PRESENTED BY DR SANDEEP.R

1. PRESENTED BY DR SANDEEP.R CARDIAC XRAY

2. 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

3. Basics of x-rayTECHNICAL QUALITY • R – ROTATION • I -- INSPIRATION • P -- PROJECTION • E -- EXPOSURE

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

5. The increase in blackness 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

6. DEGREE OF INSPIRATION • It is ascertained by counting either the number of visible anterior or posterior ribs • Adequate inspiratory effort - six complete anterior or ten posterior ribs are visible • Poor inspiratory effort - fewer than six anterior ribs • Hyperinflated lung-more than six anterior ribs

8. IMPORTANCE OF AN INSPIRATORY FILM POOR INSPIRATORY FILM NORMAL INSPIRATORY FILM 1 3 2 1.MEDIASTINAL WIDENING 2.CMGLY 3.LOWER LOBE PATCHY OPACIFICN

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. OVERPENETRATION UNDERPENETRATION NORMAL

15. 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

16. 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

17. STRUCTURES SEEN IN ANTERIOR VIEW

18. Structures in lateral view AA PT LA RV LV

19. Brachiocephalic vessels Trachea Scapula Manubrium Aorta Right upper lobe bronchus LPA RPA Retrosternal space Left upper lobe bronchus Pulmonary outflow tract Body of sternum LA Confluence of pulmonary veins RV IVC LV Right hemidiaphragm Gastric air bubble Left hemidiaphragm

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

26. Main pulmonary artery LPA

27. 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

29. Prominent mpa • Main pulmonary artery projects more than the tangent • Causes: • Increased pressure • Increased flow

30. Hypoplastic pa • MPA > 15 mm from the tangent • Concave PA segment • Causes: • TOF 2. TRUNCUS ARTERIOSUS

31. Left atrial appendage L LA ENLARGEMENT HYPERTROPHIED LA APPENDAGE

32. LEFT VENTRICLE

33. cardiomegaly • The cardiothoracic ratio should be less than 0.5. i.e. A+B/C<0.5 • A cardiothoracic ratio > 0.5 suggests cardiomegaly in adults • A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn A B C

34. CTR is more than 50% but heart is normal Extracardiac causes of cardiac enlargement • Portable AP films • Obesity • Pregnant • Ascites • Straight back syndrome • Pectusexcavatum

35. 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

36. Criteria's for cardiomegaly • Cardiothoracic ratio >0.5 in adults • Cardiothoracic ratio >0.6 in newborn • 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

37. Chamber enlargement • RA enlargement • LA enlargement • RV enlargement • LV enlargement

38. 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

39. Ab > 5cm a b

40. 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

41. La enlargement HYPERTROPHIED LA APPENDAGE

42. LEFT ATRIAL ENLARGEMENT ELEVATION OF LEFT BRONCHUS WIDENING OF CARINA LAA enlargement DOUBLE ATRIAL SHADOW

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

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

46. 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

47. 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

48. 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.

49. 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

50. 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