Acquired Heart Disease

Acquired Heart DiseaseAcquired Heart Disease

Tricia Santos MS3Tricia Santos MS3

Diagnostic RadiologyDiagnostic Radiology

December 2005December 2005

Diagnosing heart disease Diagnosing heart disease the “old fashioned” way the “old fashioned” way

History History

Physical Exam Physical Exam

Chest RadiographChest Radiograph

Approach to evaluation of the Approach to evaluation of the Heart on Chest RadiographHeart on Chest Radiograph

• Evaluate the heart for:Evaluate the heart for:– Pericardial diseasePericardial disease– Myocardial diseaseMyocardial disease– Valvular diseaseValvular disease

• Evaluate the vessels for:Evaluate the vessels for:– Pressure and flow changesPressure and flow changes– Intravascular volume statusIntravascular volume status– EdemaEdema

Size MattersSize Matters

When looking for heart disease, When looking for heart disease,

first ask yourself,first ask yourself,

““Is the heart big or Is the heart big or small?”small?”

Pericardial and Myocardial Pericardial and Myocardial disease= disease= GlobalGlobal enlargement enlargement

Small HeartSmall Heart

• • Constrictive PericarditisConstrictive Pericarditis

• • Restrictive CardiomyopathyRestrictive Cardiomyopathy

Big HeartBig Heart

• Pericardial EffusionPericardial Effusion

• Myocardial FailureMyocardial Failure

Small HeartSmall HeartPericardial or Myocardial Pericardial or Myocardial

Disease?Disease?• Use physical exam Use physical exam

to differentiateto differentiate

• Kussmaul’s sign and Kussmaul’s sign and pericardial knock pericardial knock are consistent with are consistent with constrictive constrictive pericarditispericarditis

Pericardial Calcifications

Small Heart

Globally Enlarged HeartGlobally Enlarged HeartPericardialPericardial Disease Disease

• Pericardial Effusion Pericardial Effusion

– ““Oreo” SignOreo” Sign• Fluid collection between epicardial and Fluid collection between epicardial and

retrosternal fat padsretrosternal fat pads

– WIDE vascular pedicleWIDE vascular pedicle• RA pressures are high due to RA pressures are high due to

constriction and therefore do not allow constriction and therefore do not allow blood to easily return to the RAblood to easily return to the RA

Oreo SignOreo Sign

Globally Enlarged HeartGlobally Enlarged HeartMyocardial DiseaseMyocardial Disease

• Myocardial FailureMyocardial Failure– NARROW vascular pedicleNARROW vascular pedicle

•Patients are usually on diureticsPatients are usually on diuretics

– Leads and LinesLeads and Lines•Outline the walls of the chambers if no Outline the walls of the chambers if no

effusion is presenteffusion is present

Myocardial FailureMyocardial Failure

Myocardial Failure or Pericardial Myocardial Failure or Pericardial Effusion?Effusion?


Wide Vascular Pedicle

Visible Borders of Mediastinum

Pericardial Effusion


Gehlbach, Brian K., et al. Gehlbach, Brian K., et al. The Pulmonary Manifestations of Left Heart Failure.The Pulmonary Manifestations of Left Heart Failure. Chest Chest. 2004; 125: . 2004; 125: 669-682.669-682.


Gehlbach, Brian K., et al. Gehlbach, Brian K., et al. The Pulmonary Manifestations of Left Heart Failure.The Pulmonary Manifestations of Left Heart Failure. Chest Chest. 2004; 125: . 2004; 125: 669-682.669-682.

