Chest Part 3

8/14/2019 Chest Part 3

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Radiologic Diagnosis of Heart

Diseases

An Atlas of Cardiac X-rays

PART 3PART 3

The Cardiac ShadowThe Cardiac Shadow

Radiology of cardiac chambers in health and diseaseRadiology of cardiac chambers in health and disease

Dr. Khairy Abdel Dayem

Professor of Cardiology

Ain Shams University

Radiologic Diagnosis of Heart

Diseases

An Atlas of Cardiac X-rays

PART 3PART 3

The Cardiac ShadowThe Cardiac Shadow

Radiology of cardiac chambers in health and diseaseRadiology of cardiac chambers in health and disease

Dr. Khairy Abdel Dayem

Professor of Cardiology

Ain Shams University


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The Cardiac Outline

A. The Cardiothoracic Ratio

The over all cardiac size is evaluated by measuring the

cardiothoracic ratio

How to measure the cardiothoracic ratioFig. (27):

1. Make a vertical line in the middle of the cardiac shadow.2. Measure the maximum extension of the cardiac shadow on

both sides of this line.

3. Add the right and left extensions, together to measure the

total transverse diameter of the cardiac shadow.4. Measure the maximum width of the thorax.

5. Divide the cardiac transverse diameter/the thoracic

transverse diameter = cardiothoracic (CT ratio).

6. This ratio should not exceed (50%).


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Fig. (27): Measurement of Cardiothoracic Ratio


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Changes in the Cardiothoracic Ratio

The cardiac shadow may appear smaller than normal in cases of

chronic obstructive, pulmonary disease (COPD), starvation, and

anorexia nervosa, (Fig. 28).

The cardiac shadow may appear larger than normal in cases of

cardiomegaly and/or pericardial effusion.

Changes in the Cardiothoracic Ratio

The cardiac shadow may appear smaller than normal in cases of

chronic obstructive, pulmonary disease (COPD), starvation, and

anorexia nervosa, (Fig. 28).

The cardiac shadow may appear larger than normal in cases of

cardiomegaly and/or pericardial effusion.

Fig. (28): Small cardiac shadow in a case of COPDFig. (28): Small cardiac shadow in a case of COPD


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If there is generalized enlargement of the cardiac shadow

with increased C/T ratio but with no specific configuration,

the differential diagnosis is:

1. Pericardial Effusion

2. Marked dilatation of the heart due to severe

cardiomyopathy or multivalvular disease

Radiological signs of pericardial effusion, (Fig. 29 & 30):

Rounding the cardiac borders with sharply defined

outline (the flask shape orwater bottle appearance)

Acute right cardiophrenic angle

The pulmonary vasculature may be normal if there is no

associated heart disease.

If there is generalized enlargement of the cardiac shadow

with increased C/T ratio but with no specific configuration,

the differential diagnosis is:

1. Pericardial Effusion

2. Marked dilatation of the heart due to severe

cardiomyopathyor multivalvular disease

Radiological signs of pericardial effusion, (Fig. 29 & 30):

Rounding the cardiac borders with sharply defined

outline (the flask shape orwater bottle appearance)

Acute right cardiophrenic angle

The pulmonary vasculature may be normal if there is no

associated heart disease.


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Fig. (29): Diagrammatic presentation of a case of pericardial

effusion without underlying heart disease.

Fig. (30): Left: Pericardial effusion on top of multivalvula disease.

Right: Massive pericardial effusion


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B. Abnormal Densities Within the CardiacShadow

B. Abnormal Densities Within the CardiacShadow

Several iatrogenic or pathological structures may appear

within the cardiac shadow. These include pacemaker leads,implantable cardioverter defibrillator (ICD) leads, wires and

stitches, prosthetic valves, abnormally positioned breast

shadow and abnormal calcifications.

Pacemaker implantation: The pacemaker is usually

placed subcutaneously over the left or less commonly

the right pectoralis muscle. An electrode is introduced

via a subclavian puncture into the subclavian vein to the

superior vena cava, and its tip is placed in the right atrial

appendage and/or the right ventricular apex or through

the coronary sinus to the LV lateral wall as in (Fig. 31 &

32).

