Pulmonic regurgitation Chest X-Ray: Difference between revisions

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Revision as of 16:30, 4 August 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S [2], Aysha Anwar, M.B.B.S [3]

Overview

Chest x ray may not be required for the diagnosis of pulmonic regurgitation (PR). However, lateral and PA view of chest radiograph may help determining the right ventricular enlargement. Right atrial enlargement may also be seen among patients with concomitant tricuspid regurgitation. On plain chest Xray PR may be characterized by right ventricular enlargement, prominent pulmonary trunk, features of tricuspid regurgitation (TR), and of congestive heart failure (CHF).

Chest X ray

There are no chest x ray findings required for the diagnosis of pulmonic regurgitation. However, lateral and PA view of chest radiograph may help determine the complications and associated conditions of PR, which include right ventricular enlargement. Right atrial enlargement may also be seen among patients with concomitant tricuspid regurgitation.^[1]
On plain chest Xray PR may be characterized by^[2]^[3]^[4]:
1. Right ventricular enlargement (specially among patients with surgical repair of TOF)
2. Prominent pulmonary trunk
3. Features of tricuspid regurgitation (TR) may also be present. To read more about CXR findings associated with TR, click here.
4. Features of congestive heart failure (CHF) may also be present. To read more about CXR findings associated with CHF, click here.

Right ventricular enlargement^[3]^[4]:

Progressive right ventricular enlargement is common among patients with PR after TOF repair.
On CXR, right heart failure (RHF) is chracterised by right ventricular enlargement.
- Right ventricular enlargement on PA view demonstrates rounded left heart border and uplifted cardiac apex.
- On lateral view, filling of the retrosternal space and rotation of the heart posteriorly.^[5] CXR has limited utility in the diagnosis of RHF.^[6]

Tetralogy of Fallot (TOF)

On CXR of a patient with PR as a complication of tetrology of Fallot (TOF) repair, a “boot shaped” heart may be demonstrated.^[7]

Prominent pulmonary trunk^[8]

On CXR of a patient with PR secondary to pulmonary hypertension (PAH) or idiopathic dilatation of pulmonary artery (IDPA), featurs demonstrating PAH may include prominent pulmonary trunk and broadened mediastinum.
It is also important to note that IDPA is a diagnosis of exclusion and pulmonary artery/ pulmonary trunk may appear prominent in the chest X ray of young patients, especially women or in a chest X ray AP/lordotic view.

Demonstration of Right Ventricular Enlargement

An illustration of right ventricular enlargement on PA view. The picture demonstrates the uplifting of cardiac apex - Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 46378

An illustration of right ventricular enlargement on lateral view - Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 46378

Chest X-ray Examples

Boot shaped heart demonstrated in Tetralogy of Fallot(TOF). The shoe tip is due to upturned cardiac apex owing to right ventricular hypertrophy, heel due to rounded right margin of the heart, and the top of the boot is due to a concave pulmonary arterial segment- Case courtesy of Dr Vincent Tatco, Radiopaedia.org, rID: 43059

Chest X ray PA view demonstrating pulmonary artery hypertension. An enlarged cardiac silhouette with prominent pulmonary trunk and pulmonary arteries proximally is also demonstrated - Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8653

References

↑ https://radiopaedia.org/articles/right-ventricular-enlargement Accessed on 3rd January, 2017
↑ "Pulmonary valve regurgitation | Radiology Reference Article | Radiopaedia.org".
↑ ^3.0 ^3.1 Shin, Yu Rim; Jung, Jo Won; Kim, Nam Kyun; Choi, Jae Young; Kim, Young Jin; Shin, Hong Ju; Park, Young-Hwan; Park, Han Ki (2016). "Factors associated with progression of right ventricular enlargement and dysfunction after repair of tetralogy of Fallot based on serial cardiac magnetic resonance imaging". European Journal of Cardio-Thoracic Surgery. 50 (3): 464–469. doi:10.1093/ejcts/ezw049. ISSN 1010-7940.
↑ ^4.0 ^4.1 O'Meagher S, Ganigara M, Tanous DJ, Celermajer DS, Puranik R (June 2014). "Progress of right ventricular dilatation in adults with repaired tetralogy of Fallot and free pulmonary regurgitation". Int J Cardiol Heart Vessel. 3: 28–31. doi:10.1016/j.ijchv.2014.02.003. PMC 5801270. PMID 29450166.
↑ "Right ventricular enlargement | Radiology Reference Article | Radiopaedia.org".
↑ Bouzas, Beatriz; Kilner, Philip J.; Gatzoulis, Michael A. (2005). "Pulmonary regurgitation: not a benign lesion". European Heart Journal. 26 (5): 433–439. doi:10.1093/eurheartj/ehi091. ISSN 0195-668X.
↑ Hiader EA. The boot-shaped heart sign. Radiology, 2008; 246 (1):328-9.
↑ "Enlarged pulmonary trunk on chest radiography (differential) | Radiology Reference Article | Radiopaedia.org".

