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Chapter 2

Radiology of the Heart


Brian A. Poteet

s0010 Introduction Use of a grid is imperative for adequate image


p0010 Thoracic radiography is a key component of the car- quality when chest thickness exceeds 10 cm.
diovascular evaluation. Careful attention to proper Table 2-1 is a representative thoracic technique
positioning is of primary importance to the use of chart using a 400-speed imaging system and 300
radiographic guidelines for interpretation. Radio- mA/125 kVp radiographic equipment.
graphic interpretation relies heavily on possible
Radiographic Projections s0040
disease considerations (i.e., differential diagnosis)
derived from signalment, physical examination, Lateral Projection s0050
and clinical pathology. Radiographic findings are There are subtle differences in cardiac conforma- u0020
not consistently specific enough to lead to the deri- tion and position when comparing the right ver-
vation of a definitive diagnosis without supportive sus the left lateral radiographic projection. These
clinical evidence. The radiographic study isolated differences are not significant enough to warrant
from clinical information will not provide a diagno- further discussion except to note that the same
sis. The clinician must be aware of certain param- projection should be used on all serial radio-
eters and guidelines for interpretation in order to graphic examinations when repeated evaluation
derive information from the radiographic image. is required.
Patient positioning and adequate radiographic
exposure are critical to an accurate radiographic
s0020 Radiographic Technique interpretation in the lateral projection.
s0030 Exposure Technique and Film Quality Key Point b0010

u0010 Exposure technique will vary depending on equip- A normal heart can appear diseased and vice
ment and film-screen combinations. The current versa when positioning is not adequate.
standard for veterinary radiographic equipment is
a 300 mA/125 to 75 kVp machine. Guidelines for proper exposure and positioning of p0020
The current standard for economic film-screen a lateral thoracic radiograph (Figure 2-1) include:
combination imaging systems is the rare earth Radiographic exposure should be adequate to u0030
systems. Because of the motion created by res- define the dorsal spinous process of the cranial
piration, relatively high-speed (400) film-screen thoracic vertebrae superimposed on the scapula.
combinations that allow shorter exposure times To ensure a lateral projection, the dorsal heads of
are best suited for thoracic radiography. the ribs should be superimposed.
24
Chapter 2 Radiology of the Heart 25
t0010
TABLE 2-1 Small Animal Thoracic Radiographic Technique Chart Using a 400-Speed Film-Screen
System and Standard Radiographic Equipment*

Thickness (cm)
mA Time mAs kVp
Table Top

Thorax 100 1/60 1.7 3 4 5 6 7 8 9 10 cm


48 50 52 54 56 58 60 62
In the Table (using Grid)

Thorax 200 1/60 3.3 4 5 6 7 8 9 10 11 12 13 14 15 16 cm


52 54 56 58 60 62 64 66 68 70 72 74 76

300 1/60 5 17 18 19 20 21 22 23 24 25 26 27 28 cm
76 78 80 82 84 86 88 90 92 95 90 101

Technique rules of thumb: Change exposure(1) 10% KVp; (2) two thirds of mAs.
*Single-phase fully rectified 300mA 125 KVp generator focal-film distance = 38.

1 3

Heart
A 2
2
Abdomen

B
2 3

f0010
Figure 2-1. A, Guidelines for proper exposure and positioning of a lateral thoracic radiographic projection. (1) Exposure should
allow delineation of the thoracic vertebral dorsal spinous process superimposed over the scapula. (2) The forelimbs should be pulled
forward to provide an unsuperimposed view of the cranial thorax. (3) The dorsal rib heads should be superimposed (compare with
B). (4) The exposure should be performed during inspiration, which provides maximum separation between caudal cardiac margin
and diaphragmatic cupula. B, Improperly positioned lateral thoracic radiographic projection (compare with A). (1) Nonsuperimposed
left and right rib heads. (2) The oblique projection markedly distorts cardiac silhouette conformation and intrathoracic position. (3)
Expiratory phase radiographic exposure with poor lung volume between caudal cardiac margin and cupula of the diaphragm.
26 Section I Diagnosis of Heart Disease

L L
DV DV

3
2
2
2

1
A 1 B

3
4

f0020
Figure 2-2. A, Guidelines for proper exposure and positioning of a dorsoventral/ventrodorsal thoracic radiographic projection.
L, Lateral; DV, dorsoventral. (1) The radiographic exposure should provide outline definition of thoracic vertebra superimposed
over the cardiac silhouette. (2) Exposure should be increased (usually a 10% kVp increase with obesity as suggested by an increase
in thoracic body wall thickness). (3) The thoracic vertebral dorsal spinous processes should be superimposed over the body por-
tions for the entire length of the thoracic spine. (4) Adequate lung volume between caudal cardiac margin and cupula indicates
an inspiratory phase radiographic exposure. B, Improperly positioned dorsoventral radiographic projection. Thoracic vertebral
dorsal spinous processes projected over the left hemithorax (1) and the sternal vertebra projected over the right hemithorax (2),
indicating an oblique thoracic dorsoventral radiographic projection. A lack of lung volume between caudal cardiac margin (3) and
cupula (4) indicates an expiratory phase radiographic exposure.

The forelimbs should be pulled forward so that The dorsal lung fields are hyperinflated, and the
they are not superimposed over the cranial thorax vessels to the caudal lung fields are magnified
or cranial margin of the heart. owing to increased object-film distance. This
The radiographic exposure is taken during full produces an improved radiographic definition
inspiration, identified as an adequate lung field of the large pulmonary arteries and veins of
spacing between the caudal margin of the heart the caudal lung fields. The DV projection also
and the cupula of the diagram. Two primary allows increased detection of early pulmonary
disease considerations for consistent expiratory infiltrates (most commonly with cardiac dis-
phase radiographs are: ease in the hilar and caudodorsal lung fields).
Obesity and Pickwickian syndrome, where the However, an improperly positioned DV/VD
overabundance of abdominal fat prevents ade- projection is worthless for cardiac radiographic
quate inspiratory distraction of the diaphragm interpretation.
Upper airway disease, which most commonly
causes obstruction during the inspiratory phase
of respiration Key Point b0020
Although the DV projection is preferred, a
Dorsoventral/Ventrodorsal Projection straight (symmetric) projection is the ultimate s0060
The dorsoventral (DV) radiographic projection is goal, with patient compliance determining p0030
preferred over the ventrodorsal (VD) for cardiac which projection (DV vs. VD) is attainable.
evaluation for two reasons:
The anatomic positioning of the heart in the DV u0040
p0040 projection is less dependent on thoracic cavity con- Guidelines for proper exposure and positioning for
formation (deep-chested vs. barrel-chested breeds). the DV/VD projections (Figure 2-2) include:
Chapter 2 Radiology of the Heart 27

u0050 Radiographic exposure should be sufficient to formation of early cardiogenic pulmonary edema.
define the outline of the thoracic vertebrae super- Adequate exposure is critical to ensure definition
imposed over the cardiac silhouette. of caudal pulmonary vasculature superimposed
The kVp should be increased 10% from tech- over the cupula of the diaphragm.
nique-chart values for obese patients. Examina- The radiographic detection of caudodorsal pul-
tion of the thoracic body wall thickness on the monary vasculature is the best objective parame-
VD view should assist in evaluation of obesity. ter for the detection of pulmonary edema. Vessels
The dorsal spinous processes of the thoracic in the normal lung are detected by their soft tissue
vertebrae should be centered over the vertebral opacity contrasting with the normal radiolucent
bodies along the full length of the thoracic spine. gas-filled lung parenchyma surrounding them.
The thoracic sternal vertebrae also should be su- As pulmonary parenchyma (interstitial spaces as
perimposed over the thoracic spine and be essen- well as alveoli) become filled with edema fluid,
tially indistinguishable radiographically. the normal radiographic soft tissuegas contrast
The radiograph is taken during full inspiration, is lost, and delineation of the vessels diminishes.
identified as an adequate lung field spacing be- In other words, the vessels start to disappear
tween caudal cardiac margin and cupula of the from radiographic detection with the increased
diaphragm. opacity of the surrounding edematous lung pa-
renchyma (Figure 2-3).
The phase of inspiration is critical when using this
s0070 Projection Selection in method for interpretation both in the DV/VD and
Cardiac-Related Pathology in the lateral projections. Pulmonary pathology
can be mimicked when underinflation decreases
s0080 Pulmonary Edema
the parenchymal gas content per unit volume,
u0060 The DV is preferred over the VD projection for thus decreasing the radiographic contrast be-
radiographic detection of pulmonary edema. The tween lung parenchyma and associated vascu-
DV view accentuates pathology in the dorsal lung lature. This is especially true in older patients,
field, which is the most common location for the which already have slightly increased pulmonary

