CHEST RADIOLOGY

Dr. Hari Soekersi,

Sp.Rad.

NORMAL FOUR VIEWS

OF THE HEART
1

Posteroanterior Projection

Lateral Projection

Right Anterior Oblique Projection

Left Anterior Oblique Projection

POSTEROANTERIOR
PROJECTION

1.
2.
3.
4.
5.
6.
7.
8.

Right innominate vein

Superior vena cava
Right main branch of the pulmonary artery
Upper and lower lobe veins
Right atrium
Tricuspid valve
Inferior vena cava
Arch of the aorta

POSTEROANTERIOR
PROJECTION

POSTEROANTERIOR
PROJECTION

POSTEROANTERIOR
PROJECTION
Aorta
Superior
vena
cava

Right
Atrium

Pulmonary
artery
Appendage
of the left
atrium

Left
Ventricle

LATERAL PROJECTION

1.
2.
3.
4.
5.
6.
7.
8.

Superior vena cava

Ascending aorta
Main pulmonary artery
Right atrium
Tricuspid valve
Right ventricle
Aortic arch
Left main branch of the pulmonary artery

LATERAL PROJECTION

LATERAL PROJECTION

LATERAL PROJECTION

Root of the
main pulmonary
artery

Right
Ventricle

Left
Atrium
Left
Ventricle

Because these structures are in contact with

mediastinal fat, their margin may be indistinct

RIGHT ANTERIOR OBLIQUE

PROJECTION

1.
2.
3.
4.
5.
6.
7.
8.
9.

Anterior wall of the trachea

Innominate vein
Anterior border of the superior vena cava
Superior vena cava
Right main branch of the pulmonary artery
Thoracic aorta
Left atrium
Right atrium
Inferior vena cava

RIGHT ANTERIOR OBLIQUE

PROJECTION

LEFT ANTERIOR OBLIQUE

PROJECTION

1.
2.
3.
4.
5.
6.
7.
8.

Superior vena cava

Right main branch of the pulmonary artery
Ascending aorta
Main pulmonary artery
Right atrial appendage
Tricuspid valve
Right ventricle
Left subclavian artery

LEFT ANTERIOR OBLIQUE

PROJECTION

ANATOMY OF THE HEART

HISTOLOGY OF THE HEART

1. Endocardium of
atrium
2. Myocardium of
atrium

10. Coronary artery

11. Coronary sinus

12. Coronary vein with valve

3. Annulus fibrosus
4. Mitral valve :
a. Endocardium
b. Connective tissue
core

5. Chorda tendina
6. Endocardium of
ventricle
7. Myocardium of
ventricle
8. Purkinje fibers
(conduction fibers)
9. Plate A

13. Epicardium of atrium

14. Subepicardial connective
tissue and fat

15. Perimysial septa with

blood vessels
16. Epicardium and
subepicardium of ventricle
17. Columnae carneae

18. Apex of papillary

muscle

PLAIN FILMS DIAGNOSIS OF

CARDIAC DISEASE

Analyze each case with

six steps:

6
3

PLAIN FILMS DIAGNOSIS OF

CARDIAC DISEASE

Analyze each case with

EVALUATION
OF THE THORACIC CAGE FOR SIGN
six steps:
OF PREVIOUS SURGERY OR OTHER
ABNORMALITIES

IDENTIFICATION OF THE POSITION OF THE

STOMACH BUBBLE AND HEPATIC SHADOW TO
DETERMINE BODY SITE
EVALUATION OF GREAT VESSELS FOR SIZE AND
POSITION
EVALUATION OF SPECIFIC CHAMBER ENLARGEMENT
EVALUATION OF CARDIAC SIZE AND CONTOUR
EVALUATION OF PULMONARY VASCULARITY

EVALUATION OF THE THORACIC

CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER
ABNORMALITIES

Signs of previous surgery

-

periosteal elevation
asymmetry thoracic cage
smaller and slightly deformed rib
resected rib in previous thoracotomy

