Left atrial enlargement

PA : enlargement heart to left & right side

- prominence of left auricle
- double contour at right side
- left main bronchus displaced upward
RAO/LAT :
- enlargement heart to postero-interal (displaced
esophagus to right)
- bulging of left atrial auricle/(appendage)
displaces esophagus posteriorly
Left atrial enlargement
Left ventricle enlargement
PA : left extends laterally, left diaphragm is
depressed
RAO : - heart intersects left leaf of diaphragm
- anterior apical position of heart extends
further anteriorly
- heart is displaced posteriorly, close to spinal
LAO : LV extends beyond retrocardiac space, and
cannot clear the spine
LAT : LV displaced posteriorly, close to spine
Left ventricular hypertrophy & dilatation
3. Rotation of the heart
Rotation to left side , cause of RVE,
aortic arch small and rounded, LV
To latero - posterior
Rotation to right side, cause of great
LVE, RV dextro-lateral, RA dextro-
posterior, aortic arch descending
aorta on the left side of vertebral
column
CONGENITAL ANOMALY
1. Abnormality of the septum

2. Abnormality of the great arteries ---

shape and position
3. Abnormality of chamber of the heart

4. Abnormality of position
1. Congenital anomaly with increased
pulmonary vascular markings
A. Without cyanosis
1. Atrial septal defect (ASD)
Septum primum
Ostium primum closed
Septum secundum
Foramen ovale closed
ASD secundum > ASD primum
Chest X ray
Depends on :
The severity of the
defect
Complication
L to R shunt
R to L shunt
Chest X ray
Without pulmonary hypertension
PA position
-Heart enlargement to left side
-Apex is rounded & upward
-Widening of the hila
-Widening of pulmonary artery and its tributaries
-Widening of pulmonary veins at supra and
perihilar
-Periphery pulmonary vascular are clear
-Prominence of MPA
-Aortic arch is small
Increased pulmonary vascular marking
Chest X ray
Lat Position

No enlargement of LA & LV

Enlargement of RV
ASD with Mitral Regurgitaion
With pulmonary hypertension
PA position

Enlargement of the heart on both

sides
Extremely wide of central hila and
became smaller to periphery
MPA is very prominent
Small aorta
Pulmonary veins are faint
Periphery area is more radio lucent
Barrel chest
Lateral position
LV Enlargement
LA is normal/enlarged
RV Enlargement close to upper
sternum
Hilar enlargement
Infero-posterior part of the heart
overlapping with vertebral column
3. Ventricular septal defect (VSD)
Incidence :
The most common form of CHD (20-25%) of all CHD
Clinical manifestation
-Small VSD : N growth, development, symptoms
-Moderate to large VSD : Increase exercise tolerance
-Delayed growth and development
-CHF is relative common in infancy
-Cyanosis with long standing pulmonary hypertension
 Localization of defect
1. Membranous septum
2. Muscular septum
3. Above the crista supra
ventricular/ sub ulmonic
Ventricular septal defect

Radiological Imaging depends on

defect size
pulmonary vascular changes
Chest X ray
Tiny defect (maladies de Roger )
No heart enlargement
Normal of pulmonary vascular
markings
Small defect
Heart enlargement to left side (LVH)

Dilatation of LA

Dilatation of RV

Increased pulmonary vascular

markings
Apex towards diaphragm
VSD Moderate to large
RV dilatation and hypertrophy
LV hyperthropy
RA is normal
LA dilatation
Aorta is small
Widening of pulmonary arteries
VSD with pulmonary hypertension

RV is more dilated
LA is Normal
Aorta is normal
MPA is prominent
Pulmonary artery and its central
tributaries are wider
Chest is more emphysematous
Patent Ductus Arteriousus (PDA)
Incidence : 10 % of all CHD, excluding
premature infants
Female : male = 3 : 1
A common problem in premature infants
It is a patency of a normal fetal structure
between the left PA and the descending
aorta (ductus arteriosus Botalli)
L to R shunt
Chest X ray :
LA dilatation
LV hypertrophy
PA
PV
LA are enlarged
LV
AO
RV dilatation (large defect)
Small PDA :
Heart
Pulmonary vascularities
N

