JILL IRENE Z.

CAPISTRANO MD, FPCP, DPCC

Postgraduate Education
BS Physical Therapy, Silliman University, 1996
BS Zoology, MSU-Iligan Institute of Technology 1999
Doctor of Medicine, Mindanao State University-College of Medicine
Post-graduate Internship
University of the Philippines, Philippine General Hospital
2003-2004
Internal Medicine Residency
University of the Philippines, Philippine General Hospital
2004-2007
Fellowship in Cardiology
University of the Philippines, Philippine General Hospital
2008-2011
Affiliations
Fellow, Philippine College of Physcians
Fellow, Philippine Heart Association
Diplomate, Philippine College of Cardiology

Dr. Jill Irene Z. Capistrano, FPCP,DPCC

INTERNAL MEDICINE-CARDIOLOGY

Postero-Anterior (PA) View

SVC

IVC

Postero-Anterior (PA) View

RA

Postero-Anterior (PA) View

RV

Postero-Anterior (PA) View

PA

Postero-Anterior (PA) View

LA

Postero-Anterior (PA) View

LV

Postero-Anterior (PA) View

Aorta

Postero-Anterior (PA) View

Postero-Anterior (PA) View

Right border

Superior vena cava

Right atrium
Inferior vena cava

Postero-Anterior (PA) View

Right border

Superior vena cava

Right atrium
Inferior vena cava

Left border

Aortic knob
Main pulmonary trunk
Left ventricle

Postero-Anterior (PA) View

Pulmonary Arteries

Right

Postero-Anterior (PA) View

Pulmonary Arteries

Right

Left

Postero-Anterior (PA) View

LA

Pulmonary Arteries

Right

Left

Pulmonary Veins

Lateral View

SVC
RA

IVC

Lateral View

RV

Lateral View

Lateral View

LA

Lateral View

LV

Lateral View

Aorta

Lateral View

Lateral View

Left atrium
Left ventricle

Lateral View

Left atrium
Left ventricle

Right ventricle

Lateral View

Aorta

Main Pulmonary Artery

Inferior vena cava

Lateral View

Pulmonary Arteries

Left

Right

Pulmonary Veins

Systemic Approach

Overview or overall glance at the film

Check cardiac position and situs
Cardiac size
Chamber enlargement
Great vessels
Lungs
Ancillary findings

Overview or overall glance at the film

Is it
adequate
or optimal for
cardiac evaluation?

Overview or overall glance at the film

Things to consider:
Position
Inspiration
Exposure

Overview or overall glance at the film

Things to consider:
Position

slight degrees of rotation or obliquity will

substantially affect the cardiac contour and
may alter the apparent size as well

Overview or overall glance at the film

Things to consider:
Inspiration

Should be in full inspiration

In suboptimal inspiration or supine chest
radiographs, the lower lobe markings are
crowded and may obscure the possibility
of early pulmonary edema

Overview or overall glance at the film

Things to consider:
Exposure

underexposure may simulate the

appearance of pulmonary congestion
overexposure may simulate diminished
pulmonary blood flow

Cardiac Position and Situs

Cardiac Positions:

Levocardia: the heart is predominantly in the

left chest, and the cadiac apex points leftward
Dextrocardia: the heart is predominantly in
the right chest, and the cardiac apex points
rightward
Mesocardia: the heart is positioned in the
midline, and the cardiac apex points directly
inferiorly

Cardiac Position and Situs

Cardiac Positions:

Dextroposition (dextroversion): the cardiac

apex points leftward, but the heart is located
predominantly in the right chest (typically due
to extrinsic forces)

Cardiac Position and Situs

Visceroatrial Situs:

SITUS refers to the pattern of anatomic

arrangement.
atrial situs is usually concordant with visceral
situs; hence these two are described together

Cardiac Position and Situs

Visceroatrial Situs:

Situs solitus:

the morphologic right atrium is to the right of the

morphologic left atrium
the gastric air bubble is on the left side, and the
liver is on the right

Situs inversus:

the morphologic right atrium is to the left of the

morphologic left atrium
the gastric air bubble is on the right side, and the
liver is on the left

Cardiac Position and Situs

Visceroatrial Situs:

Situs ambiguous:

this term is used when identification of visceroatrial

situs is not possible due to paucity of anatomic
markers

Cardiac Position and Situs

Dextrocardia
Situs solitus

Cardiac Position and Situs

Dextrocardia
Situs inversus

Cardiac Position and Situs

Situs ambiguous

Cardiac Size

Cardio-Thoracic Ratio

divide the widest

transverse diameter of
the heart by the widest
transverse diameter of
the thorax taken at the
inner side of the rib cage

Cardiac Size

Cardio-Thoracic Ratio

normal CT ratio in adults

is ususally 0.5 or less
normal CT ratio in the
newborn is
approximately 0.65

Chamber Enlargement

Right Atrial Enlargement

lateral bulging of the right

heart border
elongation of the right
heart border (length of
right heart border exceeds
50% of the mediastinal
cardiovascular shadow)

Cardiac enlargement

RightAtrial Enlargement

Right cardiac border > 2.5

cm from the lateral aspect
of the thoracic vertebra
and > 5.5 cm from mid
thoracic spine/spinous
process

Chamber Enlargement

Right Ventricular
Enlargement

PA View: Rounding and

upliftment of cardiac apex

Chamber Enlargement

Right Ventricular
Enlargement

PA View: Rounding and

upliftment of cardiac apex
Lateral View:
Retrosternal fullness
(contact of anterior
cardiac border greater
than 1/3 of the sternal
length

Chamber Enlargement

Left Atrial Enlargement

PA view:

Double density
Enlargement of LA
appendage
Upliftment of left mainstem
bronchus
Widening of carinal angle

Chamber Enlargement

Left Atrial Enlargement

Lateral view:

Prominent posterosuperior
cardiac border
Posterior displacement and
upliftment of left mainstem
bronchus

Chamber Enlargement

Left Ventricular
Enlargement

PA View: lateral and

downward displacement
of the cardiac apex

cardiac apex measures

<4 cm from the left
costophrenic sulcus

Chamber Enlargement

Left Ventricular
Enlargement

Lateral view:

posterior displacement of
the posterior inferior border
of the heart
Hoffman-Rigler Sign:
measured 2 cm above the
intersection of the
diaphragm & IVC; (+) if
posterior border extends
more than 1.8 cm of IVC

Pulmonary Vascular Pattern

In normal subjects, pulmonary
vascularity has a predictable
pattern.
Pulmonary arteries are usually
easily visible centrally in the
hila and progressively less so
more peripherally.
The central main right and left
pulmonary arteries are usually
not individually identifiable,
because they lie within the
mediastinum

NORMAL

Pulmonary Vascular Pattern

major arteries
-central, the clearly
distinguishable midsized
pulmonary arteries (third or
fourth order branches) are in
the middle zone
small arteries and arterioles
-normally below the limit of
resolution
-in the outer zone.

NORMAL

visible small and midsized

arteries
-sharp, clearly definable
margins because of the
sharp border between water
density and air density
structures.

Pulmonary Vascular Pattern

NORMAL

Pulmonary Vascular Pattern

NORMAL

INCREASED

Pulmonary Vascular Pattern

NORMAL

INCREASED

Pulmonary Vascular Pattern

NORMAL

DECREASED

Pulmonary Vascular Pattern

NORMAL

DECREASED

Pulmonary Vascular Pattern

NORMAL

VENOUS
CONGESTION

Pulmonary Vascular Pattern

INCREASED
ARTERIAL
BLOOD FLOW

VENOUS
CONGESTION

Pulmonary Vascular Pattern

Kerleys B lines

VENOUS
CONGESTION

Pulmonary Vascular Pattern

Perihilar Haziness

VENOUS
CONGESTION

Pulmonary Vascular Pattern

Peribronchial Cuffing

VENOUS
CONGESTION

Pulmonary Vascular Pattern

Redistribution:
equalization

VENOUS
CONGESTION

Pulmonary Vascular Pattern

Redistribution:
cephalization

VENOUS
CONGESTION

Pulmonary Vascular Pattern

Redistribution:
cephalization

Pulmonary Vascular Pattern

Kerley B Lines
VENOUS
CONGESTION

Interstitial Edema

Pulmonary Vascular Pattern

Kerley A Lines
VENOUS
CONGESTION

Kerley B Lines

Interstitial Edema

Pulmonary Vascular Pattern

Alveolar Edema

VENOUS
CONGESTION

PCWP

VASCULAR PATTERN

<8 mmHg

Normal

10-12 mmHg

Lower zones appear equal in diameter to or

smaller than the upper zone vessels

12-18 mmHg

Vessel borders become progressively hazier

because of increasing extravasation of fluid into
the interstitium Kerley B lines (horizontal,
pleura based, peripheral linear densities)

>18-20 mmHg (acute)

Pulmonary edema occurs, with interstitial fluid

present in sufficient amounts to cause a perihilar
bat wing appearance

The Great Arteries

Are they in normal position?

