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The ABC’s ofThe ABC’s of
Heart DiseaseHeart Disease
William Herring, M.D. © 2003
In Slide Show mode, to advance slides, press spacebar or click left mouse button
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William Herring, M.D.
Albert Einstein Medical Center
Philadelphia, PA
William Herring, M.D.
Albert Einstein Medical Center
Philadelphia, PA
© 2000
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With Acknowledgement
For Its Creation to
Bernard J. Ostrum, M.D.
With Acknowledgement
For Its Creation to
Bernard J. Ostrum, M.D.
© 2000
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What It Is
An approach
For congenital or acquired heart
disease in adults Asking systematic set of questions
Answers based on certainfundamental observations
Visible on frontal chest x-ray alone
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CardioCardio--thoracicthoracic
RatioRatio
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Sometimes, CTR is more than 50%But Heart is Normal
Extracardiac causes of cardiacenlargement
Portable AP films Obesity
Pregnant
Ascites
Straight back syndrome
Pectus excavatum
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>50%
Here is a heart that is larger than 50% of the cardiothoracic ratio, but it is still a normal heart.
This is because there is an extracardiac cause for the apparent cardiomegaly. On the lateralfilm, the arrows point to the inward displacement of the lower sternum in a pectus excavatum
deformity.
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Sometimes, CTR is less than 50%But Heart is Abnormal
Obstruction to outflow of the ventricles
Ventricular hypertrophy
Must look at cardiac contours
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Ascending AortaAscending Aorta
“Double density”of LA enlargement“Double density”of LA enlargement
Right atriumRight atrium Left ventricleLeft ventricle
Indentation for
LA
Indentation for
LA
Main pulmonary
artery
Main pulmonary
artery
Aortic knobAortic knob
The Cardiac ContoursThe Cardiac Contours
There are 7 contours to the heart in the
frontal projection in this system.
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Ascending AortaAscending Aorta
“Double density”of LA enlargement“Double density”of LA enlargement
Right atriumRight atrium Left ventricleLeft ventricle
Indentation for
LA
Indentation for
LA
Main pulmonary
artery
Main pulmonary
artery
Aortic knobAortic knob
The Cardiac ContoursThe Cardiac Contours
But only the top five are really important
in making a diagnosis.
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Low density,
almost straight
edgerepresents size
of ascending
aorta
Low density,
almost straight
edgerepresents size
of ascending
aorta
Ascending AortaAscending Aorta
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Small Prominent
Ascending AortaAscending Aorta
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Indentation
where “double
density” of left
atrialenlargement will
appear
Indentation
where “double
density” of left
atrialenlargement will
appear
Double density of left atrial
enlargement
Double density of left atrial
enlargement
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Left atrium
sits in middle ofheart
posteriorly
Left atriumLeft atrium
sits in middle ofsits in middle ofheartheart
posteriorlyposteriorly
Left atriumforms no border
of normal heart
in PA view
Left atriumLeft atriumforms no borderforms no border
of normal heartof normal heart
in PA viewin PA view
LA
RALV
Even though we are on the right side of the heart, we can
see left atrial enlargement. Normally the left atrium sits
right in the middle of the heart posteriorly and does notform a normal border on the frontal film.
Even though we are on the right side of the heart, we can
see left atrial enlargement. Normally the left atrium sits
right in the middle of the heart posteriorly and does notform a normal border on the frontal film.
This inset from a CT scan of the chest
shows how RA and LV obscure LA fromforming a heart border on the frontal film.
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““DoubleDouble
Density”Density”
of left atrialof left atrial
enlargementenlargement
When the LA enlarges, it will do something on the left
side of the heart we’ll talk about in a minute. And it may
produce a “double-density” on the right side of the heart.
When the LA enlarges, it will do something on the left
side of the heart we’ll talk about in a minute. And it may
produce a “double-density” on the right side of the heart.