EVALUATION OF THE THORACIC

CAGE FOR SIGN OF PREVIOUS
SURGERY OR OTHER
ABNORMALITIES

Congenital heart disease:

- premature fusion of sternum cyanotic
form
- hypersegmentation of sternum Downs
syndrome
- bulging of sternum enlarged right
ventricle

COMPLETE FUSION OF
STERNAL SEGMENTS

HYPERSEGMENTATION OF
THE STERNUM

ATRIAL SEPTAL DEFECT WITH

ENLARGED RIGHT VENTRICLE AND
ANTERIOR BULGING OF THE STERNUM

IDENTIFICATION OF THE
POSITION OF THE STOMACH
BUBBLE AND HEPATIC SHADOW
TO DETERMINE BODY SITE

Abnormal hepatic and stomach position

show abnormalities in position of the
viscera congenital cardiac disease

SITUS SOLITUS WITH DEXTROCARDIA

Stomach bubble is under the left diaphragm

Liver is on the right
Heart is on the right with cardiac axis directed
to the right

SITUS INVERSUS WITH DEXTROCARDIA

Stomach bubble is under the right diaphragm

Liver is on the left
Heart is on the right with cardiac axis directed
to the right

ISOLATED LEVOCARDIA OR SITUS

AMBIGUS

Stomach bubble is under the right

diaphragm
Liver is on the left
Normal heart position

DEXTROCAR
DIA
DEXTROVERSIO
N
Dextrocardia :

Location of the heart in the right

side of the thorax, the apex
pointing to the right
Dextroversion :
Location of the heart in the right
chest, the left ventricle remaining
in the normal position on the left
with the apex pointing the the left

EVALUATION OF GREAT VESSELS

FOR SIZE AND POSITION

Enlargement of the pulmonary artery

segment
Prominent pulmonary arterial segment along
the left upper cardiac border
In TGV and truncus arteriosusabnormal
position (concave)
Enlargement of the aorta
Three portions of the aorta can be evaluated:
ascending aorta, aortic arch dan descending
aorta.

ENLARGEMENT OF PULMONARY
ARTERY SEGMENT

TRANSPOSITION OF GREAT VESSELS

TRANSPOSITION OF GREAT VESSELS

TRUNCUS ARTERIOSUS

TRUNCUS ARTERIOSUS

ENLARGEMENT OF THE AORTA

Usually, the ascending aorta does not

extend beyond the right upper
mediastinal shadow.

EVALUATION OF SPECIFIC
CHAMBER ENLARGEMENT

Signs of left atrial

enlargement
Signs of left ventricular
enlargement
Signs of right atrial
enlargement
Signs of right ventricular
enlargement

SIGNS OF LEFT ATRIAL ENLARGEMENT

Posteroanterior projection
1. Displace the barium-filled esophagus
below the carina to the right
2. Prominent bulge along the mid-left
cardiac border
3. A double density along the right cardiac
border
4. Widening of the angle of the carina
>900
Lateral projection
1. Posterior displacement of both walls of
the barium-filled esophagus

SIGNS OF LEFT ATRIAL ENLARGEMENT

Left anterior oblique projection

Elevate the left mainstem bronchus and
obliterates the spaces between the
posterior cardicac margin and the left
mainstem bronchus

LEFT ATRIAL ENLARGEMENT

SIGNS OF LEFT VENTRICULAR

ENLARGEMENT
Posteroanterior projection
1. Left ventricular dilatation produces
downward displacement of the apex
toward diaphragm.
2. Left ventricular hypertrophy produces a
round left cardiac border
Left anterior oblique projection
Posterior cardiac margin to overlap the
vertebral column

LEFT VENTRICULAR DILATATION

LEFT VENTRICULAR HYPERTROPHY

SIGNS OF RIGHT ATRIAL

ENLARGEMENT

Posteroanterior projection
Difficult increased convexity of the lower
right heart border on PA projection