Several iatrogenic or pathological structures may appear

within the cardiac shadow. These include pacemaker leads,implantable cardioverter defibrillator (ICD) leads, wires and

stitches, prosthetic valves, abnormally positioned breast

shadow and abnormal calcifications.

Pacemaker implantation: The pacemaker is usually

placed subcutaneously over the left or less commonly

the right pectoralis muscle. An electrode is introduced

via a subclavian puncture into the subclavian vein to the

superior vena cava, and its tip is placed in the right atrial

appendage and/or the right ventricular apex or through

the coronary sinus to the LV lateral wall as in (Fig. 31 &

32).


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Fig (31): The course of peacemaker wires placed in:

A: Right atrial appendage

C: Coronary Sinus

V: Right ventricular apex

In both PA and lateral views. The pacemaker is implanted

subcutaneously overlying the right pectoralis muscle.


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Fig. (33): Three prosthetic cardiac valves replaced the mitral (M),

aortic (A) and tricuspid (T) valves.

Fig. (33): Three prosthetic cardiac valves replaced the mitral (M),

aortic (A) and tricuspid (T) valves.

Metallic markers may be inserted by the surgeon at the site of

anastmosing a graft into the aorta or in a coronary artery.

Artificial valves e.g. prosthetic mitral, aortic or tricuspid valves.

Their type can be identified e.g. ball and cage, lilting disc,

bilaflet, etc. (Fig. 33).

Metallic markers may be inserted by the surgeon at the site of

anastmosing a graft into the aorta or in a coronary artery.

Artificial valves e.g. prosthetic mitral, aortic or tricuspid valves.

Their type can be identified e.g. ball and cage, lilting disc,

bilaflet, etc. (Fig. 33).


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Breast Shadow:

Sometimes breast shadow may be superimposed partly on the

cardiac shadow and gives the impression of abnormal cardiac

configuration, (Fig. 34).

Breast Shadow:

Sometimes breast shadow may be superimposed partly on the

cardiac shadow and gives the impression of abnormal cardiac

configuration, (Fig. 34).

Fig. (34): (Left) Normal female breasts apparent on the sides of the chest

wall. (Right) Unusually elevated breasts in an elderly female (arrows)

superimposed on the cardiac shadow.


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Abnormal Calcification

Calcification may occur in the pericardium, cardiac valves, the

cardiac wall itself, intra cardiac thrombi or tumours or the aorta.

A. Calcified pericardium may appear in the PA view as

dense opacity overlying the cardiac borders or surrounding

the atrioventricular junction. It is better seen in the lateral

view, (Fig. 35, 36 & 37).

Fig. (35): in PA view Pericardial

Calcification (Diagrammatic)

Fig. (36): Pericardial Calcification surrounding

the heart seen in the lateral view


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Fig. (37): Pericardial Calcification resulting in a complete ring around the

atrioventricular groove seen inPA view and lateral view.


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Fig. (38): Calcification overlying the cardiac apex and also seen along the

atrioventricular junction (arrow head)

Fig. (38): Calcification overlying the cardiac apex and also seen along the

atrioventricular junction (arrow head)


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B. Calcified cardiac valves

Calcification occurs most commonly in the aortic and mitral

valves and is seen as dense opacity within the cardiac shadow at

the expected site of either valve, (Fig. 39 & 40).

Fig. (39): Calcification in the mitral valve (black arrow heads) andthe aortic valve (white arrow head)

Calcification of the mitral valve annulus is very common in the

elderly specially females and causes mitral regurgitation. It

underlies and displaces the posteromedial cusp and appears as an

incomplete C shaped dense ring (Fig. 41).


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Fig. (40): Position of the cardiac valves in the PA and lateral view.Fig. (40): Position of the cardiac valves in the PA and lateral view.


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Fig. (41): Calcified mitral valve annulus seen as C shape densityFig. (41): Calcified mitral valve annulus seen as C shape density


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C. Calcified Left Ventricular Aneurysm, (Fig. 42)

The aneurysms is usually seen as an eccentric protrusion in the

cardiac shadow that may rarely be calcified. Left ventricular mural

thrombus may also calcify.