L L
DV DV

Heart Heart
A B
LAa LAa
LA LA PV
PV

Alv
f0030
Figure 2-3. A, Normal radiographic definition and contrast of pulmonary venous vasculature (PV) with surrounding normal
radiolucent lung parenchyma. L, Lateral; DV, dorsoventral; LA, left atrium; LAa, left atrial auricular appendage. B, Radiographic
obliteration of pulmonary venous vasculature (PV) by alveolar consolidation (Alv) of hilar and caudal lung lobes, a characteristic
distribution for cardiogenic pulmonary edema.
28 Section I Diagnosis of Heart Disease

parenchymal radiographic opacity owing to age- degree of respiratory compromise should always
related pulmonary degenerative changes (intersti- be assessed prior to thoracic imaging.
tial fibrosis, bronchial mineralization, heterotopic If significant amounts of pleural effusion are sus-
pulmonary bone formation). pected, increasing radiographic exposure to ab-
dominal technique-chart levels results in better
intrathoracic radiographic contrast. When pos-
s0090 Pleural Effusion
sible, thoracocentesis and fluid drainage prior to
u0070 Pleural effusion is radiographically evident as fo- radiography is always preferred.
cal areas of increased soft tissue opacity located
within the thoracic cavity. It causes separation of
lung lobes from both the thoracic wall and the ad- Radiographic Anatomy s0100
jacent lobes. This is seen on the lateral projection
Lateral Thoracic Radiographic Projection s0110
as an increase in the soft tissue thickness of the
caudodorsal thoracophrenic angle and diaphragm Cardiac Parameters s0120
as well as linear soft tissue opacities (pleural fis- Even though the lateral radiographic projection de- p0050
sures) at anatomic locations comparable with fines the cranial-caudal and dorsal-ventral dimen-
interlobar fissures (Figure 2-4). Pleural effusion sions of the thorax, the anatomy of the heart of the
also contributes to loss of definition of the cra- dog and the cat as it resides in the thorax also al-
nial and caudal margins of the heart, producing a lows this projection to detail the left and right as-
radiographic positive-silhouette sign. pects of the heart. This is because in the dog and the
In cases of pleural effusion, the VD projection is cat the heart is slightly rotated along its base-apex
much preferred over the DV view for detection axis, such that the right cardiac chambers are posi-
and delineation of cardiac size and shape. If intra- tioned more cranially and the left chambers posi-
thoracic fluid volumes are severe enough, the heart tioned more caudally. Thus, the cardiac silhouette
can effectively disappear on the DV view because as it appears on the lateral projection defines the
of the relative distribution of the fluid and heart right side of the heart along the cranial margin and
in the thoracic cavity. The positive-silhouette the left side is defined by its caudal margin (Figures
phenomenon is accentuated in the DV compared 2-6 to 2-8).
with the VD view (Figure 2-5). However, patient The canine and feline heart shape or radiographic p0060
positioning for the DV projection puts less silhouette is ovoid, with the apex more pointed in
physiologic demand on the patient compromised conformation than the broader base. This base-
by pleural effusion and thus is favored over theVD apex difference in conformation is accentuated
projection. The patients physiologic stability and in the cat. The heart axis is defined by drawing a

1 1
1

f0040 Trachea Heart


Figure 2-4. Lateral thoracic radiographic projection of pleural effusion. Intrathoracic fluid accumulation causes separation of
adjacent lung lobes by (1) linear interlobar opacities, radiographically defined as pleural fissures, and (2) separation of lung lobes
from the thoracic wall.
Chapter 2 Radiology of the Heart 29

L L
VD DV

A B

f0050

Figure 2-5. A, Ventrodorsal (VD) thoracic radiographic projection of pleural effusion consisting of pleural fissure lines (closed
arrows) with blunting of the thoracophrenic angles (open arrows). Note that the cardiac silhouette is still well outlined. B, Dorso-
ventral (DV) thoracic radiographic projection of pleural effusion. The intrathoracic fluid distribution creates a positive silhouette
sign where a complete loss of the cardiac silhouette has occurred. Thus, the VD projection (A) is preferred for cardiac silhouette
definition in the presence of pleural effusion. L, Lateral.

CrVC PAS LP RP

CaV C

RA

TV

f0060 ra PV RV
Figure 2-6. Schematic lateral thoracic radiographic projection of the relative position and size of the right-side structures of the
heart. Note the more cranial position of the right chambers of the heart. CrVC, Cranial vena cava; PAS, main pulmonary artery;
PV, pulmonic valve; ra, right atrial auricular appendage; RV, right ventricle; RA, right atrium; LP, left pulmonary artery; RP, right
pulmonary artery; TV, tricuspid valve; CaVC, caudal vena cava.
30 Section I Diagnosis of Heart Disease

Aa LA

CVC

MV

LVI

f0070 Aor AV Aot LV


Figure 2-7. Schematic lateral thoracic radiographic projection of the relative position and size of the left-side structures of the
heart. Note the more caudal position of the left chambers of the heart. Aa, Aortic arch; AOr, aorta; AV, aortic valve; Aot, aortic
outflow tract; LV, left ventricle; LVi, left ventricular inflow tract; LA, left atrium; MV, mitral valve; CVC, caudal vena cava.

Trachea TB CVC

LA
RA

LV
RV Abdomen

f0080
Figure 2-8. Schematic lateral thoracic radiographic projection outlining the approximate location of the four heart chambers.
TB, Tracheal bifurcation; CVC, caudal vena cava; RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle.

line from the tracheal bifurcation (carina) to the Apso, Bulldog) tend to have more globular-shaped
apex at an angle approximately 45 degrees to the hearts, with increased sternal contact of the cra-
sternal vertebrae. This angle can decrease in the cat nial margin of the heart. The heart chambers can
with age and is often called a lazy heart. It has be roughly defined by a line connecting the apex
been postulated that this may be related to a loss to the tracheal bifurcation and a second line per-
of aortic connective tissue elasticity. This is most pendicular to the base-apex axis and positioned at
often seen in cats older than 7 years. Shallow, the level of the ventral aspect of the caudal vena
barrel-chested dog breeds (Dachshund, Lhasa cava (see Figure 2-8).
Chapter 2 Radiology of the Heart 31

Trachea T4 Unit measuring site CVC

VHS = S + L
f0090 Measured in vertebral units beginning at T4.
Figure 2-9. Schematic representation parameters for the vertebral scale system of cardiac size. The vertebral heart sum (VHS) is
the sum of the long axis cardiac dimension (L) and the maximal perpendicular short axis dimension (S). S and L are measured in
vertebral units beginning at T4. CVC, Caudal vena cava.

