Radiologi Kardiovaskular

Standard PA Positioning

For stability, arms

may be wrapped
around bucky or
film holder, but in this
position it is difficult
to roll the shoulders
forward
Standard PA Positioning Steps

2. Adjust height of film to

patient’s chest.

CR to T-7 or 3”-4”
below the jugular
notch, (top of cassette
to vertebral prominens).

Watch that ID marker

Careful centering of
film prevents clipping
AP Supine
When the patient must remain supine, the SID is 50”, 5o caudad

If done on the x-ray table the film is generally put in the bucky
tray, and is referred to as a “bucky chest.”
If done on a gurney,
a screen technique
is preferred.
The supine position is less desirable
because

1. Inspiration
2. Air fluid levels
ID not demonstrated
marker 3. Engorgement of large pulmonary
vessels, and hyperemia (small
vessels).
 THE CHEST
METHODS OF EXAMINATION Tomography

Tub Rx

Caseta/film
 THE CHEST
METHODS OF EXAMINATION
Fluoroscopy

1933 2000
 THE CHEST
METHODS OF EXAMINATION- Computed
tomografy

1975 1995
MRI

MAGNET

Coils
 CT = Computed Tomography =
Röntgen X-ray slices  3D

Tomoscan AV EasyVision

Greek  = to cut, to slice

 THORAX NORMAL
• Anatomi thorax normal identik gambaran radiologi
(Imaging Thorax normal).
• Mahasiswa harus sudah menguasai anatomi thorax
(jantung-paru-vaskularisasi & organ-organ yang
terlibat).
• Gambaran normal thorax kelainan
Anatomi Paru-Paru
Gambaran Thorax Normal

Hal-Hal yang Harus

diperhatikan :
1. Posisi
2. Simetrisasi
3. Inspirasi
4. Kondisi
 Radiographic Anatomy
of PA Chest
Rt. Clavicle
& SC joint
Posterior ribs

Pulmonary vasculature
(arteries and veins), or
lung markings Hilum of Lt lung

Rt pulmonary Knob of
artery aorta Anterior ribs

Rt cardiophrenic
angle
Heart in
Lt costophrenic
mediastinum
angle

Dome of the rt
hemidiaphragm
 Gambaran Thorax Normal
Posisi Posteroanterior & Lateral

• Pada Foto thorax

normal, hal-hal yang
perlu diperhatikan
adalah :
1. Posisi
2. Simetrisasi
3. Inspirasi
4. Kondisi
 FAKTOR POSISI
INTERPRETASI
• PA (berdiri)
• AP (berbaring)

DASAR PENILAIAN :
1. SCAPULA (DILUAR PARENKIM PARU)
2. CLAVICULA (curam)
3. UDARA FUNDUS GASTER
(MEGENBLASE)
PA AP
 AP versus PA
The Effect of Magnification

AP portable film makes the On this PA film done on the same

heart look larger than it does… patient an hour later
 FAKTOR SIMETRISASI
Jarak ujung clavicula dengan
processus spinosus (simetris/tidak)

CARA :
JARAK YANG SAMA ANTARA PROCESSUS
SPINOSUS KE SENDI STERNOKLAVIKULA KANAN
DAN KIRI
 FAKTOR INSPIRASI
DASAR PENILAIAN :
PENAMPAKAN DIAFRAGMA
PATOKAN :
VT X / COSTA BELAKANG 10 /COSTA DEPAN 6

INTERPRETASI :
• CUKUP
• KURANG
• TERLALU DALAM
 Inspiration

 About 10 posterior ribs visible is an excellent

inspiration
 In many hospitalized patients 9 posterior
ribs is an adequate inspiration
 Anterior vs. Posterior Ribs

Anterior ribs
will be visible
Posterior ribs but are harder
are those that to see. They run
are most more or less at
apparent on the a 45 degree
chest x-ray. angle
They run more downward
or less toward the feet.
horizontally.

