CARDIAC

IMAGING
Dr. Mulama. B.M

Radiologist.
 Outline
1. Interpreting a normal chest radiograph

2. Classification of congenital heart diseases

Right to Left Shunts

Left to right shunts

3. Acquired heart diseases

Rheumatic Heart disease

Heart Failure in infancy and children

Pericardial Effusions
Systematic approach to
interpreting a chest
radiograph
PAEDIATRIC CHEST RADIOGRAPHS
Echo, cardiac CT and MRI now in use, but information can still be
gained from the chest radiograph

REQUIREMENTS:

• Systematic approach to interpretation

• Understanding of normal contours of cardiomediastinum

• Some knowledge of child’s history (whether cyanotic or acyanotic)

is valuable
Systematic Approach
1. Technical Assessment
• Rotation, exposure, penetration, angulation (no excessive lordotic or kyphotic
angulation should be present), adequate inspiration
2. Pulmonary vasculature and lung fields
– may represent milder or earlier forms of CHD
Congested – Active congestion seen in left to right shunts when RV output >2.5
times that of LV. Passive congestion due to elevated pulmonary venous
pressure reflecting left cardiac dysfunction or obstruction.
• Decreased – Pulmonary oligaemia usually resulting from RV outflow
obstruction with associated right to left shunt.
Systematic Approach
3. Aorta
• Size
• Enlarged – post stenotic dilatation, increased blood flow (PDA, severe TOF,
Truncus arteriosus, valvular insufficiency), systemic hypertension
• Small – reduced blood flow, typically due to ASD or VSD, may also be due
to hypoplastic left heart syndrome
• Position
• Most right sided aortic arches incidental, ¬10% associated with CHD
• Mirror image branching anatomy mostly associated with CHD esp TOF
• Shape
• E.g. figure of 3 sign in COA
Systematic Approach
4. Pulmonary artery
• Small/inapparent – congenital hypoplasia or aplasia, decreased pulmonary
flow (TOF) or abnormal location (Truncus arteriosus, Transposition of great
arteries)
• Enlarged – Post-stenotic dilatation, increased pulmonary blood flow (left to
right shunts, pulmonary valve insufficiency), pulmonary arterial hypertension.
5. Cardiac size and shape
• Alterations in shape representing underlying chamber enlargement or
anatomic anomalies
• Also confirm orientation of heart by identifying liver and stomach below
diaphragm and reviewing side markers
6. Spine, rib cage and sternum
• Rib notching may occur in COA, hypersegmented sternums in Down syndrome
Normal
Anatom
y
Normal
Anatomy
Normal
Radiograph
PA CXR
Normal
Radiograph
Lateral CXR
Classification of
congenital heart
disease
Right to Left Shunts
(cyanotic)
Transposition of Great Arteries
• Most common cyanotic congenital heart lesion found in neonates (5-7% of
congenital cardiac malformations)
• Isolated in 90%, rarely associated with syndromes or extracardiac
malformation
• Classically egg on a string sign
• Pulmonary Artery is to right of normal location thus obscured by aorta in
AP/PA views + stress-induced thymic atrophy + hyperinflated lungs =
apparent narrowing of superior mediastinum
• Cardiac silhouette normal in first days after birth but enlarges and becomes
globular with time (LA commonly enlarged due to increased pulmonary
blood flow)
TGA

RadioGraphics,[Link]
275065148 Published in: Emma C. Ferguson; Rajesh K
Total Anomalous Pulmonary Venous
Return
• ¬2% of cardiac malformations, occurs when pulmonary vessions fail to drain into LA
and form an aberrant connection with some other cardiovascular structure.
• Type I – (55%) anomalous pulmonary veins terminate at supracardiac level (form
vertical vein).
• Snowman appearance on chest radiographs
• Venous obstruction uncommon but extrinsic obstruction may occur if vertical
vein crosses between left PA anteriorly and left main bronchus posteriorly.
• Type II – (30%) involves pulmonary venous connection at cardiac level
• Type III – (13%) involves connection at infracardiac or infradiaphragmatic level
• Almost always associated with some degree of obstructed venous return causing
cyanosis, often with early and severe CCF, also lymphangiectasia, heart size
usually normal but severe interstitial pulmonary edema, thymic atrophy and
depression of diaphragm present.
• Type IV – (2%) anomalous venous connection at two or more levels.
RadioGraphics,[Link]
275065148 Published in: Emma C. Ferguson; Rajesh K
TAPVR
Type I
Snowman
sign
a.k.a.
Figure of
8 sign

