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Radiologic Diagnosis of Heart
Diseases
An Atlas of Cardiac X-rays
PART 5PART 5
Radiological feature of common congenital cardiacRadiological feature of common congenital cardiac
malformationsmalformations
Extracardiac structures simulating cardiac diseaseExtracardiac structures simulating cardiac disease
Dr. Khairy Abdel Dayem
Professor of Cardiology
Radiologic Diagnosis of Heart
Diseases
An Atlas of Cardiac X-rays
PART 5PART 5
Radiological feature of common congenital cardiacRadiological feature of common congenital cardiac
malformationsmalformations
Extracardiac structures simulating cardiac diseaseExtracardiac structures simulating cardiac disease
Dr. Khairy Abdel Dayem
Professor of Cardiology
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PART 5PART 5 Radiological feature of common congenital
cardiac malformations The cardiac malpositions
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Pulmonary stenosis
Coarctation of aorta
Fallots tetralogy
Transposition of great arteries
Ebstein Anomaly of the Tricuspid valve
Total anomalous pulmonary venous drainage
Extracardiac structures simulating cardiac disease
PART 5PART 5 Radiological feature of common congenital
cardiac malformations The cardiac malpositions
Atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Pulmonary stenosis
Coarctation of aorta
Fallots tetralogy
Transposition of great arteries
Ebstein Anomaly of the Tricuspid valve
Total anomalous pulmonary venous drainage
Extracardiac structures simulating cardiac disease
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Radiological Features of
Common Congenital Heart
DiseasesThe Cardiac Malpositions (Fig. 84)
Radiological Features of
Common Congenital Heart
DiseasesThe Cardiac Malpositions (Fig. 84)In the normal situs solitus, the heart occupies the left side of
the thorax on the same side as the stomach, (Fig. 85). The liver is
present on the right side of the abdomen.
In situs inversus totalis all body structures are mirror image of
the normal and the heart and stomach are on the right side and the
liver on the left side. If the X-ray is inverted it will appear entirely
normal, (Fig. 86).
In isolated dextrocardia, (Fig. 87) the heart exists on the left
side of the thorax but the viscera are in their normal position (situs
solitus). This creates a discordance between the position of the
systemic veins which follow the liver, and the heart. The atria
usually follow the veins and there is atrio ventricular discordance.
In the normal situs solitus, the heart occupies the left side of
the thorax on the same side as the stomach, (Fig. 85). The liver is
present on the right side of the abdomen.
In situs inversus totalis all body structures are mirror image of
the normal and the heart and stomach are on the right side and the
liver on the left side. If the X-ray is inverted it will appear entirely
normal, (Fig. 86).
In isolated dextrocardia, (Fig. 87) the heart exists on the left
side of the thorax but the viscera are in their normal position (situs
solitus). This creates a discordance between the position of the
systemic veins which follow the liver, and the heart. The atria
usually follow the veins and there is atrio ventricular discordance.
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Fig. (85): Normal left sided cardiac
position in situs solitus in an infant
Fig. (85): Normal left sided cardiac
position in situs solitus in an infant
Fig. (84): The position of cardiac
chambers, the liver and stomach in
various malpositions.
Fig. (84): The position of cardiac
chambers, the liver and stomach in
various malpositions.
In isolated levocardia the heart remains in the left side of the
chest while the viscera are inverted, (Fig. 88). The atrium follow the
liver. Here too, there is atrio-ventricular discordance.
In isolated levocardia the heart remains in the left side of the
chest while the viscera are inverted, (Fig. 88). The atrium follow the
liver. Here too, there is atrio-ventricular discordance.
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Fig. (86): Dextrocardia in situs inversus totalisFig. (86): Dextrocardia in situs inversus totalis
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Fig. (87): Isolated lexocardia in a case
of situs inversus. Note that the
stomach is on the right side.
Fig. (87): Isolated lexocardia in a case
of situs inversus. Note that the
stomach is on the right side.
Fig. (88): Isolated dextrocardia. Note
that the stomachis situated in the left
side of abdomen (situs solitus)
Fig. (88): Isolated dextrocardia. Note
that the stomachis situated in the left
side of abdomen (situs solitus)
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Atrial Septal Defect (ASD)Atrial Septal Defect (ASD)
When there is a defect in the interatrial septum the blood will
flow from the LA to the RA (left to right shunt). This is becausethe LA empties into the thick less compliant LV while the right
atrium empties into the thin more distensible RV.