How to tell the difference between

the anterior and the posterior ribs
 Pitfall Due to Poor Inspiration

About 8 posterior ribs are showing

Poor inspiration will crowd lung markings and make it appear as though
the patient has airspace disease
Same patient

8 9

About 8 posterior ribs are showing 9-10 posterior ribs are showing

Better inspiration and the “disease”

at the lung bases has cleared
 KONDISI FOTO THORAX
DINILAI DARI :
1. KONDISI PULMO KESELURUHAN (LUSENSI PARENKIM PARU)
2. VERTEBRA THORAKALIS TAMPAK I-IV (< VT II KURANG, >
VT VI KERAS)
3. PROCESSUS SPINOSUS TAMPAK 3 ATAU 4

INTERPRETASI :
• KERAS (TERLALU HITAM/LUSENS)
• CUKUP
• KURANG (TERLALU PUTIH/OPAQUE)
 Hal-hal yang harus diperhatikan dalam
Pembacaan Foto Polos Thorax
a. Jaringan lunak, tulang
b. Corakan bronkhovaskuler
c. Parenkim paru Keadaan hilus
d. Sinus costofrenikus
e. Diafragma
f. Cor : CTR
SISTEMA TULANG DAN JARINGAN LUNAK

LOKASI DAN GAMBARAN SISTEMA TULANG :

• COSTA,
• CLAVICULA
• SCAPULA
LOKASI DAN GAMBARAN JARINGAN LUNAK
• MAMMAE,

normal: sistem tulang intak

 JANTUNG
LOKASI
BENTUK JANTUNG
CTR : NORMAL < 0,5 UNTUK BERDIRI /PA
 One of the easiest observations to make is
the cardio-thoracic ratio which is the
Cardio-thoracic widest diameter of the heart compared to
Ratio the widest internal diameter of the rib
cage

CTR= (a+b) / c
= < 50%

c
Enlarged or not?

Yes
Enlarged or not?

Yes
Enlarged or not?

No
 Contoh Pembacaan
Foto Thorax Normal
• Foto Thorax PA,errect,simetris, inspirasi dan kondisi
cukup
– Tidak ada soft tissue swelling
– Sistema tulang intak
– tampak kedua apex paru tenang
– tampak corakan bronkhovaskuler di kedua lapangan paru
normal
– sinus costophrenicus kanan-kiri lancip
– Diafragma kanan dan kiri licin
– Cor : CTR kurang dari 0,56

• Kesan : Paru dan cor dalam batas normal

Edema paru
 Congenital Heart Disease
• Tetralogy of Fallot
– 10%–11% of cases of congenital heart disease
– As a result of single defect, an anterior malalignment of the conal septum
– Components:
• Ventricular septal defect
• Infundibular pulmonary stenosis
• Overriding aorta
• Right ventricular hypertrophy.
– Heart has the shape of a wooden shoe or boot
– Blood flow to the lungs is usually reduced
Tetralogy of Fallot –
BOOT SHAPED SIGN
 Congenital Heart Disease
• Aortic Coarctation
– 5%–10% of congenital cardiac lesions
– Produced by a deformity of the aortic media and intima, which causes a
prominent posterior infolding of the aortic lumen
– Occurs at or near the junction of the aortic arch and the descending thoracic
aorta
– Infolding cause eccentric narrowing of the lumen at the level where the
ductus or ligamentum arteriosus inserts anteromedially
– Resultant luminal narrowing in turn obstructs the flow of blood from the left
ventricle
– Classic radiologic signs
• Figure-of-three sign
• Reverse figure-of-three sign
• Rib notching on CXR pathognomonic
Aortic Coarctation –
Figure of
Three, and Reverse Figure of Three
Ebstein Anomaly –
Box Shaped Heart
RADIOGRAPHIC FEATURES OF AORTIC STENOSIS

• Enlargement of the ascending aorta

due to poststenotic dilatation
• Mild or no cardiomegaly in
compensated stage
• Substantial cardiomegaly occurs
only after myocardial failure has
ensued
• No pulmonary venous hypertension
or pulmonary edema is seen during
most of the course of this disease
• Calcification of aortic valve may be
discernible on radiograph but is
more readily shown on CT
RADIOGRAPHIC FEATURES OF MITRAL STENOSES

• Pulmonary venous hypertension or edema

is present
• Pulmonary edema may be observed
intermittently
• Mild cardiomegaly is seen in isolated mitral
stenoses
• Enlargement of the left atrium is
characteristic
• Enlargement of the left atrial appendage is
frequent and suggests a rheumatic etiology
• Right ventricular enlargement indicates
some degree of pulmonary arterial
hypertension or associated tricuspid
regurgitation.
RADIOGRAPHIC FEATURES OF MITRAL STENOSES

