cardiac abc chest x ray.pdf

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The ABC’s ofThe ABC’s of

Heart DiseaseHeart Disease

William Herring, M.D. © 2003

In Slide Show mode, to advance slides, press spacebar or click left mouse button


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William Herring, M.D.

Albert Einstein Medical Center

Philadelphia, PA

William Herring, M.D.

Albert Einstein Medical Center

Philadelphia, PA

© 2000


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With Acknowledgement

For Its Creation to

Bernard J. Ostrum, M.D.

With Acknowledgement

For Its Creation to

Bernard J. Ostrum, M.D.

© 2000


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What It Is

An approach

For congenital or acquired heart

disease in adults Asking systematic set of questions

Answers based on certainfundamental observations

Visible on frontal chest x-ray alone


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CardioCardio--thoracicthoracic

RatioRatio


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Sometimes, CTR is more than 50%But Heart is Normal

Extracardiac causes of cardiacenlargement

Portable AP films Obesity

Pregnant

Ascites

Straight back syndrome

Pectus excavatum


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>50%

Here is a heart that is larger than 50% of the cardiothoracic ratio, but it is still a normal heart.

This is because there is an extracardiac cause for the apparent cardiomegaly. On the lateralfilm, the arrows point to the inward displacement of the lower sternum in a pectus excavatum

deformity.


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Sometimes, CTR is less than 50%But Heart is Abnormal

Obstruction to outflow of the ventricles

Ventricular hypertrophy

Must look at cardiac contours


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Ascending AortaAscending Aorta

“Double density”of LA enlargement“Double density”of LA enlargement

Right atriumRight atrium Left ventricleLeft ventricle

Indentation for

LA

Indentation for

LA

Main pulmonary

artery

Main pulmonary

artery

Aortic knobAortic knob

The Cardiac ContoursThe Cardiac Contours

There are 7 contours to the heart in the

frontal projection in this system.


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“Double density”of LA enlargement“Double density”of LA enlargement


Indentation for

LA

Indentation for

LA

Main pulmonary

artery

Main pulmonary

artery



But only the top five are really important

in making a diagnosis.


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Low density,

almost straight

edgerepresents size

of ascending

aorta

Low density,

almost straight

edgerepresents size

of ascending

aorta



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Small Prominent



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Indentation

where “double

density” of left

atrialenlargement will

appear

Indentation

where “double

density” of left

atrialenlargement will

appear

Double density of left atrial

enlargement

Double density of left atrial

enlargement


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Left atrium

sits in middle ofheart

posteriorly

Left atriumLeft atrium

sits in middle ofsits in middle ofheartheart

posteriorlyposteriorly

Left atriumforms no border

of normal heart

in PA view

Left atriumLeft atriumforms no borderforms no border

of normal heartof normal heart

in PA viewin PA view

LA

RALV

Even though we are on the right side of the heart, we can

see left atrial enlargement. Normally the left atrium sits

right in the middle of the heart posteriorly and does notform a normal border on the frontal film.

Even though we are on the right side of the heart, we can

see left atrial enlargement. Normally the left atrium sits

right in the middle of the heart posteriorly and does notform a normal border on the frontal film.

This inset from a CT scan of the chest

shows how RA and LV obscure LA fromforming a heart border on the frontal film.


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““DoubleDouble

Density”Density”

of left atrialof left atrial

enlargementenlargement

When the LA enlarges, it will do something on the left

side of the heart we’ll talk about in a minute. And it may

produce a “double-density” on the right side of the heart.

When the LA enlarges, it will do something on the left

side of the heart we’ll talk about in a minute. And it may

produce a “double-density” on the right side of the heart.


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RA

Two shadows,

the yellowarrow pointing

to the LA and

the red arrow

to the RA

overlap each

other where

theindentation

between the

ascendingaorta and right

heart border

meet

Two shadows,

the yellowarrow pointing

to the LA and

the red arrow

to the RA

overlap each

other where

theindentation

between the

ascendingaorta and right

heart border

meet

LALA


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Right atrium–

not important

contour inadults

Right atrium–

not important

contour inadults

The last bump on the right side is the right atrium. Since

there is no disease in an adult that causes isolatedenlargement of the RA, we’ll consider the RA together

with the RV later.

The last bump on the right side is the right atrium. SinceThe last bump on the right side is the right atrium. Since

there is no disease in an adult that causes isolatedthere is no disease in an adult that causes isolatedenlargement of the RA, we’ll consider the RA togetherenlargement of the RA, we’ll consider the RA together

with the RV later.with the RV later.


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Aortic knob

should

measure< 35mm

Aortic knob

should

measure< 35mm

Aortic KnobAortic Knob

The first bump on

the left-side is the

aortic arch. Wecan measure the

knob from the

lateral border of airin the trachea to

the edge of the

aortic knob.

The first bump on

the left-side is the

aortic arch. Wecan measure the

knob from the

lateral border of air

in the trachea to

the edge of the

aortic knob.


