IMAGING OF NORMAL

AND PATHOLOGY OF
THE HEART

Prof. Dr. Arif Faisal, Sp.Rad (K), DHSM

 IMAGING MODALITIES
1. Chest X-ray
2. Cor analysis (with barium)
3. Echocardiography
4. Computerized Tomography (CT)
5. Magnetic Resonance Imaging (MRI)
6. Nuclear Medicine
 CHEST X-RAY
• Erect position.
• Full inspiration.
• Projection:
PA – Posteroanterior
Left lateral
RAO – Right anterior oblique
LAO – Left anterior oblique
 NORMAL CHEST X-RAY

Rib
Lung
Right
pulmonary
artery

Heart
PA
LATERAL
RAO
LAO
RA
LV
 HEART BORDER - PA
RIGHT LEFT
- Right atrium - Arcus aorta
- Left atrium appendage
- Left venticle
 HEART BORDER - LATERAL
ANTERIOR POSTERIOR
- Pulmonary artery - Left atrium
- Right ventricle - Left ventricle
 HEART BORDER - RAO
ANTERIOR POSTERIOR
- Right ventricle - Left atrium
 HEART BORDER - LAO
ANTERIOR POSTERIOR
- Ascending aorta - Left atrium
- Right atrium - Left ventricle
appendage
- Right ventricle
CARDIOTHORACIC RATIO (CTR)

r+l
_______________
td + td
NORMAL CTR: < 50%
A = 12
_________ = < 0.5
B = 28

A: maximum width heart

B: maximum width thorax

B
 HEART CHAMBER ENLARGEMENT
 RV: filling retrosternal clear space (lateral view).
 LV: bulging downward and to the left (frontal view)
and posteroinferiorly (lateral view).
 RA: bulging of the right heart border.
 LA: bulging below the pulmonary artery, double
contour right heart border (frontal view),
displacement of the esophagus (lateral
view,barium), lift up left mainstem bronchus.
 PULMONARY ARTERY

Left
Right pulmonary
pulmonary artery
artery
 ANGIOGRAPHY

PULMONARY ARTERY PULMONARY VEIN

PULMONARY PHLETORA
HEART FAILURE:
- Cardiomegali
- Vessels enlarged
- Enlargement
pulmonary artery
 PULMONARY VENOUS
HYPERTENSION
Radiographic findings:
• Distended the upper lobe veins  ‘upper
lobe venous diversion’ or cephalization.
• Interstitial pulmonary oedema: fluid
accumulation in the lung interstitium.
• Radiologically : appearance of interstitial
lines (Kerley A & B lines),
 KERLEY LINES
• Represent thickening of interlobular septa..
• Kerley A line: 4 cm in length, upper and mid
portions of the lung, deep septal lines, radiate from
the hila into the central portions of the lungs.
• Kerley B lines: 1 cm or less, interlobular septal lines,
in the lower zones peripherally, and parallel to each
other, right angles to the pleural surface.
• Kerley C lines: overlapping Kerley B lines (the term
is no longer used).
KERLEY B LINES
PULMONARY VENOUS
HYPERTENSION
 CAUSES PULMONARY VENOUS
HYPERTENSION
1. Left ventricular outflow obstruction: aortic
coarctation, aortic stenosis, hypoplastic left
heart
2. Left ventricular failure
3. Mitral valve disease
4. Left atrial myxoma
5. Fibrosing mediastinitis
6. Pulmonary veno-occlusive disease
 PULMONARY ARTERIAL
HYPERTENSION
Radiographic findings:
• Cardiac enlargement (right atrial and
ventricular).
• Enlargement central pulmonary arteries.
• Tapering of peripheral arterial branches
peripheral pruning.
• Calcification central pulmonary arteries due
to atheroma (long standing).
 PULMONARY ARTERIAL
HYPERTENSION
MPA