p0070
p0100 The dorsal cardiac margin includes both atria, A more objective determination of cardiac size
pulmonary arteries and veins, the cranial and caudal has been formulated for the dog and uses a verte-
vena cavae, and the aortic arch (see Figures 2-6 to bral scale system in which cardiac dimensions are
2-8). The cranial border is formed by both the right scaled against the length of specific thoracic ver-
ventricle and the right atrial appendage, resulting in tebrae (Figure 2-9). In lateral radiographs the long
the radiographically defined cranial waist (see Fig- axis of the heart (L) is measured with a caliper
ures 2-6 and 2-8). The caudal margin is formed by the extending from the ventral aspect of the left main
left atrium and left ventricle, with the atrioventricular stem bronchus (tracheal bifurcation hilus, carina) to
junction defined as the radiographic caudal waist. the left ventricular apex. The caliper is repositioned
p0080 The base-to-apex cardiac dimension or length along the vertebral column beginning at the cranial
occupies approximately 70% of the DV distance of edge of the fourth thoracic vertebra. The length of
the thoracic cavity at its position within the thorax. the heart is recorded as the number of vertebrae cau-
For objective measurements it is important to mea- dal to that point and estimated to the nearest tenth
sure thoracic cavity distance between the thoracic of a vertebra. The maximum perpendicular short
spine and the sternum at an axis perpendicular to axis (S) is measured in the same manner beginning
the thoracic spine. at the fourth thoracic vertebra. If obvious left atrial
The cranial-caudal dimension or width as it ap- enlargement is present, the short axis measurement p0090
pears on the lateral projection is measured at its is made at the ventral juncture of left atrial and cau-
maximum width (which is usually at the level of dal vena caval silhouettes.
the ventral aspect of the insertion of the caudal vena The lengths in vertebrae (v) of the long and p0110
cava) and perpendicular to the base-apex axis. This short axes are then added to obtain a vertebral
classically has been defined as between 2.5 (deep- heart sum (VHS), which provides a single number
chested conformation breeds [Setters, Afghans, representing heart size proportionate to the size
Collies]) and 3.5 (barrel-chested conformation of the dog. The average VHS in the dog is 9.7 v
breeds [Dachshunds, Bulldogs]) intercostal spaces (range 8.5 to 10.5 v). Caution must be exercised in
(ICS) in the dog and 2.5 to 3.0 ICS in the cat. The somebreedsthathave excessively disproportionate
ICS measurement is made at an axis perpendicular skeletalbody weight conformations. An example is
to the long axis of the ribs. Thus, the cardiac width the English Bulldog, which has relatively small tho-
distance determination may have to be shifted in racic vertebrae and commonly has hemivertebrae
axis angle before comparison to ICS length. as well; thus, a normal heart may be interpreted
32 Section I Diagnosis of Heart Disease

Trachea BCrL RPA TB LPA

Heart

f0100 PA PV
Figure 2-10. Pulmonary vascular anatomy in the lateral thoracic projection. Cranial lung lobe branch of the pulmonary artery
(PA), cranial lung lobe branch of the pulmonary vein (PV), end-on view of the right main pulmonary artery (RPA) as it traverses
the thorax from left to right, and left main pulmonary artery (LPA). TB, tracheal bifurcation (carina); BCrL, Bronchus to a cranial
lung lobe.

as large with the VHS method. Although the VHS The pulmonary arteries and veins should be equal
concept is more precise, clinical judgment is still in size. The width of the vessels where they cross
necessary to avoid over diagnosing or under diag- the fourth rib should not exceed the width of the
nosing heart disease. narrowest portion of that rib at its juncture with the
rib head (the dorsal aspect of the rib near the tho-
s0130 Vessel Parameters racic spine). The dorsal section of the rib is used as
p0120 The main pulmonary artery (pulmonary trunk) can- a reference to adjust for radiographic magnification
not be seen on the lateral projection owing to a pos- owing to thoracic conformation.
itive-silhouette sign with the craniodorsal base of
Dorsoventral and Ventrodorsal Projections s0140
the heart. The left pulmonary artery can sometimes
be seen extending dorsal and caudal to the tracheal Cardiac Parameters s0150
bifurcation (carina). The right pulmonary artery is The heart is rotated on its long axis such that the p0150
frequently seen end-on as it leaves the main pul- right chambers are oriented both right and cranially,
monary artery immediately ventral to the carina and the left chambers reside both left and caudal.
(Figure 2-10). This end-on appearance may be con- The degree of rotation is less in the cat. The cranial-
fused with a mass lesion on normal radiographs and caudal rotation is most significant when defining
is accentuated in cases of pulmonary hypertension the location of the left and right atria, respectively.
such as heartworm disease. The pulmonary veins The canine heart appears radiographically as an p0160
are best identified as they enter the left atrium cau- elliptical opacity with its base-apex axis orientation
dal to the heart base. approximately 30 degrees to the left of the midline.
p0130 Using the larger, more proximal segments of the The width of the heart across its widest point is usu-
mainstem bronchi as a reference, the pulmonary ar- ally 60% to 65% of the thoracic width at its loca-
teries are dorsal to the bronchus, and the pulmonary tion within the thorax. In the cat the cardiac axis
veins are ventral to the bronchus (see Figure 2-10). is most commonly on or close to midline, and its
p0140 The vessels to the cranial lung lobes are usu- width does not usually exceed 50% of the width
ally seen as two pairs of vessels, each with their of the thoracic cavity during full inspiration. The
respective bronchi. The more cranial pair of vessels cardiac silhouette may be artificially increased in
generally corresponds to the side on which the lat- the obese patient owing to an excessive amount of
eral projection was made. Thus, in the right lateral pericardial fat. In these cases, the cardiac silhouette
projection, the right cranial lobar vessels are more margin appears to be less well defined or blurred
cranial than vessels of the left cranial lung lobe. because the margin of contrast between soft tissue
Chapter 2 Radiology of the Heart 33

AA
PAS

AV

LV
Aot

Da

f0110
Figure 2-11. Schematic anatomy of the chambers and vasculature of the left ventricular outflow tract of the heart in the dorso-
ventral radiographic projection. LV, Left ventricle; Aot, aortic outflow tract; AV, aortic valve; AA, aortic arch; PAS, pulmonary artery
segment; Da, descending aorta.

PAS

rpa lpa

LA

Pv

f0120
Figure 2-12. Schematic anatomy of the pulmonary vasculature in the dorsoventral projection. PAS, Main pulmonary artery
(radiographic descriptionpulmonary artery segment); lpa, left pulmonary artery; rpa, right pulmonary artery; LA, left atrium; Pv,
pulmonary veins.

(heart), fat (pericardial), and air is not as distinct as vertical in the thorax and thus produces a smaller
that between soft tissue and air. and more circular cardiac silhouette conformation.
Evaluating the obesity of the patient by evalu- The broad, barrel-chested breeds produce a radio- p0170
ating the thickness of the abaxial thoracic wall graphic silhouette that appears wider than that of
and width of the mediastinum (as well as exam- standard breeds.
ining the patient) will assist in the determination The margins of the heart that create the car- p0180
of pericardial fat contribution to cardiac size. In diac silhouette contain a number of structures that
deep, narrow-chested breeds, the heart stands more often overlap. A clock face analogy can be used to
34 Section I Diagnosis of Heart Disease

LAu

2
LA
2

f0130
Figure 2-13. Dorsoventral thoracic radiographic projection of a dog with severe left atrial (LA) enlargement. The left atrial
auricular appendage (LAu) contributes to the cardiac silhouette at the 2 to 3 oclock position (1). The body of the left atrium su-
perimposed over the caudal cardiac silhouette produces a radiolucent mach line, a radiographic edge effect caused by an acute
change in soft tissue thickness (2).