RadioGraphics,[Link]
275065148 Published in: Emma C. Ferguson; Rajesh K
Frontal view
with
angiocardiogra
phy
Partial Anomalous Pulmonary
Venous Return
• Scimitar sign produced by anomalous pulmonary artery draining any or
all lobes of the right lung – creates left-to-right shunt that is usually
hemodynamically insignificant, symptoms occur if 50% or more of
pulmonary blood flow shifts from the left to the right.
• Scimitar – sword with curved blade traditionally used by Persian or
Turkish warriors
• Scimitar syndrome characterised by scimitar vein and additional
features
• Hypoplasia of right lung with dextroposition of the heart
• Hypoplasia of right pulmonary artery
• Anomalous arterial supply of right lower lobe from abdominal aorta
RadioGraphics,[Link]
275065148 Published in: Emma C. Ferguson; Rajesh K
Tetralogy of Fallot
• Components are
• Ventricular septal defect
• Right ventricular outflow tract obstruction (infundibular pulmonary stenosis)
• Overriding aorta
• Right ventricular hypertrophy (typically develops in long-standing untreated disease
• Accounts for 10 -11% of CHD, thought to occur from malalignment of conal
septum (embryology)
• Boot shaped heart due to uplifting of cardiac apex secondary to RVH and
concavity of the main pulmonary artery
• Shadow of pulmonary arterial trunk almost invariably absent, and pulmonary
oligaemia occurs.
• 25% of TOF associated with right-sided aortic arch
RadioGraphics,[Link]
275065148 Published in: Emma C. Ferguson; Rajesh K
Endocardial Cushion Defect
• Gooseneck sign visible at LV angiography
• Endocardial cushion defects (¬4% of CHD)
• The endocardial cushion normally forms the lower portion of the
atrial septum, the upper portion of the interventricular septum, and
the septal leaflets of the mitral valve and the tricuspid valve.
• Gooseneck formed by deficiency of both conus and sinus portions of
intraventricular septum, with narrowing of the LV outflow tract.

RadioGraphics,[Link]
275065148 Published in: Emma C. Ferguson; Rajesh K
Ebstein Anomaly
• 0.5-0.7% of cases of CHD. Strong association reported with oral lithium therapy
during pregnancy.
• Only cyanotic congenital malformation in which both the aorta and pulmonary
trunk are smaller than normal, with pulmonary flow varying from normal(acyanotic)
to borderline/diminished(cyanotic)
• Downward displacement of septal and posterior leaflets of tricuspid valve into
outflow portion of RV leads to formation of a common right ventriculoatrial
chamber and TR.
• TR leads to dilatation of the right ventricular outflow tract and all proximal right
heart structures, worsening the TR. RA enlarged with a right-to-left shunt (through
PFO or ASD) in most patients. Cyanosis caused primarily by this shunt.
• On imaging, enlarged right atrium (consistent feature – RA may even fill entire right
hemithorax), LA normal size, but shelved appearance of left cardiac contour due to
dilated RV outflow tract. Small aorta and pulmonary trunk absent. Hence box shape.
Ebstein
anomaly
Left to right shunts
 High vascular resistance
of the fluid-filled fetal lung

Low vascular resistance

of the placenta

Right-to-left shunts
 Two right-to-left shunts occur in the fetus
• Foramen ovale — Blood shunted from the right to left
atrium
• Ductus arteriosus — Blood shunted from the
pulmonary artery to the aorta
Foramen
Ductus Ovale
Arteriosus
 Patent Ductus Arteriosus (PDA)
• PDA occurs commonly in premature infants, especially in those with
respiratory distress syndrome

• Among very low birth weight (VLBW) infants (birth weight below 1500
g) PDA occurred in 30 percent

• Excessive flow through the pulmonary circulation Pulmonary edema ,

Pulmonary hemorrhage, Bronchopulmonary dysplasia

Because of the large volume of blood flow, the ductus becomes a
large vessel with a diameter similar to that of the descending aorta
 VSD
• The most common form of CHD, accounting for up to 20-40% of patients diagnosed
with CHD

• Impact may range from asymptomatic to pulmonary HTN, LV volume overload and RVH

• Morphology: 4 types
• Membranous – most common type in adults (80%)
• Muscular – most common type in young children
• Complete AV septal (endocardial cushion) defects
• Supracristal (subarterial)
• Small defects have a
normal chest X-ray.

• Large defects with a

big shunt have
cardiomegaly and
pulmonary plethora.
• mod. cardiomegaly
• RA enlargement
• RV enlargement
• prominent main pulm
artery
• plethoric lung fields
Outflow
Obstruction
Coarctation of the Aorta
• Produced by deformity of aortic media and intima which causes a
prominent posterior infolding of the aortic lumen.
• 5-10% of CHD, usually sporadic, but increased frequency in Turner
syndrome (affects 20-36% of patients with Turner)
• Typically at or near the junction of the aortic arch and the descending
thoracic aorta.
• Cystic medial necrosis is a common occurrence at the level of
coarctation, and intimal thickening and elastic tissue disruption often
develop distal to the site; these conditions may predispose the aorta
to infective endarteritis, intimal dissection, and aneurysm.
Coarctation
of aorta
Reverse figure-of-3 sign on barium
esophagography in COA
 Pulmonary Stenosis
• A form of right ventricular outflow tract obstruction in which

stenosis is usually valvar or infundibular, or both ( rarely, supravalvar )