RPA
Right
pulmonary
artery
 CAUSES PULMONARY ARTERY
HYPERTENSION
1. Chronic lung disease: COPD, interstitial
pneumonia
2. Pulmonary embolic disease
3. Pulmonary venous hypertension
4. Intracardiac shunts (left-to-right or
bidirectional)
5. Pulmonary arteritides
6. Idiopathic
 VALVE ABNORMALITIES
1. Mitral stenosis (MS)
2. Mitral insufficiency (MI)
3. MS + MI
 MITRAL STENOSIS
• Radiographic findings :
- Initially normal heart size
- Calcified mitral valve
- Left atrial enlargement ( elevation left main
bronchus, “double density/contour” the right
heart border, posterior displacement of
esophagus (with barium), enlargement left
atrial appendage.)
 MITRAL STENOSIS
• Advanced cases:
- Left atrium may calcify.
- Right ventricular enlargement (filling in of the
retrosternal clear space).
- Signs of pulmonary venous hypertension 
cephalization and pulmonary edema.
 MS

Double
contour of
right heart
border
RHEUMATOID MITRAL STENOSIS
,LA ENLARGEMENT

Left atrium
 MITRAL INSUFFICIENCY
• Radiologic findings:
- Left atrial enlargement (all cases).
- Left ventricular enlargement .
- Mild to moderate pulmonary venous
hypertension.
- No mitral valve calcify.
MITRAL INSUFFICIENCY

LA

LA
LV
MS + MI

Esophagus

LA
 RA ENLARGEMENT

RA

PA LAO
LV ENLARGEMENT

LV
 RV ENLARGEMENT
RV

Rounded cardiac apex, filling retrosternal space

 CARDIOMYOPATHY

A group of heart diseases due to

primary heart muscle pathology.
 1. DILATED CARDIOMYOPATHI
• Most common (90%)
• Causes: alcohol, viral infection.
• Clinical sign: CHF ( right or left-sided )
• Radiographic finding: global cardiomegaly,
predominant LV.
2. HYPERTROPHIC CARDIOMYOPATHY

• Most commonly familial or pressure

overload.
• The heart muscle thicken but, the heart
may not dilate.
• Radiographic finding: 50% a normal
chest.
• Cross-sectional imaging: abnormal
thickness of the myocardium
3.RESTRICTIVE CARDIOMYOPATHY
• The rarest form of cardiomyopathy
• Causes: stiffen the myocardium
(amyloidosis and sarcoidosis).
• Chest radiograph: normal cardiac size
with pulmonary venous congestion.
HYPERTENSION HEART DISEASE

1. Cardiomegali
2. LV enlargement
3. Prominent aortic
knob
4. Elongated
descending aorta
 HYPERTENSIVE HEART FAILURE
• A form of congestive heart failure.
• Cause : the high systemic blood pressure
• Chest radiograph: severe left ventricular
hypertrophy /dilatation cardiac
enlargement.
 HEART FAILURE
The heart’s inability:
1. To supply the body’s demands for oxygen
and nutrients
2. To remove of wastes

Causes:
- ischemic damage to the myocardium
- hypertensive heart disease.
 HEART FAILURE

Right heart failure: systemic

venous congestion

Left heart failure  pulmonary

venous congestion  pulmonary
edema
CONGESTIVE HEART FAILURE
Cardiac enlargement

Cephalization of
pulmonary blood flow

Unsharpness of the
pulmonary vessels
(interstitial edema)

Pleural effusion
Septal lines (Kerley A and B
lines)

CHEST X-RAY - PA
 REFERENCES
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London: Churchill Livingstone, 2003.
3. Gunderman RB. Essential Radiology. 2nd ed. New York:
Thieme, 2006.
4. Goodman LR. Felson’s Principles of chest Roentgenology. 3nd
3d. Philadelphis: Saunders, 2007.
5. Adam A, Dixon AK. eds. Grainger & Allison’s Diagnostic
Radiology. 5th ed. Vol. 1. London: Churchill Livingstone,
2008.