Chest Part 5

8/14/2019 Chest Part 5

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Radiologic Diagnosis of Heart

Diseases

An Atlas of Cardiac X-rays

PART 5PART 5

Radiological feature of common congenital cardiacRadiological feature of common congenital cardiac

malformationsmalformations

Extracardiac structures simulating cardiac diseaseExtracardiac structures simulating cardiac disease

Dr. Khairy Abdel Dayem

Professor of Cardiology

Radiologic Diagnosis of Heart

Diseases

An Atlas of Cardiac X-rays

PART 5PART 5

Radiological feature of common congenital cardiacRadiological feature of common congenital cardiac

malformationsmalformations

Extracardiac structures simulating cardiac diseaseExtracardiac structures simulating cardiac disease

Dr. Khairy Abdel Dayem

Professor of Cardiology


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PART 5PART 5 Radiological feature of common congenital

cardiac malformations The cardiac malpositions

Atrial septal defect

Ventricular septal defect

Patent ductus arteriosus

Pulmonary stenosis

Coarctation of aorta

Fallots tetralogy

Transposition of great arteries

Ebstein Anomaly of the Tricuspid valve

Total anomalous pulmonary venous drainage

Extracardiac structures simulating cardiac disease

PART 5PART 5 Radiological feature of common congenital

cardiac malformations The cardiac malpositions

Atrial septal defect

Ventricular septal defect

Patent ductus arteriosus

Pulmonary stenosis

Coarctation of aorta

Fallots tetralogy

Transposition of great arteries

Ebstein Anomaly of the Tricuspid valve

Total anomalous pulmonary venous drainage

Extracardiac structures simulating cardiac disease


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Radiological Features of

Common Congenital Heart

DiseasesThe Cardiac Malpositions (Fig. 84)

Radiological Features of

Common Congenital Heart

DiseasesThe Cardiac Malpositions (Fig. 84)In the normal situs solitus, the heart occupies the left side of

the thorax on the same side as the stomach, (Fig. 85). The liver is

present on the right side of the abdomen.

In situs inversus totalis all body structures are mirror image of

the normal and the heart and stomach are on the right side and the

liver on the left side. If the X-ray is inverted it will appear entirely

normal, (Fig. 86).

In isolated dextrocardia, (Fig. 87) the heart exists on the left

side of the thorax but the viscera are in their normal position (situs

solitus). This creates a discordance between the position of the

systemic veins which follow the liver, and the heart. The atria

usually follow the veins and there is atrio ventricular discordance.

In the normal situs solitus, the heart occupies the left side of

the thorax on the same side as the stomach, (Fig. 85). The liver is

present on the right side of the abdomen.

In situs inversus totalis all body structures are mirror image of

the normal and the heart and stomach are on the right side and the

liver on the left side. If the X-ray is inverted it will appear entirely

normal, (Fig. 86).

In isolated dextrocardia, (Fig. 87) the heart exists on the left

side of the thorax but the viscera are in their normal position (situs

solitus). This creates a discordance between the position of the

systemic veins which follow the liver, and the heart. The atria

usually follow the veins and there is atrio ventricular discordance.


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Fig. (85): Normal left sided cardiac

position in situs solitus in an infant

Fig. (85): Normal left sided cardiac

position in situs solitus in an infant

Fig. (84): The position of cardiac

chambers, the liver and stomach in

various malpositions.

Fig. (84): The position of cardiac

chambers, the liver and stomach in

various malpositions.

In isolated levocardia the heart remains in the left side of the

chest while the viscera are inverted, (Fig. 88). The atrium follow the

liver. Here too, there is atrio-ventricular discordance.

In isolated levocardia the heart remains in the left side of the

chest while the viscera are inverted, (Fig. 88). The atrium follow the

liver. Here too, there is atrio-ventricular discordance.


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Fig. (86): Dextrocardia in situs inversus totalisFig. (86): Dextrocardia in situs inversus totalis


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Fig. (87): Isolated lexocardia in a case

of situs inversus. Note that the

stomach is on the right side.

Fig. (87): Isolated lexocardia in a case

of situs inversus. Note that the

stomach is on the right side.

