Posteroanterior Projection 1

Lateral Projection 2
Right Anterior Oblique Projection
3
Left Anterior Oblique Projection
4
1. Right innominate vein
2. Superior vena cava
3. Right main branch of the pulmonary artery
4. Upper and lower lobe veins
5. Right atrium
6. Tricuspid valve
7. Inferior vena cava
8. Arch of the aorta
9. Left main branch of the pulmonary artery
10. Main pulmonary artery
11. Left upper lobe vein
12. Appendage of the left atrium
13. Mitral valve
14. Left ventricle
15. Right ventricle

Right
Atrium
Superior
vena
cava
Left
Ventricle
Appendage
of the left
atrium
Pulmonary
artery
Aorta
1. Superior vena cava
2. Ascending aorta
3. Main pulmonary artery
4. Right atrium
5. Tricuspid valve
6. Right ventricle
7. Aortic arch
8. Left main branch of the pulmonary artery
9. Left atrium
10. Mitral valve
11. Left ventricle
12. Descending aorta
13. Inferior vena cava

Right
Ventricle
Root of the
main pulmonary
artery
Left
Ventricle
Left
Atrium
Because these structures are in contact with
mediastinal fat, their margin may be indistinct
1. Anterior wall of the trachea
2. Innominate vein
3. Anterior border of the superior vena cava
4. Superior vena cava
5. Right main branch of the pulmonary artery
6. Thoracic aorta
7. Left atrium
8. Right atrium
9. Inferior vena cava
10. Left innominate vein
11. Arch of the aorta
12. Left main branch of the pulmonary artery
13. Main stem of the pulmonary artery
14. Left main bronchus
15. Tricuspid valve
16. Mitral valve
17. Right ventricle
18. Left ventricle
1. Superior vena cava
2. Right main branch of the pulmonary artery
3. Ascending aorta
4. Main pulmonary artery
5. Right atrial appendage
6. Tricuspid valve
7. Right ventricle
8. Left subclavian artery
9. Posterior border of the trachea
10. Left main branch of the pulmonary artery
11. Left main bronchus
12. Left atrium
13. Mitral valve
14. Left ventricle
15. Inferior vena cava
2. Myocardium of
atrium
1. Endocardium of
atrium
3. Annulus fibrosus
4. Mitral valve :
a. Endocardium
b. Connective tissue
core
5. Chorda tendina
6. Endocardium of
ventricle
7. Myocardium of
ventricle
8. Purkinje fibers
(conduction fibers)
10. Coronary artery
9. Plate A
11. Coronary sinus
12. Coronary vein with valve
13. Epicardium of atrium
14. Subepicardial connective
tissue and fat
15. Perimysial septa with
blood vessels
16. Epicardium and
subepicardium of ventricle
17. Columnae carneae
18. Apex of papillary
muscle
Signs of previous surgery

- periosteal elevation
- asymmetry thoracic cage
- smaller and slightly deformed rib
- resected rib in previous thoracotomy



Congenital heart disease:

- premature fusion of sternum cyanotic form
- hypersegmentation of sternum Downs syndrome
- bulging of sternum enlarged right ventricle


Abnormal hepatic and stomach position show
abnormalities in position of the viscera congenital
cardiac disease



Stomach bubble is under the left diaphragm
Liver is on the right
Heart is on the right with cardiac axis directed to the right



Stomach bubble is under the right diaphragm
Liver is on the left
Heart is on the right with cardiac axis directed to the right



Stomach bubble is under the right diaphragm
Liver is on the left
Normal heart position


Dextrocardia :
Location of the heart in the right side of the
thorax, the apex pointing to the right
Dextroversion :
Location of the heart in the right chest, the
left ventricle remaining in the normal
position on the left with the apex pointing
the the left


Enlargement of the pulmonary artery segment
Prominent pulmonary arterial segment along the left
upper cardiac border
In TGV and truncus arteriosusabnormal position
(concave)
Enlargement of the aorta
Three portions of the aorta can be evaluated: ascending
aorta, aortic arch dan descending aorta.



