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The Chest X-ray • Still common • In patient • Portable imaging • ‘Morning Portables’ • Pre-op • Post-op • Out patient • Still effective but possibly overused http://lifeinthefastlane.com/investigations/cxr-normal/ http://cdn.lifeinthefastlane.com/wp-content/uploads/2012/08/CXR-AP.jpg The Chambers Left Atrium Right Atrium Right Ventricle Left Ventricle Right Ventricle Left Atrium Left Ventricle The Pulmonary and Aortic Vessels Aortic Arch MainRDPA PulmonaryLDPA Artery Descending Aorta Aortic Arch Main Pulmonary Artery Descending Aorta This Lecture • Pulmonary Hypertension • Ventricular Septal Defect • Mitral Stenosis vs Mitral Regurgitation • Aortic Stenosis Pulmonary HTN • Increase in pulmonary vascular resistance • Mean pulmonary artery pressure (PAP) >25mmHg at rest • At least 30 mmHg during exercise • Mean pulmonary wedge pressure < 15mmHg Causes • Group 1 • Idiopathic • Pulmonary Arterial Hypertension • Group 2 • Left Heart Disease • Pulmonary Venous Hypertension • Group 3 • Hypoxemia • COPD • Group 4 • Group 5 Clinical Indications • Dyspnea on exertion • Dizziness • Syncope • Angina Radiographic Indicators • Prominent main pulmonary artery • Convex shadow along the left cardiac border (PA) • Right ventricle enlargement • Increased cardiac border in contact with anterior chest wall (Lat) • Right descending pulmonary enlargement • Transverse diameter is greater than 16mm • Pruning of peripheral pulmonary vessels • Abrupt tapering of distal pulmonary vessels with loss of side branches • Pleural effusion/Pulmonary Edema Prominent Main Pulmonary Artery and Trunk Enlarged RDPA Pleural Effusion Case courtesy of Dr Frank Gaillard, Radiopaedia.org Enlarged Right Ventricle Enlarged Pulmonary Trunk http://posterng.netkey.at/esr/viewing/index.php?module=viewing_poster&task=viewsection&pi=100743& ti=311759&searchkey= Miniati et al. Accuracy of chest radiography in predicting pulmonary hypertension: A case-control study. M. Miniati et al. / Thrombosis Research 133 (2014) 345–351 http://www.vcuthoracicimaging.com/Historyanswer.aspx?qid=40&fid=1 Ventricular Septal Defect • Holes in the ventricular septum • • • • Conoventricular Perimembranous Inlet Muscular • Most common congenital cardiac malformation • Up to 50% in congenitally malformed hearts Causes • Can exist in isolation • Or existing with other malformations: • • • • Tetralogy of Fallot Double outlet right ventricle Transposition Univentricular hearts Clinical Indications • Dependent on size • May be asymptomatic • May be cyanotic • Retardation of growth • Pulmonary HTN • Pulmonary edema • Wheezing • Tachypnea Radiographic Indicators • Cardiomegaly • Can be difficult to diagnose due to the thymus • Increased pulmonary vascular markings Normal Ventricular Septal Defect http://www.scielo.br/scielo.php?pid=S0100-39842006000600012&script=sci_arttext&tlng=en http://radiopaedia.org/articles/ventricular-septal-defect-1 Normal Cardiomegaly RADIOLOGIC CLINICS OF NORTH AMERICA VOLUME 37 * NUMBER 6 * NOVEMBER 1999 Ventricular Septal Defect http://radiopaedia.org/cases/ventricularseptal-defect Case courtesy of Dr Frank Gaillard, Radiopaedia.org Spicer et al. Orphanet Journal of Rare Diseases (2014) 9:144 Let’s Think What Happens Tetralogy of Fallot Ventricular Septal Defect Right Ventricular outflow track obstruction Overriding Aorta Right Ventricular Hypertrophy http://radiopaedia.org/cases/tetralogy-of-fallot-1">Tetralogy of Fallot Mitral Stenosis • Leaflet thickening resulting in narrowing of the mitral valve. • Causes • Rheumatic Fever • Common in developing countries • Degenerative • Common in developed countries Healthy Mitral Valve Mitral Valve Stenosis Fish Mouth Appearance Mitral Regurgitation • Systolic retrograde flow from the left ventricle into the left atrium. • Causes • Non-Ischemic • Degenerative • Endocarditis • Rheumatic • Ischemic Healthy Mitral Valve http://www.vetmed.ucdavis.edu/vmth/small_animal/cardio_kittleson/case s/case9/figures.htm Mitral Valve Prolapse http://nethealthbook.com/cardiovascular-disease/heartdisease/mitral-valve-disease/ Clinical Indicators • Dyspnea • Exercise Intolerance • Long Murmur • Pulmonary HTN Radiographic Indicators • Left atrial enlargement • Double Density • Splayed Carina • Decreased aortic knob Double Density and Splayed Carina RV RA LV RA RV LA LA LV http://radiopaedia.org/articles/mitral-valve-regurgitation http://www.learningradiology.com/lectures/cardiaclectures/valvularlesions2012/Valvular%20Lesions%20of%20the%20Heart/Valvular%20Lesions %20of%20the%20Heart.html http://radiologyinthai.blogspot.com/2010_06_01_archive.html http://static.wikidoc.org/3/3a/Left-atrial-enlargement-002.jpg Aortic Stenosis • Narrowing of the aortic valve. • Causes: • Age (Calcific AS, Senile) • Similar to atherosclerosis • Rheumatic Valve • Congenital Calcific Aortic Stenosis Normal Aortic Valve http://www.slideshare.net/drranjithmp/echo-assessment-of-aortic-stenosis Clinical Indicators • Angina • Syncope • Heart Failure Radiographic Indicators • Aortic Valve Calcification • Prominent Ascending Aorta • Left Ventricular Enlargement Ascending aorta projects farther than right atrium Normal Descending Aorta http://www.learningradiology.com/archives2011/COW%20480-aortic%20stenosis/ascorrect.htm Calcified Aortic Valve http://www.learningradiology.com/archives04/COW%20118-Aortic%20Stenosis/ascorrect.htm Where are those valves? A M http://web.stanford.edu/dept/radiology/radiologysite/site141.html A M Aortic Valve Mitral Valve Reference • Barbosa E, Gupta N, Torgian D, Gefter W. (2012). Current Role of imaging in the diagnosis and management of pulmonary hypertension. American Journal of Roentgenology. 198, 1320-1331 • Batson G, Urquhart W, Sideris D. (1972). Radiologic Features in Aortic Stenosis. Clinical Radiology. 23, 140-144 • Carabello, Blase. (2013). Introduction to aortic stenosis. Circulation Research . , 113, 179-185. • Carabello, B & Paulus W. (2009) Aortic Stenosis. The Lancet., 373, 956-966 • Chandrashekhar Y, Westaby S, Narula J. Mitral Stenosis. (2009). The Lancet., 374, 1271-1283 • Coussement, Alain & Gooding Charles. (1973). Objective Radiographic Assessment of Pulmonary Vascularity in Children. Radiology. 109, 649-654 • Delnevo A, Tritella S, Carbonaro L, Bobrechova O, Leo G, Sardanelli F. (2012). The use of bedside radiography at a university hospital. Data on a two-week period. 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