
at apex

You cant measure size of

vessels at the left base
because the heart obscures
them

3. Normal Distribution of Flow

Central versus peripheral

Normal
tapering of
vessels
from
central to
peripheral

Central vessels
give rise to
progressively
smaller peripheral
branches

Normal Vasculature - review

2

RDPA
< 17 mm in
diameter

Gradual
tapering of
vessels
from central
to
peripheral

3
2

Lower lobe
vessels
larger than
upper lobe
vessels

Venous Hypertension
RDPA usually
> 17 mm

Upper lobe
vessels equal
to or larger
than size of
lower lobe
vessels =
Cephalization

Pulmonary Arterial Hypertension

Main
Pulmonary
Artery
projects
beyond
tangent line

RDPA usually
> 17 mm
23

Pulmonary Arterial Hypertension

Rapid
cutoff in
size of
peripheral
vessels
relative to
size of
central
vessels

31

Central vessels
appear too
large for size of
peripheral
vessels which
come from
them =
Pruning

Increased Flow
RDPA usually
> 17 mm

All of blood vessels everywhere in

lung are bigger than normal

Increased Flow
Distribution of
flow is
maintained as
in normal
Gradual
tapering from
central to
peripheral
Lower lobe
vessels bigger
than upper
lobe

Normal

Increased Flow

Increased Flow

PAH

Decreased Flow
Unrecognizable
most of the
time

Small hila

Fewer than
normal blood
vessels

The Pulmonary Vasculature

Normal
Pulmonary venous hypertension
Pulmonary arterial hypertension
Increased flow
Decreased flow - mostly
unrecognizable even when it is
present

A
Is the Left
Atrium
Enlarged?

If yes,
then

Look at the
Pulmonary
Vasculature

If no,
then

B
Is the Main
Pulmonary
Artery Big
or
Bulbous?

Normal

Mitral
regurg

Pulmonary
venous
hypertension

Mitral
Stenosis
L Myxoma

Increased

If yes,
then
Look at the
Pulmonary
Vasculature

VSD, PDA

Normal

Plum.
stenosis

Increased

ASD
(VSD)

Pulmonary
hypertension

Idiopathic
(1)

The ABCs

C
Is the Main
Pulmonary
Artery
Segment
Concave?

D
Is the
Heart
Dilated or
DeltaShaped?

If no,
then

If yes,
then

If no,
then

If yes,
then

Don't Look at
Pulmonary
Vasculature.
Look at Aorta

Normal

Cardiomyopathy

Ascending
dilated

Ao
Stenosis

Whole Ao
Dilated

Ao regurg
HBP

Cardiomyopathy
Pericardial
Effusion
Molt. valve dz

The System
Those

were all of the answers

Now here are the questions
The system is successful only if
you ask the questions in this order
The answers are the fundamental
observations you make on the
frontal film alone

A
Is The Left Atrium
Enlarged ?

A
Double
density at
site of normal
indentation

To answer that question

Straight or
convex at
site of
normal
concavity

A
If Answer To Question A Is

YES

Look At Pulmonary Vasculature

A
If Answer To Question A Is
Then...

NO

B
Is The Main Pulmonary
Artery Big ?

To answer that question

Main
pulmonary
artery projects
beyond
tangent line

B
If Answer To Question B Is

YES

Look At Pulmonary Vasculature

B
If Answer To Question B Is
Then...

NO

C
Is The Main Pulmonary
Artery Concave ?

To answer that question

25

Main
pulmonary
artery is >
15mm
away from
tangent
line

C
If Answer To Question C Is

YES

Look At Configuration of Aorta

C
If Answer To Question C Is
Then...

NO

D
Is The Heart a Dilated Or
Delta-Shaped Heart ?

1. Pericardial effusion
2. Cardiomyopathy

Cardio-thoracic ratio > 65%

A
Is the Left
Atrium
Enlarged?

If yes,
then

Look at the
Pulmonary
Vasculature

If no,
then

B
Is the Main
Pulmonary
Artery Big
or
Bulbous?

C
Is the Main
Pulmonary
Artery
Segment
Concave?

D
Is the
Heart
Dilated or
DeltaShaped?

If yes,
then

If no,
then

If yes,
then

Mitral
regurgitation

Pulmonary
venous
hypertension

Mitral
Stenosis
L Myxoma

Increased

VSD, PDA

Pulmonic
stenosis

Normal

If yes,
then

If no,
then

Normal

Look at the
Pulmonary
Vasculature

ASD
(VSD)

Increased

Pulmonary
hypertension
Normal
Don't Look at
Pulmonary
Vasculature.
Look at Aorta

Idiopathic
2 to lung dz
Cardiomyopathy

Ascending
dilated

Aortic
Stenosis

Whole Aorta
Dilated

Aortic
regurgitation
HBP

Cardiomyopathy
Pericardial
Effusion
Multiple valve dz

Choose the link

Test Yourself on the ABCs
to see how the system works
For printed notes, choose the link under
Cardiac Notes for
The ABCs of Heart Disease

The End