RIGHT ATRIAL ENLARGEMENT

SIGNS OF RIGHT VENTRICULAR

ENLARGEMENT

Posteroanterior projection
Rounding and elevation of the cardiac
apex
Lateral projection

Retrosternal space is obliterated

Left anterior oblique projection

Increased convexity of the anterior cardiac

border

RIGHT VENTRICULAR ENLARGEMENT

EVALUATION OF CARDIAC SIZE

AND CONTOUR

Index of cardiac enlargement is the

cardiothoracic ratio.
In infants: 0.55
In adults : 0.45
The lateral and oblique views must be
considered

CARDIOTHORACIC RATIO

(Cardiac width / Thoracic cage width) x 100%

EVALUATION OF PULMONARY
VASCULARITY

In normal the pulmonary vascular

marking taper gradually toward the
periphery of the lung fields, and more
prominent in the lower lung fields.
The vessels in the right hillum is larger than
in the left

SIX DIFFERENT VASCULAR

PATTERNS ARE RECOGNIZED
1. Normal pulmonary vascularity
2. Increased pulmonary vascularity due to
increased pulmonary blood flow.
- the peripheral arteries are sharply outlined
and dilated and distributed equally to both
the upper and lower lobes.
- ex. VSD, PDA, truncus arteriosus,
transposition of the great vessels.

3. Decreased pulmonary vascularity due to

right-to-left shunts.
- small pulmonary arterial segment
- reduced diameter of the hilar
pulmonary arteries
- ex. Tetralogy of Fallot, tricuspid atresia,
pulmonary stenosis

4. Pulmonary venous congestion

- occurs in condition that causes increased
resistance distal to pulmonary capillaries
- fluid accumulates in the interstitial
tissues and Kerley B lines
- ex. Mitral stenosis, acute left ventricular
failure are common causes.

5. Bronchial collateral
6. A bizarre pattern of pulmonary vascularity
- different vascular pattern in each lung

PULMONARY VASCULARITY IN
LEFT-SIDED FAILURE
Five factors influence the distribution of
pulmonary blood flow.
Interstitial osmotic and alveolar pressures
remain constant throughout the lung
Hydrostatic, pulmonary arterial and pulmonary
venous pressures, diminish from base to apex
because of gravitational effects.
In left-sided cardiac failure, the increased
pulmonary venous pressure resulting from the
elevated left ventricular end-diastolic pressure

 The transudation of fluid into the pulmonary

interstitium causes an increase in the
interstitial pressure
The earliest radiographic manifestation on
left-sided cardiac failure is:
1. An indistinctness of the vascular
markings caused by the increased
interstitial fluids.
2. The hilar vessels become enlarged and
indistinct.
3. The increased interstitial fluid can be
seen as peribronchial cuffing.

 Later, cephalization occurs. The vascular

markings are prominent in the upper lobes
owing to the constriction of the lower lobe
vessels and redistribution of flow to the upper
lobes.
Pleural effusion occurs late
Transudation of fluid into the alveoli leads to
pulmonar edema. This appears in a perihilar
location (butterfly wings or bat wings).
Kerley B lines, due to fluid in the lobular
septum.

Several non-cardiac causes as

differential diagnosis of pulmonary
edema:
1.
2.
3.
4.
5.
6.

Uremia. Increased capillary permeability.

Fluid overload. Decreased plasma osmotic
pressure.
Neurogenic. Altered capillary permeability or
capillary pressure.
Hypoproteinemia. Decreased plasma osmotic
pressure.
Transfusion and allergic reactions. Altered capillary
permeability.
Inhalation of toxic gases. Altered capillary
permeability

CEPHALIZATION

KERLEY B

KERLEY A, B, & C

Kerley A : white arrow

Kerley B : white arrow
head

EDEMA PARU INTERSTITIAL

EDEMA PARU ALVEOLAR

PULMONARY VASCULARITY IN
PULMONARY HYPERTENSION
Mild PAH

Severe PAH

Pulmonal artery segment

dilatation
Right ventricular enlargement

CONGENITAL HEART DISEASE

1. Decrease
bronchovascular
marking
a)

Acyanotic
1.

b)

2. Increase
bronchovascular
marking
a)

Pulmonary Stenosis
(PS)

1.
2.