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RA
Two shadows,
the yellowarrow pointing
to the LA and
the red arrow
to the RA
overlap each
other where
theindentation
between the
ascendingaorta and right
heart border
meet
Two shadows,
the yellowarrow pointing
to the LA and
the red arrow
to the RA
overlap each
other where
theindentation
between the
ascendingaorta and right
heart border
meet
LALA
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Right atrium–
not important
contour inadults
Right atrium–
not important
contour inadults
The last bump on the right side is the right atrium. Since
there is no disease in an adult that causes isolatedenlargement of the RA, we’ll consider the RA together
with the RV later.
The last bump on the right side is the right atrium. SinceThe last bump on the right side is the right atrium. Since
there is no disease in an adult that causes isolatedthere is no disease in an adult that causes isolatedenlargement of the RA, we’ll consider the RA togetherenlargement of the RA, we’ll consider the RA together
with the RV later.with the RV later.
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Aortic knob
should
measure< 35mm
Aortic knob
should
measure< 35mm
Aortic KnobAortic Knob
The first bump on
the left-side is the
aortic arch. Wecan measure the
knob from the
lateral border of airin the trachea to
the edge of the
aortic knob.
The first bump on
the left-side is the
aortic arch. Wecan measure the
knob from the
lateral border of air
in the trachea to
the edge of the
aortic knob.
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42mm
Enlarged with:
Increased pressure
Increased flow
Changes in aortic wall
Aortic KnobAortic Knob
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ImportantImportantImportant
MainPulmonaryArtery
MainPulmonaryArtery
The next bump down is the
main pulmonary artery and is
the keystone of this system.
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Finding the
MainPulmonaryArtery
Finding the
MainPulmonaryArtery
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The distance
between the
tangent andthe main
pulmonary
artery (between
two smallgreen arrows)
falls in a range
between 0 mm
(touching thetangent line) to
as much as 15
mm away from
the tangent line
If we draw a
tangent line
from the apexof the left
ventricle to the
aortic knob
(red line) andmeasure along
a
perpendicular
to that tangentline (yellow
line)
00 115
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0 mm0 mm
MainMainPulmonaryPulmonary
ArteryArtery
AoAo
15 mm15 mm
MainMain
PulmonaryPulmonary
ArteryArtery
AoAo
LVLV
LVLV
Main pulmonary
artery ranges from
0 mm–15mm
from tangent line
Main pulmonary
artery ranges from
0 mm–15mm
from tangent line
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Two Major Classifications
The main pulmonary artery (MPA)
projects beyond the tangent line
The main pulmonary artery is more
than 15 mm away from the tangent line
Because the MPA is small or absent
Because the tangent line is being pushed away
from the MPA
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Main
pulmonaryartery
projectsbeyondtangent
Main
pulmonaryartery
projectsbeyondtangent
Increased
pressure
Increased flow
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2 7
Main pulmonaryartery is morethan 15 mmfrom tangent
Main pulmonaryartery is morethan 15 mmfrom tangent
Small pulmonaryartery
Truncus arteriosus
Tetralogy of Fallot
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2 9
Main pulmonaryartery is morethan 15 mmfrom tangent
Main pulmonaryartery is morethan 15 mmfrom tangent
Left ventricleand/or aortic
knob push the
tangent away
Common
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0 - 15 mm00 -- 15 mm15 mmTo
recapitulate:
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Concavity where L
atrium will appear on
left side when
enlarged
Concavity where L
atrium will appear onleft side when
enlarged
Left atrial enlargementLeft atrial enlargement
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“Straightening of the
left heart border”
“Straightening of the
left heart border”
Left atriummay enlarge
without
producing
doubledensity
Left atriumLeft atriummay enlargemay enlarge
withoutwithout
producingproducing
doubledoubledensitydensity
Left atrial enlargementLeft atrial enlargement
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MainPulmonary
Artery
MainMainPulmonaryPulmonary
ArteryArtery
LeftAtrial
Appendage
LeftLeftAtrialAtrial
AppendageAppendage
In the example on the
right, not only is the
left atrium enlarged,
but the left atrial
appendage is too. Sothere is a convexity
outward where there
is normally aconcavity inward.