Fig. (88): Isolated dextrocardia. Note

that the stomachis situated in the left

side of abdomen (situs solitus)

Fig. (88): Isolated dextrocardia. Note

that the stomachis situated in the left

side of abdomen (situs solitus)


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Atrial Septal Defect (ASD)Atrial Septal Defect (ASD)

When there is a defect in the interatrial septum the blood will

flow from the LA to the RA (left to right shunt). This is becausethe LA empties into the thick less compliant LV while the right

atrium empties into the thin more distensible RV.

Additional oxygenated blood will reach the RA and RV and

pulmonary arteries. Pulmonary plethora will result, (Fig. 89).

If the pulmonary blood flow is excessive, pulmonary arteriolar

vasoconstriction will occur and causes pulmonary hypertension.

This will decrease then abolish the increased blood flow in the

lungs. It will also cause further hypertrophy and dilatation of the

RV, RA and pulmonary arteries.

Ultimately the shunt will be reversed resulting in Eisenmenger

Syndrome.

When there is a defect in the interatrial septum the blood will

flow from the LA to the RA (left to right shunt). This is becausethe LA empties into the thick less compliant LV while the right

atrium empties into the thin more distensible RV.

Additional oxygenated blood will reach the RA and RV and

pulmonary arteries. Pulmonary plethora will result, (Fig. 89).

If the pulmonary blood flow is excessive, pulmonary arteriolar

vasoconstriction will occur and causes pulmonary hypertension.

This will decrease then abolish the increased blood flow in the

lungs. It will also cause further hypertrophy and dilatation of the

RV, RA and pulmonary arteries.

Ultimately the shunt will be reversed resulting in Eisenmenger

Syndrome.


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Fig. (89): X-ray signs of ASD: dilated RA, RV, PA and

pulmonary plethora. N = normal x-ray

Fig. (89): X-ray signs of ASD: dilated RA, RV, PA and

pulmonary plethora. N = normal x-ray


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X-ray Picture (Fig 89 & 90):

Plethoric lung fields.

Dilatation of the right atrium, right ventricle and pulmonary

artery.

Small aortic arch due to low cardiac output.

Marked pulsations of the pulmonary artery and its branches

seen during fluoroscopy, i.e. hilar dance.

As pulmonary hypertension develops the plethora will

decrease then disappear and the picture will be transformed

into that pulmonary hypertension.

X-ray Picture (Fig 89 & 90):

Plethoric lung fields.

Dilatation of the right atrium, right ventricle and pulmonary

artery.

Small aortic arch due to low cardiac output.

Marked pulsations of the pulmonary artery and its branches

seen during fluoroscopy, i.e. hilar dance.

As pulmonary hypertension develops the plethora will

decrease then disappear and the picture will be transformed

into that pulmonary hypertension.


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Fig. (90): X-ray of ASD with left to right shuntFig. (90): X-ray of ASD with left to right shunt


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Ventricular Septal Defect (VSD)Ventricular Septal Defect (VSD)

When there is a defect in the interventricular septum the blood

will be shunted from the LV to the RV causing increased flow in

the pulmonary artery and pulmonary plethora. The excessive

blood returning from the lung will pass through the LA and will be

pumped by the LV into the aorta. Thus, LA and LV dilatation willoccur.

If pulmonary hypertension sets in, the RV will enlarge and the

pulmonary plethora will decrease and be transformed into

pulmonary oligemia.

In the final stage the X-ray shows only manifestations of

pulmonary hypertension.

When there is a defect in the interventricular septum the blood

will be shunted from the LV to the RV causing increased flow in

the pulmonary artery and pulmonary plethora. The excessive

blood returning from the lung will pass through the LA and will be

pumped by the LV into the aorta. Thus, LA and LV dilatation willoccur.

If pulmonary hypertension sets in, the RV will enlarge and the

pulmonary plethora will decrease and be transformed into

pulmonary oligemia.

In the final stage the X-ray shows only manifestations of

pulmonary hypertension.


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X-ray Picture:

1. X-ray is normal in cases with small defects.

2. Large defects result in:

a) Pulmonary plethora, i.e. overfilled large and tortuous

pulmonary arteries.

b) Large main pulmonary artery.

c) Left and right ventricular enlargement.

d) Left atrial enlargement.

X-ray Picture:

1. X-ray is normal in cases with small defects.

2. Large defects result in:

a) Pulmonary plethora, i.e. overfilled large and tortuous

pulmonary arteries.

b) Large main pulmonary artery.

c) Left and right ventricular enlargement.

d) Left atrial enlargement.


