Post on 08-Jul-2015
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transcript
By: Tham Yea Bing, Lim Wee Yi
Group 1 Year 5 2010/2011 MD USM, Malaysia
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Cardiac output and blood pressure are inadequate for the tissue metabolic needs despite normal venous return
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Acute vs Chronic
Right vs Left(together Congestive Heart Failure)
Forward vs Backward
Low Output vs High Output
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Coronary artery disease
Hypertension
Cardiomyopathy
Valvular heart disease
Congenital heart disease
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Right Side Left Side
Acute Severe Heart Failure
• Painful hepatomegaly• Elevated jugular venous pressure
• Pulmonary oedema• Dyspnea• Hemoptysis
Chronic Heart Failure
• Passive systemic congestion• Hepatomegaly ( chronic venous congestion)• Legs oedema• Right atrial & ventricular dilatation
• Chronic venous congestion of lungs• Exertional dyspnea• Paroxysmal nocturnal dyspnea• Pulmonary hypertension• Left atrial & ventricular dilatation
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Cardiac enlargement + specific chamber enlargement
Upper lobe diversion
Pulmonary oedema
Pleural effusions
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Cardiothoracic Ratio ( CTR) In normal people, the transverse diameter of the heart is
usually less than half the internal diameter of the chest.
CTR is only useful in erect PA films. Magnification of heart in AP view
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Cardiothoracic Ratio (CTR) = A+B/C 8
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It is rarely possible to distinguish ventricular hypertrophy from dilatation by looking at the external contours of the heart. Hypertrophy of ventricular wall encroaches on the
ventricular cavity with little change in the external contours of the heart until the ventricles fails.
Ventricular dilatation is recognised only as an overall increase in the transverse cardiac diameter.
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Left atrial enlargement Right border of enlarged left atrium is visible as a double
contour adjacent to right heart border
Usually within the main cardiac shadow
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Right atrial enlargement Increase in the curvature of right heart border
Often accompanied by enlargement of superior vena cava
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Chest X-ray Finding PCWP (mmHg) Grade
Normal 5 – 10
Cephalization (Upper lobe diversion) 10 – 15I
Kerley B line 15 – 20
Pulmonary Interstitial Edemaa. Thickening of interlobular septab. Peribronchial cuffingc. Fluid in Fissuresd. Pleural Effusions
20 – 25 II
Pulmonary Alveolar Edemaa. Acinar Shadowb. Bat’s wing appearance
> 25 III
http://www.mdconsult.com/das/book/body/216523017-2/0/1276/62.html
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Also known as:- Pulmonary wedge pressure (PWP) Pulmonary artery occlusion pressure (PAOP)
Indication: Provide indirect measurement of left atrial pressure
(LAP) Diagnose the severity of left ventricular failure Quantify degree of mitral valve disease Guide therapeutic efficacy of disease
Measure by:- Swan-Ganz catheter (pulmonary arterial catheter)
http://www.cvphysiology.com/Heart%20Failure/HF008.htm
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Normal Pressure:
5-10 mmHg
Acute pulmonary edema >20 mmHg
http://www.introtoccnursing.com/sites/calvin/_files/Image/swan%20ganz%20cath_%20jpg.gif
http://upload.wikimedia.org/wikipedia/commons/thumb/e/ea/Pulmonary_artery_catheter_english.JPG/220pxPulmonary_artery_catheter_english.JPG
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Chest X-ray Finding PCWP (mmHg) Grade
Normal 5 – 10
Cephalization (Upper lobe diversion) 10 – 15I
Kerley B line 15 – 20
Pulmonary Interstitial Edemaa. Thickening of interlobular septab. Peribronchial cuffingc. Fluid in Fissuresd. Pleural Effusions
20 – 25 II
Pulmonary Alveolar Edemaa. Acinar Shadowb. Bat’s wing appearance
> 25 III
http://www.mdconsult.com/das/book/body/216523017-2/0/1276/62.html
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http://www.ultramedicine.co.uk/images/mcqSampleHeart.gif
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In normal PCWP Blood flow to the lung bases more than apices Upper lobe blood vessels narrower On upright chest x-ray, vessels should be distinct from
peripheral 1/3 back centrally to hilar, more apparent in lower lung than upper lung
As PCWP > 10mmHg Interstitial and perivascular edema developed Most prominent at the lung bases because hydrostatic
pressure is greater Equalization in the size of the vessels at the apices and bases As PCWP increases, there will be further redistribution of
blood into the non-dependent portions of lungs
Only applies if film is taken erect!!20
NORMAL CHEST X-RAYLower lobes have more prominent blood vessels
diverting downwards and laterally
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http://www.mdconsult.com/das/book/body/216532158-2/0/1276/I4-u1.0-B0-7216-0527-3..50006-8--f66.fig?tocnode=49301040
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Visible distended interlobular septa Fluid filling the interstitium
Location and appearance Bases, peripheral beginning
from costophrenic angle 1-2 cm long, ~ 1mm thick Horizontal direction Perpendicular to pleural
surface
Other causes:- Lymphangitis carcinomatosa Pulmonary fibrosis Parasitic infection
Named after Peter J Kerley, an English radiologist who also described Kerley-A and Kerley-C lines on chest radiographs
http://2.bp.blogspot.com/_tN90RefJ5Hk/SMgo9_EYZtI/AAAAAAAAAUE/6sSJYny04C8/s400/Kerley+B.jpg
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http://www.mdconsult.com/das/book/body/216532158-2/0/1276/I4-u1.0-B0-7216-0527-3..50006-8--f66.fig?tocnode=49301040http://radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_page8.html#top_second_img
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Appear when connective tissue around bronchoarterial sheaths in lungs distends with fluid.