RAa

PAS
RA
PV

RV

CVC

f0140
Figure 2-14. Schematic anatomy of the chambers and outflow tract of the right side of the heart in the dorsoventral radio-
graphic projection. RV, Right ventricle; RA, right atrium; RAa, right atrial auricular appendage; PV, pulmonic valve; PAS, mainstem
pulmonary artery segment; CVC, caudal vena cava.

s implify the location of these structures. The aortic segment (PAS) (Figures 2-12 and 2-13). In the
arch extends from the 11 oclock to 1 oclock posi- cat, the body of the left atrium proper forms the 2
tion (Figure 2-11). The main pulmonary artery is to 3 oclock position of the cardiac silhouette. In
located from the 1 to 2 oclock position, with its the dog, the left atrium is superimposed over the
radiographic designation as the pulmonary artery caudal portion of the cardiac silhouette in the DV
Chapter 2 Radiology of the Heart 35

p rojection (see Figure 2-12). With severe cases of substantiated on multiple radiographic views where
left atrial enlargement in the dog, the left auricular applicable.
u0080 appendage contributes to the definition and enlarge- Evaluate the radiographs for technical quality,
ment of the cardiac silhouette at the 2 to 3 oclock positioning, and proper exposure. If the study is
position (Figure 2-13). The left ventricle forms the substandard, then stop right here and repeat the
left heart margin from the 2 to 6 oclock position radiographic study.
(see Figure 2-11). The right ventricle is located Determine the phase of respiration.
from the 7 to 11 oclock position (the right ven- Review the entire thoracic cavity: spine, sternum,
tricle does not extend to the apex of the heart) (Fig- diaphragm, thoracic wall, ribs, cranial and caudal
ure 2-14). The right atrium is located at the 9 to 11 mediastinum, conformation and position of the
oclock position (see Figure 2-14). Pericardial fat diaphragm.
in the dog can asymmetrically contribute to cardiac Review the portion of the cranial abdomen in-
silhouette enlargement at the 4 to 5 oclock and 8 to cluded in the projection. Thoracic radiographic
11 oclock positions. exposure is usually half of that required for ab-
dominal imaging but a cursory evaluation of ab-
s0160 Vessel Parameters dominal contrast, detail, and hepatic size (using
p0190 The pulmonary arteries originate from the main gastric axis) can be performed.
pulmonary artery or the PAS with the right branch Evaluate the position, course, and diameter of the
coursing transversely, superimposed over the trachea and mainstem bifurcations.
cranial portion of the heart silhouette, extending Evaluate the position of the cardiac apex and cau-
beyond the right heart margin at approximately the dal mediastinum.
8 oclock position (see Figure 2-12). The left pul- Evaluate the size, shape, and course of the main
monary artery branch courses caudally, superim- pulmonary artery and peripheral pulmonary ar-
posed over the caudal left ventricular portion of the teries and veins.
heart, and extends beyond the left heart margin at Evaluate the lung fields for hyperinflation or un-
approximately the 4 oclock position. The pulmo- derinflation and for distribution and pattern of
nary veins are best seen as they enter the left atrium increased or decreased opacity.
along the caudal margin of the cardiac silhouette Evaluate the cardiac margin (cranial, caudal, right,
(see Figure 2-12). Compared with the pulmonary left, clock position segmentation) for enlarge-
arteries, they are clustered in a more axial position. ment, abnormal position, or conformation.
Thus, the pulmonary arteries extend to both the cra-
nial and caudal lung fields in a more abaxial posi-
tion relative to the pulmonary veins. NoncardiacRelated s0180
p0200 The aortic arch is within the cranial mediasti- Variables that can Mimic
num at the cranial heart margin and is normally Radiographic Signs of
not visible. The descending aorta is superimposed Cardiac Disease
over the heart and extends caudally, dorsally, and
Cardiac Position s0190
medially. The left lateral margin of the aorta can
be seen to the left of the vertebral column on both Pulmonary pathology (such as lung consolida- u0090
DV and VD views (see Figure 2-11). The caudal tion, atelectasis, or pleural disease) can cause a
vena cava courses cranially from the diaphragm mediastinal shift and alter the position and axis
to the right of midline and into the right caudal of the heart in the thoracic cavity.
margin of the heart (see Figure 2-14). This is one Mediastinal mass lesions can affect the cardiac
of the most useful landmarks for determination position and axis, as well as obscure the cranial and
of proper orientation of the DV radiograph on a cardiac margins when in contact with the heart, by
viewbox. producing a radiographic positive-silhouette sign.
Pneumothorax can produce disproportionate
hemithoracic volume changes, altering cardiac
s0170 Radiographic position and axis. Pneumothorax commonly
Interpretation produces elevation of the cardiac apex from the
p0210 A systematic evaluation of the entire thoracic sternum. This is supported by other radiographic
cavity involves adherence to and inclusion of the signs of pneumothorax:
following steps with each radiographic interpreta- Premature termination of lung vasculature into
tion. Abnormalities supportive of disease should be the periphery of the thoracic cavity
36 Section I Diagnosis of Heart Disease

Lung lobe margin detection as it contrasts with Uneven lung inflation secondary to disease or
nonparenchymal free intrathoracic gas previous lobectomy can produce a mediastinal
Sternal conformational abnormalities due to con- shift and resultant apex shift.
genital defects or previous trauma can alter car- If radiographs are taken on diseased, recumbent pa-
diac position and axis. tients or patients during or immediately following
general anesthesia, then hypostatic congestion and
atelectasis of the dependent lung fields can produce
Cardiac Size and Lateral Projection s0200
a mediastinal shift, altering cardiac position.
Younger animals appear to have larger hearts Pectus excavatum or funnel chest sternal con- u0100
relative to their thoracic size than do mature formation due to congenital deformities
patients.
The heart appears smaller on inspiration than
s0230 on expiration. During expiration increased ster- Evaluation of Heart
nal contact of the right heart margin and dorsal Chamber Enlargement
elevation of the trachea occurs, falsely suggesting
s0240 Right atrial enlargement
right-heart enlargement.
s0250 Anemic or emaciated patients often have small Radiographic Signs
u0120 hearts owing to hypovolemia and are hyperin- Lateral projection (Figure 2-15):
flated to compensate for hypoxemia. In deep- Elevation of the trachea as it courses dorsally
chested conformation breeds, the cardiac apex over the right atrium
can be elevated far enough from the sternum to Accentuation of the cranial waist. Preferential
mimic pneumothorax. enlargement of the more dorsal margin of the
cranial margin of the cardiac silhouette defines
s0210 Cardiac Position, Dorsoventral/
selective enlargement of the right atrial auricu-
Ventrodorsal Projection
lar appendage.
s0220 Malposition of the Cardiac Apex to the Right Increased soft tissue opacity of the cranial
or Left aspect of the cardiac silhouette owing to in-
u0110 Malposition of the heart to the right is normal creased soft tissue thickness of the right atrium
variant in the cat. superimposed over the right ventricle

Ao Pa RA LA CVC

Abdomen

Trachea RV Normal cardiac LV


silhouette
Figure 2-15. Cardiac silhouette changes associated with vessel and chamber enlargement in the lateral thoracic radiographic
0150 projection. Ao, Aortic arch; Pa, main pulmonary artery; RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle; CVC,
caudal vena cava. Dotted line, area of right atrial superimposition over the right ventricle.
Chapter 2 Radiology of the Heart 37

Aa

PaS

LAa
RA

Normal heart
LV

RV

f0160
Figure 2-16. Cardiac silhouette changes associated with vessel and chamber enlargement in the dorsoventral radiographic
projection. Aa, Aortic arch; PaS, main pulmonary artery; LAa, left atrial auricular appendage; LV, left ventricle; RV, right ventricle;
RA, right atrium.