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Fig. (91): Two cases of small (left) and large (right) VSD. Note the left

ventricular enlargement and the pulmonary plethora.

Fig. (91): Two cases of small(left) and large (right) VSD. Note the left

ventricular enlargement and the pulmonary plethora.


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Patent Ductus Arteriosus (PDA)

The ductus arteriosus is normally present in the fetus. It

connects the aorta (at the junction of the arch with the descending

aorta) with the pulmonary artery (at the junction of the main

pulmonary artery with its left branch). It normally closes during the

first month after birth. If the ductus does not close, the followinghemodynamic changes will occur.

1. The blood flows through the ductus from the aorta to the

pulmonary artery, i.e. left to right shunt.

2. As pulmonary artery receives blood both from the shunt and

the right ventricle, pulmonary artery dilatation and

pulmonary plethora occur.

The ductus arteriosus is normally present in the fetus. It

connects the aorta (at the junction of the arch with the descending

aorta) with the pulmonary artery (at the junction of the main

pulmonary artery with its left branch). It normally closes during the

first month after birth. If the ductus does not close, the followinghemodynamic changes will occur.

1. The blood flows through the ductus from the aorta to the

pulmonary artery, i.e. left to right shunt.

2. As pulmonary artery receives blood both from the shunt and

the right ventricle, pulmonary artery dilatation and

pulmonary plethora occur.


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3. The excessive flow returns to the left atrium, the left ventricle

and the aorta resulting in:

a) Dilatation of the left atrium.

b) Dilatation and hypertrophy of the left ventricle (volume

over-load).

c) Dilatation of the ascending aorta and aortic arch.

4. If the shunt is big pulmonary vasoconstriction and hypertension

occur.

5. When the pressure in the pulmonary artery exceeds that of the

aorta, the shunt will be reversed, i.e. right to left, and differential

cyanosis occurs. This is Eisenmengers syndrome.

3. The excessive flow returns to the left atrium, the left ventricle

and the aorta resulting in:

a) Dilatation of the left atrium.

b) Dilatation and hypertrophy of the left ventricle (volume

over-load).

c) Dilatation of the ascending aorta and aortic arch.

4. If the shunt is big pulmonary vasoconstriction and hypertension

occur.

5. When the pressure in the pulmonary artery exceeds that of the

aorta, the shunt will be reversed, i.e. right to left, and differential

cyanosis occurs. This is Eisenmengers syndrome.


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Fig. (92): X-ray findings in patent ductus arteriosus. Note the enlarged pulmonary

artery and left ventricle and the pulmonary plethora. The aortic arch is prominent

Fig. (92): X-ray findings in patent ductus arteriosus. Note the enlarged pulmonary

artery and left ventricle and the pulmonary plethora. The aortic arch is prominent


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X-ray Picture:

1. X-ray is normal in cases with small ductus.

2. In moderate or large ductus the following signs appear (Fig. 92):

a) Pulmonary plethora.

b) Enlargement of the left atrium, left ventricle and the aorta.

c) Systolic dilatation of the pulmonary artery and its main

branches seen in the hilum by fluoroscopy: hilar dance.

d) Ductus itself can be seen as a line bridging the space

between the aorta and the pulmonary artery on the left

border of the heart, (Fig. 93). It may even be calcified, (Fig.

94).

X-ray Picture:

1. X-ray is normal in cases with small ductus.

2. In moderate or large ductus the following signs appear(Fig. 92):

a) Pulmonary plethora.

b) Enlargement of the left atrium, left ventricle and the aorta.

c) Systolic dilatation of the pulmonary artery and its main

branches seen in the hilum by fluoroscopy: hilar dance.

d) Ductus itself can be seen as a line bridging the space

between the aorta and the pulmonary artery on the left

border of the heart, (Fig. 93). It may even be calcified, (Fig.

94).


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Fig. (93): The patent ductus is seen in the space between the aorta (AO)

and pulmonary trunk (PT) in the X-ray (left) and angiogram (right)

Fig. (93): The patent ductus is seen in the space between the aorta (AO)

and pulmonary trunk (PT) in the X-ray(left) and angiogram (right)


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Fig. (94): Two cases of calcified ductusFig. (94): Two cases of calcified ductus


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Pulmonary stenosis may be caused by:

a. Congenital fusion of pulmonary valve cups, I.e. congenital

valvular pulmonary stenosis.

b. Congenital excessive hypertrophy of the muscles surrounding

the outflow tract of the right ventricle (I.e. the infundibulum)

below the level of the pulmonary valve, i.e. congenital

infundibular pulmonary stenosis.