Globally enlarged heart

Narrow VPW

Myocardial Failure

Valvular Disease = Valvular Disease = UnequalUnequal chamber enlargement chamber enlargement

Small/Normal HeartSmall/Normal Heart

• • Valvular StenosisValvular Stenosis- Chambers are pressure - Chambers are pressure overloadedoverloaded

- Mild dilation of chambers - Mild dilation of chambers may be seen, but general may be seen, but general hypertrophy is not seen on hypertrophy is not seen on chest radiographchest radiograph

Big HeartBig Heart

• • Valvular Valvular InsufficiencyInsufficiency- Chambers are volume - Chambers are volume overloadedoverloaded

- Marked dilation of chambers- Marked dilation of chambers

Aortic StenosisAortic Stenosis

• Chest radiographChest radiograph– Decreased pulmonary blood flow with normal flow Decreased pulmonary blood flow with normal flow

distributiondistribution– Narrow vascular pedicleNarrow vascular pedicle– Increased LVP (may have Increased LVP (may have mildmild LV enlargement) LV enlargement)– Post stenotic dilation of aortaPost stenotic dilation of aorta

• Physical Exam: Physical Exam: – Crescendo/decrescendo systolic murmur (may Crescendo/decrescendo systolic murmur (may

radiate to clavicles, carotid, or “beauty-sash” radiate to clavicles, carotid, or “beauty-sash” distribution)distribution)

– Pulsus parvus et tardusPulsus parvus et tardus– Diastolic rumble from associated aortic insufficiencyDiastolic rumble from associated aortic insufficiency


Why narrow vascular pedicle with decreased Why narrow vascular pedicle with decreased pulmonary blood flow?pulmonary blood flow?

• • Low LV output Low LV output → → decreased circulating decreased circulating blood volume blood volume → → decreased venous return decreased venous return and RV outputand RV output

• • Increase in circulating atrionatriuretic Increase in circulating atrionatriuretic factor factor → → decreased total blood volume decreased total blood volume → → decreased venous return and RV outputdecreased venous return and RV output


Mitral StenosisMitral Stenosis

• Chest radiographChest radiograph– Mild LA dilationMild LA dilation– Increased LAPIncreased LAP– Pulmonary flow inversionPulmonary flow inversion– LUL oligemia occurs in 16% of patientsLUL oligemia occurs in 16% of patients

• Possibly secondary to displaced/compressed LUL veins from Possibly secondary to displaced/compressed LUL veins from LALA

– Narrow vascular pedicleNarrow vascular pedicle

• Physical ExamPhysical Exam– Faint diastolic murmur (rumble)Faint diastolic murmur (rumble)– Opening snapOpening snap– Loud S1Loud S1

Atrial Septal DefectAtrial Septal DefectWhy?Why?

Atrial Septal Defect…Why?Atrial Septal Defect…Why?

Narrow VPW

LV Dilation

LUL Oligemia

Pulmonary Venous HTN

Mitral InsufficiencyMitral Insufficiency

• Chest RadiographChest Radiograph– Marked dilation of LAMarked dilation of LA– Pulmonary flow inversionPulmonary flow inversion

• Physical ExamPhysical Exam– Holosystolic blowing murmur Holosystolic blowing murmur

• Radiates to axillaRadiates to axilla

• No change with inspirationNo change with inspiration

– S1 and S2 may be inaudible or difficult to hearS1 and S2 may be inaudible or difficult to hear– Systolic apical thrillSystolic apical thrill

Tricuspid InsufficiencyTricuspid Insufficiency

• Chest radiographChest radiograph– Marked dilation of RAMarked dilation of RA– Wide vascular pedicleWide vascular pedicle

• Physical ExamPhysical Exam– Holosystolic blowing murmurHolosystolic blowing murmur

• Increases with inspiration/increased venous returnIncreases with inspiration/increased venous return– Elevated JVP with fused CV waveElevated JVP with fused CV wave– Side-to-side head bobSide-to-side head bob– Hepatojugular refluxHepatojugular reflux– HepatomegalyHepatomegaly– Puslatile LiverPuslatile Liver– AscitesAscites– Peripheral EdemaPeripheral Edema

Mitral and Tricuspid Mitral and Tricuspid InsufficiencyInsufficiency

Evaluate the vessels:Evaluate the vessels:Pulmonary Blood FlowPulmonary Blood Flow

