Post on 27-May-2015
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Postgraduate Education
BS Physical Therapy, Silliman University, 1996
BS Zoology, MSU-Iligan Institute of Technology 1999
Doctor of Medicine, Mindanao State University-College of Medicine
Post-graduate Internship
University of the Philippines, Philippine General Hospital
2003-2004
Internal Medicine Residency
University of the Philippines, Philippine General Hospital
2004-2007
Fellowship in Cardiology
University of the Philippines, Philippine General Hospital
2008-2011
Affiliations
Fellow, Philippine College of Physcians
Fellow, Philippine Heart Association
Diplomate, Philippine College of Cardiology
JILL IRENE Z. CAPISTRANO MD, FPCP, DPCC
Dr. Jill Irene Z. Capistrano, FPCP,DPCCINTERNAL MEDICINE-CARDIOLOGY
Postero-Anterior (PA) View
SVC
IVC
Postero-Anterior (PA) View
RA
Postero-Anterior (PA) View
RV
Postero-Anterior (PA) View
PA
Postero-Anterior (PA) View
LA
Postero-Anterior (PA) View
LV
Postero-Anterior (PA) View
Aorta
Postero-Anterior (PA) View
Postero-Anterior (PA) View
Right border
Superior vena cava
Right atrium
Inferior vena cava
Postero-Anterior (PA) View
Right border
Superior vena cava
Right atrium
Inferior vena cava
Left border
Aortic knob
Main pulmonary trunk
Left ventricle
Postero-Anterior (PA) View
Pulmonary Arteries
Right
Postero-Anterior (PA) View
Pulmonary Arteries
Right
Left
Postero-Anterior (PA) View
Pulmonary Arteries
Right
Left
Pulmonary VeinsLA
Lateral View
RA
SVC
IVC
Lateral View
RV
Lateral View
Lateral View
LA
Lateral View
LV
Lateral View
Aorta
Lateral View
Lateral View
Left atrium
Left ventricle
Lateral View
Left atrium
Left ventricle
Right ventricle
Lateral View
Aorta
Main Pulmonary Artery
Inferior vena cava
Lateral View
Pulmonary Arteries
Left
Right
Pulmonary Veins
Systemic Approach
Overview or overall glance at the film
Check cardiac position and situs
Cardiac size
Chamber enlargement
Great vessels
Lungs
Ancillary findings
Overview or overall glance at the film
Is it
adequate
or optimal for
cardiac evaluation?
Overview or overall glance at the film
Things to consider:
Position
Inspiration
Exposure
Overview or overall glance at the film
Things to consider:
Position
slight degrees of rotation or obliquity will
substantially affect the cardiac contour and
may alter the apparent size as well
Overview or overall glance at the film
Things to consider:
Inspiration
Should be in full inspiration
In suboptimal inspiration or supine chest
radiographs, the lower lobe markings are
crowded and may obscure the possibility
of early pulmonary edema
Overview or overall glance at the film
Things to consider:
Exposure
underexposure may simulate the
appearance of pulmonary congestion
overexposure may simulate diminished
pulmonary blood flow
Cardiac Position and Situs
Cardiac Positions:
Levocardia: the heart is predominantly in the
left chest, and the cadiac apex points leftward
Dextrocardia: the heart is predominantly in
the right chest, and the cardiac apex points
rightward
Mesocardia: the heart is positioned in the
midline, and the cardiac apex points directly
inferiorly
Cardiac Position and Situs
Cardiac Positions:
Dextroposition (dextroversion): the cardiac
apex points leftward, but the heart is located
predominantly in the right chest (typically due
to extrinsic forces)
Cardiac Position and Situs
Visceroatrial Situs:
“SITUS” refers to the pattern of anatomic
arrangement.