X-ray Picture:

1. Pulmonary oligemia occurs in moderate and severe cases and

results in reduced pulmonary vascular markings.

2. Right ventricular enlargement is proportional to the severity of

the stenosis. Right atrial enlargement may also occur.

Pulmonary stenosis may be caused by:

a. Congenital fusion of pulmonary valve cups, I.e. congenital

valvular pulmonary stenosis.

b. Congenital excessive hypertrophy of the muscles surrounding

the outflow tract of the right ventricle (I.e. the infundibulum)

below the level of the pulmonary valve, i.e. congenital

infundibular pulmonary stenosis.

X-ray Picture:

1. Pulmonary oligemia occurs in moderate and severe cases and

results in reduced pulmonary vascular markings.

2. Right ventricular enlargement is proportional to the severity of

the stenosis. Right atrial enlargement may also occur.

Pulmonary Stenosis


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Fig. (95): Two cases of pulmonary stenosis with post stenotic dilatation of the PAFig. (95): Two cases of pulmonary stenosis with post stenotic dilatation of the PA

3. If the stenosis is valvular, the jet of blood coming out of the

narrow orifice hits against the pulmonary artery wall and causes

its weakening and dilatation. This is post-stenotic dilatation of

the pulmonary artery.

3. If the stenosis is valvular, the jet of blood coming out of the

narrow orifice hits against the pulmonary artery wall and causes

its weakening and dilatation. This is post-stenotic dilatation of

the pulmonary artery.


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Coarctation of the aorta is narrowing of the aorta usually at the

junction of the arch with the descending aorta just distal to the leftsubclavian artery. Because of the narrowing, pressure rises in the

ascending aorta and the aortic arch and its branches.

Anastomosis forms between the branches of he aorta proximal

and distal to the obstruction. The most important of these connect

the subclavian artery through its internal mammary branch to the

intercostal arteries which arise from descending aorta. The

intercostal arteries become enlarged and tortuous and erode the

lower border of the fourth to ninth ribs causing rib notching.Appreciable anastomosis develops gradually by time. That is why

rib notching is not detectable except after the age of 10. Other

anastomosis develops around the scapula and another connects

the superior and inferior epigasric arteries (Fig. 96).

Coarctation of the aorta is narrowing of the aorta usually at the

junction of the arch with the descending aorta just distal to the leftsubclavian artery. Because of the narrowing, pressure rises in the

ascending aorta and the aortic arch and its branches.

Anastomosis forms between the branches of he aorta proximal

and distal to the obstruction. The most important of these connect

the subclavian artery through its internal mammary branch to the

intercostal arteries which arise from descending aorta. The

intercostal arteries become enlarged and tortuous and erode the

lower border of the fourth to ninth ribs causing rib notching.Appreciable anastomosis develops gradually by time. That is why

rib notching is not detectable except after the age of 10. Other

anastomosis develops around the scapula and another connects

the superior and inferior epigasric arteries (Fig. 96).

Coarctation of The Aorta


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Fig. (96): Collateral circulation in coarctation of aortaFig. (96): Collateral circulation in coarctation of aorta


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X-ray Picture (Figs. 100 & 101):

1. Right ventricular hypertrophy causes the apex to be

displaced outwards and becomes separated from the

diaphragm.

2. The aorta receives blood from both ventricles and the aortic

arch is enlarged. Sometimes the aortic arch is directed to the

right i.e. right-sided aortic arch (Fig. 102).

3. The pulmonary artery and its branches are diminished in size

due to the pulmonary stenosis (pulmonary oligemia). There

is a concavity in the region of the underdeveloped RV

outflow tract.

All the above factors result in a characteristic cardiac shadow,

i.e. coeur en sabot (Sabot = wooden shoe).

X-ray Picture (Figs. 100 & 101):

1. Right ventricular hypertrophy causes the apex to be

displaced outwards and becomes separated from the

diaphragm.

2. The aorta receives blood from both ventricles and the aortic

arch is enlarged. Sometimes the aortic arch is directed to the

right i.e. right-sided aortic arch (Fig. 102).

