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Figure 12-1: Practical application of four-view cardiac series. A. Posteroanterior view in a patient with coarctation of the aorta showing areas of rib notching bilaterally and left ventricular enlargement in the inferior and leftward direction. B. Magnified view of the left upper thorax of the same patient showing multiple areas of rib notching (arrows). The sclerotic margin of each represents a reparative process by which new bone is laid down in the defect. C. Posteroanterior view of another patient with aortic coarctation showing "3 sign" of the deformed descending aorta and "E sign" on the barium-filled esophagus. The upper arrow (on the patient's left) points to the level of coarctation. The lower arrow (on the patient's left) marks the apex of the enlarged left ventricle. The arrow on the patient's right indicates the dilated ascending aorta. D. Lateral view of a third patient with the same disease showing a barium-filled esophagus to be pushed forward (upper arrow) by the poststenotic dilatation of the descending aorta and pushed backward (middle arrow) by the enlarged left atrium. The very large left ventricle (lower arrow) simply casts a shadow behind the esophagus without displacing it. The oblique arrow points to the calcified stenotic bicuspid aortic valve. E. Right anterior oblique view of same patient whose posteroanterior view is shown in Fig. 12-7D. Note the huge right atrium casting a triangular density (lower horizontal arrow) behind the esophagus without displacing it. The esophagus is deviated posteriorly by the enlarged left atrium (upper horizontal arrow). The upper oblique arrows indicate the direction of the enlarging pulmonary trunk and right ventricle. The lower oblique arrow points to the normal left ventricle with the undisturbed left costophrenic sulcus. F. Left anterior oblique view of a patient with valvular aortic stenosis. The dilated ascending aorta (upper white arrow) is immediately above the flat anterior border of normal right ventricle. The black arrow points to the calcified aortic valve. The lower white arrow marks the enlarged left ventricle. Figure 12-2: Roentgenographic assessment of the volume of pulmonary blood flow. A. Normal. There is caudalization of the pulmonary vascularity due to gravity. The right descending pulmonary artery (rpa) measures 13 mm in diameter in this young man. B. Increased. Patient with a secundum atrial septal defect showing uniform increase in pulmonary vascularity bilaterally. The right descending pulmonary artery is markedly enlarged, measuring 27 mm. C. Decreased. Patient with tetralogy of Fallot showing a boot-shaped heart and uniform decrease in pulmonary vascularity. The right descending pulmonary artery is much smaller than normal, measuring 6 mm in diameter. Figure 12-3: Abnormal pulmonary blood flow patterns. A. Cephalization. Patient with severe mitral stenosis showing dilatation of the upper vessels with constriction of the lower vessels. B. Centralization. Patient with primary pulmonary hypertension showing marked dilatation of the pulmonary trunk and the central segments of both pulmonary arteries with pruning of the peripheral branches. C. Lateralization. Patient with massive pulmonary embolism obstructing the left main pulmonary artery. Note the uneven distribution of pulmonary blood flow between the two lungs in favor of the right. D. Localization. A cyanotic child showing localized vascular changes representing a large pulmonary arteriovenous fistula in the right lower lobe. E. Collateralization. A child with pseudotruncus arteriosus with cardiomegaly and a right aortic arch (small arrow). Note severe pulmonary oligemia with numerous small tortuous vessels (large arrow) in upper medial lung zones, representing bronchial arterial collaterals.

' Figure 12-4: Patient with situs ambiguous, interruption of the inferior vena cava, ventricular septal defect, and polysplenia. A. Posteroanterior view shows that the aortic arch and the heart are left-sided and the stomach (lower arrows) is right-sided. The azygos vein (upper arrow) is markedly enlarged. The heart is mildly enlarged, and there is a moderate increase in pulmonary vascularity. . . Lateral view shows an absent image of the inferior vena cava. The azygos arch {arrov\) is markedly dilated.

' Figure 12-5: A 16-year-old girl with straight-back syndrome. A. Posteroanterior radiograph shows normal pulmonary vascularity and normal heart size. Note leftward displacement and rotation of the heart, making its left border unusually prominent. B. Lateral view shows that the anteroposterior diameter of the chest is extremely narrow. The heart is squeezed, creating an innocent murmur.

