Radiologic Diagnosis of Heart
Diseases
An Atlas of Cardiac X-rays
PART 1Radiographic technique
The thoracic cageThe thoracic cage
Dr. Khairy Abdel DayemProfessor of Cardiology
Ain Shams University
Radiologic Diagnosis of Heart
Diseases
An Atlas of Cardiac X-rays
PART 1Radiographic technique
The thoracic cageThe thoracic cage
Dr. Khairy Abdel DayemProfessor of Cardiology
Ain Shams University
ContentsContents
PART 1PART 1
Radiographic technique
Over exposure
Under exposure
Centralization
The thoracic cage
kyphyoscoliosis
Straight back
Pectus excavatum
Precordial bulge
Rib notching
Effects of previous operations or interventions
PART 1PART 1
Radiographic technique
Over exposure
Under exposure
Centralization
The thoracic cage
kyphyoscoliosis
Straight back
Pectus excavatum
Precordial bulge
Rib notching
Effects of previous operations or interventions
PART 2PART 2
Pulmonary vasculature The normal pulmonary vasculature
Pulmonary congestion
Pulmonary Plethora
Pulmonary Oligemia
Pulmonary embolism and Infarction
Pulmonary Hypertension
PART 2PART 2
Pulmonary vasculature The normal pulmonary vasculature
Pulmonary congestion
Pulmonary Plethora
Pulmonary Oligemia
Pulmonary embolism and Infarction
Pulmonary Hypertension
PART 3PART 3 The Cardiac ShadowThe Cardiac Shadow
Cardiothoracic ratioCardiothoracic ratioPericardial effusionPericardial effusionAbnormal densitiesAbnormal densities
Pericardial calcificationsPericardial calcificationsCalcifications of valvesCalcifications of valvesCalcifications of walls of cardiac chambersCalcifications of walls of cardiac chambersCalcifications of the aortaCalcifications of the aortaCalcifications of coronary arteriesCalcifications of coronary arteries
Radiology of cardiac chambers in health and diseaseRadiology of cardiac chambers in health and diseaseNormal radiological anatomy of the heartNormal radiological anatomy of the heartNormal cardiac outlineNormal cardiac outlineThe lateral viewThe lateral viewRight atrial enlargementRight atrial enlargementRight ventricular enlargementRight ventricular enlargementPulmonary artery dilatationPulmonary artery dilatationLeft atrial enlargementLeft atrial enlargementLeft ventricular enlargementLeft ventricular enlargementDiseases of the aortaDiseases of the aorta
PART 4PART 4
Radiological features of acquired valvular diseases Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation
Tricuspid valve disease
Heart failure and cardiomyopathies
PART 4PART 4
Radiological features of acquired valvular diseases Mitral stenosis
Mitral regurgitation
Aortic stenosis
Aortic regurgitation
Tricuspid valve disease
Heart failure and cardiomyopathies
PART 5PART 5 Radiological feature of common congenital cardiac malformations
The cardiac malpositions
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Pulmonary stenosis
Coarctation of aorta
Fallot’s tetralogy
Transposition of great arteries
Ebstein Anomaly of the Tricuspid valve
Total anomalous pulmonary venous drainage
Extracardiac structures simulating cardiac disease
PART 5PART 5 Radiological feature of common congenital cardiac malformations
The cardiac malpositions
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Pulmonary stenosis
Coarctation of aorta
Fallot’s tetralogy
Transposition of great arteries
Ebstein Anomaly of the Tricuspid valve
Total anomalous pulmonary venous drainage
Extracardiac structures simulating cardiac disease
Effects of Radiographic Technique on X-ray Interpretation
Effects of Radiographic Technique on X-ray Interpretation
Certain defects in the way the X-ray was taken may alter the
cardiac shadow and/or the lung vasculature. The following are the
most common examples:
A. Defects in exposure (Dose of the X-ray)
The X-ray should not be over or under-exposed Proper
exposure is essential in order to judge the pulmonary vasculature.
Criteria of Over-exposure (Fig. 1):
1. Jet black lung fields.
2. Individual thoracic vertebrae are clearly seen within the
cardiac shadow.
3. The junction of each rib with the thoracic vertebrae is well
seen within the cardiac shadow.
Certain defects in the way the X-ray was taken may alter the
cardiac shadow and/or the lung vasculature. The following are the
most common examples:
A. Defects in exposure (Dose of the X-ray)
The X-ray should not be over or under-exposed Proper
exposure is essential in order to judge the pulmonary vasculature.
Criteria of Over-exposure (Fig. 1):
1. Jet black lung fields.
2. Individual thoracic vertebrae are clearly seen within the
cardiac shadow.
3. The junction of each rib with the thoracic vertebrae is well
seen within the cardiac shadow.
Fig. (1): Over-exposed X-ray
Errors that may be caused by over-exposure:
Over-diagnosis of pulmonary oligemia
Criteria of Under-exposure (Fig. 2):
1. The ribs and the thoracic vertebrae can not be seen at all
within the cardiac shadow.