3. The pulmonary artery and its branches are diminished in size

due to the pulmonary stenosis (pulmonary oligemia). There

is a concavity in the region of the underdeveloped RV

outflow tract.

All the above factors result in a characteristic cardiac shadow,

i.e. coeur en sabot (Sabot = wooden shoe).


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Fig. (102): Fallots tetrology with right

sided aortic arch

Fig. (102): Fallots tetrology with right

sided aortic arch

Fig. (101): Fallots tetrology with near

pulmonary atresia. The aorta is markedly

enlarged

Fig. (101): Fallots tetrology with near

pulmonary atresia. The aorta is markedly

enlarged

Fig. (100): Two cases of Fallots tetrologyFig. (100): Two cases of Fallots tetrology


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In TGA the aorta arises from the morphologically right ventricle

and the pulmonary artery from the left. The atrioventricularconnections are normal. Additional atrial or ventricular septal defect

or patent ductus are essential in order to allow oxygenated blood to

reach the body and venous blood to reach the lungs.

X-ray Picture (Fig. 103):1. The x-ray commonly give the essential clue to the diagnosis of

TGA: Increased pulmonary arterial blood flow (plethora seen in

the x-ray) in a cyanotic child. Plethora is more evident in the

right lung because of the rightward direction of the mainpulmonary artery.

2. The thynus gland is absent and the vascular pedicle is

characteristically narrow in the frontal plane because the

pulmonary artery lies behind the aorta and not by its side.

In TGA the aorta arises from the morphologically right ventricle

and the pulmonary artery from the left. The atrioventricularconnections are normal. Additional atrial or ventricular septal defect

or patent ductus are essential in order to allow oxygenated blood to

reach the body and venous blood to reach the lungs.

X-ray Picture (Fig. 103):1. The x-ray commonly give the essential clue to the diagnosis of

TGA: Increased pulmonary arterial blood flow (plethora seen in

the x-ray) in a cyanotic child. Plethora is more evident in the

right lung because of the rightward direction of the mainpulmonary artery.

2. The thynus gland is absent and the vascular pedicle is

characteristically narrow in the frontal plane because the

pulmonary artery lies behind the aorta and not by its side.

Transposition of Great Arteries(TGA)


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Fig. (103): Typical picture of TGA.Note the oval cardiac silhouette, the

narrow pedicle and the pulmonary

plethora.

Fig. (103): Typical picture of TGA.

Note the oval cardiac silhouette, the

narrow pedicle and the pulmonary

plethora.

3. The heart is enlarged and takes the shape of an egg on side

tilted so that its tip (the apex) is pointing downwards and to the

left.

The presence of additional lesions e.g. pulmonary stenosis,

pulmonary hypertension, ductus, etc. may alter or add to the

typical picture.

3. The heart is enlarged and takes the shape of an egg on side

tilted so that its tip (the apex) is pointing downwards and to the

left.

The presence of additional lesions e.g. pulmonary stenosis,

pulmonary hypertension, ductus, etc. may alter or add to the

typical picture.


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This is a rare anomaly in which the leaflets of the tricuspid valve

are adherent to the right ventricular wall. The level of the valve is

shifted towards the right ventricular apex. A portion of the right

ventricle is atrialized i.e. becomes hemodynamically part of the

right atrium. Tricuspid regurgitation is commonly severe.

X-ray Picture:

1. The most characteristic x-ray sign is enlarged right atrium

forming a prominent convexity on the lower two thirds of the

right cardiac borders.

2. The right ventricular infundibulum forms a prominence on the

left cardiac border at a level lower than that of the pulmonary

artery. This, together with the right atrial enlargement gives a

box like shape to the cardiac silhouette (Fig. 104).

This is a rare anomaly in which the leaflets of the tricuspid valve

are adherent to the right ventricular wall. The level of the valve is

shifted towards the right ventricular apex. A portion of the right

ventricle is atrialized i.e. becomes hemodynamically part of the

right atrium. Tricuspid regurgitation is commonly severe.

X-ray Picture:

1. The most characteristic x-ray sign is enlarged right atrium

forming a prominent convexity on the lower two thirds of the

right cardiac borders.

2. The right ventricular infundibulum forms a prominence on the

left cardiac border at a level lower than that of the pulmonary

artery. This, together with the right atrial enlargement gives a

box like shape to the cardiac silhouette (Fig. 104).

