THE HEART SHADOW IN THE MEDIASTINUM

On a chest radiograph, the central mediastinum area is occupied by a

large radio-opaque shadow termed the central mediastinal shadow
which is the anatomical location of the heart and great vessels. If any
heart disease is suspected, it is very important to carefully examine its
size, position and shape. Enlargement of the heart shadow might indicate
the presence of a cardiac problem such as heart failure following a
myocardial infarction. However, the heart shadow is variable in shape
even in normal subjects, mainly due to the wide variation in body build of
different people. Additionally, respiration will also affect the heart shadow.

Using the image above as a key, examine the right border of the central
mediastinal shadow.

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In its superior parts, the right margin of the shadow represents the
superior vena cava (1). This is a large vein which receives blood
draining from the upper part of the body ie head, neck, upper limbs and
part of the upper chest. Inferior to the superior vena cava, the border is
formed by the right atrium (2) of the heart.
Inferior to the right atrium, a small part of the inferior vena cava can
sometimes be identified as it enters the chest through the diaphragm,
prior to returning blood to the heart (3).

Now look at the left border.

The left border of the central mediastinal shadow is formed superiorly by

the prominent left projecting shadow of the arch of the aorta (4), also
known clinically as the aortic knuckle.
Immediately inferior to the aortic arch is a shadow formed by the left
pulmonary trunk (5). Lateral to this shadow, a larger white shadow
within the lung field is the left pulmonary artery (6) shadow.
In a more inferior direction, the left border of the central mediastinal
shadow is composed of the left margin of the heart shadow.
In its superior region, the heart shadow is formed by the tip of the
auricleof the left atrium (7). Below the auricular shadow, the border is
represented by the left ventricle (8) of the heart.
The point where the cardiac shadow meets the diaphragmatic shadow is
called the left cardiophrenic angle (9).

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The right heart structures

By marking a radiograph in the appropriate areas, it is possible to trace

out the anatomical course of the vessels connected to the right side of the
heart. You will be required to know the anatomy of these vessels.

Note the position of the superior vena cava (A). The traced outline
shows this vessel to lie to the right of the aortic knuckle. The right heart
shadow is formed by the right atrium (B). Most of this atrium is projected
to the posterior on the PA film and thus a relatively small area may be
seen on this outline. Note the approximate position of the right auricle
(C).

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The inferior vena cava enters the lower part of the atrium. Sometimes, it
can be identified as a white shadow filling the right cardiophrenic angle
(D). The approximate position of the right ventricle is show (E). This
never can be identified in outline as a separate structure on the PA
radiograph due its orientation. It thus is important that you appreciate the
normal orientation of the heart in the living subject.

Blood leaves the right ventricle via the pulmonary trunk (F). This divides
into right and left pulmonary arteries just to the left of the ascending aorta
and below the arch of the aorta.

The left heart structures.

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The outline of the left heart structures may also be studied by outlining
the vessels and chambers of the heart. The right pulmonary (A) and left
pulmonary (B) veins drain the blood from the lungs back to the heart.
The left atrium lies behind the ascending aorta and thus cannot be seen
on these views (C).

Blood then passes through the mitral valve into the left ventricle (D).
This forms the left border of the heart shadow. Blood then leaves the left
ventricle and passes upwards and to the right to enter the ascending
aorta (E). This then curves over towards the left and passes backwards
as the arch of the aorta (the so-called aortic knuckle ) (F).

The approximate positions of the brachiocephalic (G), left common

carotid (H) and left subclavian (J) arteries are indicated.

These vessels can be outlined clearly using aortic arch angiography.

THE THORACIC AORTA 1

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The course of the thoracic aorta may appear as a shadow behind the
central mediastinal structures on a PA chest radiograph.

In the radiograph displayed, identify the arch of the aorta ( aortic knuckle
) (A). This lies at the level of the sternal angle (angle of Louis).

The arch of the aorta passes backwards and to the left behind the lower
part of the manubrium of the sternum to reach the level of the 4th
thoracic vertebra (B). It is clinically important to appreciate that the aortic
arch lies superior to the left bronchus and also is to the left of the
trachea and oesophagus since a lesion of one of the structures will
frequently involve all the others.

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The thoracic aorta is the part of the descending aorta lying in the
posterior mediastinum. It is said to commence level with the lowest part of
the body of the 4th thoracic vertebra. As the aorta passes downwards
through the chest, it approaches the median plane and enters the
abdomen through the aortic hiatus anterior to the vertebral column.

The descending aorta gives off the 9 lower posterior intercostal arteries
which pass laterally into the intercostal spaces. The outline of the
descending aorta is shown on the marked radiograph (C).

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