• Increased with shunt vascularityIncreased with shunt vascularity

• Decreased with cephalizationDecreased with cephalization

• Flow inversion occurs with chronic Flow inversion occurs with chronic left heart failure and mitral stenosisleft heart failure and mitral stenosis

Normal Pulmonary FlowNormal Pulmonary Flow

• Pulmonary veins have no valves, therefore Pulmonary veins have no valves, therefore they are directly affected by pressures in they are directly affected by pressures in the LAthe LA

• In the upright person, flow is greater in the In the upright person, flow is greater in the lower lobes according to the West zoneslower lobes according to the West zones

• Gravity makes it more difficult for blood to Gravity makes it more difficult for blood to return to the LA from the lower lobe veins, return to the LA from the lower lobe veins, therefore LL vessels are largertherefore LL vessels are larger

Pulmonary Flow InversionPulmonary Flow Inversion

• Occurs with long-standing elevated LAPOccurs with long-standing elevated LAP• Actual cause of redirection of blood is unknownActual cause of redirection of blood is unknown

– One theory suggests: One theory suggests: ↑ ↑ LAP → basal edema → ↓ basilar compliance → ↓ LAP → basal edema → ↓ basilar compliance → ↓

negative interstitial pressure → vessels unable to negative interstitial pressure → vessels unable to stay open → ↓ diameter of vessels → ↑↑ resistance stay open → ↓ diameter of vessels → ↑↑ resistance to flow → blood redirected to upper lobesto flow → blood redirected to upper lobes

– OOthers theorize that the cause is organic thers theorize that the cause is organic – Cardiac output is likely decreased in the presence of Cardiac output is likely decreased in the presence of

cephalization and edemacephalization and edema• Flow inversion is Flow inversion is not not reversible with treatmentreversible with treatment

Pulmonary Flow Pulmonary Flow Left to Right ShuntsLeft to Right Shunts

• ASD, VSD, and PDA originally shunt blood ASD, VSD, and PDA originally shunt blood to the right side of the heart and to the right side of the heart and pulmonary circulationpulmonary circulation

• Pulmonary flow INCREASESPulmonary flow INCREASES• Narrow vascular pedicle secondary to Narrow vascular pedicle secondary to

decreased systemic flowdecreased systemic flow• Small aorta due to decreased LV outputSmall aorta due to decreased LV output• PE: Listen for the presence of murmursPE: Listen for the presence of murmurs

– ASD: systolic, fixed split S2ASD: systolic, fixed split S2– VSD: loud, harsh, holosystolicVSD: loud, harsh, holosystolic– PDA: “machine-like” systolic and diastolicPDA: “machine-like” systolic and diastolic

Increased or decreased flow?Increased or decreased flow?

Decreased with CephalizationDecreased with Cephalization

Larger vessels

Small Vessels

Evaluate the Vessels:Evaluate the Vessels:Pulmonary PressuresPulmonary Pressures

• Pulmonary Pulmonary VenousVenous Hypertension Hypertension– Caused by subacute to chronic impairment of pulmonary Caused by subacute to chronic impairment of pulmonary

venous drainage, i.e. venous drainage, i.e. ↑ LAP↑ LAP• Myocardial dysfunctionMyocardial dysfunction• Mitral valve diseaseMitral valve disease• ObstructionObstruction

– Secondary signs include septal thickening, indistinct LL Secondary signs include septal thickening, indistinct LL vessels, bronchial wall thickeningvessels, bronchial wall thickening

• Blood flow redistributes to the upper lobes Blood flow redistributes to the upper lobes • Diminished pulmonary blood flowDiminished pulmonary blood flow