atrial situs is usually concordant with visceral
situs; hence these two are described together
Cardiac Position and Situs
Visceroatrial Situs:
Situs solitus:
the morphologic right atrium is to the right of the
morphologic left atrium
the gastric air bubble is on the left side, and the
liver is on the right
Situs inversus:
the morphologic right atrium is to the left of the
morphologic left atrium
the gastric air bubble is on the right side, and the
liver is on the left
Cardiac Position and Situs
Visceroatrial Situs:
Situs ambiguous:
this term is used when identification of visceroatrial
situs is not possible due to paucity of anatomic
markers
Cardiac Position and Situs
Dextrocardia
Situs solitus
Cardiac Position and Situs
Dextrocardia
Situs inversus
Cardiac Position and Situs
Situs ambiguous
Cardiac Size
Cardio-Thoracic Ratio
divide the widest
transverse diameter of
the heart by the widest
transverse diameter of
the thorax taken at the
inner side of the rib cage
Cardiac Size
Cardio-Thoracic Ratio
normal CT ratio in adults
is ususally 0.5 or less
normal CT ratio in the
newborn is
approximately 0.65
Chamber Enlargement
Right Atrial Enlargement
lateral bulging of the right
heart border
elongation of the right
heart border (length of
right heart border exceeds
50% of the mediastinal
cardiovascular shadow)
Cardiac enlargement
RightAtrial Enlargement
Right cardiac border > 2.5
cm from the lateral aspect
of the thoracic vertebra
and > 5.5 cm from mid
thoracic spine/spinous
process
Chamber Enlargement
Right Ventricular
Enlargement
PA View: Rounding and
upliftment of cardiac apex
Chamber Enlargement
Right Ventricular
Enlargement
PA View: Rounding and
upliftment of cardiac apex
Lateral View:
Retrosternal fullness
(contact of anterior
cardiac border greater
than 1/3 of the sternal
length
Chamber Enlargement
Left Atrial Enlargement
PA view:
Double density
Enlargement of LA
appendage
Upliftment of left mainstem
bronchus
Widening of carinal angle
Chamber Enlargement
Left Atrial Enlargement
Lateral view:
Prominent posterosuperior
cardiac border
Posterior displacement and
upliftment of left mainstem
bronchus
Chamber Enlargement
Left Ventricular
Enlargement
PA View: lateral and
downward displacement
of the cardiac apex
cardiac apex measures
<4 cm from the left
costophrenic sulcus
Chamber Enlargement
Left Ventricular
Enlargement
Lateral view:
posterior displacement of
the posterior inferior border
of the heart
Hoffman-Rigler Sign:
measured 2 cm above the
intersection of the
diaphragm & IVC; (+) if
posterior border extends
more than 1.8 cm of IVC
Pulmonary Vascular Pattern
NORMAL
In normal subjects, pulmonary
vascularity has a predictable
pattern.
Pulmonary arteries are usually
easily visible centrally in the
hila and progressively less so
more peripherally.
The central main right and left
pulmonary arteries are usually
not individually identifiable,
because they lie within the
mediastinum
Pulmonary Vascular Pattern
NORMAL
major arteries
-central, the clearly
distinguishable midsized
pulmonary arteries (third or
fourth order branches) are in
the middle zone
small arteries and arterioles
-normally below the limit of
resolution
-in the outer zone.
visible small and midsized
arteries
-sharp, clearly definable
margins because of the
sharp border between water
density and air density
structures.
Pulmonary Vascular Pattern
NORMAL
NORMAL
Pulmonary Vascular Pattern
INCREASED
NORMAL INCREASED
Pulmonary Vascular Pattern
NORMAL
Pulmonary Vascular Pattern
DECREASED
NORMAL
Pulmonary Vascular Pattern
DECREASED
NORMAL
Pulmonary Vascular Pattern
VENOUS
CONGESTION
Pulmonary Vascular Pattern
VENOUS
CONGESTION
INCREASED
ARTERIAL
BLOOD FLOW
Pulmonary Vascular Pattern
VENOUS
CONGESTION
Kerley’s B lines
Pulmonary Vascular Pattern
VENOUS
CONGESTION
Perihilar Haziness
Pulmonary Vascular Pattern
VENOUS
CONGESTION
Peribronchial Cuffing
Pulmonary Vascular Pattern
VENOUS
CONGESTION
Redistribution:
equalization
Pulmonary Vascular Pattern
Redistribution:
cephalization
VENOUS
CONGESTION
Pulmonary Vascular Pattern
Redistribution:
cephalization
Pulmonary Vascular Pattern
VENOUS
CONGESTIONInterstitial Edema
Kerley B Lines
Pulmonary Vascular Pattern
VENOUS
CONGESTIONInterstitial Edema
Kerley B LinesKerley A Lines
Pulmonary Vascular Pattern
VENOUS
CONGESTION
Alveolar Edema
PCWP VASCULAR PATTERN
<8 mmHg Normal
10-12 mmHg Lower zones appear equal in diameter to or
smaller than the upper zone vessels
12-18 mmHg Vessel borders become progressively hazier
because of increasing extravasation of fluid into
the interstitium – Kerley B lines (horizontal,
pleura based, peripheral linear densities)
>18-20 mmHg (acute) Pulmonary edema occurs, with interstitial fluid
present in sufficient amounts to cause a perihilar
bat wing appearance
The Great Arteries
Are they in normal position?
