Conventional radiography in

Cardiac chamber enlargement

 Technical Factors
• Conventional PA film:
– FFD- 6 feets( minimize cardiac enlargement)
– Centering – at D7 spinous position determined at
before positioning the patient
– Positioning- proper positioning with arms flexed
and around the bucky to swing out scapula out of
lung field. (Proper positioning very important as
rotation can cause distortion of cardiac silhoute)
– KVp- High KVp technique
– Short exposure time to reduce motion artifact of
heart
– End inspiration
 Cardiac Silhouette/Chambers
• The image of the heart and great vessels on
the chest radiograph is a two-dimensional
display of dynamic three dimensional
structures .
• The cardiovascular silhouette varies not only
with the abnormality but also with body
habitus, age, respiratory depth, cardiac cycle,
and position of the patient
 Cardiac Silhouette
Right Heart Border Left heart Borders (Moguls)
• Superior venacava • Aortic Knuckle
• Ascending aorta ( • Pulmonary Bay
when tortous) • Left Atrial
• Right atrium appendage
• inferior venacava • Left ventricle
PA view
demonstrating cardiac
silhouette
Lateral Projection
• Anteriorly
– Right ventricle
• Posteriorly
– Left atrium
– Left ventricle
 Heart Size on Chest Radiographs

• Cardiothoracic ratio
• The heart enlarges in two
different haemodynamic
situations
–diastolic volume overload
• excessive volume of blood during
its filling phase
–pump failure.
• With good centring two thirds of the cardiac
shadow lies to the left of midline and one-
third to the right, although this is quite
variable in normal subjects.
• The transverse cardiac diameter (normal for
females less than 14.5 cm) and for males less
than 15.5 cm) and the cardiothoracic ratio are
two imp parameters.
• The normal cardiothoracic ratio is less than
50% on a PA film
• Measurement in isolation is of less value than
when previous figures are available. An
increase in excess of 1.5 cm in the transverse
diameter on comparable serial films is
significant
 Heart Disease according to cardiac
enlargement
No cardiomegaly ( CT<0.5) With cardiomegaly (CT>0.5)
• Aortic Stenosis • Aortic regurgitation
• Arterial hypertension • Mitral regurgitation
• Mitral Stenosis • Tricuspid regurgitation
• Acute Myocardial Infarction • High output states
• Hypertrophic • Congetive cardiomyopathy
cardiomyopathy • Ischemic cardiomyopathy
• Restrictive cardiomyopathy • Pericardial effussion
• Constrictive pericarditis • Paracardiac mass
 Generalized Cardiac Enlargement
• Global heart enlargement, with maintenance
of an otherwise normal cardiac contour,
usually is due to diffuse myocardial disease,
abnormal volume or pressure overload as a
consequence of valvular heart disease,
hyperthyroidism,hypothyroidism, or anemia.
• Pericardial effusions also produce generalized
enlargement of the cardiac silhouette
 Gross cardiomegaly
• Ischemic heart disease
• Pericardial effusion
• ASD
• Multivalve disease (par regurgitation)
• Congenital heart disease notably Ebstein’s
anomaly
 Left atrial enlargement

• Posterior chamber without any part

forming silhouette of heart on PA view
• Forms the posterior superior silhouette of
heart on lateral projection
• The chamber is the most posterior
structure and abutts the left main
bronchus and oseophagus posteriorly
 Left atrium
forms no border of
normal heart in PA
Left atrium view
sits in middle of
heart posteriorly

