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Radiologic Diagnosis of Heart

Diseases
An Atlas of Cardiac X-rays

PART 3
The Cardiac Shadow
Radiology of cardiac chambers in health and disease

Dr. Khairy Abdel Dayem


Professor of Cardiology
Ain Shams University
The Cardiac Outline
A. The Cardiothoracic Ratio
The over all cardiac size is evaluated by measuring the
cardiothoracic ratio

How to measure the cardiothoracic ratio Fig. (27):


1. Make a vertical line in the middle of the cardiac shadow.
2. Measure the maximum extension of the cardiac shadow on
both sides of this line.
3. Add the right and left extensions, together to measure the
total transverse diameter of the cardiac shadow.
4. Measure the maximum width of the thorax.
5. Divide the cardiac transverse diameter/the thoracic
transverse diameter = cardiothoracic (CT ratio).
6. This ratio should not exceed ½ (50%).
Fig. (27): Measurement of Cardiothoracic Ratio
Changes in the Cardiothoracic Ratio
 The cardiac shadow may appear smaller than normal in cases of
chronic obstructive, pulmonary disease (COPD), starvation, and
anorexia nervosa, (Fig. 28).
 The cardiac shadow may appear larger than normal in cases of
cardiomegaly and/or pericardial effusion.

Fig. (28): Small cardiac shadow in a case of COPD


If there is generalized enlargement of the cardiac shadow
with increased C/T ratio but with no specific configuration,
the differential diagnosis is:

1. Pericardial Effusion

2. Marked dilatation of the heart due to severe


cardiomyopathy or multivalvular disease

Radiological signs of pericardial effusion, (Fig. 29 & 30):


 Rounding the cardiac borders with sharply defined
outline (the flask shape or water bottle appearance)
 Acute right cardiophrenic angle

 The pulmonary vasculature may be normal if there is no


associated heart disease.
Fig. (29): Diagrammatic presentation of a case of pericardial
effusion without underlying heart disease.

Fig. (30): Left: Pericardial effusion on top of multivalvula disease.


Right: Massive pericardial effusion
B. Abnormal Densities Within the Cardiac
Shadow
Several iatrogenic or pathological structures may appear
within the cardiac shadow. These include pacemaker leads,
implantable cardioverter defibrillator (ICD) leads, wires and
stitches, prosthetic valves, abnormally positioned breast
shadow and abnormal calcifications.
 Pacemaker implantation: The pacemaker is usually
placed subcutaneously over the left or less commonly
the right pectoralis muscle. An electrode is introduced
via a subclavian puncture into the subclavian vein to the
superior vena cava, and its tip is placed in the right atrial
appendage and/or the right ventricular apex or through
the coronary sinus to the LV lateral wall as in (Fig. 31 &
32).
Fig (31): The course of peacemaker wires placed in:
A: Right atrial appendage
C: Coronary Sinus
V: Right ventricular apex
In both PA and lateral views. The pacemaker is implanted
subcutaneously overlying the right pectoralis muscle.
Fig. (32): Pacemakers placed over the left or right pectoralis muscle. Pacemaker wire
connects the pacemaker to the right ventricular apex as seen in the PA view (arrow)
or LA view.
 Metallic markers may be inserted by the surgeon at the site of
anastmosing a graft into the aorta or in a coronary artery.
 Artificial valves e.g. prosthetic mitral, aortic or tricuspid valves.
Their type can be identified e.g. ball and cage, lilting disc,
bilaflet, etc. (Fig. 33).

Fig. (33): Three prosthetic cardiac valves replaced the mitral (M),
aortic (A) and tricuspid (T) valves.
Breast Shadow:
Sometimes breast shadow may be superimposed partly on the
cardiac shadow and gives the impression of abnormal cardiac
configuration, (Fig. 34).

Fig. (34): (Left) Normal female breasts apparent on the sides of the chest
wall. (Right) Unusually elevated breasts in an elderly female (arrows)
superimposed on the cardiac shadow.
Abnormal Calcification
Calcification may occur in the pericardium, cardiac valves, the
cardiac wall itself, intra cardiac thrombi or tumours or the aorta.