Evaluate the Vessels:Evaluate the Vessels:Pulmonary PressuresPulmonary Pressures

• Pulmonary Pulmonary ArterialArterial Hypertension Hypertension– Caused by increased resistance or chronic increase in Caused by increased resistance or chronic increase in

pulmonary flowpulmonary flow– Cardiac causes include ASD, VSD, PDA, AV septal defectsCardiac causes include ASD, VSD, PDA, AV septal defects

• Chest RadiographChest Radiograph– Early PAH: Increased convexity of main pulmonary arteryEarly PAH: Increased convexity of main pulmonary artery– Hilar vessels enlarge with decrease in size of peripheral Hilar vessels enlarge with decrease in size of peripheral

vesselsvessels

• Physical ExamPhysical Exam– Widely split S2Widely split S2– Chronic PAH: elevated JVP, enlarged liver, peripheral edemaChronic PAH: elevated JVP, enlarged liver, peripheral edema

• Secondary to right heart failureSecondary to right heart failure

Evaluate the vesselsEvaluate the vesselsMain Pulmonary ArteryMain Pulmonary Artery

• Enlarged main pulmonary artery – 3 typesEnlarged main pulmonary artery – 3 types

1. Large PA and large pulmonary veins 1. Large PA and large pulmonary veins – Correlates with increased Correlates with increased flowflow– Ex: ASDEx: ASD

2. PA larger than draining veins2. PA larger than draining veins– Correlates with increased Correlates with increased pressurepressure– Ex: HypertensionEx: Hypertension

3. Equally enlarged PA and veins + wide vascular 3. Equally enlarged PA and veins + wide vascular pediclepedicle

– Correlates with increased circulating blood Correlates with increased circulating blood volumevolume– Ex: Renal FailureEx: Renal Failure

Renal failureRenal failure

Evaluate the Vessels:Evaluate the Vessels:Intravascular Volume StatusIntravascular Volume Status

• Increased intravascular volume leads to Increased intravascular volume leads to increased vascular pedicle width (VPW)increased vascular pedicle width (VPW)

• There are no valves in the veins from the There are no valves in the veins from the base of the skull to the RA or from the RA base of the skull to the RA or from the RA down to the femoral veinsdown to the femoral veins

• Therefore, there is a continuous column of Therefore, there is a continuous column of blood from base of skull to femoral veinsblood from base of skull to femoral veins

Evaluate the VesselsEvaluate the VesselsCardiac Causes of Wide VPWCardiac Causes of Wide VPW

• Chronic Left Heart Failure (wide VPW without diuretics)Chronic Left Heart Failure (wide VPW without diuretics)– Enlarged cardiac silhouette, cardiogenic pulmonary edema, cephalizationEnlarged cardiac silhouette, cardiogenic pulmonary edema, cephalization– Most common cause is ischemicMost common cause is ischemic– PE: S3, S4 gallop, basilar cracklesPE: S3, S4 gallop, basilar crackles

• Acute Right Heart FailureAcute Right Heart Failure– Abrupt increase in VPW without pulmonary edema, possible pleural effusionsAbrupt increase in VPW without pulmonary edema, possible pleural effusions– Caused by sudden elevation of pulmonary vascular resistance (massive PE, Caused by sudden elevation of pulmonary vascular resistance (massive PE,

bacterial emboli from IVDU, tumor emboli)bacterial emboli from IVDU, tumor emboli)– PE: Elevated JVPPE: Elevated JVP

• Chronic Right Heart FailureChronic Right Heart Failure– Most commonly secondary to left heart failureMost commonly secondary to left heart failure– Enlarged RV, wide VPW, possible pleural effusionsEnlarged RV, wide VPW, possible pleural effusions– PE: Right ventricular heave, elevated JVP, enlarged liver, peripheral edemaPE: Right ventricular heave, elevated JVP, enlarged liver, peripheral edema

• TamponadeTamponade– Wide VPW, but decreased pulmonary blood volumeWide VPW, but decreased pulmonary blood volume– PE: Pulsus ParadoxusPE: Pulsus Paradoxus