LA
4 RA

3 LV
RV
2 Abdomen
1

f0170 Trachea CVC


Figure 2-17. Schematic representation of radiographic signs associated with right- heart enlargement in the lateral projection.
(1) Dorsal lifting of apex from sternum. (2) Increased sternal contact of cranial cardiac margin. (3) Disproportionate enlargement
of the cranial portion of the cardiac silhouette when empirically divided into its right and left chambers. (4) Elevation of the tra-
chea as it courses dorsally over the right atrium. RA, Right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; CVC, caudal
vena cava.

DV projection (Figure 2-16): Cardiomyopathy


Enlargement of the cardiac margin at 9 to 11 Right atrial neoplasia (e.g., hemangiosarcoma)
oclock
Enlargement can be dramatic in severe cases Differential Diagnosis s0270
(especially in the cat) and can be easily mis- Cranial mediastinal mass u0140
taken for pulmonary hilar mass lesion. Heart base neoplasia (most common in brachyce-
phalic breeds)
s0260 Causes of Right Atrial Enlargement Tracheobronchial lymphadenopathy
u0130 Right-heart failure Superimposition of the aortic arch or main pul-
Tricuspid insufficiency monary artery
38 Section I Diagnosis of Heart Disease

Right cranial or middle lobar pulmonary alveolar Cardiomyopathy


consolidation or mass lesion Cor pulmonale
Dirofilariasis
s0280 Right ventricular enlargement
Congenital heart disease: pulmonic stenosis,
s0290 Radiographic Signs patent ductus arteriosus (PDA), ventricular sep-
u0150 Lateral projections (see Figure 2-15) tal defects, tetralogy of Fallot, tricuspid valve
Increased sternal contact of cranial cardiac dysplasia
margin
Left Atrial Enlargement s0310
Elevation of the cardiac apex from the ster-
num Radiographic Signs s0320
Rounding of the conformation of the entire car- Lateral projection (see Figure 2-15) u0170
diac silhouette; increased cardiac width Dorsal elevation of the caudal portion of tra-
Disproportionate enlargement of the cranial chea and carina
portion of the cardiac silhouette when empiri- Disproportionate dorsal elevation of the main-
cally divided into its right and left chambers stem bronchi (the two will no longer be super-
(Figure 2-17) imposed; the left bronchus will appear more
Dorsal elevation of the caudal vena cava dorsal than the right bronchus)
DV projection (see Figure 2-16) Enlargement and straightening of the cau-
Cardiac silhouette enlargement at the 6 to 11 dodorsal portion of the cardiac silhouette
oclock position with almost a right-angle margin confor
Given the enlargement and rounded conformation mation (Figure 2-18); straightening of the
of the right margin, the left margin in comparison caudal margin of the heart and loss of the
assumes a more straightened conformation; an caudal waist (determined by the atrioven-
overall reverse-D conformational appearance tricular junction)
of the cardiac silhouette results DV projection (see Figure 2-16)
Shift of cardiac apex to the left The dog
Enlargement of the atrial auricular append-
s0300 Causes of Right Ventricular Enlargement age, which now produces a noticeable focal
u0160 Secondary to left-heart failure bulge enlargement at the 2 to 3 oclock po-
Tricuspid insufficiency sition (see Figures 2-13 and 2-16)

Trachea

3 5

4
LA
RA
2

RV LV

180
Figure 2-18. Schematic representation of radiographic signs associated with left- heart enlargement in the lateral projection.
(1) Rounding and widening of the cardiac apex conformation. (2) Straightening and increased vertical axis of the caudal cardiac
margin. (3) Left atrial enlargement with characteristic right-angular caudodorsal margin conformation. (4) Dorsal elevation of the
intrathoracic portion of the trachea, carina, and mainstem bronchi. The angle between the thoracic spine axis and the trachea is
diminished to the point of becoming parallel. (5) Separation of normally superimposed caudal mainstem bronchi. Left more dorsal
in position than the right. RA, Right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle.
Chapter 2 Radiology of the Heart 39

A double opacity of the atrial body


s0380 Enlargement of the aortic arch and aorta
over the caudal aspect of the cardiac
s0390 silhouette; the body of the left atrium su- Radiographic Signs
u0220 perimposed over the caudal cardiac silhou- Lateral projection (see Figure 2-15)
ette producesaradiolucent mach line, Widening of the dorsal aspect of the cardiac
a radiographic edge effect caused by an silhouette
acute change in soft tissue thickness (see Enlargement of the craniodorsal cardiac
Figure 2-13) margin
The cat DV projection (see Figure 2-16)
Enlargement if the cardiac margin at the 2 to Widening and increased cranial extensions of the
3 oclock position of the silhouette cardiac margin between the 11 and 1 oclock
positions.
s0330 Causes of Left Atrial Enlargement
u0180 Mitral insufficiency Causes of Aortic Arch Enlargement s0400
Cardiomyopathy PDA; enlargement more abaxial (1 oclock) u0230
Congenital heart disease; mitral valve dyspla- Aortic stenosis with poststenotic enlargement of
sia, PDA, ventricular septal defects, atrial septal the aortic arch; enlargement more axial and cra-
defects nial (11 oclock)
Left ventricular failure Aortic aneurysm (very rare)

s0340 Differential Diagnosis Differential Diagnosis s0410


u0190 Hilar lymphadenopathy Normal variation in some dogs u0240
Pulmonary mass adjacent to hilus Very common variant in older cats with lazy
heart conformation; very prominent on the DV
s0350 Left Ventricular Enlargement
projection
s0360 Radiographic Signs Cranial mediastinal mass
u0200 Lateral projection (see Figure 2-15) Thymus, or the sail-sign in young dogs
Loss of the caudal waist Cranial mediastinal fat in obese brachycephalic
Caudal cardiac margin straighter and more ver- dogs
tical than normal
Enlargement of the pulmonary artery s0420
Dorsal elevation of the intrathoracic portion
of the trachea, carina, and mainstem bronchi; Radiographic Signs s0430
the angle between the thoracic spine axis and Lateral projection (see Figure 2-15) u0250
trachea is diminished to the point of becoming Protrusion of the craniodorsal heart border
parallel DV projection (see Figure 2-16)
Disproportionate enlargement of the caudal Lateral bulge of the cardiac margin at 1 to 2
portion of the cardiac silhouette when em- oclock position
pirically divided into its right and left cardiac Radiographically defined as the pulmonary ar-
chambers (see Figure 2-18) tery segment (PAS)
DV projection (see Figure 2-16)
Rounding and enlargement of left ventricular Causes of Pulmonary Artery Segment s0440
margin Enlargement
Rounding and broadening of the cardiac apex Dirofilariasis u0260
conformation Pulmonary thrombosis and thromboembolism
Shift of the cardiac apex to the right Cor pulmonale
Congenital disease: pulmonic stenosis, PDA, sep-
s0370 Causes of Left Ventricular Enlargement tal defects both ventricular and atrial with left-to-
u0210 Mitral insufficiency right shunting
Cardiomyopathy
Congenital heart disease: PDA, aortic stenosis, Differential Diagnosis s0450
ventricular septal defects Previous dirofilariasis infection and treatment u0270
High-output cardiac disease: fluid overload, Rotational (oblique) positional artifact (usually
chronic anemia, peripheral arteriovenous fistula, on VD projection) most commonly experienced
obesity, chronic renal disease, hyperthyroidism with deep-chested conformation dogs
40 Section I Diagnosis of Heart Disease