• Enlargement of the pulmonary arterial

segment is indicative of associated
pulmonary arterial hypertension
• Right ventricular enlargement in the
absence of prominence of the main
pulmonary artery suggests associated
tricuspid regurgitation. The right
atrium is also enlarged with tricuspid
regurgitation
• The ascending aorta and aortic arch are
usually inconspicuous in isolated mitral
stenosis. Even slight enlargement of
the thoracic aorta raises the question
of associated aortic valve disease
 RADIOGRAPHIC FEATURES OF HYPERTROPHIC
CARDIOMYOPATHY

• Normal in most patients

• Mild cardiomegaly and pulmonary
venous hypertension in a minority
of patients
• Left atrial enlargement can be
caused by associated mitral
insufficiency or reduced left
ventricular compliance
• In the obstructive form (subaortic
stenosis), ascending aortic
enlargement is infrequent
• Left ventricular enlargement may
occur in end-stage disease
 RADIOGRAPHIC FEATURES OF RESTRICTIVE
CARDIOMYOPATHY

• Pulmonary venous hypertension is

typical
• Pulmonary edema may occur
intermittently
• Normal heart size or mild
cardiomegaly in most patients
• Left atrial enlargement
• Left atrial appendage is typically
not enlarged
• Moderate to severe cardiomegaly
can ensue in end-stage disease
 RADIOGRAPHIC FEATURES OF AORTIC
REGURGITATION

• Absence of pulmonary venous

hypertension or pulmonary edema
until late in the course of this lesion
• Moderate to severe cardiomegaly
• Left ventricular enlargement
• Enlargement of ascending aorta and
aortic arch
 RADIOGRAPHIC FEATURES OF MITRAL
REGURGITATION

• Variable degree of pulmonary

venous hypertensive or pulmonary
edema (less severe than with mitral
stenosis)
• Moderate to severe cardiomegaly
• Left ventricular enlargement
• Left atrial enlargement
• Enlargement of left atrial
appendage
 RADIOGRAPHIC FEATURES OF TRICUSPID
REGURGITATION

• No pulmonary venous hypertension

or pulmonary edema (isolated
tricuspid regurgitation)
• Pulmonary venous hypertension or
edema indicates associated mitral
valve disease
• Moderate to severe cardiomegaly
• Right ventricular enlargement
• Right atrial enlargement
RADIOGRAPHIC FEATURES OF CONGESTIVE (DILATED)
CARDIOMYOPATHY

• Pulmonary venous hypertension or

pulmonary edema may be but is
not invariably present
• Moderate to severe cardiomegaly
• Left ventricular enlargement
• Left atrial enlargement is
infrequently evident but can be
caused by mitral regurgitation
caused by left ventricular
enlargement
Congestive Heart Failure
Congestive Heart Failure (CHF)
Kerley B lines: Infiltration or thickening of interlobar
septa in area of costophrenic angles.
(Kerely A = extending from hilum,
Kerely C = middle of pulmonary tissue.)

CHF

Detail of
fluid in the
interstitial
spaces
(pulomary
edema)

Cardiomegaly (enlarged heart) Heart shadow normally

occupies 1/3 of thoracic cavity on PA CXR.
 RADIOGRAPHIC FEATURES OF PERICARDIAL
EFFUSION

• No pulmonary venous hypertension

or pulmonary edema
• Moderate to severe enlargement of
cardiac silhouette
• Associated pleural effusion is not
uncommon
• Specific features, such as “fat pad”
and/or “variable density” signs, are
infrequently evident
ENLARGEMENT OF MAIN PULMONARY ARTERY

• Etiology
– Pulmonary arterial hypertension
– Excess pulmonary blood flow (left to
right shunts, chronic high output states)
– Valvular pulmonic stenosis
– Pulmonary regurgitation
– Congenital absent pulmonary valve
(aneurysmal pulmonary artery)
– Absence of left pericardium
– Aneurysm of pulmonary artery
– Idiopathic dilatation of pulmonary
artery
Cardiac Size