Radiologic Diagnosis of Heart Diseases

An Atlas of Cardiac X-rays

PART 1
Radiographic technique
The thoracic cage

Dr. Khairy Abdel Dayem

Professor of Cardiology
Ain Shams University
 Contents
PART 1
Radiographic technique
 Over exposure
 Under exposure
 Centralization

The thoracic cage

 kyphyoscoliosis
 Straight back
 Pectus excavatum
 Precordial bulge
 Rib notching
 Effects of previous operations or interventions
PART 2
Pulmonary vasculature
 The normal pulmonary vasculature
 Pulmonary congestion
 Pulmonary Plethora
 Pulmonary Oligemia
 Pulmonary embolism and Infarction
 Pulmonary Hypertension
PART 3
The Cardiac Shadow
Cardiothoracic ratio
Pericardial effusion
Abnormal densities
Pericardial calcifications
Calcifications of valves
Calcifications of walls of cardiac chambers
Calcifications of the aorta
Calcifications of coronary arteries

Radiology of cardiac chambers in health and disease

Normal radiological anatomy of the heart
Normal cardiac outline
The lateral view
Right atrial enlargement
Right ventricular enlargement
Pulmonary artery dilatation
Left atrial enlargement
Left ventricular enlargement
Diseases of the aorta
PART 4
Radiological features of acquired valvular diseases
 Mitral stenosis
 Mitral regurgitation
 Aortic stenosis
 Aortic regurgitation
 Tricuspid valve disease

Heart failure and cardiomyopathies

PART 5 Radiological feature of common congenital
cardiac malformations
 The cardiac malpositions
 Atrial septal defect
 Ventricular septal defect
 Patent ductus arteriosus
 Pulmonary stenosis
 Coarctation of aorta
 Fallot’s tetralogy
 Transposition of great arteries
 Ebstein Anomaly of the Tricuspid valve
 Total anomalous pulmonary venous drainage

Extracardiac structures simulating cardiac disease

 Effects of Radiographic Technique on
X-ray Interpretation
Certain defects in the way the X-ray was taken may alter the
cardiac shadow and/or the lung vasculature. The following are the
most common examples:

A. Defects in exposure (Dose of the X-ray)

The X-ray should not be over or under-exposed Proper
exposure is essential in order to judge the pulmonary vasculature.

Criteria of Over-exposure (Fig. 1):

1. Jet black lung fields.
2. Individual thoracic vertebrae are clearly seen within the
cardiac shadow.
3. The junction of each rib with the thoracic vertebrae is well
seen within the cardiac shadow.
Fig. (1): Over-exposed X-ray
Errors that may be caused by over-exposure:
 Over-diagnosis of pulmonary oligemia

Criteria of Under-exposure (Fig. 2):

1. The ribs and the thoracic vertebrae can not be seen at all
within the cardiac shadow.
2. Partial veiling of lung fields

Errors that may be caused by under-exposure:

 Inability to judge pulmonary vasculature.
 Over-diagnosis of:
 Pulmonary congestion
 Pulmonary plethora
 Pulmonary fibrosis
 Pleural effusion
Fig. (2): Under-exposed X-ray
B. Defects in Centralization
The patient should be centralized, not rotated, standing erect
and directly facing the X-ray tube.

Criteria for proper centralization:

The medial ends of both clavicles should be equidistant from
the middle line. This is represented by the spinal processes of the
vertebrae. Both clavicles should also be at the same level as in
(Fig. 3).

This (Fig. 4) shows a non-centralized patient as evidenced by

the unequal distance between the medial ends of the clavicles
and the spinal processes of the vertebrae. The clavicles are not at
the same level.
 Fig. (3): Left: Centralized Patient, Right: Uncentralized Patient
Note: The unequal space between the medial end of both clavicles
and the middle line

Error that may be caused by a non-centralized patient:

 Abnormal cardiac configuration without the presence of heart
disease.
Abnormalities in the Thoracic Cage that may Affect
Interpretation of Cardiac X-ray
Before looking at the cardiac outline, the
thoracic cage must be examined carefully for
evidence of the following abnormalities:

1. Skeletal abnormalities include

kyphosis, scoliosis or kyphoscoliosis.
If marked, these skeletal abnormalities
may drastically change the
configuration of the cardiac shadow as
in (Fig. 4). Fig. (4): Kyphoscoliosis

In this X-ray kyphoscoliosis is manifested by:

a) Sideway curves of the vertebral column.
b) Intercostal spaces on the right side are much wider than on
the left side.
Other skeletal abnormalities that may affect the cardiac size and
configuration include:
a) Straight back syndrome: straight back causes diminution of
the antroposterior thoracic diameter compressing the heart
against the spine and causing it to appear enlarged in the PA
view, (Fig. 5).

Fig. (5): (Right) Straight back and (Left) Apparent enlargement of the
pulmonary artery due to the skeletal deformity
b) Pectus excavatum: the depressed sternum displaces the heart
towards the left. The right cardiac border disappears behind
the sternum and the cardiac outline is distorted, (Fig. 6).

Fig. (6): Pectus excavatum: Inward displacement of the

lower third of the sternum
2. Precordial Bulge
Skeletal abnormalities may result from heart disease. Chronic
and early enlargement of the heart may displace the chest wall
anteriorly resulting in precordial bulge. This is diagnosed in the
lateral view of the X-ray by anterior displacement of the sternum,
(Fig. 7).

Fig. (7): Marked enlargement of the heart causing anterior displacement of the
sternum and the ribs (Precordial Bulge)
3. Rib Notching
Notching on the lower edges of the fourth to the ninth ribs
indicate enlarged intercostal arteries eroding the lower border
of the ribs in cases of coarctation of the aorta, (Fig. 8 & 9).

Fig. (8): X-ray of coarctation of aorta showing Fig. (9): Enlarged view of the
rib notching starting from the 4thth rib. The left ribs showing notching of their
border of the heart shows the 3 sign lower borders
4. Effect of previous Operations or Interventions e.g.
 Open heart surgery is usually done through a median
strenotomy incision. The 2 halves of the sternum are
approximated by wires as in (Fig. 10).

Fig. (10): Lateral view showing wires that are used to join the two
halves of the sternum together