Catheterizationand Cardiovascular Diagnosis 7341
Letter to the Editor
Terminology for Radiographic Projections in Cardiac
Angiography
TO THE EDITOR
Modem trends in cardiac angiography
call for a flexible and multidirectional ap-
proach to cardiac imaging rather than the
more standardized procedures of the past.
A great number of equipment manufactur-
ers have responded to these needs and have
designed several devices that allow
changes in projections, not only by rotation
around the patient but also by angulation
and tilt in relation to the patients long body
axis. These new devices enjoy increasing
popularity among angiographers and are
being installed at a rapid pace in most
existing angiographic laboratories or are
included in new facilities. On the occasion
of the most recently held 53rd Scientific
Session of the American Heart Associa-
tion, I was asked by the Council on Car-
diovascular Radiology to organize a post-
graduate seminar under the title, The
Angled Views in Angiocardiography, in
which the application of this new radio-
graphic approach was presented and dis-
cussed as it pertains to the performance of
coronary arteriography, left ventriculog-
raphy, and the angiographic diagnosis of
congenital heart disease. Participants were
Dr. Ivan Bunnell of Buffalo New York,Dr.
Kenneth Fellows, Jr., of Boston Mas-
sachusetts, and Dr. Lewis Wexler of
Stanford, California. A final presentation
included a Proposal for Common
Nomenclature on Angulated Views , the
content ofwhich is the purpose of this brief
presentation.
0098-656918110703-0341SOl.500 1981 Alan R. Llss, inc.
- 344 (1981)
Traditionally, radiographic projections
are described as if the observer sees the
object transluminated by the x-ray source
located on the opposite side. The objects
(patients) surface facing the observer de-
termines the identification of a specific
view. Figure 1 illustrates schematically the
most common views where the patient is
seen from above. In the top illustration, the
x-ray beam penetrates the patients chest in
a postero-anterior direction resulting in an
anterior (A) view. In the secondillustration
from above, the patient is turned 18W, and
his chest is penetrated from anterior to
posterior resulting in a posterior (P)view.
In the third illustration, a lateral view is
presented. The x-ray beam penetrates the
patient from the right to the left, depicting
the object in left (L)lateral view. The final
two illustrations present the most com-
monly practiced projections in cardiac
radiography, ie, the left anterior oblique
(LAO) and the right anterior oblique (RAO)
views. All these views entail changes in
projectionaround the patients longitudinal
body axis and are accomplished either by
rotation of the radiographic equipment
around the patient or by rotation of the
patient within the system.
The terminology for radiographic
projections relates to the patients body
and not to the orientation in space. Thus, as
shown in Figure 2, an anterior (A) view is
accomplished with the patient in standing
position (to the left), in supine position
342 Paulin

anterior
A
view

right left
iaterat L

left ant.

"
oblique LAO

right ant.
oblique RAo

anterior

(53 A

ante-'-*
A

2
Figs. 1 and 2.
 Terminology for Radiographic Projections
: cranio-caudal
Fig. 3.
most frequently practiced in angiocardiog-
raphy (illustrationtoupper right), as well as
with the patient rotated in a cradle with the
right side down and a corresponding rota-
tion of the radiographic equipment. Al-
though the patient's position in space is not
unimportant for proper interpretation of
angiographic findings, it is not recom-
mended to incorporate such terms in the
abbreviated nomenclaturefor radiographic
projections, but rather to present such in-
formation by supplementary statement,
should it be different from the conventional
supine position.
The new "angulated" views add to the
conventional views a tilt in relation to the
long axis of the patient. It may occur in a
caudo-cranial(CR) or a cranio-caudal (CA)
direction, as illustrated in an example of a
patient placed in supine position (Fig. 3).
The general direction of the x-ray beam
from the patient's back to the anterior wall
of the chest is determined by the under-
couch position of the x-ray tube and the
overhead placement of the image inten-
sifier. Reversed position of the radio-
graphic equipment-ie, placement of the
343
x-ray tube above the supine positioned
patient-should not be used in x-ray cine-
matography because of the significantradi-
ation exposure to personnel. It may be
practiced when performing large-sized
rapid film sequence with an automatic film
changer, a technique that is not dealt with
in this brief presentation.
Tilts in cranial or caudal direction can
occur in combination with any of the con-
ventional views. The illustration in the
center of Figure 4 depicts an anterior view
of the heart in a supine patient, the basic
view from which the angulations around
the long axis of the body (Figs. 1-3) as well
as those tilting the x-ray beam in relation to
the long axis are to be defined. The degree
of angulation can be expressed numerically
in either direction from the anterior view as
an origin (0 angulation).
Example: CR30",L40",A 0 view
This implies that the radiographic
equipment has been tilted in relation to the
patient's anterior view by 30" in cranial di-
rection and by 40" to the left.
344 Paulln
Example: CAW, RW, A 0 view
Here the radiographic equipment was
tilted by 2 4 in caudal direction and 60" to
the right, away from the anterior view.
R O C O l l l ~ O f W
Use symbols CR (cranial) and CA
(caudal)for corresponding angulations and
add to the conventional, traditional sym-
bols A (anterior). P (posterior), L (left lat-
eral), R (right lateral), LAO (left anterior
oblique), RAO(right anterior oblique), etc.
Add degree of angulation numerically in
elevated position following the corre-
sponding symbol as counted from the an-
terior position (0 point) if such precision is
deemed essential.
Give supplementary information on pa-
tient's position if this should deviate from
the common supine positiob-eg, sitting,
right recumbent, Trendelenburg. etc.
Avoid such terms as angulated view,
tilted view, axial view, half-axial view,
sit-up view, four-chamber view, septal
projection, atrial view, elongated view, or
modified view.
This recommendation makes no claim of
originality, but is presented merely as an
effort to accomplish improved under-
standing between angiographers, anat-
omists, surgeons, and clinicians, and is in
conformity with previously practiced and
traditionally accepted standards of radie
graphic terminology.
Sven Paulin, MD
Boston, Massachusetts