' Figure 12-6: Roentgen appearance of left-sided heart failure. A. Acute. Patient with acute mitral regurgitation due to rupture of chordae tendineae showing "bat wings" appearance of severe alveolar type of pulmonary edema and a normal-sized heart. B. Chronic. Patient with severe mitral and tricuspid regurgitation and mild aortic regurgitation. This is a predominantly left-sided failure pattern. Note gross cardiomegaly with striking cephalization and interstitial pulmonary edema. The giant left atrium forms the right cardiac border (open arrow), makes its appendage bulge outward on the left side (upper large arrow), and splays the mainstem bronchi wide apart (solidlines). The huge right atrium forms a double density within the right cardiac border (three small arrows). The upper small arrow marks the peribronchial cuffing of edema fluid. The lower large arrow points to multiple Kerley B lines. C. Magnified view of right costophrenic sulcus showing multiple Kerley B lines (arrow). D. A 44-year-old woman with severe mitral stenosis. Her radiograph shows a diffuse stippling with fine nodules representing hemosiderosis. Hemosiderin-laden macrophages were found in her sputa. E. Posteroanterior radiograph of a 63-year-old man with severe mitral stenosis, status post mitral valve replacement, shows multiple scattered bony nodules (arrows) 2 to 10 mm in diameter throughout the lower two-thirds of both lungs, compatible with pulmonary ossification.

' Figure 12-7: Roentgen appearance of right-sided heart failure. A. Patient with severe obstructive emphysema showing overaeration of the lungs, centralized flow pattern, and a small heart size. B. Three years later, the patient was in frank right-sided heart failure. Note that the heart got bigger as his emphysema got worse. The centralized flow pattern became more severe. C. Patient with Ebstein's anomaly showing gross cardiomegaly with severe decrease in pulmonary vascularity. The right cardiac border represents the huge right atrium, and the left cardiac border represents the giant right ventricle. D. Patient with mitral stenosis showing a giant right atrium (arrow) representing severe functional tricuspid regurgitation due to unrelenting left-sided failure. The pulmonary venous congestion had improved following the onset of right-sided heart failure.

' Figure 12-8: Left ventricular aneurysms. A. Posteroanterior view of patient 1 shows a localized bulge (arrows) along the left cardiac border representing a left ventricular aneurysm from the anterolateral wall. B. Lateral view shows a double density with sharp borders anteriorly and superiorly (arrows). This is the left ventricular aneurysm that casts a shadow on the normal right ventricle. Fluoroscopically, it is easy to confirm its origin and to separate it from the right ventricle by rotating the patient under direct vision. C. Posteroanterior view of patient 2, a 69-year-old man, shows total calcification of an anterolateral apical left ventricular aneurysm (arrows). D. Lateral view shows the same (arrows).

' Figure 12-9: A 71-year-old woman with syphilitic aortitis. Her posteroanterior radiograph

(A) shows a huge, calcified ascending aortic aneurysm (arrows). In addition, the entire aorta and the left ventricle are markedly dilated, compatible with severe aortic regurgitation (From Chen,14 with permission.) A magnified view of the ascending aorta

(B) shows the calcified aneurysm to better advantage.

Figure 12-10: Developing pericardial effusion in 2 weeks. A. A magnified view of the retrosternal area showing the hairlike normal pericardium (arrow) sandwiched between the subepicardial fat stripe interiorly and the mediastinal fat stripe exteriorly. The maximal width of normal pericardium is 2 mm. B. The same patient 2 weeks later, with moderate pericardial effusion. The pericardial cavity now measured more than 1 cm in width (arrow).

Figure 12-11: Traumatic constrictive-effusive pericarditis in a young man. Following emergent pericardiocentesis and injection of air, a radiograph was taken in the supine position. Air is confined to the left side of the pericardium. Note markedly thickened parietal layer (arrows).

Figure 12-12: Posteroanterior view of a patient with dextrocardia and situs solitus. Note that the aortic arch and the stomach air bubble are both on the left (situs solitus) and the apex of the ventricles is pointing to the right inferiorly. According to statistics and proved by cardiac catheterization, this patient had the typical combination of congenitally corrected transposition of the great arteries, ventricular septal defect, and pulmonary stenosis. He was cyanotic. The pulmonary vascularity appears decreased. Figure 12-13: A 17-year-old boy with congenital aortic valve stenosis. Note dilatation of the ascending aorta, increased convexity of the left ventricle, and normal pulmonary vascularity. The systolic aortic pressure gradient was 100 mmHg.

Figure 12-14: A 45-year-old man with Marfan's syndrome, severe aortic regurgitation, and proximal aortic dissection into the pericardial cavity. A. Posteroanterior view shows a huge left ventricular and aneurysmal dilatation of the ascending aorta. There is no sign of heart failure. B. Lateral view shows a small pericardial effusion (arrow). Figure 12-15: Posteroanterior view of a 77-year-old man shows a huge descending aortic aneurysm (arrows).

