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CHEST

ROENTGENOGRAPHY
PEDIATRIC CARDIOLOGY
JULY 2014

CHEST X RAY - Posteroanterior And Lateral


Views

HEART SIZE AND SILHOUETTE


HEART SIZE
CARDIOTHORACIC (CT) RATIO :
relating the largest transverse diameter of
the heart to the widest internal diameter of
the chest
(A+ B ) / C
> 0.5 cardiomegaly
Newborn & small infants :
Estimation of cardiac volume by inspecting
PA
and lateral views

Isolated right ventricular enlargement may not be


obvious on a posteroanterior film but is obvious on a
lateral film.
In a patient with a flat chest (or narrow anteroposterior
diameter of the chest), a posteroanterior film may
erroneously show cardiomegaly.
An enlarged heart on chest x-ray films more reliably
reflects a volume overload than a pressure overload.

NORMAL CARDIAC SILHOUETTE

Lateral projection of the


cardiac silhouette is formed
anteriorly by the RV and
posteriorly by the LA above
and the LV below

ABNORMAL CARDIAC SILHOUETTE

Left vertical vein, left


innominate vein & dilated
SVC snowmans head

Narrow-waisted & egg-shaped


heart
Narrow-waisted due to absence of
large thymus and abnormal
relationship of great arteries
Increased PBF

EVALUATION OF CARDIAC CHAMBERS & GREAT


ARTERIES

SIZE OF THE GREAT ARTERIES

SIZE OF THE GREAT ARTERIES

SIZE OF THE GREAT ARTERIES

PULMONARY VASCULAR MARKINGS


INCREASED PULMONARY BLOOD FLOW
the right and left pas appear enlarged and extend into the lateral third of the lung field,
where they are not usually present
there is increased vascularity to the lung apices where the vessels are normally
collapsed
the external diameter of the right pa visible in the right hilus is wider than the internal
diameter of the trachea.
Increased pulmonary blood flow in :
- an acyanotic child represents ASD, VSD, PDA, ECD, PAPVR, or any combination of these.
- a cyanotic infant : TGA, TAPVR, HLHS, Persistent truncus arteriosus or single ventricle

PULMONARY VASCULAR MARKINGS


DECREASED PULMONARY BLOOD FLOW
the hilum appears small
the remaining lung fields appear black
the vessels appear small and thin
Ischemic lung fields are seen in cyanotic heart diseases with
decreased pulmonary blood flow such as :
- critical stenosis or atresia of the pulmonary or tricuspid
valves,
including TOF

PULMONARY VASCULAR MARKINGS


PULMONARY VENOUS CONGESTION
a hazy and indistinct margin of the pulmonary vasculature
this is caused by pulmonary venous hypertension secondary to left
ventricular failure or obstruction to pulmonary venous drainage
(e.g., mitral stenosis, TAPVR, cor triatriatum).
kerley's b lines are short, transverse strips of increased density best seen in
the costophrenic sulci.
this is caused by engorged lymphatics and interstitial edema of the
interlobular septa secondary to pulmonary venous congestion.

PULMONARY VASCULAR MARKINGS


NORMAL PULMONARY VASCULATURE
in patients with :
- obstructive lesions such as pulmonary stenosis or aortic
stenosis.
Unless the stenosis is extremely severe, pulmonary vascularity
remains normal in pulmonary stenosis
- small left-to-right shunt lesions also show normal pulmonary
vascular markings.

SYSTEMIC APPROACH
LOCATION OF THE LIVER AND STOMACH GAS BUBBLE
the cardiac apex should be on the same side as the stomach or opposite the hepatic
shadow.
SKELETAL ASPECT OF CHEST X-RAY FILM
- Pectus excavatum may flatten the heart in the anteroposterior dimension and cause a
compensatory increase in its transverse diameter, creating the false impression of
cardiomegaly.
- Thoracic scoliosis and vertebral abnormalities are frequent in cardiac patients.
- Rib notching is a specific finding of coa in an older child (usually older than 5 years) and
is usually found between the fourth and eighth ribs.

IDENTIFICATION OF THE AORTA


1.

Identification of the descending aorta along the left margin of the spine usually indicates
a left aortic arch; identification along the right margin of the spine indicates a right aortic
arch. right aortic arch is frequently associated with TOF or persistent truncus arteriosus.

2.

When the descending aorta is not directly visible, the position of the trachea and esophagus
may help locate the descending aorta. If the trachea and esophagus are located slightly to
the right of the midline, the aorta usually descends normally on the left (i.e., left aortic arch).
In the right aortic arch, the trachea and esophagus are shifted to the left.

3.

In a heavily exposed film, the precoarctation and postcoarctation dilatation of the aorta may
be seen as a figure of 3. this may be confirmed by a barium esophagogram with e-shaped
indentation.

UPPER MEDIASTINUM
1.

The thymus is prominent in healthy infants and may give a false impression of cardiomegaly.
It may give the classic sail sign.

2.

The thymus shrinks in cyanotic infants or infants under severe stress from CHF .
In TGA, the mediastinal shadow is narrow (narrow waist), partly because of the shrinkage of

the
thymus gland. Infants with digeorge syndrome have an absent thymic shadow and a high
incidence of aortic arch anomalies.
3.

A snowman figure (or figure-of-8 configuration) is seen in infants, who are usually older than
4 months, with anomalous pulmonary venous return draining into the svc through the left svc
(vertical vein) and the left innominate vein

PULMONARY PARENCHYMA

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