Location and appearance
Near hilum not reaching periphery of lung
Run obliquely
Longer than B lines (up to 6cm)
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When PCWP = 20-25 mmHg
Features:-1. Thickening of interlobular septa (Kerley B lines)
2. Peribronchial cuffing
3. Fluid in Fissures
4. Pleural Effusions
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Interstitial fluid accumulate around bronchi
Thickening of bronchial wall
When see on-end, looks like numerous, small, ring like shadows (little doughnuts)
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Fluid collects in subpleural space Between lung parenchyma and visceral pleural
Normal fissure is the thickness of a sharpened pencil line
Fluid may collect in any fissure Major(oblique), minor(horizontal), and azygous fissure
Thicker, irregular and visible
If prolonged, repeated bouts of failure, Fibrosis results in permanent thickening of fissures
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NORMAL FISSURES THICKENED FISSURES
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Normal pleural fluid volume 2-5 ml not visible on radiograph.
Usually bilateral effusion it can be asymmetrical. Almost always right sided.
Two important radiographic findings:1. Blunting the costophrenic angles
300ml of fluid blunt lateral costophrenic angle (frontal view) 75ml of fluid blunt posterior costophrenic angle (lateral view)
2. Meniscus sign Pleural fluid appears to rise higher along the lateral margin than it
does medially, causing the meniscus shape in upright position. Lateral view, fluid assume U shape ascending equally high both the
anteriorly and posteriorly.31
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Right pleural effusion, meniscoid appearance. On the frontal projection in the upright
position, an effusion typically ascends more laterally (open white arrow)than it does
medially(open black arrow)because of factors affecting the natural elastic recoil of the lung.
On the lateral projection the fluid ascends about the same amount anteriorly and
posteriorly, forming a U-shaped density(closed white arrows).
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Laminar effusion: Almost always the results of elevated atrial pressure, as
in congestive heart failure or secondary to lymphangiticspread of malignancy.
The fluid assumes a thin, bandlike density along the lateral chest wall, especially near the costophrenic angle.
The lateral costophrenic angle appears to maintain its sharpness.
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There is a thin band of increased density that extends
superiorly from the lung base (open white arrow) but
does not appear to cause blunting of the costophrenic
angle (closed black arrow).
Notice how normally aerated lung extends to
the inner margin of each of the ribs (open black
arrow). 35
Fissural Pseudotumor/ Vanishing Tumour Sharply marginated collection of pleural fluid contained
either within an interlobar pulmonary fissure or in a subpleural location adjacent to a fissure
Result from transudation from the pulmonary vascular space
Commonly manifest as incidental radiographic findings in patients with congestive heart failure
Other causes of transudates include Hypoalbuminemia
Renal insufficiency
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http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow159sidebyside.jpg
Frontal and lateral views of an 89 year-old female with an oval soft tissue density superimposed on the minor fissure on both the frontal and lateral views. The lesion has slight "points" where it abuts the minor fissure, a sign of a "pseudotumor" or "vanishing tumor" in the minor fissure.
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Fissural Pseudotumour/ Vanishing Tumour Imaging findings
Lenticular or biconvex contour (lemon-like)
Located along the course of interlobar fissures
Most occur in the minor (horizontal) fissure (more than 75%) and are seen on both the frontal and lateral radiograph
Those that occur in the oblique or major fissure may only be seen on the lateral view well
Infrequently, they occur in the horizontal and oblique fissures simultaneously
Most are less than 4 cm in size
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When PCWP >25 mmHg1. Acinar shadow
2. Bat-wing or butterfly appearance Pulmonary shadowing maximal close to the hilar
Outer third of lung frequently spared
Always bilateral, involving all lobes
Lower lung zones more affected than upper lung zones
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http://www.learningradiology.com/lectures/cardiaclectures/chfppt.pdf
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http://www.mdconsult.com/das/book/body/216539325-2/0/1276/I4-u1.0-B0-7216-0527-3..50006-8--f67.fig?tocnode=49301040
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1. Basal kerley B lines in the left hemithorax2. Pleural effusion on the right side. 3. Cardiomegaly4. Apical vascular redistribution.5. Bat’s wing appearance
http://www.mypacs.net/cgi-bin/repos/mpv3_repo/wrm/repo-view.pl?cx_subject=1666444&cx_prefsize=medium&cx_repo=mpv4_repo
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