Additional oxygenated blood will reach the RA and RV and
pulmonary arteries. Pulmonary plethora will result, (Fig. 89).
If the pulmonary blood flow is excessive, pulmonary arteriolar
vasoconstriction will occur and causes pulmonary hypertension.
This will decrease then abolish the increased blood flow in the
lungs. It will also cause further hypertrophy and dilatation of the
RV, RA and pulmonary arteries.
Ultimately the shunt will be reversed resulting in Eisenmenger
Syndrome.
When there is a defect in the interatrial septum the blood will
flow from the LA to the RA (left to right shunt). This is becausethe LA empties into the thick less compliant LV while the right
atrium empties into the thin more distensible RV.
Additional oxygenated blood will reach the RA and RV and
pulmonary arteries. Pulmonary plethora will result, (Fig. 89).
If the pulmonary blood flow is excessive, pulmonary arteriolar
vasoconstriction will occur and causes pulmonary hypertension.
This will decrease then abolish the increased blood flow in the
lungs. It will also cause further hypertrophy and dilatation of the
RV, RA and pulmonary arteries.
Ultimately the shunt will be reversed resulting in Eisenmenger
Syndrome.
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Fig. (89): X-ray signs of ASD: dilated RA, RV, PA and
pulmonary plethora. N = normal x-ray
Fig. (89): X-ray signs of ASD: dilated RA, RV, PA and
pulmonary plethora. N = normal x-ray
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X-ray Picture (Fig 89 & 90):
Plethoric lung fields.
Dilatation of the right atrium, right ventricle and pulmonary
artery.
Small aortic arch due to low cardiac output.
Marked pulsations of the pulmonary artery and its branches
seen during fluoroscopy, i.e. hilar dance.
As pulmonary hypertension develops the plethora will
decrease then disappear and the picture will be transformed
into that pulmonary hypertension.
X-ray Picture (Fig 89 & 90):
Plethoric lung fields.
Dilatation of the right atrium, right ventricle and pulmonary
artery.
Small aortic arch due to low cardiac output.
Marked pulsations of the pulmonary artery and its branches
seen during fluoroscopy, i.e. hilar dance.
As pulmonary hypertension develops the plethora will
decrease then disappear and the picture will be transformed
into that pulmonary hypertension.
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Fig. (90): X-ray of ASD with left to right shuntFig. (90): X-ray of ASD with left to right shunt
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Ventricular Septal Defect (VSD)Ventricular Septal Defect (VSD)
When there is a defect in the interventricular septum the blood
will be shunted from the LV to the RV causing increased flow in
the pulmonary artery and pulmonary plethora. The excessive
blood returning from the lung will pass through the LA and will be
pumped by the LV into the aorta. Thus, LA and LV dilatation willoccur.
If pulmonary hypertension sets in, the RV will enlarge and the
pulmonary plethora will decrease and be transformed into
pulmonary oligemia.
In the final stage the X-ray shows only manifestations of
pulmonary hypertension.
When there is a defect in the interventricular septum the blood
will be shunted from the LV to the RV causing increased flow in
the pulmonary artery and pulmonary plethora. The excessive
blood returning from the lung will pass through the LA and will be
pumped by the LV into the aorta. Thus, LA and LV dilatation willoccur.
If pulmonary hypertension sets in, the RV will enlarge and the
pulmonary plethora will decrease and be transformed into
pulmonary oligemia.
In the final stage the X-ray shows only manifestations of
pulmonary hypertension.
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X-ray Picture:
1. X-ray is normal in cases with small defects.
2. Large defects result in:
a) Pulmonary plethora, i.e. overfilled large and tortuous
pulmonary arteries.
b) Large main pulmonary artery.
c) Left and right ventricular enlargement.
d) Left atrial enlargement.
X-ray Picture:
1. X-ray is normal in cases with small defects.
2. Large defects result in:
a) Pulmonary plethora, i.e. overfilled large and tortuous
pulmonary arteries.
b) Large main pulmonary artery.
c) Left and right ventricular enlargement.
d) Left atrial enlargement.
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Fig. (91): Two cases of small (left) and large (right) VSD. Note the left
ventricular enlargement and the pulmonary plethora.