Moderate PDA :
Ascending aorta
N/slightly enlarged
aorta arch
PA : prominent next to AO
Pulmonary vascular markings : increased
Hila : wide R
LA : enlarged
LV
RV are enlarged
PDA with pulmonary hypertension
RV dilatation (hypertrophy and dilatation)
LA : normal
Asc aorta : wide
Aortic arch : prominent
MPA : prominent
Hila : wide
Periphery pulmonary vascularities : faint
Partial anomalous pulmonary venous
return (PAPVR)
Incidence Less than 1 % of all CHD
One or more (but not all) pulmonary veins
drain into the RA or its tributaries, such as
the SVC, IVC, left innominate vein
Important consideration
The number of anomalous pulmonary
vein
The prescence and the size of ASD
The pulmonary vascular resistance
Chest X ray
Important RA
RV are enlarged
PA
Similar to ASD
Heart enlargement (RA, RV)
Widening of MPA
Widening of hila
Occasionally : a dilated PVC, a
crescent, shaped, vertical shadow in
the right lower lung
B. Increased pulmonary vascular
markings with cyanosis
1. Total anomalous pulmonary
venous return (TAPVR)
Incidence : 1 % of all CHD
No direct communication between
the pulmonary veins and LA
Depending on the site of the
drainage of the pulmonary
veins
Supracardiac SVC
Cardiac coronary smos
Infra cardiac PV, HV, IVC
Mixed type
2. Persistent truncus arteriosus
Incidence : less than 1 % of all
CHD
VSD : is always present
Only a single trunk leaves the
heart and gives rise to
pulmonary, systemic and
coronary circulations
Blood from RV & LV drain into
the trunk cyanotic
Chest X rays
Heart enlargement, oval shaped
(RV, LV, LA)
Increased pulmonary vascularity
A right aortic arch (50%)
Transposition of the great vessel
Incidence 5% of all CH defect
More common in males M : F = 3 : 1
The aorta arises anteriorly from RV
The pulmonary artery arises posteriorly
from LV
ASD, VSD, PDA are necessary for survival
More common bidirectional shunt
More common R to L shunt
Chest X-ray
Heart enlargement, oval/egg shaped, with a
narrow superior mediastinum
Increases pulmonary vascularity
Congenital heart anomalies with
decrease pulmonary vascularity

A. Without cyanosis
1. Pulmonary stenosis
Incidence 5% - 8% of all congenital
heart defects
Valvular stenosis
Subvalvular stenosis (infundibulum)
Supravalvular stenosis (mainstem of
PA)
Chest X rays
Heart size is normal
RV enlargement : hyperthrophy
dilatation
MPA is prominent
Pulmonary vascularity is normal
decreased
Heart enlargement (CHF)
Lung : more lucency (small lung vessels)
Different vascularization between right
and left lung on valvular stenosis
Post stenotic dilatation
B. With cyanosis
1. Tetralogy of Fallot
Incidence 10% of all congenital heart
diseases
The most common cyanotic cardiac defect
beyond infancy
Four abnormalities
VSD (R to L)
Pulmonary stenosis infundibular/valvular
Over riding aorta
Right ventricular hypertrophy
The severity of RVH and defect of VSD
depend on stenotic of pulmonary artery
Chest X ray
RV : enlargement, extends heart to left
Apex : upturned
Concavity of heart waist/MPA
Booth shaped/coeur en sabot
Lungs vessels are smaller increased
radiolucency
Widening of the aortic arch
Right sided aorta/aortic arch (25%)
2. Trilogy of Fallot
Similar to Tetralogy of Fallot excluded
VSD/overriding aorta
Abnormalities are :
Pulmonary stenosis
RVH
Leakage of atrial septum thru ASD/persisten
foramen ovale
Chest X ray
Similar to PS imaging
RVH
Apex : uptoward
Decreased pulmonary vascularity
3. Pulmonary atresia
Is a part of RV hypoplasie
RV : small
PA : absent
VSD : absent
Combination between ASD & PDA