Ebstein Anomaly of The TricuspidValve


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3. The overall cardiac size may vary from huge (specially in

infants) to normal.

3. The overall cardiac size may vary from huge (specially in

infants) to normal.

4. The lungs vasculature is normal or reduced .

The differential diagnose of the x-ray film is pericardial

effusion, dilated cardiomyopathy and heart failure due to critical

valve lesion.

4. The lungs vasculature is normal or reduced .

The differential diagnose of the x-ray film is pericardial

effusion, dilated cardiomyopathy and heart failure due to critical

valve lesion.

Fig. (104): Ebstein anomaly. The right

atrium is enlarged. The right ventricular

inlet is atrialized and the right ventricular

infindibulum is prominent.

Fig. (104): Ebstein anomaly. The right

atrium is enlarged. The right ventricular

inlet is atrialized and the right ventricular

infindibulum is prominent.


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Anomalous pulmonary venous drainage may be total or partial

and may be supracardiac, cardiac or infracardiac according to the

level in which the pulmonary venous flow joins the systemic

circulation: i.e. either in:

Superior vena cava, or

Right atrium or coronary

sinus, or

Inferior vena cava.

Anomalous pulmonary venous drainage may be total or partial

and may be supracardiac, cardiac or infracardiac according to the

level in which the pulmonary venous flow joins the systemic

circulation: i.e. either in:

Superior vena cava, or

Right atrium or coronary

sinus, or

Inferior vena cava.

Fig. (105): The course of circulation in

total anomalous venous drainage

opening in the superior vena cava

Fig. (105): The course of circulation in

total anomalous venous drainage

opening in the superior vena cava

Total Anomalous Pulmonary VenousDrainage


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In total anomalous pulmonary venous drainage the pulmonary

veins join a transverse common vein that ends in an anomalous

vertical channel which, in turn opens in the left side of theinnominate vein (Fig. 105).

X-ray Picture:

The x-ray resembles that of an atrial septal defect.

The commonest form of total anomalous venous connection

gives the snow man or figure of 8 silhouette. The upper

portion of the 8 is formed by the dilated left vertical venouschannel and the right superior vena cava. The lower portion is

made by the dilated right atrium and right ventricle (Fig. 106).

In total anomalous pulmonary venous drainage the pulmonary

veins join a transverse common vein that ends in an anomalous

vertical channel which, in turn opens in the left side of theinnominate vein (Fig. 105).

X-ray Picture:

The x-ray resembles that of an atrial septal defect.

The commonest form of total anomalous venous connection

gives the snow man or figure of 8 silhouette. The upper

portion of the 8 is formed by the dilated left vertical venous

channel and the right superior vena cava. The lower portion is

made by the dilated right atrium and right ventricle (Fig. 106).


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Fig. (106): (Left): an angiogram and (right): X-ray of a case of total anomalous

venous drainage in which the common venous channel opens in the superior

vena cava. The X-ray shows the figure of 8 or the snow-man appearance.

Fig. (106): (Left): an angiogram and(right): X-ray of a case of total anomalous

venous drainage in which the common venous channel opens in the superior

vena cava. The X-ray shows the figure of 8 or the snow-man appearance.


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Extracardiac Structures Simulating Cardiac Enlargement

Pathological masses in the anterior or superior mediastinum may be

superimposed on the cardiac shadow and simulate enlargement of various

cardiac chambers and great vessels. They include lymphomas, dermoidcyst, retrosternal goiter, thymoma, etc.., (Figs. 107, 108, 109 & 110).

Extracardiac Structures Simulating Cardiac Enlargement

Pathological masses in the anterior or superior mediastinum may be

superimposed on the cardiac shadow and simulate enlargement of various

cardiac chambers and great vessels. They include lymphomas, dermoidcyst, retrosternal goiter, thymoma, etc.., (Figs. 107, 108, 109 & 110).

Fig. (107):Fig. (107): Fig. (108):Fig. (108): Fig. (109):Fig. (109):

When such masses occur, can be suspected by the presence of a normal

cardiac size and normal pulmonary vasculation.

When such masses occur, can be suspected by the presence of a normal

cardiac size and normal pulmonary vasculation.


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Fig. (111): Enlarged thymus gland in an infantFig. (111): Enlarged thymus gland in an infant

Chest Part 5

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