CARDIAC X-

RAYS
DR.NASHIR UDDIN AHMED
WHAT TO CHECK IN
CXR?
Identification of the patient
Date of X-ray
Position of the patient looking to medial ends of the
clavicles whether equidistant from spinous process or not
Side of the X-ray right or left
Soft tissue shadow outside skeleton
Bony configuration
Position of trachea
Location of diaphragmatic domes- rt dome is at the level of
anterior end of 6th rib and posterior end of the 10th rib. Left
dome is 2.5 cm below the rt dome
Costophrenic and cardiophrenic angles-
Heart size- maximum transverse diameter of the heart is
slightly less than maximum transverse diameter of the chest
WHAT TO CHECK?
In left ventricular enlargement apex is displaced
downwards and to the left,cardio phrenic angle is obtuse
and merges with diaphragm
In right ventricular enlargement apex is round and
elevated above the diaphragm
In left atrial enlargement there is double border in right
side
In right atrial enlargement the right border is more
curved
Medistinal shadow-Normally one third is in right side
and two third is in left side
Look for any widening of the medistinum due to
retrosternal goiter, lymphoma and aortic aneurysm
WHAT TO CHECK?
Right border is formed by( above
downwards) the following- superior vena cava
with ascending aorta, outer border of the right
atrium
Left border is formed by(above downward)
by the following-prominent aortic knucle by
arch of aorta, straight line due to pulmonary
artery, left atrial appendage and left ventricle
Hilar shadow- is consists of pulmonary
artery, pulmonary vein, hilar lymph nodes,
Left hilum is slightly higher(2.5cm) than the
right hilum
WHAT TO CHECK
Lung fields- are divided in 3 zones
Upper zone-this is the part above a horizontal line
through the lower border of the anterior end of the
second rib
Mid zone-part between the lower border of upper
zone and a horizontal line through the lower border
of the anterior end of the 4 th rib
Lower zone- its the part below the mid zone
NB: Radiological zone does not correspond with
with lobe of the lungs-
To see the lobe lateral view should be done
Some time in PA view horizontal fissure in right
lung divide upper ond middle lobe
DESCRIBE THE X-
RAYS
X-ray chest PA view showing
Heart is enlarged in transverse diameter, globular, pear
shaped and with clear margin
Lung fields are oligaemic
Both cardiophrenic angles are acute
Assessment- Pericardial effusion
CAUSES OF
CARDIOMEGALY IN X-
RAY
Pericardial effusion
Cardiomyopathy
Multiple valvular heart diseases
Myocarditis
Biventricular failure
Extensive myocardial infarction
Hyperdynamic circulatory states
Ebsteins anomaly
CAUSES OF OLIGAEMIC
LUNG FIELD

