CXR in Heart disease: Part 2

11 April 2024

CXR in Heart disease: Part 2

Cardiomyopathy vs Pericardial diseases

Pericardial effusion

• Narrow vascular pedicle

• Cardiomegaly directly proportional to severity of pericardial effusion

• Rounded, globular appearance with no particular chamber enlargement

• Cardiophrenic angle become more and more acute

• Oligaemic pulmonary vascular markings

• Marked change in cardiac silhouette in decubitus posture

• ‘Epicardial fat pad sign’- anterior pericardial strip bordered by epicardial fat post. and mediastinal fat ant.>2mm

Dilated Cardiomyopathy

• Chambers can be identified

• Cardiophrenic angle is obtuse

• Increased pulmonary venous hypertension

• No change in cardiac silhouette in decubitus

• Vascular pedicle is dilated or normal

Clinical Vignette: Differential Diagnosis of Massive Cardiomegaly

Pericardial effusion
Dilated cardiomyopathy
Multivalvular heart disease(AR +MR with/without LV dysfunction)
Ebsteins anomaly
Aneurysmal left atrium(when LA enlarges right and left and approaches within an inch of lateral chest wall)

Constrictive Pericarditis

Straightening of the right border

Pericardial thickening > 4 mm

Pericardial calcification (50% cases)

Dilatation of SVC and azygous vein

Clinical Vignette: Differential Diagnosis of Straightening of Right heart border

Congenital absence of pericardium

(i) Focal bulge in area of main pulmonary artery

(ii) Sharply marginated

(iii) Increased distance between sternum and heart due to absence of sterno pericardial ligament

Constrictive Pericarditis
Tricuspid Atresia (type IIb) with Juxtaposed atrial appendage (also seen in D -TGA)

Clinical Vignette: Differential Diagnosis of Straightening of Left heart border

RV dilatation
LA dilatation
cc-TGA
Congenital absence of left pericardium
Pericardial Effusion
Ebstein’s anomal
Assessment of Aortic and Pulmonary diseases

Pulmonary embolism

Westermark sign – oligaemia (clarified area) distal to a large vessel that is occluded by a pulmonary embolus.

Hampton’s hump – wedge- shaped opacity with a rounded convex apex directed towards the hilum

Fleischner’s sign- prominent central pulmonary artery

Palla’s sign- enlargement of the right descending pulmonary artery proximal to a cut off of the pulmonary artery due to acute pulmonary embolism

Chang’s sign – dilatation and abrupt change in calibre of the rt. Descending PA

Ascending aorta and Arch enlargement

PDA

CoA

Truncus Arteriosus

AS, AR, Hypertension

Ascending aortic aneurysm

Bicuspid aortic valve with/without AS

Aortic dissection

Widened mediastinum

Double/irregular aortic contour

Calcium sign (inward displacement of atherosclerotic calcification (>1 cm from the aortic margin)

Aortic kinking

Pleural effusion

Tracheal deviation

CXR in Congenital heart diseases

Acyanotic heart diseases

ATRIAL SEPTAL DEFECT

OS ASD: Right atrium and ventricle enlargement

Large pulmonary artery and increased pulmonary vascularity

RPA>LPA = Jug handle appearance

OP ASD: LV enlargement also

SV ASD: Subtle localized dilatation of SVC

VENTRICULAR SEPTAL DEFECT

Small VSD – normal chest Xray

Significant shunt – Qp/Qs>2: Cardiomegaly, LA/LV/ enlargement, increased pulmonary vascularity, both PAs are prominent

Disproportionate RA enlargement suspect Gerbode defect

PATENT DUCTUS ARTERIOSUS

Cardiomegaly

LA/LV enlargement

Increased pulmonary vascularity/both PAs equally dilated

Filling up of angle between PA and AA(most specific sign)

Unequal distribution of pulmonary arterial blood flow, especially sparing of left upper lobe

Enlargement of aorta

Ductal calcification (Cap of Zinn)

COARCTATION OF AORTA

Aortic figure- 3 configuration due to pre-stenotic dilatation of aorta, indentation of aorta

caused by coarctation, post-stenotic dilatation

Inferior rib notching involving ribs 3 to 8

Prominent left heart border due to left ventricular hypertrophy

Normal pulmonary vascularity

Critical CoA(neonates)

PVH/pulmonary oedema

Cardiomegaly with LV enlargement

No rib notching/aortic knob not characteristic

Pulmonary plethora – no VSD/PDA

PULMONIC STENOSIS

Cardiomegaly

Oligemic lung fields

Dilated right ventricular outflow and right ventricle

Post stenotic dilatation of MPA and LPA

AVSD

Cardiomegaly

RA enlargement with left AVV regurgitation

Left cardiac border straightened by prominent RVOT

Increased pulmonary vascularity

Other trisomy 21 findings :11 ribs, multiple manubrial ossification centres

Clinical Vignette on Rib Notching

Unusual in patients <5 years of age as seen in long standing cases
1^stand 2^nd posterior intercostal arteries arise from the costo-cervical trunk (a branch of the subclavian artery) and do not communicate with the aorta, these are not involved in collateral formation
Anterior ribs are spared because anterior intercostal arteries do not run-in intercostal grooves.
Bilateral rib notching is seen in coarctation distal to the origin of both subclavian arteries, to enable bilateral collaterals to form
Unilateral right rib notching is seen when-
1. the coarctation lies distal to the brachiocephalic trunk but proximal to the origin of the leftsubclavian artery
2. there may be a right sided aortic arch with aberrant left subclavian artery distal to coarctation
Unilateral left rib notching suggests an associatedaberrant right subclavian artery arising after the coarctation and the coarctation is distal to the origin of the left subclavian artery, therefore collaterals form on the left