2. Partial veiling of lung fields
Errors that may be caused by under-exposure:
Inability to judge pulmonary vasculature.
Over-diagnosis of:
Pulmonary congestion
Pulmonary plethora
Pulmonary fibrosis
Pleural effusion
Fig. (2): Under-exposed X-ray
B. Defects in Centralization
The patient should be centralized, not rotated, standing erect
and directly facing the X-ray tube.
Criteria for proper centralization:
The medial ends of both clavicles should be equidistant from
the middle line. This is represented by the spinal processes of the
vertebrae. Both clavicles should also be at the same level as in
(Fig. 3).
This (Fig. 4) shows a non-centralized patient as evidenced by
the unequal distance between the medial ends of the clavicles
and the spinal processes of the vertebrae. The clavicles are not at
the same level.
B. Defects in Centralization
The patient should be centralized, not rotated, standing erect
and directly facing the X-ray tube.
Criteria for proper centralization:
The medial ends of both clavicles should be equidistant from
the middle line. This is represented by the spinal processes of the
vertebrae. Both clavicles should also be at the same level as in
(Fig. 3).
This (Fig. 4) shows a non-centralized patient as evidenced by
the unequal distance between the medial ends of the clavicles
and the spinal processes of the vertebrae. The clavicles are not at
the same level.
Fig. (3): Left: Centralized Patient, Right: Uncentralized PatientNote: The unequal space between the medial end of both clavicles and the middle line
Error that may be caused by a non-centralized patient: Abnormal cardiac configuration without the presence of heart
disease.
Abnormalities in the Thoracic Cage that may Affect Interpretation of Cardiac X-ray
Abnormalities in the Thoracic Cage that may Affect Interpretation of Cardiac X-ray
Before looking at the cardiac outline, the
thoracic cage must be examined carefully for
evidence of the following abnormalities:
1. Skeletal abnormalities include
kyphosis, scoliosis or kyphoscoliosis.
If marked, these skeletal abnormalities
may drastically change the
configuration of the cardiac shadow as
in (Fig. 4).
Before looking at the cardiac outline, the
thoracic cage must be examined carefully for
evidence of the following abnormalities:
1. Skeletal abnormalities include
kyphosis, scoliosis or kyphoscoliosis.
If marked, these skeletal abnormalities
may drastically change the
configuration of the cardiac shadow as
in (Fig. 4). Fig. (4): KyphoscoliosisFig. (4): Kyphoscoliosis
In this X-ray kyphoscoliosis is manifested by:
a) Sideway curves of the vertebral column.
b) Intercostal spaces on the right side are much wider than on
the left side.
In this X-ray kyphoscoliosis is manifested by:
a) Sideway curves of the vertebral column.
b) Intercostal spaces on the right side are much wider than on
the left side.
Other skeletal abnormalities that may affect the cardiac size and
configuration include:
a) Straight back syndrome: straight back causes diminution of
the antroposterior thoracic diameter compressing the heart
against the spine and causing it to appear enlarged in the PA
view, (Fig. 5).
Other skeletal abnormalities that may affect the cardiac size and
configuration include:
a) Straight back syndrome: straight back causes diminution of
the antroposterior thoracic diameter compressing the heart
against the spine and causing it to appear enlarged in the PA
view, (Fig. 5).
Fig. (5): (Right) Straight back and (Left) Apparent enlargement of the pulmonary artery due to the skeletal deformity
b) Pectus excavatum: the depressed sternum displaces the heart
towards the left. The right cardiac border disappears behind
the sternum and the cardiac outline is distorted, (Fig. 6).
b) Pectus excavatum: the depressed sternum displaces the heart
towards the left. The right cardiac border disappears behind
the sternum and the cardiac outline is distorted, (Fig. 6).
Fig. (6): Pectus excavatum: Inward displacement of the lower third of the sternum
2. Precordial BulgeSkeletal abnormalities may result from heart disease. Chronic
and early enlargement of the heart may displace the chest wall anteriorly resulting in precordial bulge. This is diagnosed in the lateral view of the X-ray by anterior displacement of the sternum, (Fig. 7).
Fig. (7): Marked enlargement of the heart causing anterior displacement of the sternum and the ribs (Precordial Bulge)
3. Rib Notching
Notching on the lower edges of the fourth to the ninth ribs
indicate enlarged intercostal arteries eroding the lower border
of the ribs in cases of coarctation of the aorta, (Fig. 8 & 9).
Fig. (8): X-ray of coarctation of aorta showing rib notching starting from the 4th rib. The left
border of the heart shows the 3 sign
Fig. (8): X-ray of coarctation of aorta showing rib notching starting from the 4th rib. The left
border of the heart shows the 3 sign
Fig. (9): Enlarged view of the ribs showing notching of their
lower borders
Fig. (9): Enlarged view of the ribs showing notching of their
lower borders
4. Effect of previous Operations or Interventions e.g.
Open heart surgery is usually done through a median
strenotomy incision. The 2 halves of the sternum are
approximated by wires as in (Fig. 10).
Fig. (10): Lateral view showing wires that are used to join the two halves of the sternum together