Usually, the ascending aorta does not extend
beyond the right upper mediastinal shadow.
Here, there is enlargement of the aorta.

Signs of left atrial enlargement
Signs of left ventricular enlargement
Signs of right atrial enlargement
Signs of right ventricular enlargement
Posteroanterior projection
1. Displace the barium-filled esophagus below the
carina to the right
2. Prominent bulge along the mid-left cardiac border
3. A double density along the right cardiac border
4. Widening of the angle of the carina >90
0
Lateral projection
1. Posterior displacement of both walls of the
barium-filled esophagus
Left anterior oblique projection
Elevate the left mainstem bronchus and
obliterates the spaces between the posterior
cardicac margin and the left mainstem bronchus
Posteroanterior projection
1. Left ventricular dilatation produces downward
displacement of the apex toward diaphragm.
2. Left ventricular hypertrophy produces a round left
cardiac border
Left anterior oblique projection
Posterior cardiac margin to overlap the vertebral
column
Posteroanterior projection
Difficult increased convexity of the lower right heart
border on PA projection


Posteroanterior projection
Rounding and elevation of the cardiac apex
Lateral projection
Retrosternal space is obliterated
Left anterior oblique projection
Increased convexity of the anterior cardiac border


Index of cardiac enlargement is the cardiothoracic ratio.
In infants: 0.55
In adults : 0.45
The lateral and oblique views must be considered

In normal the pulmonary vascular marking taper
gradually toward the periphery of the lung fields, and
more prominent in the lower lung fields.
The vessels in the right hillum is larger than in the left
1. Normal pulmonary vascularity
2. Increased pulmonary vascularity due to increased
pulmonary blood flow.
- the peripheral arteries are sharply outlined and
dilated and distributed equally to both the upper and
lower lobes.
- ex. VSD, PDA, truncus arteriosus, transposition of the
great vessels.

3. Decreased pulmonary vascularity due to right-to-left
shunts.
- small pulmonary arterial segment
- reduced diameter of the hilar pulmonary arteries
- ex. Tetralogy of Fallot, tricuspid atresia,
pulmonary stenosis
4. Pulmonary venous congestion
- occurs in condition that causes increased resistance
distal to pulmonary capillaries
- fluid accumulates in the interstitial tissues and
Kerley B lines
- ex. Mitral stenosis, acute left ventricular failure are
common causes.

5. Bronchial collateral

6. A bizarre pattern of pulmonary vascularity
- different vascular pattern in each lung

Five factors influence the distribution of pulmonary blood
flow.
Interstitial osmotic and alveolar pressures remain constant
throughout the lung
Hydrostatic, pulmonary arterial and pulmonary venous
pressures, diminish from base to apex because of
gravitational effects.
In left-sided cardiac failure, the increased pulmonary
venous pressure resulting from the elevated left
ventricular end-diastolic pressure
The transudation of fluid into the pulmonary
interstitium causes an increase in the interstitial
pressure
The earliest radiographic manifestation on left-sided
cardiac failure is:
1. An indistinctness of the vascular markings caused
by the increased interstitial fluids.
2. The hilar vessels become enlarged and indistinct.
3. The increased interstitial fluid can be seen as
peribronchial cuffing.
Later, cephalization occurs. The vascular markings are
prominent in the upper lobes owing to the constriction
of the lower lobe vessels and redistribution of flow to the
upper lobes.
Pleural effusion occurs late
Transudation of fluid into the alveoli leads to pulmonar
edema. This appears in a perihilar location (butterfly
wings or bat wings).
Kerley B lines, due to fluid in the lobular septum.
Several non-cardiac causes as differential
diagnosis of pulmonary edema:
1. Uremia. Increased capillary permeability.
2. Fluid overload. Decreased plasma osmotic pressure.
3. Neurogenic. Altered capillary permeability or capillary pressure.
4. Hypoproteinemia. Decreased plasma osmotic pressure.
5. Transfusion and allergic reactions. Altered capillary
permeability.
6. Inhalation of toxic gases. Altered capillary permeability
Kerley A : white arrow
Kerley B : white arrow head
Kerley C : black arrow head
Pulmonal artery segment dilatation
Right ventricular enlargement
Reduced bronchovascular marking

