By: Tham Yea Bing, Lim Wee Yi

Group 1 Year 5 2010/2011 MD USM, Malaysia

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Cardiac output and blood pressure are inadequate for the tissue metabolic needs despite normal venous return

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Acute vs Chronic

Right vs Left(together Congestive Heart Failure)

Forward vs Backward

Low Output vs High Output

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Coronary artery disease

Hypertension

Cardiomyopathy

Valvular heart disease

Congenital heart disease

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Right Side Left Side

Acute Severe Heart Failure

• Painful hepatomegaly• Elevated jugular venous pressure

• Pulmonary oedema• Dyspnea• Hemoptysis

Chronic Heart Failure

• Passive systemic congestion• Hepatomegaly ( chronic venous congestion)• Legs oedema• Right atrial & ventricular dilatation

• Chronic venous congestion of lungs• Exertional dyspnea• Paroxysmal nocturnal dyspnea• Pulmonary hypertension• Left atrial & ventricular dilatation

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Cardiac enlargement + specific chamber enlargement

Upper lobe diversion

Pulmonary oedema

Pleural effusions

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Cardiothoracic Ratio ( CTR) In normal people, the transverse diameter of the heart is

usually less than half the internal diameter of the chest.

CTR is only useful in erect PA films. Magnification of heart in AP view

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Cardiothoracic Ratio (CTR) = A+B/C 8

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It is rarely possible to distinguish ventricular hypertrophy from dilatation by looking at the external contours of the heart. Hypertrophy of ventricular wall encroaches on the

ventricular cavity with little change in the external contours of the heart until the ventricles fails.

Ventricular dilatation is recognised only as an overall increase in the transverse cardiac diameter.

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Left atrial enlargement Right border of enlarged left atrium is visible as a double

contour adjacent to right heart border

Usually within the main cardiac shadow

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Right atrial enlargement Increase in the curvature of right heart border

Often accompanied by enlargement of superior vena cava

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Chest X-ray Finding PCWP (mmHg) Grade

Normal 5 – 10

Cephalization (Upper lobe diversion) 10 – 15I

Kerley B line 15 – 20

Pulmonary Interstitial Edemaa. Thickening of interlobular septab. Peribronchial cuffingc. Fluid in Fissuresd. Pleural Effusions

20 – 25 II

Pulmonary Alveolar Edemaa. Acinar Shadowb. Bat’s wing appearance

> 25 III

http://www.mdconsult.com/das/book/body/216523017-2/0/1276/62.html

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Also known as:- Pulmonary wedge pressure (PWP) Pulmonary artery occlusion pressure (PAOP)

Indication: Provide indirect measurement of left atrial pressure

(LAP) Diagnose the severity of left ventricular failure Quantify degree of mitral valve disease Guide therapeutic efficacy of disease

Measure by:- Swan-Ganz catheter (pulmonary arterial catheter)

http://www.cvphysiology.com/Heart%20Failure/HF008.htm

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Normal Pressure:

5-10 mmHg

Acute pulmonary edema >20 mmHg

http://www.introtoccnursing.com/sites/calvin/_files/Image/swan%20ganz%20cath_%20jpg.gif

http://upload.wikimedia.org/wikipedia/commons/thumb/e/ea/Pulmonary_artery_catheter_english.JPG/220pxPulmonary_artery_catheter_english.JPG

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Chest X-ray Finding PCWP (mmHg) Grade

Normal 5 – 10

Cephalization (Upper lobe diversion) 10 – 15I

Kerley B line 15 – 20

Pulmonary Interstitial Edemaa. Thickening of interlobular septab. Peribronchial cuffingc. Fluid in Fissuresd. Pleural Effusions

20 – 25 II

Pulmonary Alveolar Edemaa. Acinar Shadowb. Bat’s wing appearance

> 25 III

http://www.mdconsult.com/das/book/body/216523017-2/0/1276/62.html

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http://www.ultramedicine.co.uk/images/mcqSampleHeart.gif

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In normal PCWP Blood flow to the lung bases more than apices Upper lobe blood vessels narrower On upright chest x-ray, vessels should be distinct from

peripheral 1/3 back centrally to hilar, more apparent in lower lung than upper lung

As PCWP > 10mmHg Interstitial and perivascular edema developed Most prominent at the lung bases because hydrostatic

pressure is greater Equalization in the size of the vessels at the apices and bases As PCWP increases, there will be further redistribution of

blood into the non-dependent portions of lungs

Only applies if film is taken erect!!20

NORMAL CHEST X-RAYLower lobes have more prominent blood vessels

diverting downwards and laterally

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http://www.mdconsult.com/das/book/body/216532158-2/0/1276/I4-u1.0-B0-7216-0527-3..50006-8--f66.fig?tocnode=49301040

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Visible distended interlobular septa Fluid filling the interstitium

Location and appearance Bases, peripheral beginning

from costophrenic angle 1-2 cm long, ~ 1mm thick Horizontal direction Perpendicular to pleural

surface

Other causes:- Lymphangitis carcinomatosa Pulmonary fibrosis Parasitic infection

Named after Peter J Kerley, an English radiologist who also described Kerley-A and Kerley-C lines on chest radiographs

http://2.bp.blogspot.com/_tN90RefJ5Hk/SMgo9_EYZtI/AAAAAAAAAUE/6sSJYny04C8/s400/Kerley+B.jpg

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http://www.mdconsult.com/das/book/body/216532158-2/0/1276/I4-u1.0-B0-7216-0527-3..50006-8--f66.fig?tocnode=49301040http://radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_page8.html#top_second_img

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Appear when connective tissue around bronchoarterial sheaths in lungs distends with fluid.