Fig. (91): Two cases of small(left) and large (right) VSD. Note the left
ventricular enlargement and the pulmonary plethora.
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Patent Ductus Arteriosus (PDA)
The ductus arteriosus is normally present in the fetus. It
connects the aorta (at the junction of the arch with the descending
aorta) with the pulmonary artery (at the junction of the main
pulmonary artery with its left branch). It normally closes during the
first month after birth. If the ductus does not close, the followinghemodynamic changes will occur.
1. The blood flows through the ductus from the aorta to the
pulmonary artery, i.e. left to right shunt.
2. As pulmonary artery receives blood both from the shunt and
the right ventricle, pulmonary artery dilatation and
pulmonary plethora occur.
The ductus arteriosus is normally present in the fetus. It
connects the aorta (at the junction of the arch with the descending
aorta) with the pulmonary artery (at the junction of the main
pulmonary artery with its left branch). It normally closes during the
first month after birth. If the ductus does not close, the followinghemodynamic changes will occur.
1. The blood flows through the ductus from the aorta to the
pulmonary artery, i.e. left to right shunt.
2. As pulmonary artery receives blood both from the shunt and
the right ventricle, pulmonary artery dilatation and
pulmonary plethora occur.
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3. The excessive flow returns to the left atrium, the left ventricle
and the aorta resulting in:
a) Dilatation of the left atrium.
b) Dilatation and hypertrophy of the left ventricle (volume
over-load).
c) Dilatation of the ascending aorta and aortic arch.
4. If the shunt is big pulmonary vasoconstriction and hypertension
occur.
5. When the pressure in the pulmonary artery exceeds that of the
aorta, the shunt will be reversed, i.e. right to left, and differential
cyanosis occurs. This is Eisenmengers syndrome.
3. The excessive flow returns to the left atrium, the left ventricle
and the aorta resulting in:
a) Dilatation of the left atrium.
b) Dilatation and hypertrophy of the left ventricle (volume
over-load).
c) Dilatation of the ascending aorta and aortic arch.
4. If the shunt is big pulmonary vasoconstriction and hypertension
occur.
5. When the pressure in the pulmonary artery exceeds that of the
aorta, the shunt will be reversed, i.e. right to left, and differential
cyanosis occurs. This is Eisenmengers syndrome.
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Fig. (92): X-ray findings in patent ductus arteriosus. Note the enlarged pulmonary
artery and left ventricle and the pulmonary plethora. The aortic arch is prominent
Fig. (92): X-ray findings in patent ductus arteriosus. Note the enlarged pulmonary
artery and left ventricle and the pulmonary plethora. The aortic arch is prominent
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X-ray Picture:
1. X-ray is normal in cases with small ductus.
2. In moderate or large ductus the following signs appear (Fig. 92):
a) Pulmonary plethora.
b) Enlargement of the left atrium, left ventricle and the aorta.
c) Systolic dilatation of the pulmonary artery and its main
branches seen in the hilum by fluoroscopy: hilar dance.
d) Ductus itself can be seen as a line bridging the space
between the aorta and the pulmonary artery on the left
border of the heart, (Fig. 93). It may even be calcified, (Fig.
94).
X-ray Picture:
1. X-ray is normal in cases with small ductus.
2. In moderate or large ductus the following signs appear(Fig. 92):
a) Pulmonary plethora.
b) Enlargement of the left atrium, left ventricle and the aorta.
c) Systolic dilatation of the pulmonary artery and its main
branches seen in the hilum by fluoroscopy: hilar dance.
d) Ductus itself can be seen as a line bridging the space
between the aorta and the pulmonary artery on the left
border of the heart, (Fig. 93). It may even be calcified, (Fig.
94).
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Fig. (93): The patent ductus is seen in the space between the aorta (AO)
and pulmonary trunk (PT) in the X-ray (left) and angiogram (right)
Fig. (93): The patent ductus is seen in the space between the aorta (AO)
and pulmonary trunk (PT) in the X-ray(left) and angiogram (right)
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Fig. (94): Two cases of calcified ductusFig. (94): Two cases of calcified ductus
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Pulmonary stenosis may be caused by:
a. Congenital fusion of pulmonary valve cups, I.e. congenital
valvular pulmonary stenosis.
b. Congenital excessive hypertrophy of the muscles surrounding
the outflow tract of the right ventricle (I.e. the infundibulum)
below the level of the pulmonary valve, i.e. congenital
infundibular pulmonary stenosis.