1. Decrease bronchovascular
marking
a) Acyanotic
1. Pulmonary Stenosis (PS)
b) Cyanotic
a) Tetralogy Fallot
b) Trilogy Fallot
c) Atresia Pulmonal
d) Atresia Tricuspid
e) Ebstein Anomaly



CONGENITAL HEART DISEASE
2. Increase bronchovascular
marking
a) Acyanotic
1. Atrial septal defect (ASD)
2. Ventricle septal defect (VSD)
3. Right atrioventricular anomaly
4. Patent ductus arteriosus (PDA)
5. Partial Anomalous Pulmonary
Venous Return (PAPVR)
b) Cyanotic
1. Total Anomalous Pulmonary
Venous Return (TAPVR)
2. Truncus Arteriosus
3. Transposition of the Great Vessels
(TGV)
PULMONARY STENOSIS
PULMONARY STENOSIS
Pulmonary stenosis make right ventricular
resistancy increased, causing radiographic
feature:
Right ventricular enlargement
Rounding and elevation of the cardiac apex
Bulging of pulmonary trunc
Bronkhovascular marking decreased
TETRALOGY FALLOT
TETRALOGY FALLOT
The malformation has four components:
Right ventricular hypertrophy, Overriding aorta,
Pulmonary stenosis, and Ventricular septal defect
Radiographic features:
Right ventricular enlargement
Boot shape contour
Pulmonary artery segment concave
Right sided aortic arch
Pulmonary vascularity decreased

EBSTEIN ANOMALY
EBSTEIN ANOMALY
Atrial septal defect
Displace tricuspid valve
Radiographic feature:
Vary
Widening of right heart border
Rounded heart (cardiomegali all chamber)
Bronchovascular marking decreased

ATRESIA PULMONAL
ATRESIA PULMONAL



Radiographic feature:
Cardiomegali with oval heart contour
Bronchovascular marking decreased



ATRESIA TRICUSPID
ATRESIA TRICUSPID
~ Atresia pulmonal
Cardiomegali with oval heart contour
Pulmonary vascularity decreased

ATRIAL SEPTAL DEFECT
ATRIAL SEPTAL DEFECT
The feature related to how large the defect and the
complication on the pulmonary vascularity
Radiographic feature:
Right atrial enlargement, widening right heart border
Right ventricular enlargement, rounded and
elevation of the cardiac apex
Prominent conus pulmonalis, with widening of hillum
Bronchovascular marking increased
Signs of pulmonary hypertension

VENTRICULAR SEPTAL DEFECT
VENTRICULAR SEPTAL DEFECT



Radiographic feature:

Small defect (Maladie de Roger)
Heart is not enlarged
Normal pulmonary vascularization
Mild
Heart is enlarged to the left (left ventricle hypertrophy)
Apex downward to the diaphragm.
Right ventricle has not enlarged.
Left atrium dilated
Increase pulmonary vascularization.



VENTRICULAR SEPTAL DEFECT



Radiographic feature:
Moderate Severe
Right ventricle dilatation and hypertrophy.
Left atrium dilatation.
Widening of the pulmonary artery and its branches
Normal right atrium.
Left ventricle hypertrophy.
Small aorta.
Pulmonary hypertension
Right ventricle is enlarged.
Pulmonary artery is widening with prominent of conus pulmonalis.
Normal left atrium.
Small aorta.
Decrease peripheral pulmonary vasculature.
Pulmonary emphysematous



PATENT DUCTUS ARTERIOSUS
PATENT DUCTUS ARTERIOSUS
Small defect
Normal
Moderate
Normal or mild enlargement of descendent aorta and
aortic arch.
Prominent of conus pulmonary.
Widening of the pulmonary artery and its branches.
Left atrial enlargement.
Right and left ventricle enlargement.



PATENT DUCTUS ARTERIOSUS
Severe (pulmonary hypertension)
Enlarge central pulmonary vasculature.
Decrease peripheral pulmonary vasculature.
Prominent conus pulmonalis.
Widening of the ascendent aorta with prominent
aortic knob.
Normal left atrium.




