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Chest X-ray continues to have an important and integral role in diagnosis of both
congenital heart diseases (CHD) and acquired heart diseases (AHD). Its role
may have declined over the past two decades because of many factors. These
factors include advent of echocardiography, less of late diagnosis, thereby
decline of classical X-ray appearances and appearance of newer imaging tools.
Still it has a pride of place in clinical cardiology, both in adults and children.
In children with suspected heart lesions, usually X-ray chest frontal view
is taken; which is most often a PA view. The usual X-ray source – plate distance
in adults is 180 cms, but is shorter in infants and young children. In small infants
often what we obtain is an AP view. Lateral view could be useful as well as
oblique view, but to a limited extent. Barium study is more or less extinct except
in suspected vascular ring, vascular sling or situs problems. Fluoroscopy can be
useful in assessing prosthetic valve function.
It is to be noted that normal chest x-ray need not rule out structural
cardiac problem and conversely a normal heart can have an apparently abnormal
cardiac shadow. Still, a well taken chest x-ray is an important clinical tool for
Pediatrician, Pediatric Cardiologist, Radiologist and Family physician.
X-rays are routinely taken using a non portable machine. Portable x-rays
are AP and have other inherent limitations, including creating an impression of
cardiomegaly.
Currently digital x-rays are becoming popular in bigger centers and labs.
It can be of indirect digital format or direct digital format. Direct format are film
less. Digital radiographs have the advantages of ability for storage, archival,
transmission, less of radiation and less of time consumption.
C. Contour
Contour of heart shadow usually gives information regarding ventricular
hypertrophy / enlargement.
Mild right ventricular enlargement does not cause cardiomegaly. Modest
or marked enlargement causes cardiomegaly with rotated apex which is elevated
from diaphragm which gives rise to an upturned apex. An upturned apex without
cardiac enlargement occurs in right ventricular hypertrophy.
RV Apex - No cardiomegaly
Tetralogy of Fallot
Valvular PS
Eisenmenger syndrome
DORV. VSD.PS
- Cardiomegaly d- TGA.
DORV. VSD. PAH
ASD Eisenmenger
Late PPH
TAPVC
ASD
VSD . PAH
Left ventricle (LV) is border forming on the left side and hence can be
evidently enlarged easily. The apex is shifted down and laterally and even can be
below diaphragm. There will be rounding off the apex and elongation of long axis
of LV. In DCM heart can be enlarged and can be globular. In LV aneurism, there
could be a bulge on left heart border. Cardiomegaly with LV apex occurs in large
PDA, VSD, AR, MR and DCM.
D. ATRIA
Right atrial enlargement is relatively rare in children. It forms a
prominent convexity on the right side which is lower and more lateral. It can be
seen as a large diffuse bulge on right side. In adults right atrial enlargement is
said to be present if distance from midline to right heart border is > 5.5 cms. In
young children it is > 4 cms. RA enlargement can occur in Ebstein, RV EMF and
Tricuspid Atresia.
Left atrial enlargement in frontal view can manifest in many ways.
a. Prominent LA appendage on left border (normally this area is
concave).
b. Elevation of left bronchus (well appreciated in well penetrated or
digital X-ray)
c. Widening of carinal angle
d. Shadow on shadow (double shadow) appearance.
E. Great Vessels
Ascending aorta can be border forming on the right side and aortic
knuckle is the upper most part of left heart border. Arching – left or right can be
made out by ipsilateral indentation of trachea. Dilated aortic shadow can occur in
AS, AR, Hypertension, Coarctation of Aorta and aneurism of Aorta. Bicuspid
Aortic valve with no AS can also make Aorta prominent.
Main pulmonary artery (MPA) and its branches can be assessed. MPA
divides into right and left and the left PA is a continuation of MPA. RPA shortly
divides into 2 branches at right hilum – a smaller ascending pulmonary artery and
a larger descending pulmonary artery (RDPA). In adults both LPA and
descending RPA are between 9-15 mm in size near the hilum. Pa s are dilated in
PS, PAH, Idiopathic Dilatation, Absent Pulmonary Valve syndrome and in
Eisenmenger syndrome.
F. Pulmonary vascularity
Abnormal pulmonary vascularity can be generally divided into four types.
1. Oligemia
2. Plethora
3. Pulmonary venous hypertension
4. Pulmonary Edema
a. Pulmonary oligemia
Vascular shadows are reduced. They are not seen even in the
intermediate Lung zones. MPA, LPA and Right descending PA (RDPA) are all
small. (Normally RDPA is of the same size as Rt Lower lobe bronchus). Oligemia
occurs in TOF, severe PAH, critical PS with reversal of shunt etc.
b. Pulmonary plethora
Vascular shadows are numerous. They are seen in the lateral one third of
lung fields. MPA, LPA and RDPA are large. End on vessels are more in number
(> 5 in number per both lungs). The end on vessel diameter is more than that of
accompanying bronchus. There will be left atrial or right atrial enlargement
usually.
Plethora occurs in L → R shunts, Admixture lesions and d-TGA without
PS. To have plethora L → R should be at least 1.5:1.
Occasionally there can be unilateral plethora as in BT shunt, unilateral
MAPCA. Asymmetry in lung vascularity can also occur in Glenn surgery and PA
branch stenosis.
d. Pulmonary edema
There is alveolar edema, reaching to hilum and a typical ‘bat Wing’ appearance.
PVH and Edema occur in mitral valve disease, obstructed TAPVC, HLHS,
DCM etc.
Pulmonary Vascularity
(Distribution problems)
Are
i. Cephalization - in PVH
occlusive disease
G. Other Abnormalities
They include cervical rib, rib notching (3 rd to 8th ribs), ductal calcium,
SPECIAL SITUATIONS:
2. Thymus
* in infants
College, Thiruvananthapuram
Thiruvananthapuram