X-ray Picture:
1. Pulmonary oligemia occurs in moderate and severe cases and
results in reduced pulmonary vascular markings.
2. Right ventricular enlargement is proportional to the severity of
the stenosis. Right atrial enlargement may also occur.
Pulmonary stenosis may be caused by:
a. Congenital fusion of pulmonary valve cups, I.e. congenital
valvular pulmonary stenosis.
b. Congenital excessive hypertrophy of the muscles surrounding
the outflow tract of the right ventricle (I.e. the infundibulum)
below the level of the pulmonary valve, i.e. congenital
infundibular pulmonary stenosis.
X-ray Picture:
1. Pulmonary oligemia occurs in moderate and severe cases and
results in reduced pulmonary vascular markings.
2. Right ventricular enlargement is proportional to the severity of
the stenosis. Right atrial enlargement may also occur.
Pulmonary Stenosis
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Fig. (95): Two cases of pulmonary stenosis with post stenotic dilatation of the PAFig. (95): Two cases of pulmonary stenosis with post stenotic dilatation of the PA
3. If the stenosis is valvular, the jet of blood coming out of the
narrow orifice hits against the pulmonary artery wall and causes
its weakening and dilatation. This is post-stenotic dilatation of
the pulmonary artery.
3. If the stenosis is valvular, the jet of blood coming out of the
narrow orifice hits against the pulmonary artery wall and causes
its weakening and dilatation. This is post-stenotic dilatation of
the pulmonary artery.
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Coarctation of the aorta is narrowing of the aorta usually at the
junction of the arch with the descending aorta just distal to the leftsubclavian artery. Because of the narrowing, pressure rises in the
ascending aorta and the aortic arch and its branches.
Anastomosis forms between the branches of he aorta proximal
and distal to the obstruction. The most important of these connect
the subclavian artery through its internal mammary branch to the
intercostal arteries which arise from descending aorta. The
intercostal arteries become enlarged and tortuous and erode the
lower border of the fourth to ninth ribs causing rib notching.Appreciable anastomosis develops gradually by time. That is why
rib notching is not detectable except after the age of 10. Other
anastomosis develops around the scapula and another connects
the superior and inferior epigasric arteries (Fig. 96).
Coarctation of the aorta is narrowing of the aorta usually at the
junction of the arch with the descending aorta just distal to the leftsubclavian artery. Because of the narrowing, pressure rises in the
ascending aorta and the aortic arch and its branches.
Anastomosis forms between the branches of he aorta proximal
and distal to the obstruction. The most important of these connect
the subclavian artery through its internal mammary branch to the
intercostal arteries which arise from descending aorta. The
intercostal arteries become enlarged and tortuous and erode the
lower border of the fourth to ninth ribs causing rib notching.Appreciable anastomosis develops gradually by time. That is why
rib notching is not detectable except after the age of 10. Other
anastomosis develops around the scapula and another connects
the superior and inferior epigasric arteries (Fig. 96).
Coarctation of The Aorta
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Fig. (96): Collateral circulation in coarctation of aortaFig. (96): Collateral circulation in coarctation of aorta
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X-ray Picture (Figs. 100 & 101):
1. Right ventricular hypertrophy causes the apex to be
displaced outwards and becomes separated from the
diaphragm.
2. The aorta receives blood from both ventricles and the aortic
arch is enlarged. Sometimes the aortic arch is directed to the
right i.e. right-sided aortic arch (Fig. 102).
3. The pulmonary artery and its branches are diminished in size
due to the pulmonary stenosis (pulmonary oligemia). There
is a concavity in the region of the underdeveloped RV
outflow tract.
All the above factors result in a characteristic cardiac shadow,
i.e. coeur en sabot (Sabot = wooden shoe).
X-ray Picture (Figs. 100 & 101):
1. Right ventricular hypertrophy causes the apex to be
displaced outwards and becomes separated from the
diaphragm.
2. The aorta receives blood from both ventricles and the aortic
arch is enlarged. Sometimes the aortic arch is directed to the
right i.e. right-sided aortic arch (Fig. 102).