KARDIOVASKULER PATOLOGIS
CHD
Dengan Pembuluh darah paru bertambah

Tanpa Cyanosis
Dengan Cyanosis
ASD
VSD
ECD
PDA
PAPVR
TAPVR
Trunkus Arteriosus
Persisten
Transposisi Pembuluh
darah besar
CHD
Gambaran Pembuluh darah paru yg berkurang
Tanpa sianosis
Dengan sianosis
Pulmonal stenosis
valvuler
infundibuler
supravalvuler
Hipertensi Pulmonal
primer
TOF
Trilogi of Fallot
Atresia pulmonalis
Atresia tricuspidalis
Ebstein anomali
VSD

Kelainan jantung bawaan yang paling sering
ditemukan di masyarakat, selain gejala klinis
untuk mendiagnosa VSD diperlukan pemeriksaan
radiologi foto torak PA atau AP dan lateral.
VSD adalah suatu kelainan jantung bawaan
dimana terjadi kebocoran pada septum
interventrikuler yang menyebabkan gambaran
pembesaran jantung dengan corakan
bronkovaskuler yang bertambah atau berkurang
pada keadaan yang lebih lanjut.

PATOFOSIOLOGI

Defek pada septum interventrikuler
kebocoran darah dengan arah aliran dari kiri
ke kanan jumlah darah di ventrikel kanan
dan arteri pulmonalis bertambah .

GAMBARAN RADIOLOGI

Kebocoran yang sangat kecil : jantung tidak membesar,
dan pembuluh darah paru-paru normal
Kebocoran ringan : jantung membesar ke kiri, apex
menuju ke diafragma, pembuluh darah paru-paru
bertambah
Kebocoran sedang - berat, ventrikel kanan dilatasi dan
hipertrofi, atrium kiri dilatasi, pembuluh darah paru-
paru bertambah.
Keadaan dengan hipertensi pulmonal , ventrikel kanan
membesar, hilus tampak melebar, pembuluh darah
paru-paru berkurang.

X-Ray chest PA View of a chid with ventricular septal defect and left to right shunt
and hyperdynamic pulmonary hypertension. There is cardiomegaly, prominent
main pulmonary artery segment and right pulmonary artery. Enlarged left
pulmonary artery shadow is seen below the lef cardiac border, within the cardiac
silhouette. The enhanced vascular markings are visible on the right side whereas
it is obscured by the cardiac shadow on the left side. This child needs cardiac
cathterisation for evaluation of shunt and pulmonary vascular resistance and its
reversibility to decide on surgical option.

ASD
ASD adalah suatu kelainan jantung bawaan
dimana terjadi kebocoran pada septum
interatrial yang menyebabkan gambaran
pembesaran jantung dengan corakan
bronkovaskuler yang bertambah atau
berkurang pada keadaan yang lebih lanjut.

PATOFISIOLOGI
Defek pada septum interatrial kebocoran
darah dengan arah aliran dari kiri ke kanan
jumlah darah di atrium, ventrikel kanan dan
arteri pulmonalis bertambah.
GAMBARAN RADIOLOGI
Pembesaran jantung kanan (atrium dan
ventrikel), corakan bronkovaskuler bertambah.
Pada keadaan dengan hipertensi pulmonal ,
hilus tampak melebar dengan pembuluh
darah paru-paru berkurang

X-ray Torax ASD X-ray Dada ASD serta
Hipertensi Arteri Pulmonar
BENDUNGAN PARU
Bendungan vaskuler paru(arteri dan vena)
biasanya terjadi disebabkan oleh peningkatan
tekanan di atrium kiri yang biasanya
disebabkan oleh kelainan katup mitral.
Kelainan katup mitral dapat disebabkan oleh :
- Rhematic fever
- Viral
- Bakteri streptokokus

PATOFISIOLOGI
Darah banyak terakumulasi pada jantung kiri ,
hal ini menyebabkan darah dari vena
pulmonalis terbendung.