s0550
Evaluation of the Radiographic Diagnosis s0460
Pulmonary Circulation of Heart Failure
p0220 The radiographic diagnosis of heart failure is de-
Undercirculation s0470
pendent upon recognition of imbalances in the
Radiographic Signs blood and fluid distribution within the body. This s0480
Lung field more radiolucent than normal owing circulatory imbalance is the result of diminished u0280
to lack of pulmonary vascular volume cardiac output into the pulmonary or systemic
Hyperinflation due to hypoxemia or ventilation/ vascular systems or reduced acceptance of blood
perfusion mismatch by the failing ventricle (hypertrophy), or both. De-
Pulmonary arteries smaller than normal; may be pending on which side of the heart is most severely
smaller in size when compared with correspond- affected, blood is shifted from the systemic to the
ing pulmonary veins pulmonary circulation (left-heart failure) or from
the pulmonary to the systemic circulation (right-
s0490 Causes of Pulmonary Undercirculation heart failure).
u0290 Congenital disease: pulmonic stenosis, te-
Right-heart failure s0560
tralogy of Fallot, reverse PDA (right-to-left
shunting) Physiologic Phenomenon s0570
In right-heart failure, an inadequate right ven- u0340
s0500 Differential Diagnosis tricular output into the pulmonary arteries ex-
u0300 Emphysema, chronic obstructive pulmonary ists concurrently with a reduced acceptance of
disease blood from the systemic veins. The blood vol-
Hyperinflation ume and pressure in the splanchnic and systemic
Pneumothorax veins are elevated. The venous congestion causes
Overexposure hepatomegaly.
Pulmonary thromboembolism With further progression of right-heart failure,
Hypovolemia, shock (the heart will also be a progression of systemic hypertension leads to
smaller than normal) increased amounts of fluid, solutes, and protein
Hypoadrenocorticism (Addisons disease); the escaping from the capillary beds of the major
heart may also be smaller than normal organs. The lymphatic circulation is overtaxed,
and fluid exudes into the serosal cavities, pro-
s0510 Overcirculation
ducing ascites, pleural, and even pericardial
s0520 Radiographic Signs effusions.
u0310 Both the pulmonary arteries and the veins are The extracardiac radiographic signs of progres-
enlarged sively worsening right-heart failure are hepato-
Arteries are frequently larger than the veins megaly, ascites, and then pleural effusion.
Pulmonary thoracic opacity is increased because
of larger vascular volume Radiographic Signs s0580
Right-sided cardiomegaly (see Figures 2-15 u0350
s0530 Causes of Pulmonary Overcirculation through 2-17). Patients with concentric cardiac
u0320 Dirofilariasis (arteries are larger than correspond- hypertrophy (e.g., pulmonic stenosis), thin-
ing veins) walled cardiomyopathy, or acute arrhythmias
PDA: both arteries and veins enlarged often may not have dramatic radiographic cardio-
Left-to-right shunts (ventricular and atrial septal megaly. Thus, subtle cardiac silhouette changes
defects): both arteries and veins enlarged in both the DV and the lateral projections must
Congestive heart failure: veins may be larger than be considered significant with supportive clinical
arteries if mainly left sided; both arteries and evidence of cardiac disease.
veins enlarged with concurrent left- and right- Hepatomegaly: rounded liver margin, which ex-
sided failure tends caudal to last rib; displacement of stomach
Fluid overload caudally and to the left
Ascites: abdominal distention; diffuse loss of
s0540 Differential Diagnosis intra-abdominal detail
u0330 Underexposure Pleural effusion
Expiratory phase of respiration Generalized increase in thoracic opacity
Chapter 2 Radiology of the Heart 41

Visualization of interlobar pleural fissures (see Engorgement and distention of the pulmonary
Figures 2-4 and 2-5, A) veins, especially in the hilar area as they enter
Obliteration of cardiac silhouette definition the left atrium. On the DV view these are iden-
(best demonstrated on the DV projection) (see tified as the more axial of the caudal vascula-
Figure 2-5, B) ture (see Figure 2-12).
Separation of pulmonary visceral pleural mar- The diameter of the pulmonary veins is greater
gin away from thoracic wall (see Figures 2-4 than that of their corresponding pulmonary ar-
and 2-5) teries (best seen on the lateral projection with
cranial lobar vessels) (see Figure 2-10).
s0590 Causes of Pleural Effusion Secondary to Right- The radiopacity of the lung parenchyma distal
Heart Failure and peripheral to the hilus is unchanged.
u0360 Decompensated mitral and tricuspid insufficiency Interstitial edema
Decompensated pulmonic stenosis, tetralogy of Diffuse increased radiopacity of the lung fields
Fallot owing to a hazy interstitial opacity is apparent.
Dirofilariasis (caval syndrome) The margins of the pulmonary veins and arter-
Pericardial effusion with tamponade ies are indistinct owing to perivascular edema.
Restrictive pericarditis As the lung parenchyma surrounding the pul-
monary vasculature fills with fluid, the normal
s0600 Differential Diagnosis pulmonary radiographic contrast between gas
u0370 Pleuritis (air-filled lung) and soft tissue (blood-filled
Chylothorax vessels) is lost. Thus, the pulmonary vascu-
Hemothorax laturebecomes indistinct and begins to dis
Pyothorax appearin the surrounding, fluid-filled lung
Hypoproteinemia parenchyma.
Neoplasia (pleural, mediastinal, cardiac, pulmo- In some patients, fluid accumulates around ma-
nary, primary, or metastatic) jor bronchi, producing prominent peribronchial
markings.
s0610 Left-heart failure
Alveolar edema
s0620 Physiologic Phenomenon Radiographic signs
u0380 In left-heart failure, inadequate left ven Fluid enters the alveolar air spaces and
tricular output into the aorta occurs, and a peripheral bronchioles, causing a coales-
diminished acceptance of blood from the pul- cent fluffy alveolar infiltrate. Air broncho
monary veins entering the left atrium results. grams(black tubes in a white radiopaque
This causes pulmonary venous congestion background) and air alveolograms (lung
and leakage of fluid into the pulmonary in- parenchyma with the radiopacity of liver
terstitium, with progression to flooding of the containing no vascular markings) are pres-
alveoli. ent. In the cat, cardiogenic alveolar consoli-
Clinically, this evolves as a progression of physi- dations can appear as a very well margined,
ologic events: pulmonary venous congestion, in- cloudlike conformation area of increased
terstitial pulmonary edema, alveolar edema, and pulmonary radiopacity.
lung consolidation. The margins of the pulmonary vessels are
usually completely obscured (see Figure 2-3,
s0630 Radiographic Signs B). The alveolar infiltrate is of greatest opac-
u0390 Left-sided cardiomegaly (see Figure 2-18). Pa- ity in the perihilar area, fading peripherally.
tients with concentric cardiac hypertrophy (e.g., In the dog, alveolar edema can be asymmet-
aortic stenosis), thin-walled cardiomyopathy rical, with the right lung fields more severely
(large- and giant-breed dogs), or acute arrhyth- affected than the left (best seen on the DV
mias often may not have dramatic radiographic projection).
cardiomegaly. Thus, subtle cardiac silhouette Differential diagnosis for pulmonary edema
changes in both the DV and lateral projections Neurogenic: electrocution, head trauma, post
as well as noncardiac changes (pulmonary vas- seizure, encephalitis, brain neoplasm
cular changes, pulmonary edema, etc.) must be Hyperdynamic (excessive negative intratho-
evaluated. racic pressures): choking, strangulation, up-
Pulmonary venous congestion per airway obstructions
42 Section I Diagnosis of Heart Disease

Trachea CVC

1
2

3 Abdomen

Pericardial Normal cardiac Pericardial


f0190 effusion silhouette effusion
Figure 2-19. Schematic representation of radiographic signs associated with pericardial effusion. (1) Dorsal elevation of the
intrathoracic portion of the trachea, carina, and mainstem bronchi. The angle between the thoracic spine axis and the trachea is
diminished to the point of becoming parallel. (2) Convex enlargement of the caudodorsal cardiac margin without a right-angle
conformation characteristic for left atrial enlargement. (3) Increased sternal contact of cranial margin. (4) Dorsal elevation and
enlargement of the caudal vena cava (CVC). The cardiac silhouette takes on a smoothly contoured circular conformation with
obliteration of normal cardiac contour.