Chest X ray
Heart enlargement, oval shaped
LA enlargement
RA enlargement
LV enlargement
Concavity of heart waist
4. Tricuspid valve atresia
Connection of LA & RA thru ASD
Connecting of LV & RV thru VSD
5. Ebstein anomaly
Chest X ray
Extreme cardiomegaly
Decreased pulmonary vascular
markings
Acquired heart disease
1. Mitral stenosis
Incidence : - Rare in children
- The most common valvular involvement in
adult rheumatic patients
Etiology : - Rheumatic fever
- Viral
- Streptococcus bacteria
Involved area :
- Valves
- Ring of valves
- Papillary muscles
- Myocardium
- Pericardium
 Involved valves valves weakness 2
chorda tendinae weakness valves are
insuficient narrowing of the valve
Valve narrowing LA dilatation
(because of blood accumulation)
increased LA pressure congestion of
the pulmonary veins pulmonary
hypertension increased resistancy in
capillaries obstruction of blood from
RV increased in RV pressure RVH
Chest X ray
Changing of : - heart shaped &

- pulmonary
vascularity
PA
LA dilatation
Double contour in right side
Prominence of LAA, MPA
Elevation of main stein left bronchus
Small aorta
Heart enlargement to left with upright
apex
Displaced esophagus to right side
Lateral
Without contrast
Holtzknecht space is clear
With contrast
Displaced esophagus posteriorly
2. Mitral insuficiency
Incidence : - the most common valvular
involvement in children with RHD
- Males are more commonly affected
than females
Etiology : Rheumatic fever
- Paralyzed of mitral valve, chorda hendriae
- Paralyzed of papillary muscls
- Prolaps of one valve leaflet
- Dilatation of ring valve
Blood few back into LA
Chest X rays
PA : - Enlargement of LA & LV
- Pulmonary vascularity is usually within
normal limits
- Double contour
- Auricle of LA prominent
- Elevation of the left mainstem bronchus
- Displacement esophagus to right
Lat : - Displacement esophagus
posteriorly
- LV protruded posteriorly
3. Aorta insuficiency
Incidence : - More common in males than females
- Rheumatic endocarditis
- Aneurysma
- Aortasclerotic
Regurgitation of blood into LV dilatation LVH +
dilatation
Chest X ray :
PA : - apex turned down
- aortic arch : prominent wide
- concavity of pulmonal, auricle area
- aortic configuration
Lat : retrocardiac space is occupied (LV dilatation)
4. Aortic stenosis
Incidence : - 5% of all congenital heart defect
- more common in males than
females (4:1)
Chest X ray :
PA : - heart enlargement to left side
- apex turned down
- occasionally widening of ascending aorta
Lat : anterior part of ascending
Aorta : prominent (post stenotic dilatation)
RV, LV N
5. Tricuspid insuficiency
Incidence : - 2% of all congenital disease in
infancy
Etiology : - congenital
- rheumatic
Chest X ray :
PA : - RA dilatation
- pulmonary vascularity : decreased
LAO : auricle RA : more prominent
RAO : enlargement RA, protruded posteriorly,
beneath LA
6. Pulmonary stenosis
Etiology : most commonly congenital
Aortic anomalies/abnormalities
Etiology : - inflammation process
- degenerative process
- traumatic factor
- congenital
1. Aortitis
2. Aortasclerotic
3. Aortaelongation
4. Aortic aneurysm
5. Coarctatio aortae
6. Vascular ring
 Pericard abnormalities
Etiology : - infection
- trauma
1. Cardiac tamponade
2. Pericardial effusion
3. Pericarditis
4. Pericardial cyst

Cor pulmonale
Heart disturbances because of chronic
pulmonary diseases