Cyanotic
a)
b)
c)
d)
e)

Acyanotic

3.

Tetralogy Fallot
Trilogy Fallot
Atresia Pulmonal
Atresia Tricuspid
Ebstein Anomaly

4.
5.

b)

Atrial septal defect (ASD)

Ventricle septal defect
(VSD)
Right atrioventricular
anomaly
Patent ductus arteriosus
(PDA)
Partial Anomalous
Pulmonary Venous Return
(PAPVR)

Cyanotic
1.

Total Anomalous Pulmonary

PULMONARY STENOSIS

PULMONARY STENOSIS

Pulmonary stenosis make right

ventricular resistancy increased,
causing radiographic feature:
Right ventricular enlargement
Rounding and elevation of the
cardiac apex
Bulging of pulmonary trunc
Bronkhovascular marking decreased

TETRALOGY FALLOT

TETRALOGY FALLOT

The malformation has four components:

Right ventricular hypertrophy, Overriding
aorta, Pulmonary stenosis, and Ventricular
septal defect
Radiographic features:
Right ventricular enlargement
Boot shape contour
Pulmonary artery segment concave
Right sided aortic arch
Pulmonary vascularity decreased

EBSTEIN ANOMALY

EBSTEIN ANOMALY

Atrial septal defect

Displace tricuspid valve
Radiographic feature:
Vary
Widening of right heart border
Rounded heart (cardiomegali all
chamber)
Bronchovascular marking
decreased

ATRESIA PULMONAL

ATRESIA PULMONAL

Radiographic feature:
Cardiomegali with oval heart
contour
Bronchovascular marking
decreased

ATRESIA TRICUSPID

ATRESIA TRICUSPID

~ Atresia pulmonal
Cardiomegali with oval heart contour
Pulmonary vascularity decreased

ATRIAL SEPTAL DEFECT

ATRIAL SEPTAL DEFECT

The feature related to how large the defect

and the complication on the pulmonary
vascularity
Radiographic feature:
Right atrial enlargement, widening right
heart border
Right ventricular enlargement, rounded
and elevation of the cardiac apex
Prominent conus pulmonalis, with
widening of hillum

VENTRICULAR SEPTAL DEFECT

VENTRICULAR SEPTAL DEFECT

Radiographic feature:
Small defect (Maladie de Roger)
Heart is not enlarged
Normal pulmonary vascularization
Mild
Heart is enlarged to the left (left ventricle hypertrophy)
Apex downward to the diaphragm.
Right ventricle has not enlarged.
Left atrium dilated
Increase pulmonary vascularization.

VENTRICULAR SEPTAL DEFECT

Radiographic feature:
Moderate Severe
Right ventricle dilatation and hypertrophy.
Left atrium dilatation.
Widening of the pulmonary artery and its branches
Normal right atrium.
Left ventricle hypertrophy.
Small aorta.
Pulmonary hypertension
Right ventricle is enlarged.
Pulmonary artery is widening with prominent of conus pulmonalis.
Normal left atrium.
Small aorta.
Decrease peripheral pulmonary vasculature.
Pulmonary emphysematous

PATENT DUCTUS ARTERIOSUS

PATENT DUCTUS ARTERIOSUS

Small defect
Normal

Moderate
Normal or mild enlargement of descendent
aorta and aortic arch.
Prominent of conus pulmonary.
Widening of the pulmonary artery and its
branches.
Left atrial enlargement.
Right and left ventricle enlargement.

PATENT DUCTUS ARTERIOSUS

Severe (pulmonary hypertension)

Enlarge central pulmonary vasculature.
Decrease peripheral pulmonary
vasculature.
Prominent conus pulmonalis.
Widening of the ascendent aorta with
prominent aortic knob.
Normal left atrium.

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