A. Calcified pericardium may appear in the PA view as


dense opacity overlying the cardiac borders or surrounding
the atrioventricular junction. It is better seen in the lateral
view, (Fig. 35, 36 & 37).

Fig. (35): in PA view Pericardial Fig. (36): Pericardial Calcification surrounding


Calcification (Diagrammatic) the heart seen in the lateral view
Fig. (37): Pericardial Calcification resulting in a complete ring around the
atrioventricular groove seen in PA view and lateral view.
Fig. (38): Calcification overlying the cardiac apex and also seen along the
atrioventricular junction (arrow head)
B. Calcified cardiac valves
Calcification occurs most commonly in the aortic and mitral
valves and is seen as dense opacity within the cardiac shadow at
the expected site of either valve, (Fig. 39 & 40).

Fig. (39): Calcification in the mitral valve (black arrow heads) and
the aortic valve (white arrow head)

Calcification of the mitral valve annulus is very common in the


elderly specially females and causes mitral regurgitation. It
underlies and displaces the posteromedial cusp and appears as an
incomplete C shaped dense ring (Fig. 41).
Fig. (40): Position of the cardiac valves in the PA and lateral view.
Fig. (41): Calcified mitral valve annulus seen as C shape density
C. Calcified Left Ventricular Aneurysm, (Fig. 42)
The aneurysms is usually seen as an eccentric protrusion in the
cardiac shadow that may rarely be calcified. Left ventricular mural
thrombus may also calcify.

Fig. (42): Calcified myocardial aneurysm seen in PA view (a) and lateral view (b)
D. Calcification Left Atrium, (Fig. 43).
Rarely the left atrial wall itself is calcified and very rarely
calcification may be seen in an atrial myxoma.

Fig. (43): Calcification in the left atrial wall in a case of rheumatic mitral valve
disease seen in the PA (a) and lateral (b) views
E. Calcification of the Aorta
 Calcification may occur in an atherosclerotic plaque in any
part of the aorta.

 Calcification restricted to the ascending aorta is usually


due to syphilis.

 Calcification is most easily detected in the aortic arch as a


crescentic dense shadow along the edge of the aortic
knuckle (Fig. 44).

F. Calcification of atherosclerotic coronary arteries


 Is very common but difficult to see in the routine X-ray. It’s
better visualized by fluoroscopy or by electron beam CT.
Fig. (44): Calcification of Aortic Arch
The Size and Configuration of each
Individual Cardiac Chambers
In order to evaluate each cardiac chamber, the normal and
abnormal radiological anatomy of the heart and the components
of the cardiac borders must be known, (Fig. 45).

Fig. (45): The Surface Anatomy of Cardiac Chambers


Radiological Anatomy of the Heart in the PA View: (Fig. 46)
1. The superior vena cava forms the upper third of the right
cardiac border. The inferior vena cava forms an extremely short
segment on the lower part of the right border. Both drain into
the right atrium.

2. The right atrium forms the lower two thirds of the right cardiac
border. The tricuspid valve, which is situated behind the lower
end of the sternum, connects it to the right ventricle.

3. The right ventricle is pyramidal in shape. It is separated from


the right cardiac border by the right atrium and from the left
border by the left ventricle. Thus it does not appear on any of
the cardiac borders in the PA view. It forms the anterior surface
of the heart and is thus better delineated in the lateral view.
Fig. (46): The radiological anatomy of different cardiac chambers

4. The pulmonary artery segment forms a concavity on the left


border of the heart at the medial end of the second left intercostal
space.

5. The left atrium is an oval chamber in the middle of the cardiac


shadow. The left atrial appendage extends to the left and forms a
part of the left cardiac border at the medial end of the third left
intercostals space.
6. The left ventricle is oblong in shape and forms the lower half of
the left border of the heart. Its long axis is directed downwards
and to the left.