Pericardial effusion
Fallots tetralogy
Pulmonary stenosis
Pulmonary hypertension
Eisenmengers syndrome due to VSD, ASD AND PDA
SIGNS OF
PERICARDIAL
EFFUSION?
Pulse-low volume tachycardia,may be pulsus paradoxus
indicates pericardial temponade
JVP- raised, Kussmauls sign positive(raised JVP during
inspiration)
Blood pressure- Low systolic and normal diastolic
pressure, narrow pulse pressure
SIGNS -CONTINUED
Precordium-
Area of cardiac dullness is increased
Apex beat is difficult to palpate, if palpable
within area of cardiac dullness
Heart sounds are muffled or distant
Bronchial breath sound in the inferior angle
of scapula(Ewarts sign) due to compression of
left lung base by enlarged heart
Liver is enlarged
CAUSES OF
PERICARDIAL EFFUSION
Following acute pericarditis- viral or bacterial
Tuberculosis
Collagen diseases like- SLE, RA
Myxodema
Lymphoma
Neoplasm- from breast, bronchus
Uraemia
After radiotherapy
DONE IN
PERICARDIAL
EFFUSION?
CBC, ESR- ESR high in TB, SLE
ECG- low voltage and tachycardia
Echocardiogram- Diagnostic
Paracentesis-Fluid analysis for biocemistry,
grams staining, AFB staining, C/S, malignant
cell
MRI for haemopericardium and loculated
effusion
RA test , ANA, anti ds DNA,
Tuberculin test
TFTs- TSH, FT3, FT4
PERICARDIAL
TEMPONADE
Compression of heart by accumulation of
pericardial fluid which interfereswith
diastolic filling of the heart
Patient develops shock
Rapid accumulation of 200 ml of fluid can
cause but if slow may need 2000 ml to
cause temponade
Treatment is immediate paracentesis
Complication of paracentesis are- injury
to coronary vessels and ventricles,
arrythmias and bleeding
DESCRIBE THE X-
RAYS
(A & B)CXR PA view showing that heart is
normal in transverse diameter with
straightening of left boarder- Diagnosis is
mitral stenosis
C & D)- CXR PA view showing Heart is
normal in transverse diameter, Straight left
border with fullness and outwards bulging
of pulmonary conus, there is double
boarder in right side. Diagnosis is mitral
stenosis
CAUSES OF MITRAL
STENOSIS
Chronic rheumatic heart diseases- most common cause
Rare causes like- calcification of valve,
Congenital and carcinoid syndrome
Q- which disease is confused with MS?
Ans. Left atrial myxoma and ball valve thrombus in left
atrium- here murmur changed with posture
WHAT ARE THE
INVESTIGATIONS
DONE IN MS?
CBC, ESR
CXR
X-Ray Barium Swallow Oesophagus
ECG- P mitrale, RVH, LAH
Echocardiogram
Cardiac catheterisation in some cases
FINDINGS ON
EXAMINATION OF THE
PRECORDIUM IN MS?
Inspection- visible cardiac impulse in mitral area
Palpation- apex beat is taping and diastolic thrill
in apical area
Auscultation- First heart sound is loud in all
areas but sometimes only in MA, 2nd heart sound is
normal but P2 is loud if pulmonary hypertension
Murmur- lowpitched rumbling mid diastolic
murmur in apex best heard in left lateral position,
breath holding on expiration, with the bell of the
stetho lightly held.There may be presystolic
accentuation (absent in AF)
There may be opening snap
WHAT ARE THE
SIGNS OF PH
Low volume pulse
Prominent a wave in jogular venous pulse
Palpable P2 indicates RVH
Left parasternal heave indicates RVH
Epigastric pulsation indicates RVH
Loud P2 on auscultation
Early diastolic murmur(Graham steel murmur) due to
pulmonary regurgitation
SIGNS OF SEVERE MS
Pulse is low volume
First heart sound is soft
Opening snap nearer to the second sound
MDM prolonged
Signs of pulmonary hypertension
Later on opening snap disappears and MDM is quiet
COMPLICATIONS OF
MS

AF
Pulmonary oedema
Pulmonary HTN with CCF
Systemic embolism- cerebral infarction with
hemiplegia ,also mesenteric and renal
Pulmonary infarction
Haemoptysis
Ortners syndrome-Hoarseness of voice due to
recurrent laryngeal nerve paralysis by pressure of left
atrium
Dysphagia
Chest pain
ILD due to prolonged pulmonary oedema
INDICATION OF
SURGERY IN MS
Significant symptoms , disturbed normal activity
Recurrent thromboembolism
Pulmonary edema with out precipitating cause
Associated AF not responding to treatment
Pulmonary HTN or recurrent haemoptysis
Pregnancy with pulmonary oedema in 2nd trimester
TREATMENT OF MS
Usually patient needs prophylaxis by Benzathin penicillin
12 lac deep IM monthly
Diuretics if heart failure- tab lasix 20-40 mg/ day
AF- digoxin .25 mg OD
Warferin to prevent thromboembolism
Periodic checkup in OPD
Surgery if indicated
WHAT IS THE
DIAGNOSIS?
Mitral stenosis-
WHAT ARE THE
FINDINGS IN X-RAYS
Heart is enlarged in transverse diameter
Double border in right side due to biatrial
enlargement
Enlarged left atrial appendix
Diagnosis- Mixed mitral valvular disease, MS
+ MR
Note: If heart is enlarged should be MR is
prominent if heart is not enlarged MS is
prominent or pure MS. Diagnosis is confirmed
by colour doopler echocardiogram
SIGNS OF MR
Inspection-visible cardiac impulse in MA
Palpation- apex is shifted, diffuse and thrusting in
character, systolic thrill in apex
Auscultation- first heart sound is soft in MA ,normal in
other areas,3rd heart sound may be present,pansystolic
murmur in MA radiates to axilla best heard on expiration than
inspiration
D/D- VSD and TR
WHY NOT TR?