Clinical Vignette: D/D’s of Rib Notching

CoA (post subclavian)
Classical BT shunt(unilateral)
SVC obstruction(collateral intercostal venous dilatation)
Thrombosis of abdominal aorta(notching of lower ribs)
Neurofibromatosis
Intercostal AV fistula

Clinical Vignette: Calcification in Main pulmonary artery

Eisenmenger syndrome
PDA(Cap of Zinn)
Severe Pulmonary artery hypertension(rarely)
Metastatic pulmonary artery calcification

Clinical Vignette: Aneurysmal dilatation of MPA

Eisenmenger syndrome
TOF with Absent pulmonary valve
Idiopathic dilatation of pulmonary artery
Primary pulmonary hypertension
Connective tissue ds, rheumatologic ds (typically seen in Behcets ds)
Infectious ds like TB, Syphilis

CYANOTIC HEART DISEASE

EBSTEINS ANOMALY	Large ‘square/box shaped’ heart due to left side: horizontal position of RV outflow; right side: RA enlargement Small aortic knuckle Small pulmonary arteries and decreased vascularity
D-TGA	‘Egg on side’ contour: RA abnormally convex + convex left border (increased PBF) Narrow superior mediastinum Increased pulmonary vascularity Pulmonary trunk not visible due to posterior position Thymic shadow absent
L-TGA	Abnormal AA contour because of leftward position of the arch LA enlargement Right pulmonary hilus elevated over left pulmonary hilus(water-fall appearance) Pulmonary trunk and aorta are not apparent because of their posterior position Hump shaped appearance (prominent inverted infundibulum) Septal notch due to apical position of interventricular groove Dextrocardia in 20 % Abdominal situs solitus and dextrocardia should raise the suspicion of cc TGA
TRICUSPID ATRESIA	WITH TGA AND PS (Type 2b) Pointed bulge on the left border of the mediastinal shadow below the region where the pulmonary artery should be seen The right border of the right atrium is straight because the absence of right ventricle pulls the border towards the right atrium (Juxtaposed atrial appendage) Mediastinal pedicle is narrow because of TGA WITH RESTRICTIVE VSD AND NRGA(1b) Enlarged RA and flat receding inferior border reflecting absence of RV Enlarged LV occupies apex Inconspicuous MPA/enlarged Ao Pulmonary vascularity is reduced
TOTAL ANOMOLOUS PULMONARY VENOUS RETURN (TAPVC)	Figure of eight or Snowmans appearance The upper half of the figure of eight is formed by the dilated superior vena cava on the right side, the left brachiocephalic vein in the top and the dilated vertical vein on the left side The lower portion of the figure of eight is formed by the dilated right atrium and ventricle VSD with large thymus: Pseudo-snowman appearance
TETRALOGY OF FALLOT	Boot shaped heart- Coeur en sabot (enlarged RV + small or concave pulmonary artery) Normal cardiac size Decreased pulmonary vascularity Dilated Asc aorta 25 % Right aortic arch TOF with pulmonary atresia: B/L reticular formation due to broncho-pulmonary collaterals, cardiomegaly TOF with APV: Dilated RV with enlarged RA, decreased distal pulmonary vascularity, aneurysmal main pulmonary artery
TRUNCUS ARTERIOSUS	Enlargement of aortic shadow (which represents the truncus) All four chambers dilated(L>>R) Increased pulmonary vascularity 1/3^rd cases – Right aortic Arch Absence of PA is same side as aortic arch in contrast to TOF
DOUBLE OUTLET RIGHT VENTRICLE	WITH SUBAORTIC VSD AND NO PS Prominent RA/dilated LV occupies the apex Pulmonary vascularity is increased PT is moderately convex WITH SUBAORTIC VSD AND PS Resembles TOF WITH SUBPULMONIC VSD (TAUSSIG-BING ANOMALY) Prominent RA/dilated LV occupies the apex Pulmonary vascularity is increased Vascular pedicle is narrow
SINGLE VENTRICLE	WITH INVERTED OUTLET CHAMBER SV and RA are dilated Outlet chamber forms a convex bulge and gives rise to Ao WITH NON-INVERTED OUTLET CHAMBER Dilated RA/dilated SV Narrow vascular pedicle

Clinical Vignette: Narrow and Wide vascular pedicle

Wide	Narrow
DORV	Tricuspid atresia Type II
L-TGA	D-TGA
Single ventricle	TOF
Truncus A	Ebsteins anomaly

Conclusion

A systematic approach is key to interpretation of chest radiograph in cardiac diseases. Careful assessment of cardiac and mediastinal contours and familiarity with normal chest radiograph including lateral projection at times is required to discern subtle features of cardiac chamber pathology and congenital heart disease