C. Calcified Left Ventricular Aneurysm, (Fig. 42)

The aneurysms is usually seen as an eccentric protrusion in the

cardiac shadow that may rarely be calcified. Left ventricular mural

thrombus may also calcify.

Fig. (42): Calcified myocardial aneurysm seen in PA view (a) and lateral view (b)Fig. (42): Calcified myocardial aneurysm seen in PA view(a) and lateral view(b)


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D. Calcification Left Atrium, (Fig. 43).

Rarely the left atrial wall itself is calcified and very rarely

calcification may be seen in an atrial myxoma.

D. Calcification Left Atrium, (Fig. 43).

Rarely the left atrial wall itself is calcified and very rarely

calcification may be seen in an atrial myxoma.

Fig. (43): Calcification in the left atrial wall in a case of rheumatic mitral valve

disease seen in the PA (a) and lateral (b) views

Fig. (43): Calcification in the left atrial wall in a case of rheumatic mitral valve

disease seen in thePA (a) and lateral(b) views


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E. Calcification of the Aorta

Calcification may occur in an atherosclerotic plaque in any

part of the aorta.

Calcification restricted to the ascending aorta is usually

due to syphilis.

Calcification is most easily detected in the aortic arch as a

crescentic dense shadow along the edge of the aortic

knuckle (Fig. 44).

F. Calcification of atherosclerotic coronary arteries

Is very common but difficult to see in the routine X-ray. Its

better visualized by fluoroscopy or by electron beam CT.

E. Calcification of the Aorta

Calcification may occur in an atherosclerotic plaque in any

part of the aorta.

Calcification restricted to the ascending aorta is usually

due to syphilis.

Calcification is most easily detected in the aortic arch as a

crescentic dense shadow along the edge of the aortic

knuckle (Fig. 44).

F. Calcification of atherosclerotic coronary arteries

Is very common but difficult to see in the routine X-ray. Its

better visualized by fluoroscopy or by electron beam CT.


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Fig. (44): Calcification of Aortic ArchFig. (44): Calcification of Aortic Arch


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The Size and Configuration of each

Individual Cardiac Chambers

The Size and Configuration of each

Individual Cardiac Chambers

In order to evaluate each cardiac chamber, the normal and

abnormal radiological anatomy of the heart and the components

of the cardiac borders must be known, (Fig. 45).

In order to evaluate each cardiac chamber, the normal and

abnormal radiological anatomy of the heart and the components

of the cardiac borders must be known, (Fig. 45).

Fig. (45): The Surface Anatomy of Cardiac ChambersFig. (45): The Surface Anatomy of Cardiac Chambers


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Radiological Anatomy of the Heart in the PA View: (Fig. 46)

1. The superior vena cava forms the upper third of the right

cardiac border. The inferior vena cava forms an extremely shortsegment on the lower part of the right border. Both drain into

the right atrium.

2. The right atrium forms the lower two thirds of the right cardiac

border. The tricuspid valve, which is situated behind the lower

end of the sternum, connects it to the right ventricle.

3. The right ventricle is pyramidal in shape. It is separated from

the right cardiac border by the right atrium and from the left

border by the left ventricle. Thus it does not appear on any of

the cardiac borders in the PA view. It forms the anterior surface

of the heart and is thus better delineated in the lateral view.

Radiological Anatomy of the Heart in the PA View: (Fig. 46)

1. The superior vena cava forms the upper third of the right

cardiac border. The inferior vena cava forms an extremely shortsegment on the lower part of the right border. Both drain into

the right atrium.

2. The right atrium forms the lower two thirds of the right cardiac

border. The tricuspid valve, which is situated behind the lower

end of the sternum, connects it to the right ventricle.

3. The right ventricle is pyramidal in shape. It is separated from

the right cardiac border by the right atrium and from the left

border by the left ventricle. Thus it does not appear on any of

the cardiac borders in the PA view. It forms the anterior surface

of the heart and is thus better delineated in the lateral view.