3. The pulmonary artery and its branches are diminished in size
due to the pulmonary stenosis (pulmonary oligemia). There
is a concavity in the region of the underdeveloped RV
outflow tract.
All the above factors result in a characteristic cardiac shadow,
i.e. coeur en sabot (Sabot = wooden shoe).
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Fig. (102): Fallots tetrology with right
sided aortic arch
Fig. (102): Fallots tetrology with right
sided aortic arch
Fig. (101): Fallots tetrology with near
pulmonary atresia. The aorta is markedly
enlarged
Fig. (101): Fallots tetrology with near
pulmonary atresia. The aorta is markedly
enlarged
Fig. (100): Two cases of Fallots tetrologyFig. (100): Two cases of Fallots tetrology
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In TGA the aorta arises from the morphologically right ventricle
and the pulmonary artery from the left. The atrioventricularconnections are normal. Additional atrial or ventricular septal defect
or patent ductus are essential in order to allow oxygenated blood to
reach the body and venous blood to reach the lungs.
X-ray Picture (Fig. 103):1. The x-ray commonly give the essential clue to the diagnosis of
TGA: Increased pulmonary arterial blood flow (plethora seen in
the x-ray) in a cyanotic child. Plethora is more evident in the
right lung because of the rightward direction of the mainpulmonary artery.
2. The thynus gland is absent and the vascular pedicle is
characteristically narrow in the frontal plane because the
pulmonary artery lies behind the aorta and not by its side.
In TGA the aorta arises from the morphologically right ventricle
and the pulmonary artery from the left. The atrioventricularconnections are normal. Additional atrial or ventricular septal defect
or patent ductus are essential in order to allow oxygenated blood to
reach the body and venous blood to reach the lungs.
X-ray Picture (Fig. 103):1. The x-ray commonly give the essential clue to the diagnosis of
TGA: Increased pulmonary arterial blood flow (plethora seen in
the x-ray) in a cyanotic child. Plethora is more evident in the
right lung because of the rightward direction of the mainpulmonary artery.
2. The thynus gland is absent and the vascular pedicle is
characteristically narrow in the frontal plane because the
pulmonary artery lies behind the aorta and not by its side.
Transposition of Great Arteries(TGA)
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Fig. (103): Typical picture of TGA.Note the oval cardiac silhouette, the
narrow pedicle and the pulmonary
plethora.
Fig. (103): Typical picture of TGA.
Note the oval cardiac silhouette, the
narrow pedicle and the pulmonary
plethora.
3. The heart is enlarged and takes the shape of an egg on side
tilted so that its tip (the apex) is pointing downwards and to the
left.
The presence of additional lesions e.g. pulmonary stenosis,
pulmonary hypertension, ductus, etc. may alter or add to the
typical picture.
3. The heart is enlarged and takes the shape of an egg on side
tilted so that its tip (the apex) is pointing downwards and to the
left.
The presence of additional lesions e.g. pulmonary stenosis,
pulmonary hypertension, ductus, etc. may alter or add to the
typical picture.
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This is a rare anomaly in which the leaflets of the tricuspid valve
are adherent to the right ventricular wall. The level of the valve is
shifted towards the right ventricular apex. A portion of the right
ventricle is atrialized i.e. becomes hemodynamically part of the
right atrium. Tricuspid regurgitation is commonly severe.
X-ray Picture:
1. The most characteristic x-ray sign is enlarged right atrium
forming a prominent convexity on the lower two thirds of the
right cardiac borders.
2. The right ventricular infundibulum forms a prominence on the
left cardiac border at a level lower than that of the pulmonary
artery. This, together with the right atrial enlargement gives a
box like shape to the cardiac silhouette (Fig. 104).
This is a rare anomaly in which the leaflets of the tricuspid valve
are adherent to the right ventricular wall. The level of the valve is
shifted towards the right ventricular apex. A portion of the right
ventricle is atrialized i.e. becomes hemodynamically part of the
right atrium. Tricuspid regurgitation is commonly severe.
X-ray Picture:
1. The most characteristic x-ray sign is enlarged right atrium
forming a prominent convexity on the lower two thirds of the
right cardiac borders.
2. The right ventricular infundibulum forms a prominence on the
left cardiac border at a level lower than that of the pulmonary
artery. This, together with the right atrial enlargement gives a
box like shape to the cardiac silhouette (Fig. 104).
