Author: Tim Milligan

Right ventricular hypertrophy is suggested by elevation of the cardiac apex from the diaphragm on this PA projection of a patient with rheumatic heart disease. The lateral view supports the diagnosis by demonstrating loss of the retrosternal airspace and increased contact of the right ventricle against the sternum. Also noted in this patient are mitral valve calcification, evidence of left atrial and pulmonary artery enlargement, and evidence of chronic congestive heart failure.

As pulmonary edema fluid initially collects in the interstitium, mild pulmonary edema shows the following features:

• loss of definition of pulmonary vasculature
• peribronchial cuffing
• Kerley B lines
• reticulonodular pattern
• thickening of interlobar fissures

If the pulmonary edema is due to heart failure or fluid overload, you may also see cardiomegaly and distension of the pulmonary veins, particularly in the upper lung fields. This latter phenomenon is referred to as vascular redistribution and can be seen in normal supine radiographs of the chest. As pulmonary edema progresses, fluid begins to collect in alveoli, causing diffuse airspace disease often in a “bat-wing” or “butterfly” pattern, tending to spare the outermost lung fields. Pleural effusion may be a feature of pulmonary edema.

Left: Normal
Right: Enlarged upper lobe vessels

Evidence of a pericardial effusion can be as follows:
a) a globular heart
b) loss of the indentations of the left mediastinal border
c) separation of peri- and epicardial fat pads on lateral film.
The appearance is very similar to a dilated cardiomyopathy, therefore you will need a CT scan to distinguish them.

PA film of a patient with a large pericardial effusion. Note the abnormal (>0.5) cardiothoracic ratio and classic “globular” shape to the heart. Other features of pericardial effusion (not seen) include a loss of the indentations on the left mediastinal border and, on the lateral film, separation of the peri- and epicardial fat pads.

A prosthetic mitral valve is noted on PA and lateral radiographs of a patient with rheumatic heart disease. Sternal wires are most likely from the valve replacement surgery. There is also evidence of consolidation in the right lower lobe.

Note the calcified mitral valve on this lateral projection of a patient with rheumatic heart disease.