LV
RA

LA
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.
 Left atrial enlargement
• Retrocardiac density forming double
heart shadow on right heart border
• The distance from the middle of the left
atrial border on the double heart shadow
to middle of left main bronchus more
than 7cm
• Ocassionally the left atrial border can
outgrow the right heart border and forms
the right cardiac border- atrial escape
 Left atrial enlargement
• elevate the left main bronchus
• splaying of the carina
• straightening of the left heart border
below the left main bronchus, then as
a discrete bulge on the left
• Elevated left main bronchus appears
as walking man on lateral view
• Oesophageal indentation
/displacement
• Isolated left atrial enlargement most
commonly is due
to mitral valve stenosis caused by rheumatic
heart disease.
• Left atrial myxoma and cor triatriatum can
also cause isolated left atrial enlargement.
• Isolated enlargement of the left atrial
appendage or apparent enlargement due to a
pericardial defect and focal herniation of the
appendage may cause a localized bulge in the
upper left cardiac contour without other signs
of left atrial dilatation.
• Left atrial enlargement in combination with
additional chamber involvement may be
produced by various conditions, such as left
ventricular failure, left-sided obstructive lesions,
and certain shunts (e.g., ventricular septal defect,
patent ductus arteriosus,).
• However,left atrial enlargement is not seen with
simple atrial septal defects.
• When left atrial enlargement is marked, it most
often is due to rheumatic valvular disease
 Left atrial enlargement
• Volume loading – Mitral regurgitation, VSD,
PDA
• Pressure loading –Lt ventricular failure, Mitral
stenosis, Mitral valve obstruction due to
tumor
 Left ventricle enlargement
• Rounding of the apex of the heart
• Elongation of the long axis of the left
ventricle - left and downwards
• In the lateral view, dilatation of the body of
the left ventricular cavity is recognized when
the shadow of the heart bulges behind the
IVC
• Hoffman Rigler sign- border of left ventricle
at 2 cm above the diaphragm from posterior
border of IVC of more than 1.8cm suggest left
ventricular enlargement.
Left ventricle

Left Ventricle
• Obstruction to left ventricular emptying or
increased afterload, as caused by systemic
hypertension, aortic coarctation, or aortic valve
stenosis, leads to hypertrophy initially, with
rounding of the cardiac apex .
• Left ventricular dilatation with cardiac failure may
follow. Dilated cardiomyopathy, especially
ischemic cardiomyopathy, primarily enlarges the
left ventricle.
• Aortic valve regurgitation and mitral valve
regurgitation enlarge the left ventricle and are
associated with dilatation of the aorta and left atrium,
respectively.
• Left ventricular aneurysms, usually the result of a
previous myocardial infarction, occasionally result in a
localized bulge that projects beyond the normal
ventricular contour or an angulation of the left
ventricular contour
• In the absence of heart failure, left ventricular
hypertrophy must be massive before the heart shadow
enlarges.
 Left ventricular enlargement
• Myocardial disease- Ischaemic heart disease ,
cardiomyopathy
• Volume loading-AR,MR,PDA
• Pressure loading-HTN,AS
 Selective Right Atrial Enlargement
• right heart border becomes more convex
• protrudes to the right away from the
midline (>5.5cm ), >3cm from rt lat
vertebra.
• fill in of the space between the sternum
and the front of the upper part of the
cardiac silhouette in the lateral
radiograph,
• Vertical dimention of rt heart border >
50% of the thoracic vertical dimension
• Isolated right atrial enlargement is uncommon
and usually is due to tricuspid stenosis or right
atrial tumor.
• Right atrial dilatation associated with other
chamber enlargement,primarily right
ventricular enlargement, can be seen in
several conditions, such as tricuspid
regurgitation, pulmonary arterial
hypertension, shunts to the right atrium, and
cardiomyopathies
• Marked isolated right atrial enlargement
resulting in a “box-shaped” heart is seen
in Ebstein’s malformation of the tricuspid
valve .
• This configuration of the heart is the
result of marked angulation at the
superior vena caval-right atrial junction
as the right atrium enlarges.
 Rt atrial enlargement
• 2ndry to rt ventricular failure
• Volume loading-Tricuspid
regurgitation,ASD,VSD,Anomalous
pulmonary venous return
• Pressure loading-Tricuspid
stenosis,tricuspid valve obstruction
from tumor or thrombus
RIGHT VENTRICULAR ENLARGEMENT
• area of contact between the front surface of
the heart and the sternum increases
• The characteristic elevation of the apex of the
heart
• Dilatation of the right ventricle may cause
tilting-up and posterior displacement of the
left ventricle if this is normal in size
• selective right ventricular enlargement
include a large main pulmonary artery and
abnormal peripheral pulmonary arteries,
which may be increased, pruned, or
decreased.
 Rt ventricular enlargement
• Volume loading-Tricuspid
regurgitation,pulmonary
regurgitation,ASD,VSD,Anomalous
pulmonary venous drainage
• Pressure overload-Pulmonary
HTN,Pulmonary stenosis,Acute PE
 Pulmonary vasculature