Ebstein Anomaly of The TricuspidValve
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3. The overall cardiac size may vary from huge (specially in
infants) to normal.
3. The overall cardiac size may vary from huge (specially in
infants) to normal.
4. The lungs vasculature is normal or reduced .
The differential diagnose of the x-ray film is pericardial
effusion, dilated cardiomyopathy and heart failure due to critical
valve lesion.
4. The lungs vasculature is normal or reduced .
The differential diagnose of the x-ray film is pericardial
effusion, dilated cardiomyopathy and heart failure due to critical
valve lesion.
Fig. (104): Ebstein anomaly. The right
atrium is enlarged. The right ventricular
inlet is atrialized and the right ventricular
infindibulum is prominent.
Fig. (104): Ebstein anomaly. The right
atrium is enlarged. The right ventricular
inlet is atrialized and the right ventricular
infindibulum is prominent.
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Anomalous pulmonary venous drainage may be total or partial
and may be supracardiac, cardiac or infracardiac according to the
level in which the pulmonary venous flow joins the systemic
circulation: i.e. either in:
Superior vena cava, or
Right atrium or coronary
sinus, or
Inferior vena cava.
Anomalous pulmonary venous drainage may be total or partial
and may be supracardiac, cardiac or infracardiac according to the
level in which the pulmonary venous flow joins the systemic
circulation: i.e. either in:
Superior vena cava, or
Right atrium or coronary
sinus, or
Inferior vena cava.
Fig. (105): The course of circulation in
total anomalous venous drainage
opening in the superior vena cava
Fig. (105): The course of circulation in
total anomalous venous drainage
opening in the superior vena cava
Total Anomalous Pulmonary VenousDrainage
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In total anomalous pulmonary venous drainage the pulmonary
veins join a transverse common vein that ends in an anomalous
vertical channel which, in turn opens in the left side of theinnominate vein (Fig. 105).
X-ray Picture:
The x-ray resembles that of an atrial septal defect.
The commonest form of total anomalous venous connection
gives the snow man or figure of 8 silhouette. The upper
portion of the 8 is formed by the dilated left vertical venouschannel and the right superior vena cava. The lower portion is
made by the dilated right atrium and right ventricle (Fig. 106).
In total anomalous pulmonary venous drainage the pulmonary
veins join a transverse common vein that ends in an anomalous
vertical channel which, in turn opens in the left side of theinnominate vein (Fig. 105).
X-ray Picture:
The x-ray resembles that of an atrial septal defect.
The commonest form of total anomalous venous connection
gives the snow man or figure of 8 silhouette. The upper
portion of the 8 is formed by the dilated left vertical venous
channel and the right superior vena cava. The lower portion is
made by the dilated right atrium and right ventricle (Fig. 106).
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Fig. (106): (Left): an angiogram and (right): X-ray of a case of total anomalous
venous drainage in which the common venous channel opens in the superior
vena cava. The X-ray shows the figure of 8 or the snow-man appearance.
Fig. (106): (Left): an angiogram and(right): X-ray of a case of total anomalous
venous drainage in which the common venous channel opens in the superior
vena cava. The X-ray shows the figure of 8 or the snow-man appearance.
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Extracardiac Structures Simulating Cardiac Enlargement
Pathological masses in the anterior or superior mediastinum may be
superimposed on the cardiac shadow and simulate enlargement of various
cardiac chambers and great vessels. They include lymphomas, dermoidcyst, retrosternal goiter, thymoma, etc.., (Figs. 107, 108, 109 & 110).
Extracardiac Structures Simulating Cardiac Enlargement
Pathological masses in the anterior or superior mediastinum may be
superimposed on the cardiac shadow and simulate enlargement of various
cardiac chambers and great vessels. They include lymphomas, dermoidcyst, retrosternal goiter, thymoma, etc.., (Figs. 107, 108, 109 & 110).
Fig. (107):Fig. (107): Fig. (108):Fig. (108): Fig. (109):Fig. (109):
When such masses occur, can be suspected by the presence of a normal
cardiac size and normal pulmonary vasculation.
When such masses occur, can be suspected by the presence of a normal
cardiac size and normal pulmonary vasculation.
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Fig. (111): Enlarged thymus gland in an infantFig. (111): Enlarged thymus gland in an infant