Location and appearance

Near hilum not reaching periphery of lung

Run obliquely

Longer than B lines (up to 6cm)

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When PCWP = 20-25 mmHg

Features:-1. Thickening of interlobular septa (Kerley B lines)

2. Peribronchial cuffing

3. Fluid in Fissures

4. Pleural Effusions

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Interstitial fluid accumulate around bronchi

Thickening of bronchial wall

When see on-end, looks like numerous, small, ring like shadows (little doughnuts)

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Fluid collects in subpleural space Between lung parenchyma and visceral pleural

Normal fissure is the thickness of a sharpened pencil line

Fluid may collect in any fissure Major(oblique), minor(horizontal), and azygous fissure

Thicker, irregular and visible

If prolonged, repeated bouts of failure, Fibrosis results in permanent thickening of fissures

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NORMAL FISSURES THICKENED FISSURES

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Normal pleural fluid volume 2-5 ml not visible on radiograph.

Usually bilateral effusion it can be asymmetrical. Almost always right sided.

Two important radiographic findings:1. Blunting the costophrenic angles

300ml of fluid blunt lateral costophrenic angle (frontal view) 75ml of fluid blunt posterior costophrenic angle (lateral view)

2. Meniscus sign Pleural fluid appears to rise higher along the lateral margin than it

does medially, causing the meniscus shape in upright position. Lateral view, fluid assume U shape ascending equally high both the

anteriorly and posteriorly.31

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Right pleural effusion, meniscoid appearance. On the frontal projection in the upright

position, an effusion typically ascends more laterally (open white arrow)than it does

medially(open black arrow)because of factors affecting the natural elastic recoil of the lung.

On the lateral projection the fluid ascends about the same amount anteriorly and

posteriorly, forming a U-shaped density(closed white arrows).

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Laminar effusion: Almost always the results of elevated atrial pressure, as

in congestive heart failure or secondary to lymphangiticspread of malignancy.

The fluid assumes a thin, bandlike density along the lateral chest wall, especially near the costophrenic angle.

The lateral costophrenic angle appears to maintain its sharpness.

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There is a thin band of increased density that extends

superiorly from the lung base (open white arrow) but

does not appear to cause blunting of the costophrenic

angle (closed black arrow).

Notice how normally aerated lung extends to

the inner margin of each of the ribs (open black

arrow). 35

Fissural Pseudotumor/ Vanishing Tumour Sharply marginated collection of pleural fluid contained

either within an interlobar pulmonary fissure or in a subpleural location adjacent to a fissure

Result from transudation from the pulmonary vascular space

Commonly manifest as incidental radiographic findings in patients with congestive heart failure

Other causes of transudates include Hypoalbuminemia

Renal insufficiency

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http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow159sidebyside.jpg

Frontal and lateral views of an 89 year-old female with an oval soft tissue density superimposed on the minor fissure on both the frontal and lateral views. The lesion has slight "points" where it abuts the minor fissure, a sign of a "pseudotumor" or "vanishing tumor" in the minor fissure.

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Fissural Pseudotumour/ Vanishing Tumour Imaging findings

Lenticular or biconvex contour (lemon-like)

Located along the course of interlobar fissures

Most occur in the minor (horizontal) fissure (more than 75%) and are seen on both the frontal and lateral radiograph

Those that occur in the oblique or major fissure may only be seen on the lateral view well

Infrequently, they occur in the horizontal and oblique fissures simultaneously

Most are less than 4 cm in size

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When PCWP >25 mmHg1. Acinar shadow

2. Bat-wing or butterfly appearance Pulmonary shadowing maximal close to the hilar

Outer third of lung frequently spared

Always bilateral, involving all lobes

Lower lung zones more affected than upper lung zones

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http://www.learningradiology.com/lectures/cardiaclectures/chfppt.pdf

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http://www.mdconsult.com/das/book/body/216539325-2/0/1276/I4-u1.0-B0-7216-0527-3..50006-8--f67.fig?tocnode=49301040

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1. Basal kerley B lines in the left hemithorax2. Pleural effusion on the right side. 3. Cardiomegaly4. Apical vascular redistribution.5. Bat’s wing appearance

http://www.mypacs.net/cgi-bin/repos/mpv3_repo/wrm/repo-view.pl?cx_subject=1666444&cx_prefsize=medium&cx_repo=mpv4_repo

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