• Tricuspid RegurgitationTricuspid Regurgitation– Enlarged RA from volume overload Enlarged RA from volume overload – PE: See previous slidesPE: See previous slides

Chronic Right and Left Heart Chronic Right and Left Heart FailureFailure

Wide VPW, Enlarged RV and LVWide VPW, Enlarged RV and LV

Evaluate the Vessels:Evaluate the Vessels:Cardiogenic EdemaCardiogenic Edema

• Cardiogenic edema occurs secondary Cardiogenic edema occurs secondary to hydrostatic forces and therefore to hydrostatic forces and therefore predominately occurs in the lower predominately occurs in the lower lobeslobes

• Most commonly secondary to left Most commonly secondary to left heart failure (acute or chronic)heart failure (acute or chronic)

• Vascular indistinctnessVascular indistinctness

Which represents edema?Which represents edema?

Which represents edema?Which represents edema?

Vascular Indistinctness Well-defined vessels

Cardiogenic Edema and LHFCardiogenic Edema and LHF

• Acute LHFAcute LHF– Extensive EdemaExtensive Edema– No flow redistributionNo flow redistribution– No change in VPWNo change in VPW– NL Heart SizeNL Heart Size– CausesCauses

• Massive MIMassive MI

• Abrupt onset valvular Abrupt onset valvular diseasedisease

• Ruptured papillary Ruptured papillary musclemuscle

• Chronic LHFChronic LHF– Basilar EdemaBasilar Edema– CephalizationCephalization– VPW usually narrowVPW usually narrow– Enlarged cardiac Enlarged cardiac

silhouettesilhouette– Most commonly Most commonly

ischemic ischemic cardiomyopathycardiomyopathy

Cardiogenic Edema Cardiogenic Edema

In SummaryIn Summary

• Acquired heart disease can be Acquired heart disease can be diagnosed with a thorough history diagnosed with a thorough history and physical exam and careful and physical exam and careful evaluation of the chest radiographevaluation of the chest radiograph

• This method provides an an This method provides an an inexpensive, non-invasive, and inexpensive, non-invasive, and reliable way to diagnose heart reliable way to diagnose heart disease. disease.

ReferencesReferences

*Primary Sources:*Primary Sources:

• • Milne, Eric N.C and Pistolesi, Massimo. Milne, Eric N.C and Pistolesi, Massimo. Reading the Chest Reading the Chest Radiograph:Radiograph: A Physiologic Approach. A Physiologic Approach. Mosby. 1993.Mosby. 1993.

• • Gosselin, Marc. Gosselin, Marc. Radiographic Approach to Acquired Radiographic Approach to Acquired Cardiopulmonary Disease. Cardiopulmonary Disease.

Secondary Sources:Secondary Sources:• Philbin, Edward F., et al. Philbin, Edward F., et al. Relationship between Cardiothoracic Relationship between Cardiothoracic

Ratio and Left Ventricular Ejection Fraction in Congestive Heart Ratio and Left Ventricular Ejection Fraction in Congestive Heart Failure.Failure. Archives of Internal Medicine.Archives of Internal Medicine. 1998; 158: 501-506 1998; 158: 501-506

• Baron, Murray G. Baron, Murray G. Pericardial EffusionPericardial Effusion. . Circulation.Circulation. 1971; 44: 294. 1971; 44: 294.• Gehlbach, Brian K., et al. Gehlbach, Brian K., et al. The Pulmonary Manifestations of Left The Pulmonary Manifestations of Left

Heart Failure.Heart Failure. Chest Chest. 2004; 125: 669-682.. 2004; 125: 669-682.• Wesley, Ely E., et al. Wesley, Ely E., et al. Using the Chest Radiograph to Determine Using the Chest Radiograph to Determine

Intravascular Volume Status.Intravascular Volume Status. Chest Chest. 2002; 121: 942-950. . 2002; 121: 942-950.

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Acquired Heart Disease