Are they of normal size?

The Great Arteries

Aorta

normal
prominent
diminutive

Main pulmonary
artery

normal
prominent
concave

The Great Arteries

Aorta

normal
prominent
diminutive

Main pulmonary
artery

normal
prominent
concave

The Great Arteries

Aorta

normal
prominent
diminutive

Main pulmonary
artery

normal
prominent
concave

The Great Arteries

Aorta

normal
prominent
diminutive

Main pulmonary
artery

normal
prominent
concave

The Great Arteries

Aorta

normal
prominent
diminutive

Main pulmonary
artery

normal
prominent
concave

Sample Cases

Chest X-ray exercises

Compiled from the Specialty Board
of Adult Cardiology Exam

normal

normal

TOF-

Ventricle enlarged, apex slightly elevated RV

Trachea displaced to left aorta on right side. Vascular pattern decreased

TOF - previous syst pulmo shunt. Pulmo vasc normal.

Right sided aortic arch.

TOF

Hypovascular lung
Concave MPA
Prominent aorta
RVH

Transposition decreased vasc pattern, heart

slightly enlarged, very narrow vascular pedicle.

Ebstein anomaly massively enlarged heart,

huge left sided structures. Extension of the RA to R (RAE)

Total anomalous pulmonary venous return

figure of 8 deformity or snaoman heart, large veins forming a
convexity on either side of mediastinum

Patial anomalous venous return scimitar

syndrome. Hypervascularity and large vessel paralleling the
border of the right side of hear and extending below diapragm
anomalous PV

PAPVR Hypoplastic right lung

PAPVR

PDA slightly enlarged heart, some minor decrease in

vascular pattern. Large aortic knob

PDA hypervascular, prominent Ao, prominent MPA, LVH

ASD RV, PA enlargement. Increased PBF. Lateralanterior bowing of sternum indicative of hyperventilation L to
R shunt

ASD Hypervascular, Dilated MPA, Dimunitive aorta, RVH, RAE

Pulmonic stenosis great enlargement

of the PA large hilar vessels on left represent postenotic
dilatation

PS VALVAR

Hypovascular
Dilated MPA
RVH

Transposition of great vessels slight convexity of

the left upper border due to ascending aorta. No
aortic shadow on right.

Coarctation of the aorta heart slightly enlarged 2 to LVH.

Ao unremarkable.
Rib notching scalloping of inferior surfaces of ribs with
sclerosis

Coarctation of the aorta LVH, ascending aorta

somwhat prominent. Descending aorta with indentation with
postenotic dilatation. L subclavian artery enlarged on L superior
mediastinum.

Pseudocoarctation of the aorta transverse aortic

arch is high, very broad convexity of the aorta to
the left, below the arch

Mitral stenosis LA enlargement. LA appendage

projecting on the L below PA. Right sided double density

MS cephalization, Normal aorta, Dilated MPA, LAE, RAE, RVH,

MS PULMO CONGESTION, LAE, RAE, DILATED MPA

MS MR CEPHALIZATION, DILATED MPA, LAE,

LVH, RVE

LA wall calcification dense calcification outlining

LA. Either in the wall or thrombus that lines the
chamber.

Mitral regurgitation enlargement of both left sided

chambers. Dilated LA appendage. Double density.

Aortic stenosis heart slightly enlarged, rounding of apex 2

LVH. Ascending Ao enlargement. Densely calcified valve.

Aortic insufficiency LV dilatation

AI

Normal vascularity
Dilated aorta
LVH

LV aneurysm LV dilatation, congested pulmonary

vascular marking (Kerly B lines).
3 weeks after- with bulge along LV border.

Calcified myocardial infarct curvilinear

calcification extending most of the way around the
apex

Pericardial effusion grossly enlarged cardiac silhoutte, After

pericardial tap and air injection with note of pericardial
calcification

Aortic aneurysm

PULMONARY EDEMA