The Heart Size

C:T RATIO: The simplest way to estimate the heart size.

Measured by relating the widest diameter of the heart to the
widest internal diameter of the chest.

C:T Ratio = A + B / C
A & B: maximum right and
left cardiac dimensions from
the midline
C: widest internal chest
diameter

Cardio-Thoracic Ratio

normal CT ratio in adults is usually 0.5 or less

normal CT ratio in the newborn is approximately 0.65

Postero-Anterior (PA) View

SVC

IVC

Postero-Anterior (PA) View

RA

Right Atrial Enlargement

Increased convexity
of the lower right
heart border

Postero-Anterior (PA) View

Right Atrium

In some cases, the length

of right heart border exceeds
50% of the mediastinal
cardiovascular shadow

Postero-Anterior (PA) View

RV

Right Ventricle Enlargement

PA View:
Rounding and
upliftment of cardiac
apex

Postero-Anterior (PA) View

PA

Postero-Anterior (PA) View

LA

Left Atrial Enlargement

PA view:
1. Double density,
(r) cardiac border
2. Enlargement of
LA appendage

Left Atrial Enlargement

PA View:
3. Widening of carinal
angle, >60o
4. Upliftment of left
mainstem
bronchus

Postero-Anterior (PA) View

LV

Left Ventricular Enlargement

PA View:
- Round (L) cardiac border
- Lateral, downward
displacement of cardiac
apex
-Elongation LV outflow
tract

Postero-Anterior (PA) View

Aorta

Postero-Anterior (PA) View

Postero-Anterior (PA) View

Right border
Superior vena cava
Right atrium
Inferior vena cava

Postero-Anterior (PA) View

Right border
Superior vena cava
Right atrium
Inferior vena cava

Left border
Aortic knob
Main pulmonary trunk
Left ventricle

Postero-Anterior (PA) View

Pulmonary Arteries
Right

Postero-Anterior (PA) View

Pulmonary Arteries

Right

Left

Postero-Anterior (PA) View

Pulmonary Arteries
Right
Left

LA

Pulmonary Veins

Lateral View

SVC

RA

IVC

Lateral View

RV

Right Ventricle
Lateral View

Retrosternal
fullness
R heart
border greater than
1/3 of the retro
sternal length

Lateral View

Lateral View

LA

Left Atrial Enlargement

Lateral view:
- LA fills the upper part
of the retro cardiac
free space.
- Barium filled
esophagus displaced
posteriorly

Lateral View

LV

Lateral View

Aorta

Lateral View

Left Ventricle
Hoffman Rigler Sign

Left Ventricle Enlargement

Lateral View
Posterior displacement
posterior border
of the heart
*Hoffman-Rigler Sign:
measured 2 cm above the intersection
of the diaphragm and IVC.
(+) posterior border of the LV extends
more than 1.8 cm of IVC

Lateral View

Left atrium
Left ventricle

Lateral View

Left atrium
Left ventricle

Right ventricle

Lateral View
Aorta

Main Pulmonary Artery

Inferior vena cava

Lateral View

Pulmonary Arteries
Left
Right
Pulmonary Veins

Teleradiography, 4
1.
2.
3.
4.

PA
Upright
Deep inspiration
Tube-film
distance
of 6 feet

Areas to be inspected
Lungs
Mediastinum
including the heart and
the great vessels
Trachea and central
bronchi
Diaphragm

T
A

H
D

Areas to be inspected
Bony thorax
Soft tissues of the
thorax and neck
Sub diaphragmatic upper
abdominal structures

PR

PIS
AR

CP

CP

Areas to be inspected / LAT

T
A

RS

R
RS
D

Lung Zones

Normal

Inner zone / inner third large main trunk vessels

Middle zone - intermediate
sized vessels
Peripheral - vessels less than
1 mm in diameter