[abc-1] ttps://radiopaedia.org/articles/right-ventricular-enlargement Accessed on 3rd January, 2017

[urlPulmonary_valve_regurgitation_|_Radiology_Reference_Article_|_Radiopaedia.org-2] "Pulmonary valve regurgitation | Radiology Reference Article | Radiopaedia.org".

[ShinJung2016-3] 3.0 ^3.1 Shin, Yu Rim; Jung, Jo Won; Kim, Nam Kyun; Choi, Jae Young; Kim, Young Jin; Shin, Hong Ju; Park, Young-Hwan; Park, Han Ki (2016). "Factors associated with progression of right ventricular enlargement and dysfunction after repair of tetralogy of Fallot based on serial cardiac magnetic resonance imaging". European Journal of Cardio-Thoracic Surgery. 50 (3): 464–469. doi:10.1093/ejcts/ezw049. ISSN 1010-7940.

[pmid29450166-4] 4.0 ^4.1 O'Meagher S, Ganigara M, Tanous DJ, Celermajer DS, Puranik R (June 2014). "Progress of right ventricular dilatation in adults with repaired tetralogy of Fallot and free pulmonary regurgitation". Int J Cardiol Heart Vessel. 3: 28–31. doi:10.1016/j.ijchv.2014.02.003. PMC 5801270. PMID 29450166.

[urlRight_ventricular_enlargement_|_Radiology_Reference_Article_|_Radiopaedia.org-5] "Right ventricular enlargement | Radiology Reference Article | Radiopaedia.org".

[BouzasKilner2005-6] Bouzas, Beatriz; Kilner, Philip J.; Gatzoulis, Michael A. (2005). "Pulmonary regurgitation: not a benign lesion". European Heart Journal. 26 (5): 433–439. doi:10.1093/eurheartj/ehi091. ISSN 0195-668X.

[7] Hiader EA. The boot-shaped heart sign. Radiology, 2008; 246 (1):328-9.

[urlEnlarged_pulmonary_trunk_on_chest_radiography_(differential)_|_Radiology_Reference_Article_|_Radiopaedia.org-8] "Enlarged pulmonary trunk on chest radiography (differential) | Radiology Reference Article | Radiopaedia.org".