Are they of normal size?
The Great Arteries
Aorta
normal
prominent
diminutive
Main pulmonary
artery
normal
prominent
concave
The Great Arteries
Aorta
normal
prominent
diminutive
Main pulmonary
artery
normal
prominent
concave
The Great Arteries
Aorta
normal
prominent
diminutive
Main pulmonary
artery
normal
prominent
concave
The Great Arteries
Aorta
normal
prominent
diminutive
Main pulmonary
artery
normal
prominent
concave
The Great Arteries
Aorta
normal
prominent
diminutive
Main pulmonary
artery
normal
prominent
concave
Sample Cases
Compiled from the Specialty Board
of Adult Cardiology Exam
Chest X-ray exercises
normal
normal
TOF- Ventricle enlarged, apex slightly elevated – RV
Trachea displaced to left – aorta on right side. Vascular pattern decreased
TOF - previous syst pulmo shunt. Pulmo vasc normal.
Right sided aortic arch.
TOF
Hypovascular lung
Concave MPA
Prominent aorta
RVH
Transposition – decreased vasc pattern, heart
slightly enlarged, very narrow vascular pedicle.
Ebstein anomaly – massively enlarged heart,
huge left sided structures. Extension of the RA to R (RAE)
Total anomalous pulmonary venous return –figure of 8 deformity or snaoman heart, large veins forming a
convexity on either side of mediastinum
Patial anomalous venous return – scimitar
syndrome. Hypervascularity and large vessel paralleling the
border of the right side of hear and extending below diapragm –
anomalous PV
PAPVR – Hypoplastic right lung
PAPVR
PDA – slightly enlarged heart, some minor decrease in
vascular pattern. Large aortic knob
PDA hypervascular, prominent Ao, prominent MPA, LVH
ASD – RV, PA enlargement. Increased PBF. Lateral-
anterior bowing of sternum indicative of hyperventilation – L to
R shunt
ASD – Hypervascular, Dilated MPA, Dimunitive aorta, RVH, RAE
Pulmonic stenosis – great enlargement
of the PA large hilar vessels on left – represent postenotic
dilatation
PS VALVAR
Hypovascular
Dilated MPA
RVH
Transposition of great vessels – slight convexity of
the left upper border due to ascending aorta. No
aortic shadow on right.
Coarctation of the aorta – heart slightly enlarged 2 to LVH.
Ao unremarkable.
Rib notching – scalloping of inferior surfaces of ribs with
sclerosis
Coarctation of the aorta – LVH, ascending aorta
somwhat prominent. Descending aorta with indentation with
postenotic dilatation. L subclavian artery enlarged on L superior
mediastinum.
Pseudocoarctation of the aorta – transverse aortic
arch is high, very broad convexity of the aorta to
the left, below the arch
Mitral stenosis – LA enlargement. LA appendage
projecting on the L below PA. Right sided double density
MS – cephalization, Normal aorta, Dilated MPA, LAE, RAE, RVH,
MS PULMO CONGESTION, LAE, RAE, DILATED MPA
MS MR CEPHALIZATION, DILATED MPA, LAE,
LVH, RVE
LA wall calcification – dense calcification outlining
LA. Either in the wall or thrombus that lines the
chamber.
Mitral regurgitation – enlargement of both left sided
chambers. Dilated LA appendage. Double density.
Aortic stenosis – heart slightly enlarged, rounding of apex 2
LVH. Ascending Ao enlargement. Densely calcified valve.
Aortic insufficiency – LV dilatation
AI
Normal vascularity
Dilated aorta
LVH
LV aneurysm – LV dilatation, congested pulmonary
vascular marking (Kerly B lines).
3 weeks after- with bulge along LV border.
Calcified myocardial infarct – curvilinear
calcification extending most of the way around the
apex
Pericardial effusion – grossly enlarged cardiac silhoutte, After
pericardial tap and air injection – with note of pericardial
calcification
Aortic aneurysm
PULMONARY EDEMA