Fluid overload: overhydration Dorsal elevation of the trachea (similar to left-


Toxicity side enlargement)
Systemic shock Hepatomegaly, ascites, and pleural effusion second-
Hypersensitization ary to cardiac tamponade (see Figures 2-4 and 2-5)
Drowning
Increased bronchial markings in some cases
s0650 Summary of Radiographic
Pleural effusion
Signs
In the dog, this can occur only in very progres-
p0230 sive or severe forms of left-heart failure; this The clinician must be armed with both potential
usually indicates early concurrent left- and radiographic parameters and a clinically derived
right-heart failure. differential diagnostic list for cardiac disease
In the cat, pleural effusion is very common before the radiographic image can begin to pro-
with only left-heart failure; this can be sepa- vide useful information. Table 2-2 summarizes the
rated from right-heart failure by the absence of radiographic signs associated with congenital and
accompanying hepatomegaly and ascites. acquired heart diseases. Awareness of noncardiac
and artifactual conditions that can present with the
same radiographic signs is also paramount to a cor-
s0640 Radiographic Diagnosis of rect diagnosis.
Pericardial Effusion
u0400 Generalized enlargement of cardiac silhouette in
s0660 Introduction to Digital
a basketball conformation, with elimination of
Radiography
all normal cardiac margin contours on all views
p0240 Increased sternal contact of the cranial margin Digital radiography is a relatively new technology
and convex bulging of the caudal margin, without that is becoming common place in veterinary medi-
the angular conformation and straightening char- cine. It is been used in human medicine for over 20
acteristic for left atrial and ventricular enlarge- years and has been thoroughly tested and proven.
ments (Figure 2-19) There are many advantages to digital radiography
Elevation and enlargement of the caudal vena beyond the excellent image quality (Figure 2-20)
cava which include:
t0020
TABLE 2-2 Summary of Radiographic Signs of Congenital and Acquired Cardiac Disease

Lesion RA RV LA LV Aorta MPAs PAb PV VC Failure/Side Failure/Type

Congenital defects
Patent ductus arteriosus N In In In In In In In N/In Left Volume
Pulmonic stenosis In In N/De N/De N In N/De N/De In Right Pressure
Aortic stenosis N N/In N/In In In N N N/In N Left Pressure
Ventricular septal defect N In In In N N/In In In N/In Left Volume
Tetralogy of Fallot N/In In N/De N/De N De/N/In De De N Right Pressure
Atrial septal defect In In N/In N N N/In N/In N/In N/In Left Volume
Acquired heart disease
Mital insufficiency N N/In In In N N N In N Left Fluid
Tricuspid insufficiency In In N N N N N N In Right Fluid
Aortic insufficiency N N In In N/In N N In N Left Fluid
Hypertrophic cardiomyopathy In In In In N N N/In N/In N/In Left>Right Myocardial
Dilated cardiomyopathy In In In In N N N/In N/In N/In Right>Left Myocardial
Pericardial effusion In In In In N N N/De N/De In Right Tamponade

RA, Right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; MPAs, main pulmonary artery segement; PAb, pulmonary artery branches; PV, Pulmonary vein; VC, caudal vena cava;
In, enlarged or increased; De, smaller or decreased; N, normal.
Chapter 2 Radiology of the Heart
43
44 Section I Diagnosis of Heart Disease

f0200
Figure 2-20. Right lateral view of the thorax taken with a flat panel detector system (DR). Note that all structures (bone, lung,
pulmonary vessels, spine, etc) are visible in the same image. There are no areas of overexposure or underexposure.

Other devices such as film scanners and digital


cameras can be used to digitize conventional
x-ray film that allows the image to be stored on a
computer. Once the image is acquired and stored
it can be manipulated by the user to taste.
There are financial savings over time including:
No cost for radiology disposable (film, chemi-
cals)
No expense for processor maintenance, film
jackets and storage space
Perhaps the most significant means of recoup-
ing revenue pertains to the fact there will be a
significant reduction in the number of retakes
because there should be little to no need to re-
take images due to under or overexposure.
Flat panel technology (also known as digital
f0210 radiography [DR] or direct digital radiography
Figure 2-21. Flat panel detector (DR plate) made by Can-
[DDR] [Figure 2-21]) is the most expensive form
on (CXDI-50G). This plate is mounted out of sight under of digital radiography; however, this technol-
the x-ray table top in the location of the Bucky tray. The plate ogy results in the highest quality image. These
converts x-ray photon energy to an electrical pulse which is systems consist of a DR plate that is physically
then interfaced with an acquisition station computer.
mounted in the area of the Bucky tray under the
x-ray table top. The plate is then electronically
interfaced to both the x-ray machine and a dedi-
u0410 No lost films cated computer (acquisition station). Of the three
No film degradation over time forms of digital radiography, DR systems are ex-
The ability to view images on any networked tremely forgiving as far as technique (kVp and
computer at your clinic or home mAs settings) (Figure 2-22). This in turn simpli-
The ability to easily send images to specialists fies a typical technique chart to essentially three
for consultation or four settings (small, medium, large and extra
There are several types of digital acquisition sys- large) no matter if you are imaging bone, tho-
tems, including flat panel radiology, computed rax, or abdomen. Another advantage of DR sys-
radiography, and charge-coupled device systems. tems include extremely quick image time (3 to 8
Chapter 2 Radiology of the Heart 45

f0220
Figure 2-22. Technique independence. These three exposures were made with different mAs settings and identical kVp (90). A,
1.8 mAs. B, 2.5 mAs. C, 5.0 mAs. Note that all three exposures appear similar and are diagnostic. The computer software corrects
for under or overexposure automatically. This decreased the number of retakes and increases productivity. On the other hand, if
image A is magnified, it will appear much grainier than the other images.
46 Section I Diagnosis of Heart Disease

seconds before the image is seen on a computer


monitor) which allows the user to either save or
delete the image immediately if it is not satisfac-
tory (rotated, crooked, etc).
Computed radiography (CR) systems use im-
aging plates that resemble traditional x-ray
cassettes. The major difference is that the in-
tensifying screen and film within the cassette is
replaced by a flexible phosphor plate that has
the ability to store a latent image. These storage
phosphor plates operate similarly to the screen
inside a conventional cassette in that they emit
light (scintillate) in response to incident x-ray en-
ergy. However, unlike an x-ray screen, a storage
phosphor plate retains a portion of the energy as
a latent image, which is extracted (read out) by
a CR reader. In general, the image quality from a
CR system is very high (similar to that of DR);
however, CR is typically less forgiving as far as
technique (compared to DR) which necessitates
a more complicated technique chart. The image
time for most CR systems range from about 55 to
90 seconds. CR systems are less expensive than
DR systems, however.
Charge-coupled device systems consist of a phos- f0230
phor storage plate mounted under the x-ray table Figure 2-23. Dedicated x-ray film scanner (Vidar Sierra). An
top that is in turn interfaced with a small light x-ray film is fed into the machine, and it is converted to a
sensitive chip (CCD chip) similar to that found in digital image that can be stored on a computer.