In TR PSM is present in lower left parasternal area, no

radiation to axilla
Murmur is present on inspiration and less on expiration
Raised JVP with prominent V wave
Enlarged tender and pulsatile liver
WHY NOT VSD?

In VSD pansystolic murmur is in left parasternal

area( fourth or fifth intercostal space)
There is no radiation of this murmur
Best heard on lying flat
WHAT ARE THE
INVESTIGATIONS
DONE?
CBC, ESR
X-Ray chest PA view- cardiomegaly with other features
ECG- LVH, LAH, AF
Echocardiogram- colour doopler study
Cardiac catherisation in some cases
CAUSES OF MR
Chronic rheumatic heart disease
Mitral valve prolapse
Acute MI- due to papillary muscle
dysfunction
Infective endocarditis
Trauma or mitral valvotomy
CTD- RA, SLE, Marfens syndrome
Ankylosing spondylitis
Cardiomyopathy
Secondary to left ventricular dilatation ( HTN
and Aortic valvular diseases)
CAUSES OF
PANSYSTOLIC MURMUR

Mitral regurgitation
Mitral valve prolapse
Tricuspid regurgitation
Ventricular septal defect
Flow murmur due to hyperdynamic circulatory state
COMPLICATIONS OF
MR

Acute LVF
Infective endocarditis
Embolism
Arrhythmias ( AF, ectopics)
CCF
TREATMENT OF MR
Mild to moderate case-Diuretics
Ace inhibitor
Anticoagulation with warferin if AF or
pulmonary embolism
Digoxin if fast AF
Prophylactic penicillin if RHD and to prevent
endocarditis
Follow up 6 monthly or as needed by
echocardiogram
If EF less than 55% or left ventricular
dilatation more than 60 mm valve replacement
DESCRIBE THE X-RAY
CXR PA view showing- heart is enlarged in transverse
diameter, fullness of pulmonary conus with outward
convexity, left costophrenic angle is normal, left
cardiophrenic angle is acute, apex is right ventricular type,
lung fields are oligaemic
Diagnosis- ASD with reverse shunt.
D/D- VSD, PDA and mixed mitral valvular disease
HOW TO DIAGNOSE
ASD?
Normal first heart sound
Wide and fixed splitting of second heart sound
There is ejection systolic murmur in left 2nd and
3rd intercostal area is due to increased flow
through pulmonary valve
There may be diastolic murmur in tricuspid area-
due to increased flow through tricuspid valve
ECG-RBBB with right or left axis deviation
Color doppler echocardiogram
Cardiac catheterization in some cases
WHAT IS
EISENMENGERS
SYNDROME?

When pulmonary hypertension develops in

ASD, VSD or PDA it is called
Eisenmengers syndrome
CLINICAL FEATURES
OF EMS
Dyspnea, fatigue, syncope, angina
,hemoptysis and features of CCF
On examination- cyanosis, clubbing, low
volume pulse, prominent a wave in JVP and
other signs of pulmonary hypertension
Like systolic murmur in pulmonary area,
palpable P2, right parasternal heave
ECG- will show RVH, RAH and RAD
ECHO- can detect the lesion
CAUSES OF DEATH IN
EISENMENGERS
SYNDROME

Right heart failure

Pulmonary infarction
Infective endocarditis
Cerebral thrombosis or abscess
Arrhythmia
WHAT ARE THE
FINDINGS IN X-RAY

Heart is enlarged in transverse diameter

Enlarged pulmonary artery in both sides
Pulmonary conus is full
Lung fields are oligaemic
Diagnosis-ASD/VSD/PDA, with reversal of the shunt, Mitral
valvular disease with PH
CLINICAL FINDINGS
IN VSD
Systolic thrill in left parasternal area in 4th or 5th intercostal
space
Pan systolic murmur in 4th and 5th intercostal space If
EMS develops then PSM can disappear
There may be mid diastolic murmur due to increased flow
through mitral valve
COMPLICATIONS OF
VSD
Infective endocarditis
PH with reversal of the shunt( Eisenmengers syndrome)-
there is cyanosis, clubbing, evidence of pulmonary
hypertension
Heart failure
TREATMENT OF VSD
If small VSD- wait and see for spontaneous
closure and penicillin prophylaxis for infective
endocarditis
Moderate to large VSD- surgical closure
before development of PH
If EMS develops- surgery is contraindicated
If right heart failure- treatment by diuretic,
digoxin, venesection in polycythemia and
organ transplantation
CAUSES OF
CARDIOMEGALY IN CXR
Multiple valvular heart disease
CCF due to any cause
Cardiomyopathy
Myocarditis
Shunt anomaly- ASD, VSD and PDA
Hyperdynamic circulation- severe anaemia, thyrotoxicosis
Pericardial effusion
WHAT ARE THE
FINDINGS IN THE X-
RAY?