• Normal

• Pulmonary venous hypertension

• Pulmonary arterial hypertension

• Increased flow

• Decreased
WHAT TO SEE

MAIN PULMONARY ARTERY

RIGHT PULMONARY DESCENDING ARTERY

DISTRIBUTION OF VESSELS-
CENTRAL VS PERIPHERAL,
UPPER LOBE VS LOWER LOBE
Main
Pulmonary
Artery
If we draw a The distance
between the
tangent line tangent and
from the the main
apex of the pulmonary
left ventricle artery
to the aortic (between two
knob (red small green
arrows) falls in
line) and a range
measure between 0 mm
along a (touching the
perpendicul tangent line)
ar to that to as much as
tangent line 15 mm away
from the
(yellow line) tangent line
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
16
 Venous hypertension

• Normal: 8-12 mm of Hg.

• Stage 1: cephalisation of
the blood flow (13-18 mm
of Hg)
RDPA >16
Stage 2: intrstitial edema ,pleural
effusion (19-25mm Hg)
–Kerly lines, peribronchial cuffing
–Background haze
–Septal and interstitial oedema
Stage 3 : Alveolar oedema (>25)
Bat wing appearance
 Signs of plethora
1 Presence of shunt vessels ,end on vessels more
than 2 times the diameter of accompanying bronchus
2. Prominent upper and lower zone vessels .
3. En-face vessels below 10th posterior rib
4. Prominent vessels below the crest of diaphragm
5. RDPA diameter more than that of trachea
6. RDPA >16mm in diameter
7. >6 vessels in peripheral one third of lung
8. Prominent hilar vessels on lateral view
9. In infants and children ,generalized mottling seen
 Approach
• Is left atrium enlarged?
• Is main pulmonary artery Big of
bullous?
• Is main pulmonary artery segment
concave?
• Is heart globular?
 Enlarged left atrium
• Assess Pulmonary vasculature
– Normal
• Mitral regurgitation (cardiomegaly)
– Pulmonary venous HTN
• Mitral stenosis ( normal Heart size)
• Left atrial myxoma
• Pappilary muscle dysfunction
• Left heart failure
– Increased flow
• Shunts- VSD, PDA
– Pulmonary arterial hypertension
• MS- with features of PVH
• VSD, PDA with features of pulmonary plethora
 Enlarged main pulmonary artery
• Assess pulmonary vasculature
– Normal
• Pulmonary stenosis
• Idiopathic pulmonary arterial dilatation
• Hyperdynamic states (anemia, hyperthyroid)
– Pulmonary venous HTN
• None- consider left atrial enlargement
– Increased flow
• Shunts- VSD, PDA, ASD (LA not always enlarged)
• Anomalous pulmonary venous return
– Pulmonary arterial hypertension
• Primary – normal lungs
• Secondary- pulmonary emboli, arteritis, COAD
 Small main pulmonary artery
• Pulmonary vasculature normal always or
oligemic
– Small pulmonary artery or pulmonary
stenosis
– Tetralogy of Fallots
– Increased concavity of pulmonary bay due to
dilatation of aorta
• Hypertension
• Atherosclerotic cardiovascualr disease
• Aortic regurgitation
• Aortic stenosis
• Coarctation of aorta
 Globular heart

• Pericardial effusion
• Multivalvular heart disease
• cardiomyopathy
 Home message
• Chest radiographs that show cardiac abnormality are
a very important part of cardiology examinations.
• Always take a systematic approach to reading chest
radiographs. Always identify the border-forming
structures of the heart on both the frontal and lateral
views.
• Use the pulmonary blood vessels to help explain all
abnormal contours.
• Always try to compare a chest radiograph with any
available previous study.
• Q. Small sized heart in CXR? (bahira dekhi
vitra)
• emphysema
• constrictive pericarditis
• addison's
• severe malnutrition
• hypoplastic left heart syndrome
THANK U
• CRITERIA FOR LEFT ATRIUM ENLARGEMENT
• CRITERIA FOR RIGHT ATRIAL ENLARGEMENT
• CRITERIA FOR RIGHT VENTRICULAR ENLARGEMENT
• CRITERIA FOR LEFT VENTRICULAR ENLARGEMENT
• Features of PULMONARY ARTERY HYPERTENSION
• Features of plethora
• Features of pulmonary venous hypertension