• * Simple, pure, isolated pulmonary valvar stenosis(70%)

• * Pulmonary stenosis with normal aortic root

Patterns of pulmonary stenosis

1. Critical valvar pulmonary stenosis in neonates

2. Pulmonary stenosis in infants, children, & adults

• Pulmonary vascularity is often
normal in mild cases.
• In some cases of pulmonary valvular
stenosis, the flow of blood through
the stenotic valve preferentially
enter the left pulmonary artery
which may result to an enlarged left
pulmonary artery and slightly
increased left lung vascularity.
 Aortic Stenosis
CAUSES • Typical murmur and thrill for slightly
• Congenital narrowed, thickened, or roughened valves
• Systolic ejection murmur at the aortic area
• Rheumatic fever transmitted to the neck and apex for mild or
• Degenerative calcification
moderate cases
• Palpable left ventricular heave or thrill, a
• Obstructive infective vegetations weak to absent aortic second sound, or
reversed splitting of the second sound are
• Paget’s disease of the bone
present in severe cases of AS because of
• Systemic lupus erythematous prolonged ejection time
• S4 is common and reflects increased atrial
• Rheumatoid disease
contribution to ventricular filling
Acquired Heart Disease
 RHEUMATIC HEART DISEASE
• Rheumatic Heart Disease is the permanent heart valve damage
resulting from one or more attacks of ARF.

• It is thought that 40-60% of patients with ARF will go on to

developing RHD.

• The commonest valves affecting are the mitral and aortic, in that
order. However all four valves can be affected
 Mitral Stenosis
•cardiomegaly
•double right heart border
(enlarged left atrium and
normal right atrium)
•prominent left atrial
appendage
•splaying of the subcarinal angle
MR
 Pulmonary Hypertension
• Pulmonary hypertension is defined as a resting mean pulmonary arterial pressure of 25
mmHg or greater at right heart catheterisation

1. includes idiopathic and familial PH, as well as PH associated with conditions such as
collagen vascular disease, congenital shunts, cirrhosis and portal hypertension, HIV,
hemoglobinopathies, and schistosomiasis

2. left ventricular (LV) or left-sided valvular disease.

3. PH secondary to chronic lung diseases, hypoxia or both

4. CTEPH ( Chronic Thromboembolic Pulmonary Hypertension)

• elevated cardiac apex due to
right ventricular hypertrophy
• enlarged right atrium
• prominent pulmonary outflow
tract
• enlarged pulmonary arteries
• pruning of peripheral
pulmonary vessels
 Pulmonary Oedema
• increased hydrostatic pressure -edema
• two pathophysiological and radiological phases are recognised in the development of
pressure oedema
• interstitial oedema
• alveolar flooding or alveolar oedema
• these phases are virtually identical for left-sided heart failure and fluid overload
• permeability oedema with diffuse alveolar damage (DAD)
• permeability oedema without diffuse alveolar damage
• mixed oedema due to simultaneous increased hydrostatic pressure and
permeability changes
• It can arise from a range of cardiogenic and non-cardiogenic causes.
 Pulmonary Oedema
• One grading system on pulmonary oedema based on chest radiograph
appearances and pulmonary capillary wedge pressure (PCWP) is as follows:

• grade 0: normal chest radiograph, PCWP 8-12 mmHg

• grade 1: shows evidence of upper lobe diversion on a chest radiograph, PCWP 13-
18 mmHg

• grade 2: shows interstitial oedema on a chest radiograph, PCWP 19-25 mmHg

• grade 3: shows alveolar oedema on a chest radiograph, PCWP >25 mmHg

Grade 1 Pulmonary
OedemaUpper lobe pulmonary
venous diversion (cephalisation) reflects
elevation of left atrial pressure and can
occur with pulmonary oedema. It
produces Stag-antler's sign on frontal
chest x-ray.
The normal left atrial pressure is 5-10
mmHg. An elevation of left atrial
pressure to 10-15 mmHg will result in
cephalisation.
Grade 2 Pulmonary
Oedema
features of pulmonary
interstitial oedema:

peri-bronchial cuffing and

perihilar haze

septal lines / Kerley lines

thickening of interlobar
fissures
Grade 3
Pulmonary
Oedema
bilateral opacities that
demonstate extend in a fan
shape outward from the
hilum in a ‘batwing’
pattern.

With worsening alveolar

oedema, the lung
opacification can become
increasingly homogenous.

Air bronchograms can be

seen with alveolar oedema
Dilated
Cardiomyopathy
Cardiac
Tamponade
References
1. Ferguson EC, Krishnamurthy R, Oldham SAA. Classic Imaging Signs
of Congenital Cardio-vascular Abnormalities. RadioGraphics 2007;
27: 1323-1334. Published online 10.1148/rg.275065148.
2. [Link]