Rib notching in 6th,7th and 8th ribs on both sides

Causes- Coarctation of aorta, subclavian artery
obstruction, superior venacaval ovstruction
FINDINGS IN A PATIENT
OF COARCTATION OF
THE AORTA
BP is higher in upper limb and low in lower limb
Pulse is high volume in upper limb and feeble femoral pulse,
radio femoral delay
Carotid pulse may be vigorous and high volume
May be visible suprasternal, supraclavicular and carotid pulse
Visible dilated tortuous artery can be seen around scapula,
anterior axilla and over left sternal area
On examination- apex is heaving, thrill over the collateral
arteries
Normal or accentuated heart sound
Systolic murmur in 4th intercostal space in back
Some tomes EDM due to bicuspid valve
COMPLICATION OF
COARCTATION OF
AORTA
HTN and its complication( LVF, CVD)
Infective endocarditis
Rupture
Dissection
Aneurysm
SAH
Death due to- Acute LVF, Dissection, SAH
WHAT ARE THE
FINDINGS IN CXR?

Boat shaped heart- there is concavity in the bay of

pulmonary vessel
Oligaemic lung field( hilar blood vessels and lung vessels
are also few, small pulmonary artery
Diagnosis is -TOF
WHAT ARE THE
COMPONENTS OF TOF?
Pulmonary stenosis
Overriding or dextroposition of aorta ( aortic origin two-
third from the left ventricle and one third from the right
ventricle
RVH
VSD- large- so there is no murmur of VSD in TOF
HOW TO DIAGNOSE
TOF?
Patient presents with cyanotic spell during
exercise, SOB, syncope and retarded growth
On examination- there is cyanosis, clubbing, left
parasternal lift and epigastric pulsation, systolic
thrill in PA, 1st heart sound is normal
2nd heart sound p2 is soft or absent
Harsh ESM in pulmonary area which radiates to
suprasternal notch
Echocardiogram- Color doppler
COMPLICATION OF
TOF

Infective endocarditis,
Paradoxical embolism
Cerebral abscess
Polycythemia due to hypoxia
Coagulation abnormality
WHAT ARE THE
FINDINGS IN CXR?

Fluffy or woolly opacities, spreading from the both hilar

region, giving a butterfly or bats wing appearance, relatively
less in periphery
Heart is enlarged in TD
Diagnosis- Pulmonary edema
WHAT ARE THE CAUSES
OF THIS TYPE OF X-
RAY?
Acute LVF
ARDS
Bilateral consolidation
Fibrosing alveolitis
Pneumocystis carinii pneumonia
Radiotherapy
Lung metastasis from breast, kidney, bones and
liver
Bilateral extensive PTB
Bronchopneumonia
CAUSES OF ACUTE
LVF
HTN
Acute MI
Aortic valvular disease
MR
CHD like Coarctation, PDA
Cardiomyopathy
Myocarditis
Volume overload due to over transfusion
CLINICAL FINDINGS
IN ACUTE LVF
Dyspnea, orthopnea, cough, frothy sputum
Patient is restless and agitated
Cyanosis may be present in severe cases
Tachypnea, tachycardia, may be pulsus alternans
BP usually high may be low
Heart- evidence of cardiomegaly, apex is shifted
Gallop rhythm
Primary cause may be found
Bibasal creps usually progress up to whole lungs
TREATMENT OF
ACUTE LVF
Propped up position
O2 inhalation-high concentration O2
Inj. Frusemide-40 to 80 mg IV usually
repeated asper BP and clinical response
Inj. Morphine 5- 20 mg IV as per clinical
response
Vasodilator-nitroglycerine if no
contraindication
ACE inhibitor- Captopril or Enalapril
Treatment of primary cause
Thank you