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Fig. (46): The radiological anatomy of different cardiac chambers

4. The pulmonary artery segment forms a concavity on the left

border of the heart at the medial end of the second left intercostal

space.

5. The left atrium is an oval chamber in the middle of the cardiac

shadow. The left atrial appendage extends to the left and forms a

part of the left cardiac border at the medial end of the third left

intercostals space.

4. The pulmonary artery segment forms a concavity on the left

border of the heart at the medial end of the second left intercostal

space.

5. The left atrium is an oval chamber in the middle of the cardiac

shadow. The left atrial appendage extends to the left and forms a

part of the left cardiac border at the medial end of the third left

intercostals space.


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6. The left ventricle is oblong in shape and forms the lower half of

the left border of the heart. Its long axis is directed downwards

and to the left.

7. The aorta is subdivided into three parts:

a. The ascending aorta extends upwards and to the right. It

comes very close to the upper third of the right cardiac

border.

b. The aortic arch curves to the left and posteriorly and forms

a prominence on the left cardiac border at the medial end of

the first left intercostals space.

c. The descending aorta runs medially and downwards and

does not normally form any part of the cardiac borders.

6. The left ventricle is oblong in shape and forms the lower half of

the left border of the heart. Its long axis is directed downwards

and to the left.

7. The aorta is subdivided into three parts:

a. The ascending aorta extends upwards and to the right. It

comes very close to the upper third of the right cardiac

border.

b. The aortic arch curves to the left and posteriorly and forms

a prominence on the left cardiac border at the medial end of

the first left intercostals space.

c. The descending aorta runs medially and downwards and

does not normally form any part of the cardiac borders.


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The Lateral View:

In the lateral view the right ventricle and the pulmonary artery

are the most anterior structures. They are seen immediately under

the sternum. The right ventricle comes in contact with the lower

third of the sternum but is normally separated from its upper two

thirds by the lung (the retrosternal space). The left atrium and the

left ventricle are situated posteriorly. The left atrium is the most

posterior structure and lies directly in front of the esophagus, (Fig.47). The left ventricle is separated from the vertebral column by the

retrocardiac space.

The Lateral View:

In the lateral view the right ventricle and the pulmonary artery

are the most anterior structures. They are seen immediately under

the sternum. The right ventricle comes in contact with the lower

third of the sternum but is normally separated from its upper two

thirds by the lung (the retrosternal space). The left atrium and the

left ventricle are situated posteriorly. The left atrium is the most

posterior structure and lies directly in front of the esophagus, (Fig.47). The left ventricle is separated from the vertebral column by the

retrocardiac space.

Fig. (47): Normal LV in the lateral viewFig. (47): Normal LV in the lateral view


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The Normal Cardiac Borders in the PA View: (Fig. 48)The Normal Cardiac Borders in the PA View: (Fig. 48)

Fig. (48): Component of

cardiac Borders

Fig. (48): Component of

cardiac Borders

A) The left cardiac border is formed from above down by:

1. The aortic arch (= knob, knuckle).

2. The main pulmonary artery.

3. The left atrial appendage.

4. The left ventricle.

B) The right border of the heart is formed by:

1. In the lower two thirds by the right atrium.

2. In the upper third by the superior vena cava.

A) The left cardiac border is formed from above down by:

1. The aortic arch (= knob, knuckle).

2. The main pulmonary artery.

3. The left atrial appendage.

4. The left ventricle.

B) The right border of the heart is formed by:

1. In the lower two thirds by the right atrium.

2. In the upper third by the superior vena cava.


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Right Ventricular Enlargement:

1. There are no reliable signs for its diagnosis in the PA view, but

better seen in the lateral view. However, enlargement of the RVdisplaces the apex outwards which may become separated form

the diaphragm, (Fig. 51).

Right Ventricular Enlargement:

1. There are no reliable signs for its diagnosis in the PA view, but

better seen in the lateral view. However, enlargement of the RVdisplaces the apex outwards which may become separated form

the diaphragm, (Fig. 51).

Fig. (51):RV enlargement causes the apex to be displaced outwardsFig. (51):RV enlargement causes the apex to be displaced outwards


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2. In cases of Fallots tetrology right ventricular enlargement

causes the cardiac silhouette to resemble the wooden shoe

(sabot) resulting in the characteristic coeur en sabot, (Fig. 52).

