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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.
Normal Chest X-ray
Whenever an X-ray chest is assessed one must note the age of child,
date of X-ray and position (marker – right or left).
A. Site
We expect the heart shadow to be on the left side. But dextrocardia can
occur as evidenced by occupation of major cardiac shadow on the right
hemithorax with apex pointing to right. There can be a midline heart also
(Mesocardia). Dextrocardia has to be differentiated from dextroposition, where the
heart is on the right due to abnormal thoracic structures or changes eg:
diaphragmatic hernia; agenesis of lung; collapse or fibrosis of lung.
In the presence of true dextrocardia one should make out situs – whether
liver is on the right and stomach shadow is on left or vice versa – situs solitus and
in versus. In dextrocardia with situs inversus, CHD is present in 5%; in situs
solitus with dextrocardia it is 90% and in Levocardia with situs in versus CHD
occurs in 100%.
B.
Size
A small heart (microcardia) can rarely occur when CTR is less than 40%. It
occurs in Addison’s disease, anorexia nervosa, severe PEM and in COPD.
C. Contour
Contour of heart shadow usually gives information regarding ventricular
hypertrophy / enlargement.
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
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.
F. Pulmonary vascularity
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.
d. Pulmonary edema
Occurs when Pulmonary Venous pressure exceeds 25-28 mmHg.
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
iii. Lateralization
iv. Localization
- in pulmonary AV Fistula
v. Collateralization
- in TOG etc.
G. Other Abnormalities
They include cervical rib, rib notching (3 rd to 8th ribs), ductal calcium,
SPECIAL SITUATIONS:
1.
New born X-ray
classical radiological features like figure of8 appearance etc. Lungs appear
2. Thymus
Thymic shadow in infancy can cause diagnostic confusion. It can mimic
cardiomegaly, tumor of mediastinum and even TAPVC.