Cardiomegaly chest x ray

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor in Chief: Cafer Zorkun, M.D., Ph.D. [2]

Chest X Ray

• Cardiomgaly is traditionally defined as an increase in the cardiothoracic ratio to be > 0.5 on a PA film. To calculate the thoracic ratio, the width of the cardiac silhouette is divided by the width of the entire thoracic cage.
• If the heart is viewed on an AP film, the heart can appear to be artificially enlarged because the X ray beam moves from anterior to posterior direction and therefore the heart which lies anterior is magnified.

  • Postero Anterior (PA) Projection: adult heart is 12 cm from base to apex and 8-9 cm in transverse direction
  • Lateral Projection: The adult heart is 6 cm in the Antero Posterior (AP) direction

X-ray findings for left ventricular enlargement

• Left heart border is displaced leftward, inferiorly, or posteriorly.
• Rounding of the cardiac apex

Cardiomegaly.
Image courtesy of C. Michael Gibson MS. MD

Cardiomegaly in a patients after mitral valve replacement. AP view. Image courtesy of RadsWiki

Cardiomegaly in a patients after mitral valve replacement. Lateral view. Image courtesy of RadsWiki.

X-ray findings for left atrial enlargement

• Double density sign: Occur when the right side of the left atrium pushes into the adjacent lung.
• Convex left atria appendage: usually reflect prior rheumatic heart disease
• Splaying of the carina
• Posterior displacement of the left main stem bronchus on lateral radiograph
• Superior displacement of the left main stem bronchus on frontal view
• Posterior displacement of a barium filled esophagus

Double density sign

Double density sign

X-ray findings for right ventricular enlargement

• Frontal view

• Rounded left heart border
• Uplifted apex

• Lateral view

• Filling of the retrosternal space
• Rotation of the heart posteriorly

X-ray findings for right atrial enlargement

• On a frontal view, the right atrium is visible because of its interface with the right middle lobe.
• Subtle and moderate right atrial enlargement is not accurately determined on plain films because there is normal variability in the shape of the right atrium.