7. The aorta is subdivided into three parts:

a. The ascending aorta extends upwards and to the right. It


comes very close to the upper third of the right cardiac
border.

b. The aortic arch curves to the left and posteriorly and forms
a prominence on the left cardiac border at the medial end of
the first left intercostals space.

c. The descending aorta runs medially and downwards and


does not normally form any part of the cardiac borders.
The Lateral View:
In the lateral view the right ventricle and the pulmonary artery
are the most anterior structures. They are seen immediately under
the sternum. The right ventricle comes in contact with the lower
third of the sternum but is normally separated from its upper two
thirds by the lung (the retrosternal space). The left atrium and the
left ventricle are situated posteriorly. The left atrium is the most
posterior structure and lies directly in front of the esophagus, (Fig.
47). The left ventricle is separated from the vertebral column by the
retrocardiac space.

Fig. (47): Normal LV in the lateral view


The Normal Cardiac Borders in the PA View: (Fig. 48)

Fig. (48): Component of


cardiac Borders

A) The left cardiac border is formed from above down by:


1. The aortic arch (= knob, knuckle).
2. The main pulmonary artery.
3. The left atrial appendage.
4. The left ventricle.
B) The right border of the heart is formed by:
1. In the lower two thirds by the right atrium.
2. In the upper third by the superior vena cava.
Radiological Signs of Enlargement of
Individual Cardiac Chambers and Great
Vessels
Right Atrial Enlargement:
This causes displacement of the lower two thirds of the right
cardiac border outwards, (Fig. 49). It is usually associated with
right ventricular enlargement but may rarely be isolated in cases
of tricuspid stenosis (Fig. 50).

X-ray. (49): Enlargement of the Right X-ray. (50): Isolated Enlargement of the
Atrium and Ventricle Right Atrium in case of Tricaspid Stenosis
Right Ventricular Enlargement:
1. There are no reliable signs for its diagnosis in the PA view, but
better seen in the lateral view. However, enlargement of the RV
displaces the apex outwards which may become separated form
the diaphragm, (Fig. 51).

Fig. (51):RV enlargement causes the apex to be displaced outwards


2. In cases of Fallot’s tetrology right ventricular enlargement
causes the cardiac silhouette to resemble the wooden shoe
(sabot) resulting in the characteristic coeur en sabot, (Fig. 52).

Fig. (52):Right ventricular enlargement with right sided aortic arch; diagrammatic
and in the X-ray of a case of Fallot’s Tetrology
3. In the lateral view the anterior wall of the right ventricle lies
directly behind the lower third of the sternum. In the upper two-
thirds lung tissue separates the sternum from the cardiac
shadow and the retrosternal space is radiotranslucent. As the
right ventricle enlarges, it displaces the lung tissue and the
retrosternal space becomes filled with the right ventricle, (Fig.
53).

Fig. (53): Right ventricular enlargement


seen in the lateral view as it encroach
on the retrosternal space
Left Atrial Enlargement: (Fig. 54)
1. The enlarged left atrial appendage causes straightening or
convexity of the left cardiac border at the medial end of the
third left intercostal space (mitralization), (Fig. 54).

Fig. (54): Enlarged left atrium


2. The outline of the enlarged left atrium can be seen through the
right atrial shadow, i.e. the double contour, (Fig. 55).
3. Massive dilatation of the left atrium may extend so far to the
right that it forms a convexity on the right border of the heart,
outside the border of the right atrium, (Fig. 55).

Fig. (55): Moderate (left) and aneurysmal (right) dilatation of the left atrium

4. The left atrium pushes the left main bronchus upwards which
becomes more horizontal than normal and causes widening of
the carina.
5. The left atrial size can be estimated by giving the patient barium
to swallow and X-ray is taken in the lateral or right anterior
oblique positions. The esophagus is displaced backwards by
the enlarged left atrium, (Fig. 56).

Fig. (56): Enlarged left atrium displacing the esophagus posteriorly. The right
ventricle is also enlarged causing obliterations of the retrosternal
space and causing anterior displacement of the sternum (precordial
bulge)
Left Ventricular Enlargement:
1. In cases of concentric LV hypertrophy due to pressure
overload the only sign may be accentuation of the convexity of
the lower half of the left cardiac border which becomes
chunky, (Fig. 57).