digital cameras and video cameras. These CCD


chips are commonly about 2 cm in size and may of significant grey scale data. Because of this
have thousands of individual light sensitive ele- fact, the use of film scanners and digital cameras
ments on them. Because of the small size of the are not recommended as a means of sending im-
chips, the aerial image (14 17, etc.) must be ages for consultation (teleradiology).
minified down to the size of the CCD chip. This
is usually accomplished using a series of mirrors
and lenses, which unfortunately results in a sig-
nificant loss (90%) of the photon data. This loss
of data can often make the resultant image appear b0030 Key Points
grainy or pixilated on the computer monitor Digital Radiography (DR) is extremely fast,
which is accentuated if the image is electroni- is technique independent, has the highest
cally magnified. On the other hand, CCD systems image quality but is the most expensive
have fast image time (similar to DR systems) and method.
are less expensive than DR systems. Because Computed Radiography (CR) is slower, is
of the nature of these systems, they are usually somewhere between conventional film-
sold as a complete system that includes the x-ray screen technology and DR as far as reliance
machine. on x-ray technique, has high image quality,
Dedicated x-ray film scanners (Figure 2-23) and and is moderately expensive.
digital cameras are not forms of digital radiogra- Charged Coupled Devices (CCD) systems
are fast, are similar to CR systems as far as
phy. Both of these methods only reproduce the
technical factors, have the poorest image
traditional hard copy radiograph, and in gen- quality, and are the least expensive.
eral do a poor job of image reproduction. Even Film scanners and digital cameras are not
expensive multi-megapixel digital cameras now forms of digital radiography and have a lim-
available do a poor job of converting an analog ited role.
xray image into a digital format without the loss
Chapter 2 Radiology of the Heart 47

for free) and they do not need to have specific


Introduction to s0670
GE software to view the images. DICOM allows
Teleradiology
the practicing veterinarian to send non-lossy,
Teleradiology (telemedicine) offers the practi- high-quality images that incorporate patient data p0250
tioner quick access to board certified special- directly to any radiologist of their choosing. Al-
ists for case consultation. Once the radiographic though DICOM compliance initially met with
images are in a digital format, they can be sent resistance (mostly from vendors), it has become
to any specialist for review via the World Wide common place in veterinary medicine and will
Web. There are several methods of accomplish- continue to flourish.
ing this including using dedicated teleradiology
companies, emailing images directly to special- Frequently Asked Questions b0040
ists, or by using DICOM.
At this time, there are four or five companies in A Weimaraner dog is being anesthetized. Because of u0420
the United States that cater to veterinary telemed- a murmur and mild coughing episodes, the heart and
especially lung fields are of interest. The DV radio-
icine. In general, these companies provide the graph is not too light, and not too dark. This judgment
necessary software that allows the veterinarian is determined by the:
to upload digital images to the companys server 1. Inability to see the bony column details (very
and they in turn send those images to affiliated white), but a light (white) appearance of the lung
radiologists, internists, etc. The referring practice fields to increase detail visualization there.
pays a fee to the teleradiology company which 2. Ability to see the outline of the heart clearly
in turn pays the specialists to read their images. against the lungs.
3. Ability to see the thoracic vertebrae in the area
The disadvantage of this type of service is that where they overlap the cardiac silhouette.
the referring veterinarian often pays a premium 4. The appearance of the lungs as a dark air densi-
fee (more than they would pay if they could send ty, and full visualization of the bony structures.
the images directly to the specialist), they may The most correct answer is #3. This indicates
not have any or little input on exactly which spe- the appropriate technique. The first option indi-
cialist their images are sent to and they may have cates that this is too light a technique. This is com-
little ability to directly communicate with that mon where the technique has not been adjusted in
obese patients. In #2, seeing the outline of the heart
specialist. clearly against the lungs is not necessarily associ-
Submission of images via standard email can be ated with technique, but may be due to pathology in
simple, but it is not recommended. Because of the area. The #4 answer is burning through the soft
the very large image size of digital radiographs tissues and is not appropriate for heart and lung stud-
(a 14 17 radiograph of the thorax can be 14 ies.
megabytes of information) these images must be A new digital radiography system has just been in-
compressed or saved in a lossy format (such as stalled. The practice has opted for the flat panel tech-
nology. It does not appear that the image is different
jpg) before emailing, thus making the transmit- even when thin, obese or barrel shaped dogs are im-
ted image of poor quality. Also, in the authors aged using the same settings. This means:
experience, these images are often submitted 1. Further staff training is needed.
with a lack of necessary patient information and 2. This is normalonly four basic settings will be
history. needed with digital radiography, and that is why
DICOM (Digital Image Communication in Med- we chose the system!
icine) is a proven and world wide recognized 3. The chart needs to be evolved further, because
something must be wrong if the same setting
method of transmitting high-quality, lossless, dig- works for a large range of animals.
ital radiographs (and other medical images such 4. The equipment is working better than prom-
as ultrasound) from one place to another. DICOM ised.
images are embedded with very specific informa- Answer #2 is most correct. Answer #1 is not probably
tion regarding patient data as well as the type an issue because this is the most forgiving of the im-
of system that the images were acquired on and aging systems, digital or traditional.
this information cannot be altered. Also, DICOM Answer #3 is not relevant because only three or
four settings will capture all dog breeds and body
allows transmission of images without the need condition scores. Answer #4 is normal for this system.
for proprietary software that is vendor specific. Though most expensive, this digital radiography sys-
For example, if you have a GE brand ultrasound tem is known to be the most forgiving and is known
machine, the images can be read by any radiolo- to produce the highest quality images.
gist with a DICOM viewer (which can be found
48 Section I Diagnosis of Heart Disease

s0680 Suggested Readings


The thoracic radiographs for this patient are not
easily interpreted so the plan is to: Animal Insides. http://www.animalinsides.com (accessed
1. Take another view and use foam supports to help October, 2006).
stabilize the body in a fully vertical position, to Buchanan JW, Bucheler J: Vertebral scale system to mea-
ensure sternum and spine are superimposed sure canine heart size in radiographs. J Am Vet Med
which gives a better image. This still does not Assoc 206:194-199, 1995.
provide a clear answer, so no significant find- Bushberg JT, Seibert JA, Leidholdt EM, et al: The essen-
ings is placed on the medical record, assuming tial physics of medical imaging, Philadelphia, 2002,
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2. Follow the steps in answer #1 and send a jpg to 1970, WB Saunders.
the telemedicine group for a radiologist opinion. Kittleson MD, Kienle RD: Small animal cardiovascular
3. Follow the steps in answer #1 and send a DI- medicine. St Louis, 1998, Mosby.
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Answer #3 is the best option as a lossless format, ogy. ed 2, Philadelphia, 1999, WB Saunders.
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here. Answer #2 is going to degrade the imageif
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it could compromise patient care. #1 is a good first
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step, but if the attending clinician does not have a
confident interpretation, then use of a specialist will
provide the gold standard for care. Generalist prac-
titioners cannot be the master of all trades, and with
the ability to transmit high-quality images of reason-
able size, questionable interpretations for radiographs
should always be referred for a specialist evaluation
via telemedicine.