L ft t i l
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Left VentricleLeft Ventricle
Left ventricleLeft ventricle
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Which Ventricle is Enlarged?
The best way to determine which
ventricle is enlarged is to look atthe corresponding outflow tract for
each ventricle
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Which Ventricle is Enlarged?
If Heart Is Enlarged,
And Main Pulmonary
Artery is Big
>50%Then Right Ventricle isEnlarged
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Which Ventricle is Enlarged?
If Heart Is Enlarged,
And Aorta is Big
Then Left Ventricle
is Enlarged>50%
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Which ventricle is enlarged?
The best way to determine which
ventricle is enlarged is to look at
the corresponding outflow tract
for each ventricle
Aorta for the LV
MPA for the RV
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Which Ventricle is Enlarged?
Once one ventricle is enlarged,
it’s impossible to tell if other ventricle
is also enlarged
The Cardiac ContoursThe Cardiac Contours
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Ascending AortaAscending Aorta
“Double density”
of LA enlargement
“Double density”
of LA enlargement
Right atriumRight atrium Left ventricleLeft ventricle
Indentation for
LA
Indentation for
LA
Main pulmonary
artery
Main pulmonary
artery
Aortic knobAortic knob
The Cardiac ContoursThe Cardiac Contours
The Cardiac ContoursThe Cardiac Contours
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Ascending AortaAscending Aorta
“Double density”
of LA enlargement
“Double density”
of LA enlargement
Right atriumRight atrium Left ventricleLeft ventricle
Indentation for
LA
Indentation for
LA
Main pulmonary
artery
Main pulmonary
artery
Aortic knobAortic knob
The Cardiac ContoursThe Cardiac Contours
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The PulmonaryThe Pulmonary
VasculatureVasculature
Fi e States of the P lmonar
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Five States of the Pulmonary
Vasculature
Normal
Pulmonary venous hypertension
Pulmonary arterial hypertension
Increased flow
Decreased flow
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What We’re Going to Evaluate
Right Descending Pulmonary Artery
Distribution of flow in the lungs
Upper versus lower lobes
Central versus peripheral
What to EvaluateWhat to Evaluate
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What to EvaluateWhat to Evaluate
11
33
22
22
1 Right Descending Pulmonary Artery1 Right Descending Pulmonary Artery
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Right
Descending
Pulmonary
Artery
Right
Descending
Pulmonary
Artery
Serves right
middle andlower lobes
Serves right
middle andlower lobes
1. Right Descending Pulmonary Artery1. Right Descending Pulmonary Artery
1 Right Descending Pulmonary Artery1 Right Descending Pulmonary Artery
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1. Right Descending Pulmonary Artery1. Right Descending Pulmonary Artery
Diameter can
be measured
(before
bifurcation)
Diameter can
be measured
(before
bifurcation)
RDPA< 17 mm
Normally, theright
descending
pulmonaryartery should
not be more
than 17mm indiameter
2. Normal Distribution of Flow2. Normal Distribution of Flow
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Upper Versus Lower LobesUpper Versus Lower Lobes
In erect position,
blood flow to
bases > than flow
to apices
In erect position,
blood flow to
bases > than flow
to apicesSize ofvessels at
bases is
normally
> than sizeof vessels
at apex You can’t measure size ofvessels at the left base
because the heart obscuresthem
3. Normal Distribution of Flow3. Normal Distribution of Flow
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Normaltapering of
vessels
from
central toperipheral
Normaltapering of
vessels
from
central toperipheral
Central vesselsgive rise to
progressively
smaller peripheral
branches
Central vesselsgive rise to
progressively
smaller peripheral
branches
Central versus peripheralCentral versus peripheral
Normal Vasculature - reviewNormal Vasculature - review
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11
33
22
22RDPA< 17 mm in
diameter
Lower lobevesselslarger thanupper lobevessels
Gradualtapering of
vessels
from central
to
peripheral
Venous HypertensionVenous Hypertension
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RDPA usually
> 17 mm
Upper lobe
vessels equal
to or larger