GAMBARAN RADIOLOGI

Pada foto torak akan tampak vena-vena
pulmonalis yang melebar disekitar hilus
(kranialisasi), disusul dengan bendungan pada
arteri pulmonalis (hilus melebar).

Kranialisasi (cephalisation)
Cephalization: Vessels in upper chest is more prominent as a manifestation of
pulmonary venous hypertension.
EDEMA PARU
Edema paru merupakan akumulasi cairan yang
terdapat pada ruang interstitial atau ruang
alveolar.
ETIOLOGI :
Kardiogenik
Non kardiogenik

PATOFISIOLOGI
Pada keadaan-keadaan patologis tertentu
dimana terjadi peningkatan tekanan di dalam
kapiler-kapiler pembuluh darah paru
peningkatan permeabilitas pembuluh darah,
atau perubahan tekanan osmose darah akan
menyebabkan cairan didalam pembuluh darah
keluar ke interstitial, apabila pembuluh
limfe sudah tidak mampu mengkompensasi
maka terjadilah akumulasi cairan pada ruang
interstitial atau ruang alveolar.

Patofisiologi edema paru
GAMBARAN RADIOLOGI
Pada foto torak edema interstitial akan
tampak garis-garis septa (garis Kerley), pada
edema alveolar tampak bercak-bercak yang
tebal di kedua perihiler sehingga batas-batas
pembuluh darah menjadi suram.

Pulmonary edema
Alveolar
Pulmonary Alveolar Edema.
There is extensive, bilateral airspaces disease with fluid in the
minor fissure (blue arrow) and bilateral pleural effusions (ref
arrows).
Although the heart is not enlarged, the cause was still on a
cardiogenic basis.
Pulmonary edema
intestitial
ARDS/non cardiogenic pulmonary
edema
Adult Respiratory Distress Syndrome
Non-cardiogenic pulmonary edema
Distinguishing characteristics:
Normal size heart
No pleural effusion

KELAINAN KATUP MITRAL
Kelainan katup mitral yang sering adalah mitral
stenosis dan mitral insufisiensi (kebocoran).
Mitral stenosis merupakan keadaan dimana katup
mitral tidak dapat terbuka sempurna, sedangkan
pada mitral isufisiensi, katup mitral tidak dapat
tertutup sempurna.
ETIOLOGI
- Rheumatic fever
- Viral
- Bakteri streptokokus
PATOFISIOLOGI
Keadaan akut : terjadi kelemahan-kelemahan pada katup
dan chorda tendinea, sehingga mula-mula terjadi
insufisiensi katup,
Bila keadaan menjadi kronis, terjadilah penyempitan dari
katup, karena terjadi pengerutan dan perlekatan-
perlekatan katup dan cincin katup, sehingga lubang mitral
menjadi sempit dan kecil.
Mitral stenosis darah banyak terakumulasi pada atrium
kiri .
Mitral insufisiensi : regurgitasi darah dari ventrikel kiri ke
atrium kiri pada keadaan systole, sehingga pada diastole
darah yang diterima oleh ventrikel kiri jumlahnya
meningkat, terjadilah dilatasi dan hipertrofi.
GAMBARAN RADIOLOGI
Pada mitral stenosis terjadi pembesaran dari
atrium kiri, sedangkan pada mitral insufisiensi
terjadi pembesaran dari atrium maupun
ventrikel kiri yang disertai oleh gambaran
kranialisasi.

Mitral stenosis
Ukuran jantung >
Apex terangkat
LA > , LV N,
RV >
Aortic arch <
vascular markings,
terutama suprahilar
Double contour