Figure 12-16: A 37-year-old woman with congenital valvular pulmonary stenosis. Note enlarged pulmonary trunk and left pulmonary artery versus diminished right pulmonary artery. Also note increased pulmonary blood flow on the left side and decreased pulmonary blood flow on the right side.

Figure 12-17: Patient with congestive heart failure. Note gross cardiomegaly, cephalization, interstitial pulmonary edema, and right-sided pleural effusion. Some of the fluid was loculated in the minor interlobar fissure (arrow), which disappeared with improved cardiac function.

Figure 12-18: A child suffering from nephrotic syndrome, which was treated successfully.

A. Posteroanterior view during the worst period of his disease shows general anasarca, pulmonary edema, and pleural effusion. Note considerable soft tissue edema in the chest wall. B. With proper treatment, everything returned to normal in 2 weeks.

Figure 12-19: Patients with Holt-Oram syndrome. A. Posteroanterior view of patient 1, a 7-year-old girl, shows a globular cardiac contour with increased pulmonary blood flow. The aortic arch is on the right side. Catheterization diagnosis: secundum atrial septal defect. B. Her left arm shows absent radius and thumb with radial clubhand. Her right arm is a mirror image of the left (not shown). C. Forearms of patient 2, a 33-year-old woman with secundum atrial septal defect, show bilateral absence of thumb.

Figure 12-20: Young man with acute pericarditis with effusion. A. Posteroanterior view shows a water bottle-shaped cardiomegaly, clear lungs, and normal pulmonary vascularity.

B. Repeat film taken 5 days later shows excellent response to therapy.

s Figure 12-21: Statistical guidance focusing on the best diagnostic possibilities. A.

Posteroanterior view of a patient with tetralogy of Fallot showing a right aortic arch, avian type. Note that the esophagus and trachea are deviated to the left. The cardiovascular structures are otherwise within normal limits. B. Lateral view of the same patient showing the aortic arch normally situated, in front of the trachea and esophagus. C. Posteroanterior radiograph of a healthy woman shows a right aortic arch (large arrow) with a large aortic diverticulum (small arrow) that protrudes to the left of the midline. The distal segment of the trachea is deviated to the left side by the right arch. Unlike double aortic arch, the left lateral margin of the trachea is not indented because the diverticulum is posterior and not lateral in position. D. Lateral view of similar patient, a healthy man. Note that both the esophagus and the trachea are markedly displaced anteriorly by a huge diverticulum, which invariably gives rise to the aberrant left subclavian artery.

B*® Figure 12-22: A 42-year-old man with Eisenmenger's atrial septal defect. Note increased pulmonary blood flow with a centralized pattern.

s Figure 12-23: Patient with calcific constrictive pericarditis. Typically there is only mild postcapillary pulmonary hypertension due to left-sided constriction. Severe pulmonary venous congestion is prevented by the concurrent right-sided constriction. A. Posteroanterior view shows moderate cardiomegaly and mildly cephalic pulmonary blood flow pattern. B. Lateral view shows heavy calcification of the pericardium (arrows) and left atrial enlargement deviating the barium-filled esophagus posteriorly.

s Figure 12-24: Schematic representation of dynamic changes of aortic regurgitation. Blue interrupted lines represent images in systole; solid lines, those in diastole.

' Figure 12-25: Lateral view shows heavy railroad track-like calcification of all three major coronary arteries. r, right coronary artery; a, anterior descending; c, circumflex; p, posterior descending. Note the ringlike densities representing vessels viewed on end.

' Figure 12-26: Schematic representation of the subepicardial fat stripes in relation to major coronary arteries. A. Posteroanterior view. B. Lateral view. C. Right anterior oblique view. D. Left anterior oblique view. AL, left atrioventricular groove (circumflex); aR, right atrioventricular groove (right); vA, anterior interventricular groove (anterior descending); vP, posterior interventricular groove (posterior descending); F, apical fat pad; AO, aorta; LV, left ventricle.

' Figure 12-27: A young man with a slowly developed pericardial effusion without cardiac tamponade. His posteroanterior view shows a huge water bottle-like cardiac silhouette. Note the lungs are clear and the PBF pattern is normal. The subepicardial fat stripe (black curvilinear line) within the immobile pericardial effusion was clearly visible and bouncing vigorously under the fluoroscope. The amplitude of excursion of the fat stripe reflected the normally functioning myocardium.

Figure 12-28: Patient with congenitally corrected transposition of the great arteries. The left-sided atrioventricular valve was replaced with a St. Jude prosthesis. The valve was caught in the opened position (in diastole), when both leaflets were seen as a pair of parallel lines (arrows). The same valve was invisible in the closed position (not shown).


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