2. In cases of Fallots tetrology right ventricular enlargement

causes the cardiac silhouette to resemble the wooden shoe

(sabot) resulting in the characteristic coeur en sabot, (Fig. 52).

Fig. (52):Right ventricular enlargement with right sided aortic arch; diagrammatic

and in the X-ray of a case of Fallots Tetrology

Fig. (52):Right ventricular enlargement with right sided aortic arch; diagrammatic

and in the X-ray of a case of Fallots Tetrology


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3. In the lateral view the anterior wall of the right ventricle lies

directly behind the lower third of the sternum. In the upper two-

thirds lung tissue separates the sternum from the cardiac

shadow and the retrosternal space is radiotranslucent. As theright ventricle enlarges, it displaces the lung tissue and the

retrosternal space becomes filled with the right ventricle, (Fig.

53).

3. In the lateral view the anterior wall of the right ventricle lies

directly behind the lower third of the sternum. In the upper two-

thirds lung tissue separates the sternum from the cardiac

shadow and the retrosternal space is radiotranslucent. As theright ventricle enlarges, it displaces the lung tissue and the

retrosternal space becomes filled with the right ventricle, (Fig.

53).

Fig. (53): Right ventricular enlargement

seen in the lateral view as it encroach

on the retrosternal space

Fig. (53): Right ventricular enlargement

seen in the lateral view as it encroach

on the retrosternal space


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Left Atrial Enlargement: (Fig. 54)

1. The enlarged left atrial appendage causes straightening or

convexity of the left cardiac border at the medial end of the

third left intercostal space (mitralization), (Fig. 54).

Left Atrial Enlargement: (Fig. 54)

1. The enlarged left atrial appendage causes straightening or

convexity of the left cardiac border at the medial end of thethird left intercostal space (mitralization), (Fig. 54).

Fig. (54): Enlarged left atriumFig. (54): Enlarged left atrium


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2. The outline of the enlarged left atrium can be seen through the

right atrial shadow, i.e. the double contour, (Fig. 55).

3. Massive dilatation of the left atrium may extend so far to the

right that it forms a convexity on the right border of the heart,outside the border of the right atrium, (Fig. 55).

2. The outline of the enlarged left atrium can be seen through the

right atrial shadow, i.e. the double contour, (Fig. 55).

3. Massive dilatation of the left atrium may extend so far to the

right that it forms a convexity on the right border of the heart,outside the border of the right atrium, (Fig. 55).

Fig. (55): Moderate (left) and aneurysmal (right) dilatation of the left atriumFig. (55): Moderate (left) and aneurysmal(right) dilatation of the left atrium

4. The left atrium pushes the left main bronchus upwards which

becomes more horizontal than normal and causes widening of

the carina.

4. The left atrium pushes the left main bronchus upwards which

becomes more horizontal than normal and causes widening of

the carina.


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5. The left atrial size can be estimated by giving the patient barium

to swallow and X-ray is taken in the lateral or right anterior

oblique positions. The esophagus is displaced backwards by

the enlarged left atrium, (Fig. 56).

5. The left atrial size can be estimated by giving the patient barium

to swallow and X-ray is taken in the lateral or right anterior

oblique positions. The esophagus is displaced backwards by

the enlarged left atrium, (Fig. 56).

Fig. (56): Enlarged left atrium displacing the esophagus posteriorly. The right

ventricle is also enlarged causing obliterations of the retrosternal

space and causing anterior displacement of the sternum (precordial

bulge)

Fig. (56): Enlarged left atrium displacing the esophagus posteriorly. The right

ventricle is also enlarged causing obliterations of the retrosternal

space and causing anterior displacement of the sternum (precordial

bulge)


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Left Ventricular Enlargement:

1. In cases of concentric LV hypertrophy due to pressure

overload the only sign may be accentuation of the convexity of

the lower half of the left cardiac border which becomeschunky, (Fig. 57).