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@@ Line 4: / Line 4: @@
 ==Overview==
-[[Chest x ray]] may not be required for the diagnosis of [[pulmonic regurgitation]] (PR). However, lateral and [[PA view]] of [[chest radiograph]] may help determining the [[right ventricle|right ventricular]] enlargement. [[Right atrial enlargement]] may also be seen in patients with concomitant [[tricuspid regurgitation]].<ref name=abc>https://radiopaedia.org/articles/right-ventricular-enlargement Accessed on 3rd January, 2017</ref>
+[[Chest x ray]] may not be required for the diagnosis of [[pulmonic regurgitation]] (PR). However, lateral and [[PA view]] of [[chest radiograph]] may help determining the [[right ventricle|right ventricular]] enlargement. [[Right atrial enlargement]] may also be seen among [[patients]] with concomitant [[tricuspid regurgitation]]. On plain chest Xray [[PR]] may be characterized by [[Right ventricle|right ventricular]] enlargement, prominent [[pulmonary trunk]], features of [[tricuspid regurgitation]] (TR), and of [[congestive heart failure]] (CHF).
 ==Chest X ray==
-*There are no [[chest x ray]] findings required for the diagnosis of [[pulmonic regurgitation]]. However, lateral and [[PA view]] of chest radiograph may help determine the complications and associated conditions of [[PR]], which include [[right ventricle|right ventricular]] enlargement. [[Right atrial enlargement]] may also be seen in [[patients]] with concomitant [[tricuspid regurgitation]].<ref name=abc>https://radiopaedia.org/articles/right-ventricular-enlargement Accessed on 3rd January, 2017</ref>
+*There are no [[chest x ray]] findings required for the diagnosis of [[pulmonic regurgitation]]. However, lateral and [[PA view]] of chest radiograph may help determine the complications and associated conditions of [[PR]], which include [[right ventricle|right ventricular]] enlargement. [[Right atrial enlargement]] may also be seen among [[patients]] with concomitant [[tricuspid regurgitation]].<ref name=abc>https://radiopaedia.org/articles/right-ventricular-enlargement Accessed on 3rd January, 2017</ref>
 *On plain chest Xray [[PR]] may be characterized by<ref name="urlPulmonary valve regurgitation | Radiology Reference Article | Radiopaedia.org">{{cite web |url=https://radiopaedia.org/articles/pulmonary-valve-regurgitation?lang=us |title=Pulmonary valve regurgitation &#124; Radiology Reference Article &#124; Radiopaedia.org |format= |work= |accessdate=}}</ref><ref name="ShinJung2016">{{cite journal|last1=Shin|first1=Yu Rim|last2=Jung|first2=Jo Won|last3=Kim|first3=Nam Kyun|last4=Choi|first4=Jae Young|last5=Kim|first5=Young Jin|last6=Shin|first6=Hong Ju|last7=Park|first7=Young-Hwan|last8=Park|first8=Han Ki|title=Factors associated with progression of right ventricular enlargement and dysfunction after repair of tetralogy of Fallot based on serial cardiac magnetic resonance imaging|journal=European Journal of Cardio-Thoracic Surgery|volume=50|issue=3|year=2016|pages=464–469|issn=1010-7940|doi=10.1093/ejcts/ezw049}}</ref><ref name="pmid29450166">{{cite journal |vauthors=O'Meagher S, Ganigara M, Tanous DJ, Celermajer DS, Puranik R |title=Progress of right ventricular dilatation in adults with repaired tetralogy of Fallot and free pulmonary regurgitation |journal=Int J Cardiol Heart Vessel |volume=3 |issue= |pages=28–31 |date=June 2014 |pmid=29450166 |pmc=5801270 |doi=10.1016/j.ijchv.2014.02.003 |url=}}</ref>:
-*#[[Right ventricle|Right ventricular]] enlargement (specially in [[patients]] with surgical repair of [[TOF]])
+*#[[Right ventricle|Right ventricular]] enlargement (specially among [[patients]] with surgical repair of [[TOF]])
 *#Prominent [[pulmonary trunk]]
 *#Features of [[tricuspid regurgitation]] (TR) may also be present. To read more about CXR findings associated with TR, [[Tricuspid regurgitation chest x ray|click here]].
 *#Features of [[congestive heart failure]] (CHF) may also be present. To read more about CXR findings associated with CHF, [[Congestive heart failure chest x ray|click here]].
 ===[[Right ventricle|Right ventricular]] enlargement<ref name="ShinJung2016">{{cite journal|last1=Shin|first1=Yu Rim|last2=Jung|first2=Jo Won|last3=Kim|first3=Nam Kyun|last4=Choi|first4=Jae Young|last5=Kim|first5=Young Jin|last6=Shin|first6=Hong Ju|last7=Park|first7=Young-Hwan|last8=Park|first8=Han Ki|title=Factors associated with progression of right ventricular enlargement and dysfunction after repair of tetralogy of Fallot based on serial cardiac magnetic resonance imaging|journal=European Journal of Cardio-Thoracic Surgery|volume=50|issue=3|year=2016|pages=464–469|issn=1010-7940|doi=10.1093/ejcts/ezw049}}</ref><ref name="pmid29450166">{{cite journal |vauthors=O'Meagher S, Ganigara M, Tanous DJ, Celermajer DS, Puranik R |title=Progress of right ventricular dilatation in adults with repaired tetralogy of Fallot and free pulmonary regurgitation |journal=Int J Cardiol Heart Vessel |volume=3 |issue= |pages=28–31 |date=June 2014 |pmid=29450166 |pmc=5801270 |doi=10.1016/j.ijchv.2014.02.003 |url=}}</ref>:===
@@ Line 23: / Line 22: @@
 *On [[CXR]] of a [[patient]] with [[PR]] as a complication of [[TOF|tetrology of Fallot]] (TOF) repair, a “boot shaped” heart may be demonstrated.<ref>Hiader EA. The boot-shaped heart sign. Radiology, 2008; 246 (1):328-9.</ref>
-===Prominent [[pulmonary trunk]]===
+===Prominent [[pulmonary trunk]]<ref name="urlEnlarged pulmonary trunk on chest radiography (differential) | Radiology Reference Article | Radiopaedia.org">{{cite web |url=https://radiopaedia.org/articles/enlarged-pulmonary-trunk-on-chest-radiography-differential |title=Enlarged pulmonary trunk on chest radiography (differential) &#124; Radiology Reference Article &#124; Radiopaedia.org |format= |work= |accessdate=}}</ref>===
-*On [[CXR]] of a [[patient]] with [[PR]] secondary to [[pulmonary hypertension]] (PAH), featurs demonstrating [[PAH]] may include prominent [[pulmonary trunk]] and broadened [[mediastinum]].
+*On [[CXR]] of a [[patient]] with [[PR]] secondary to [[pulmonary hypertension]] (PAH) or [[idiopathic]] dilatation of [[pulmonary artery]] (IDPA), featurs demonstrating [[PAH]] may include prominent [[pulmonary trunk]] and broadened [[mediastinum]].
+*It is also important to note that IDPA is a diagnosis of exclusion and [[pulmonary artery]]/ pulmonary trunk may appear prominent in the chest X ray of young [[patients]], especially [[women]] or in a chest X ray AP/lordotic view.
 ==Demonstration of Right Ventricular Enlargement==
@@ Line 36: / Line 36: @@
 <br clear="left"/>
+[[File:Pulmonary-arterial-hypertension.jpg|thumb|350px|left|Chest X ray PA view demonstrating [[pulmonary artery hypertension]]. An enlarged cardiac silhouette with prominent pulmonary trunk and [[pulmonary arterie]]s proximally is also demonstrated - Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8653]]
+<br clear="left"/>
 ==References==
 {{Reflist|2}}