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42mm

Enlarged with:

Increased pressure

Increased flow

Changes in aortic wall

Aortic KnobAortic Knob


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ImportantImportantImportant

MainPulmonaryArtery

MainPulmonaryArtery

The next bump down is the

main pulmonary artery and is

the keystone of this system.


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Finding the

MainPulmonaryArtery

Finding the

MainPulmonaryArtery


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The distance

between the

tangent andthe main

pulmonary

artery (between

two smallgreen arrows)

falls in a range

between 0 mm

(touching thetangent line) to

as much as 15

mm away from

the tangent line

If we draw a

tangent line

from the apexof the left

ventricle to the

aortic knob

(red line) andmeasure along

a

perpendicular

to that tangentline (yellow

line)

00 115


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0 mm0 mm

MainMainPulmonaryPulmonary

ArteryArtery

AoAo

15 mm15 mm

MainMain

PulmonaryPulmonary

ArteryArtery

AoAo

LVLV

LVLV

Main pulmonary

artery ranges from

0 mm–15mm

from tangent line

Main pulmonary

artery ranges from

0 mm–15mm

from tangent line


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Two Major Classifications

The main pulmonary artery (MPA)

projects beyond the tangent line

The main pulmonary artery is more

than 15 mm away from the tangent line

Because the MPA is small or absent

Because the tangent line is being pushed away

from the MPA


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Main

pulmonaryartery

projectsbeyondtangent

Main

pulmonaryartery

projectsbeyondtangent

Increased

pressure

Increased flow


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2 7

Main pulmonaryartery is morethan 15 mmfrom tangent


Small pulmonaryartery

Truncus arteriosus

Tetralogy of Fallot


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2 9



Left ventricleand/or aortic

knob push the

tangent away

Common


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0 - 15 mm00 -- 15 mm15 mmTo

recapitulate:


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Concavity where L

atrium will appear on

left side when

enlarged

Concavity where L

atrium will appear onleft side when

enlarged

Left atrial enlargementLeft atrial enlargement


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“Straightening of the

left heart border”

“Straightening of the

left heart border”

Left atriummay enlarge

without

producing

doubledensity

Left atriumLeft atriummay enlargemay enlarge

withoutwithout

producingproducing

doubledoubledensitydensity

Left atrial enlargementLeft atrial enlargement


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MainPulmonary

Artery

MainMainPulmonaryPulmonary

ArteryArtery

LeftAtrial

Appendage

LeftLeftAtrialAtrial

AppendageAppendage

In the example on the

right, not only is the

left atrium enlarged,

but the left atrial

appendage is too. Sothere is a convexity

outward where there

is normally aconcavity inward.

L ft t i l


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Left VentricleLeft Ventricle

Left ventricleLeft ventricle


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Which Ventricle is Enlarged?

The best way to determine which

ventricle is enlarged is to look atthe corresponding outflow tract for

each ventricle


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If Heart Is Enlarged,

And Main Pulmonary

Artery is Big

>50%Then Right Ventricle isEnlarged


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If Heart Is Enlarged,

And Aorta is Big

Then Left Ventricle

is Enlarged>50%


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Which ventricle is enlarged?

The best way to determine which

ventricle is enlarged is to look at

the corresponding outflow tract

for each ventricle

Aorta for the LV

MPA for the RV


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Once one ventricle is enlarged,

it’s impossible to tell if other ventricle

is also enlarged



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“Double density”

of LA enlargement


of LA enlargement


Indentation for

LA

Indentation for

LA

Main pulmonary

artery

Main pulmonary

artery





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of LA enlargement


of LA enlargement


Indentation for

LA

Indentation for

LA

Main pulmonary

artery

Main pulmonary

artery




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The PulmonaryThe Pulmonary

VasculatureVasculature

Fi e States of the P lmonar


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Five States of the Pulmonary

Vasculature

Normal

Pulmonary venous hypertension

Pulmonary arterial hypertension

Increased flow

Decreased flow


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What We’re Going to Evaluate

Right Descending Pulmonary Artery

Distribution of flow in the lungs

Upper versus lower lobes

Central versus peripheral

What to EvaluateWhat to Evaluate


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What to EvaluateWhat to Evaluate

11

33

22

22

1 Right Descending Pulmonary Artery1 Right Descending Pulmonary Artery


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Right

Descending

Pulmonary

Artery

Right

Descending

Pulmonary

Artery

Serves right

middle andlower lobes

Serves right

middle andlower lobes

1. Right Descending Pulmonary Artery1. Right Descending Pulmonary Artery

1 Right Descending Pulmonary Artery1 Right Descending Pulmonary Artery


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1. Right Descending Pulmonary Artery1. Right Descending Pulmonary Artery

Diameter can

be measured

(before

bifurcation)

Diameter can

be measured

(before

bifurcation)