Left Ventricular Enlargement:

1. In cases of concentric LV hypertrophy due to pressure

overload the only sign may be accentuation of the convexity of

the lower half of the left cardiac border which becomeschunky, (Fig. 57).

Fig. (57): Dilatation of the LV associated with generalized dilatation

of the aorta in a case of hypertension.

Fig. (57): Dilatation of the LV associated with generalized dilatation

of the aorta in a case of hypertension.


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2. When the LV dilates in cases of volume overload and/or left

ventricular failure, the apex is displaced downwards and

outwards. By counting the anterior intercostal spaces, the apex

will be found in the sixth or even the seventh space and the left

cardiac border may appear to cross the diaphragm, (Fig. 58).

2. When the LV dilates in cases of volume overload and/or left

ventricular failure, the apex is displaced downwards and

outwards. By counting the anterior intercostal spaces, the apex

will be found in the sixth or even the seventh space and the left

cardiac border may appear to cross the diaphragm, (Fig. 58).

Fig. (58): LV dilatation causes displacement of

apex downwards and outwards

Fig. (58): LV dilatation causes displacement of

apex downwards and outwards


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3. When LV dilatation is associated with enlarged aortic arch as in

cases of aortic regurgitation, the general configuration of the

cardiac silhouette may come to resemble a boot, i.e. the bootshaped heart or aortic configuration, (Fig. 59 & 60).

3. When LV dilatation is associated with enlarged aortic arch as in

cases of aortic regurgitation, the general configuration of the

cardiac silhouette may come to resemble a boot, i.e. the bootshaped heart or aortic configuration, (Fig. 59 & 60).

Fig. (59): (A) Normal Heart and (B)

Aortic Configuration

Fig. (59): (A) Normal Heart and(B)

Aortic Configuration

Fig. (60): Aortic ConfigurationFig. (60): Aortic Configuration


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4. In the lateral view (Fig. 61) the enlarged LV extends posteriorly.

It crosses the shadow of the inferior vena cava and encroaches

on the retro-cardiac space.

4. In the lateral view (Fig. 61) the enlarged LV extends posteriorly.

It crosses the shadow of the inferior vena cava and encroaches

on the retro-cardiac space.

Fig. (61): Left ventricular enlargement detected by encroachment on

the retro-cardiac space

Fig. (61): Left ventricular enlargement detected by encroachment on

the retro-cardiac space


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The Aorta: Fig. (63)The Aorta: Fig. (63)

1. Enlargement of the ascending aorta causes a convexity on the

upper third of the right cardiac border. This may be isolated in

cases of aortic stenosis with poststenotic dilatation of the

ascending aorta. The aortic valve may also be calcified as in

(Figs. 64 & 65).

1. Enlargement of the ascending aorta causes a convexity on the

upper third of the right cardiac border. This may be isolated in

cases of aortic stenosis with poststenotic dilatation of the

ascending aorta. The aortic valve may also be calcified as in

(Figs. 64 & 65).

Fig. (63): Radiological Signs of Diseases of AortaFig. (63): Radiological Signs of Diseases of Aorta


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Fig. (64): Poststenotic dilatation of the

ascending aorta in a case of aortic valve

stenosis

Fig. (64): Poststenotic dilatation of the

ascending aorta in a case of aortic valve

stenosis

Fig. (65): Case of aortic stenosis with

calcification of aortic valve and post

stenotic dilatation of ascending aorta

Fig. (65): Case of aortic stenosis with

calcification of aortic valve and post

stenotic dilatation of ascending aorta


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2. Enlargement of the aortic arch increases the prominence of the

aortic knob in the medial end of the first left intercostal space,

(Fig. 66).

2. Enlargement of the aortic arch increases the prominence of the

aortic knob in the medial end of the first left intercostal space,

(Fig. 66).

Fig. (66): Aneurysmal dilatation of the aortic archFig. (66): Aneurysmal dilatation of the aortic arch


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3. Generalized enlargement of the ascending aorta and aortic arch

occurs in cases of increased pressure or flow in the aorta, e.g.

hypertension, coarctation, aortic regurgitation and hyper

dynamic circulatory state.