Fig. (57): Dilatation of the LV associated with generalized dilatation


of the aorta in a case of hypertension.
2. When the LV dilates in cases of volume overload and/or left
ventricular failure, the apex is displaced downwards and
outwards. By counting the anterior intercostal spaces, the apex
will be found in the sixth or even the seventh space and the left
cardiac border may appear to cross the diaphragm, (Fig. 58).

Fig. (58): LV dilatation causes displacement of


apex downwards and outwards
3. When LV dilatation is associated with enlarged aortic arch as in
cases of aortic regurgitation, the general configuration of the
cardiac silhouette may come to resemble a boot, i.e. the boot
shaped heart or aortic configuration, (Fig. 59 & 60).

Fig. (59): (A) Normal Heart and (B)


Aortic Configuration

Fig. (60): Aortic Configuration


4. In the lateral view (Fig. 61) the enlarged LV extends posteriorly.
It crosses the shadow of the inferior vena cava and encroaches
on the retro-cardiac space.

Fig. (61): Left ventricular enlargement detected by encroachment on


the retro-cardiac space
5. In cases of LV aneurysm (resulting from myocardial infarction)
part of the LV is excessively enlarged and causes an eccentric
protrusion in the border of the LV in the PA or the lateral views,
(Fig. 62).

Fig. (62): Small (left) and large (right) left ventricular aneurysm
The Aorta: Fig. (63)

Fig. (63): Radiological Signs of Diseases of Aorta

1. Enlargement of the ascending aorta causes a convexity on the


upper third of the right cardiac border. This may be isolated in
cases of aortic stenosis with poststenotic dilatation of the
ascending aorta. The aortic valve may also be calcified as in
(Figs. 64 & 65).
Fig. (64): Poststenotic dilatation of the Fig. (65): Case of aortic stenosis with
ascending aorta in a case of aortic valve calcification of aortic valve and post
stenosis stenotic dilatation of ascending aorta
2. Enlargement of the aortic arch increases the prominence of the
aortic knob in the medial end of the first left intercostal space,
(Fig. 66).

Fig. (66): Aneurysmal dilatation of the aortic arch


3. Generalized enlargement of the ascending aorta and aortic arch
occurs in cases of increased pressure or flow in the aorta, e.g.
hypertension, coarctation, aortic regurgitation and hyper
dynamic circulatory state.

Fig. (67): Aneurysmal dilatation of the ascending aorta


4. Unfolding of the aorta causes the descending aorta to appear
as a vertical shadow on the left border of the heart.

5. Aneurysmal dilatation may involve any segment of the aorta or


all of them together as in cases of cystic medionecrosis,
Marphan syndrome or syphilis, (Fig 67).

6. Dissecting aneurysm of the Aorta:


In this condition, a tear in the aortic intima occurs allowing
the blood to force its way in the media splitting it into two
layers with a false blood filled lumen in between. The aortic
shadow rapidly enlarges and the site of the enlargement and
dissection depends on the site of the tear.

Dissection is classified into two types: A (proximal) and B


(distal). Type A is any dissection involving the ascending aorta
(Fig. 68).
Proximal Type (A) Distal Type (B)

Fig. (68): Left: Types of dissection of the Aorta.


Right: Proximal (type A) dissection
Enlargement of the Pulmonary Artery: (Fig. 69)
Dilated pulmonary artery causes straightening or convexity on
the left cardiac border at the medial end of the second left
intercostal space. This may be an isolated finding in cases of
pulmonary valve stenosis with post stenotic dilatation Fig. (69)
and cases of idiopathic dilatation of the pulmonary artery.

Fig. (69): Dilated main pulmonary artery in a patient with


pulmonary valve stenosis and poststenotic dilatation
 In cases of pulmonary hypertension the enlargement of the main
pulmonary artery is accompanied by enlargement of its right
and left branches. The left pulmonary artery may be partly
concealed behind the enlarged main pulmonary artery. The right
pulmonary artery, on the other hand, appears as a comma
shaped shadow extending from the right cardiac border, (Fig.
70).

Fig. (70): Case of bilharzial pulmonary hypertension causing dilatation


of the main pulmonary and its branches
Fig. (71): Two cases of mild (left) and aneurysmal (right)
dilatation of the pulmonary artery and its branch

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