than size oflower lobe
vessels =
Cephalization
Upper lobe
vessels equal
to or larger
than size oflower lobe
vessels =
Cephalization
ypy
Pulmonary Arterial HypertensionPulmonary Arterial Hypertension
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y yp
RDPA usually
> 17 mm
RDPA usually
> 17 mm
Main
Pulmonary
Arteryprojects
beyond
tangent line
Main
Pulmonary
Arteryprojects
beyond
tangent line
2 3
Pulmonary Arterial HypertensionPulmonary Arterial Hypertension
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Rapid
cutoff in
size of
peripheralvessels
relative to
size of
centralvessels
Rapid
cutoff in
size of
peripheralvessels
relative to
size of
centralvessels
Central vessels
appear too
large for size ofperipheral
vessels which
come from
them =
Pruning
3 1
Increased FlowIncreased Flow
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RDPA usually
> 17 mm
RDPA usually
> 17 mm
All of blood vessels everywhere inlung are bigger than normal
Increased FlowIncreased Flow
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Distribution of
flow is
maintained as
in normal
Gradual
tapering from
central to
peripheral
Lower lobevessels bigger
than upper
lobe
NormalNormal Increased FlowIncreased Flow
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Increased FlowIncreased Flow PAHPAH
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Decreased FlowDecreased Flow
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Unrecognizable
most of the
time
Small hila
Fewer thannormal blood
vessels
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The Pulmonary Vasculature
Normal
Pulmonary venous hypertension
Pulmonary arterial hypertension
Increased flow
Decreased flow - mostlyunrecognizable even when it ispresent
If Look at the
Normal
Pulmonary
Mitral
regurg
Mitral
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AIs the Left
AtriumEnlarged?
If yes,then
If no,then
Look at thePulmonaryVasculature
Increased
Pulmonaryvenous
hypertension
BIs the MainPulmonaryArtery Big
orBulbous?
If yes,
then
If no,then
Look at thePulmonaryVasculature
CIs the MainPulmonary
ArterySegmentConcave?
If yes,then
If no,then
DIs theHeart
Dilated orDelta-
Shaped?
If yes,then
Don't Look atPulmonary
Vasculature.Look at Aorta
Normal
Increased
Pulmonaryhypertension
CardiomyopathyPericardial
EffusionMolt. valve dz
MitralStenosisL Myxoma
VSD, PDA
Plum.stenosis
ASD(VSD)
Idiopathic(1°)
Normal
Ascendingdilated
Whole AoDilated
Cardiomyopathy
AoStenosis
Ao regurgHBP
The ABC’sThe ABC’s
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The System
Those were all of the answers
Now here are the questions
The system is successful only if youask the questions in this order
The answers are the fundamentalobservations you make on the frontal
film alone
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To answer that question
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Straight orconvex at
site of
normal
concavity
“Double
density” at
site of normal
indentation
To answer that question
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If Answer To Question “A” Is YES
Look At Pulmonary Vasculature
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If Answer To Question “A” Is NO
Then...
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Is The Main Pulmonary
Artery Big ?
To answer that question
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Main
pulmonary
artery projectsbeyond
tangent line
q
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If Answer To Question “B” Is YES
Look At Pulmonary Vasculature
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If Answer To Question “B” Is NO
Then...
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Is The Main Pulmonary
Artery Concave ?
To answer that question
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Mainpulmonary
artery is >
15mmaway from
tangent
line
To answer that question
2 5
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If Answer To Question “C” Is YES
Look At Configuration of Aorta
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If Answer To Question “C” Is NO
Then...
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Is The Heart a Dilated Or
Delta-Shaped Heart ?
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Choose the link“Test Yourself on the ABCs”
to see how the system works
For printed notes, choose the link underCardiac Notes for
“The ABCs of Heart Disease”
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The End