3. Generalized enlargement of the ascending aorta and aortic arch

occurs in cases of increased pressure or flow in the aorta, e.g.

hypertension, coarctation, aortic regurgitation and hyper

dynamic circulatory state.

Fig. (67): Aneurysmal dilatation of the ascending aortaFig. (67): Aneurysmal dilatation of the ascending aorta


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4. Unfolding of the aorta causes the descending aorta to appear

as a vertical shadow on the left border of the heart.

5. Aneurysmal dilatation may involve any segment of the aorta orall of them together as in cases of cystic medionecrosis,

Marphan syndrome or syphilis, (Fig 67).

6. Dissecting aneurysm of the Aorta:

In this condition, a tear in the aortic intima occurs allowing

the blood to force its way in the media splitting it into two

layers with a false blood filled lumen in between. The aortic

shadow rapidly enlarges and the site of the enlargement and

dissection depends on the site of the tear.

Dissection is classified into two types: A (proximal) and B

(distal). Type A is any dissection involving the ascending aorta

(Fig. 68).

4. Unfolding of the aorta causes the descending aorta to appear

as a vertical shadow on the left border of the heart.

5. Aneurysmal dilatation may involve any segment of the aorta orall of them together as in cases of cystic medionecrosis,

Marphan syndrome or syphilis, (Fig 67).

6. Dissecting aneurysm of the Aorta:

In this condition, a tear in the aortic intima occurs allowing

the blood to force its way in the media splitting it into two

layers with a false blood filled lumen in between. The aortic

shadow rapidly enlarges and the site of the enlargement and

dissection depends on the site of the tear.

Dissection is classified into two types: A (proximal) and B

(distal). Type A is any dissection involving the ascending aorta

(Fig. 68).


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Fig. (68): Left: Types of dissection of the Aorta.

Right: Proximal (type A) dissection

Fig. (68): Left: Types of dissection of the Aorta.

Right: Proximal (type A) dissection

Proximal Type (A) Distal Type (B)

f


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Enlargement of the Pulmonary Artery: (Fig. 69)

Dilated pulmonary artery causes straightening or convexity on

the left cardiac border at the medial end of the second left

intercostal space. This may be an isolated finding in cases ofpulmonary valve stenosis with post stenotic dilatation Fig. (69)

and cases of idiopathic dilatation of the pulmonary artery.

Enlargement of the Pulmonary Artery: (Fig. 69)

Dilated pulmonary artery causes straightening or convexity on

the left cardiac border at the medial end of the second left

intercostal space. This may be an isolated finding in cases ofpulmonary valve stenosis with post stenotic dilatation Fig. (69)

and cases of idiopathic dilatation of the pulmonary artery.

Fig. (69): Dilated main pulmonary artery in a patient with

pulmonary valve stenosis and poststenotic dilatation

Fig. (69): Dilated main pulmonary artery in a patient with

pulmonary valve stenosis and poststenotic dilatation

I f l h t i th l t f th i I f l h t i th l t f th i


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In cases of pulmonary hypertension the enlargement of the main

pulmonary artery is accompanied by enlargement of its right

and left branches. The left pulmonary artery may be partly

concealed behind the enlarged main pulmonary artery. The right

pulmonary artery, on the other hand, appears as a comma

shaped shadow extending from the right cardiac border, (Fig.

70).

In cases of pulmonary hypertension the enlargement of the main

pulmonary artery is accompanied by enlargement of its right

and left branches. The left pulmonary artery may be partly

concealed behind the enlarged main pulmonary artery. The right

pulmonary artery, on the other hand, appears as a comma

shaped shadow extending from the right cardiac border, (Fig.

70).

Fig. (70): Case of bilharzial pulmonary hypertension causing dilatation

of the main pulmonary and its branches

Fig. (70): Case of bilharzial pulmonary hypertension causing dilatation

of the main pulmonary and its branches


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Fig. (71): Two cases of mild (left) and aneurysmal (right)

dilatation of the pulmonary artery and its branch

Fig. (71): Two cases of mild(left) and aneurysmal(right)

dilatation of the pulmonary artery and its branch

Chest Part 3

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