Pulmonary Vascular Pattern

Pulmonary Vascular Pattern

NORMAL

Pulmonary Vascular Pattern

NORMAL

Pulmonary Vascular Pattern

NORMAL

INCREASED

Pulmonary Vascular Pattern

NORMAL

INCREASED

Pulmonary Vascular Pattern

NORMAL

DECREASED

Pulmonary Vascular Pattern

DECREASED

NORMAL

Pulmonary Vascular Pattern

NORMAL

VENOUS
CONGESTION

Pulmonary Vascular Pattern

INCREASED
ARTERIAL
BLOOD FLOW

VENOUS
CONGESTION

Pulmonary Vascular Pattern

Kerley B Lines

VENOUS
CONGESTION

Interstitial Edema

Pulmonary Vascular Pattern

Kerley A Lines
VENOUS
CONGESTION

Kerley B Lines

Interstitial Edema

MITRAL STENOSIS

MITRAL STENOSIS
Normal to slightly
enlarged heart
> LA >Lung >RV
Pulmonary venous
HPN
Equalization
Reversal/
Cephalization

Mitral Stenosis

PA: Prominent MPAS and branches; constriction of

arteries in mid and peripheral lung zones
Small aorta

Severe MS
Pulmonary arterial
hypertension, RV
Pulmonary
hemosiderosis,
ossified densities, LL
Calcification, LA wall,
laminated clot,
thrombus

Kerley B in MS

Short, horizontal dense

lines, interstitial edema
and dilatation of the
lymphatics, lower lung
fields

MITRAL REGURGITATION

MITRAL REGURGITATION
Cardiomegaly/Big Heart
Chamber Prominence:
LA (MR>MS)
LV
Pulmonary venous HPN
(MR<MS)
Equalization, cephalization
Mitral annulus calcification
Small aorta

AORTIC STENOSIS

AORTIC STENOSIS
Normal-sized heart,
mild cardiomegaly
LV
+/- Pulmonary venous
hypertension

AORTIC STENOSIS
Dilated
ascending aorta
+/- Aortic valve
calcification

AORTIC REGURGITATION

AORTIC REGURGITATION
Cardiomegaly
LV
Dilated ascending
aorta and aortic arch
(LV outflow tract)
Normal pulmonary
vascularity

AORTIC REGURGITATION
LV enlargement
Apex extends below the
dome of the (L) hemi
diaphragm
Aorta ascending, dilated
Aortic knob often
prominent
Cor bovinum

Combined Aortic Valve Disease

Difficult to ascertain
the prominent valve
lesion
In cardiac failure, signs
of pulmonary
congestion develop
with relative MI, LA
enlargement

TRICUSPID VALVE DISEASE

TRICUSPID VALVE DISEASE

RA enlargement; Elongated (R) cardiac border; +/SVC or IVC prominence

Congestive Heart Failure

Four Reliable Signs

Kerley B lines

Pleural effusions

Fluid in the fissures

Peribronchial cuffing

Four Reliable Signs of CHF

Short (1 -2 cm)
white lines at the
lung bases,
perpendicular to
the pleural surface
representing
distended
interlobular septa

Kerley B Lines

Four Reliable Signs of CHF

Pleural Effusions

Four Reliable Signs of CHF

Fluid in the minor
fissure. The fissures
may be seen normally
but they should be
about as thin as a line
drawn with a
sharpened pencil.

Fluid in the fissures

Four Reliable Signs of CHF

Fluid in the walls of

the bronchi make
them visible and
produce numerous
doughnut densities
throughout the
periphery of the lung.

Peribronchial cuffing

63 yr old man with chest pain

Widened mediastinum
Left pleural effusion
Chest pain
Should make you think
of an aortic dissection

63 yr old man with chest pain

Linear lucency
in the contrastfilled
descending
aorta is the
intimal flap of an
aortic dissection

63 yr old man with chest pain

Classification of Dissecting Aneurysms

Widened mediastinum

Left pleural effusion

Chest pain

Stanford classification