RDPA< 17 mm

Normally, theright

descending

pulmonaryartery should

not be more

than 17mm indiameter

2. Normal Distribution of Flow2. Normal Distribution of Flow


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Upper Versus Lower LobesUpper Versus Lower Lobes

In erect position,

blood flow to

bases > than flow

to apices

In erect position,

blood flow to

bases > than flow

to apicesSize ofvessels at

bases is

normally

> than sizeof vessels

at apex You can’t measure size ofvessels at the left base

because the heart obscuresthem

3. Normal Distribution of Flow3. Normal Distribution of Flow


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Normaltapering of

vessels

from

central toperipheral

Normaltapering of

vessels

from

central toperipheral

Central vesselsgive rise to

progressively

smaller peripheral

branches

Central vesselsgive rise to

progressively

smaller peripheral

branches

Central versus peripheralCentral versus peripheral

Normal Vasculature - reviewNormal Vasculature - review


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11

33

22

22RDPA< 17 mm in

diameter

Lower lobevesselslarger thanupper lobevessels

Gradualtapering of

vessels

from central

to

peripheral

Venous HypertensionVenous Hypertension


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RDPA usually

> 17 mm

Upper lobe

vessels equal

to or larger

than size oflower lobe

vessels =

Cephalization

Upper lobe

vessels equal

to or larger

than size oflower lobe

vessels =

Cephalization

ypy

Pulmonary Arterial HypertensionPulmonary Arterial Hypertension


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y yp

RDPA usually

> 17 mm

RDPA usually

> 17 mm

Main

Pulmonary

Arteryprojects

beyond

tangent line

Main

Pulmonary

Arteryprojects

beyond

tangent line

2 3

Pulmonary Arterial HypertensionPulmonary Arterial Hypertension


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Rapid

cutoff in

size of

peripheralvessels

relative to

size of

centralvessels

Rapid

cutoff in

size of

peripheralvessels

relative to

size of

centralvessels

Central vessels

appear too

large for size ofperipheral

vessels which

come from

them =

Pruning

3 1

Increased FlowIncreased Flow


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RDPA usually

> 17 mm

RDPA usually

> 17 mm

All of blood vessels everywhere inlung are bigger than normal

Increased FlowIncreased Flow


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Distribution of

flow is

maintained as

in normal

Gradual

tapering from

central to

peripheral

Lower lobevessels bigger

than upper

lobe

NormalNormal Increased FlowIncreased Flow


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Increased FlowIncreased Flow PAHPAH


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Decreased FlowDecreased Flow


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Unrecognizable

most of the

time

Small hila

Fewer thannormal blood

vessels


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The Pulmonary Vasculature

Normal

Pulmonary venous hypertension

Pulmonary arterial hypertension

Increased flow

Decreased flow - mostlyunrecognizable even when it ispresent

If Look at the

Normal

Pulmonary

Mitral

regurg

Mitral


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AIs the Left

AtriumEnlarged?

If yes,then

If no,then

Look at thePulmonaryVasculature

Increased

Pulmonaryvenous

hypertension

BIs the MainPulmonaryArtery Big

orBulbous?

If yes,

then

If no,then

Look at thePulmonaryVasculature

CIs the MainPulmonary

ArterySegmentConcave?

If yes,then

If no,then

DIs theHeart

Dilated orDelta-

Shaped?

If yes,then

Don't Look atPulmonary

Vasculature.Look at Aorta

Normal

Increased

Pulmonaryhypertension

CardiomyopathyPericardial

EffusionMolt. valve dz

MitralStenosisL Myxoma

VSD, PDA

Plum.stenosis

ASD(VSD)

Idiopathic(1°)

Normal

Ascendingdilated

Whole AoDilated

Cardiomyopathy

AoStenosis

Ao regurgHBP

The ABC’sThe ABC’s


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The System

Those were all of the answers

Now here are the questions

The system is successful only if youask the questions in this order

The answers are the fundamentalobservations you make on the frontal

film alone


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To answer that question


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Straight orconvex at

site of

normal

concavity

“Double

density” at

site of normal

indentation



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If Answer To Question “A” Is YES

Look At Pulmonary Vasculature


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If Answer To Question “A” Is NO

Then...


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Is The Main Pulmonary

Artery Big ?



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Main

pulmonary

artery projectsbeyond

tangent line

q


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If Answer To Question “B” Is YES

Look At Pulmonary Vasculature


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If Answer To Question “B” Is NO

Then...


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Is The Main Pulmonary

Artery Concave ?



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Mainpulmonary

artery is >

15mmaway from

tangent

line


2 5


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If Answer To Question “C” Is YES

Look At Configuration of Aorta


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If Answer To Question “C” Is NO

Then...


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Is The Heart a Dilated Or

Delta-Shaped Heart ?


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Choose the link“Test Yourself on the ABCs”

to see how the system works

For printed notes, choose the link underCardiac Notes for

“The ABCs of Heart Disease”


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The End

cardiac abc chest x ray.pdf

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