Mitral Stenosis
STENOSIS MITRAL
RADIOLOGIS :
1. P A :
BATAS KIRI MENONJOL
DOUBLE CONTOUR
BATAS KANAN
APEX BULAT
BRONCHUS KIRI
TERANGKAT
VASKULARISASI
BERTAMBAH
2. LATERAL DAN RAO :
ESOPHAGUS
TERDORONG
3. LAO :
ATRIUM KIRI
MEMBESAR DI BAWAH
BRONCHUS
Etiologi : endokarditis
rheumatika. Akut :
kelemahan katup & corda
tendinea insufisiensi
katup kronis
pengerutan katup
lubang katup kecil (sampai
0,5 cm, N : 4-6cm)
Ro:
Ringan : LA dilatasi.
Moderat & berat :
1. Dilatasi LA : pendorongan esofagus, double kontur batas
kanan, aurikel LA menonjol, bronkhus utama kiri terangkat,
2. aorta mengecil, a. pulmonalis menonjol,
3. RV hipertrofi apex membulat, mitral konfiguration
4. Paru : makin berat makin banyak vena tampak. Hipertensi
vena disusul hipertensi arteri hilus melebar
5. Edema paru, kerley, hemosiderosis,
Radiograph of the heart: The abnormalities characteristic
of mitral stenosis are more expressed in this case. The
heart is enlarged, the dilatation of the left ventricle
(arrow) is associated with the dilatation of the right
ventricle.
Left atrial enlargement, dilated pulmonary
arteries and left atrial calcification seen in the
chest X-ray of a patient with severe MS
MS
- endocarditis rhematika
- N: 4 cm, stenosis : 0,5 cm
- Faktor : tek LA & LV meningkat, RV
meningkat PH arterial, aliran darah
menurun ke LV & aorta

- Ro : - RV & LA >
- LV N, aorta kecil
- CBV suprahilar >
- Pinggang jantung menonjol
- Double contour sisi kanan
- Konfigurasi mitral
KOMBINASI STENOSIS MITRAL DAN INSUFISIENSI MITRAL
A. ATRIUM KIRI LEBIH BESAR
B. APEX MELEBAR KE KIRI DAN KE BAWAH
C. RAO : ESOPHAGUS TERDORONG DI BAWAH
D. VASKULARISASI BERTAMBAH
COR PULMONALE
COR PULMONALE adalah kelainan dari jantung
terutama jantung kanan (ventrikel kanan) karena
adanya kelainan-kelainan pada paru yang
menyebabkan hambatan besar pada sirkulasi
jantung paru-paru.

ETIOLOGI :
Akut : Emboli pulmonal, kompresi atelektasis,
tension pneumotorak, reseksi paru
Kronis: empisema, bronchitis kronis, fibrosis paru,
tuberkulosis luas, karsinoma paru

PATOFISIOLOGI
Pada keadaan normal terdapat keseimbangan
antara luasnya penampung pembuluh darah
dengan volume darah yang mengalir didalamnya.
Bila luasnya pembuluh darah ini berkurang , maka
timbul hambatan-hambatan pada sirkulasi darah,
dan menyebabkan hipertensi pulmonal, dan
jantung kanan terutama ventrikel kanan
mempunyai beban yang berat sehingga menjadi
hipertrofi


GAMBARAN RADIOLOGI
Pertama terdapat kelainan pada paru-paru,
diikuti oleh hilus yang melebar dan
menyempit di bagian perifernya, jantung
kanan terutama ventrikel kanan tampak
membesar.

Cor Pulmonale
Deff :kelainan jantung t.u kanan (RV) krn kelainan paru
hambatan besar pada sirkulasi jantung paru
(krn luasnya PD berkurang oleh suatu sebab
hambatan2 sirkulasi darah hipertensi pulmonal.
-Akut : pulmonal emboli, kompresi atelektasis, tension
pneumotho, setelah reseksi paru.
- kronis : emfisema, bronkitis kronis, fibrosis paru, TB
luas, penyebaran hematogen Ca paru.
- Jantung kanan (RV) beban berat hipertrofi
jalur keluar a. pulmonalis membesar.
Rontgen :
1. Kelainan pada paru
2. Cardiomegali ke kiri dengan apex membulat di atas diafragma
( RV) , a. pulmonalis segmen menonjol, a. pulmonalis sentral
& hilus melebar, bag perifer menyempit.
3. Radiolusen paru bertambah emfisema paru.
4. LA & LV tdk membesar, aortabiasa atau mengecil , V.
Pulmonalis tdk tampak.