Original subtitles

this lecture will describe the classic

chest x-ray findings that are associated

with congestive heart failure

congestive heart failure can produce a

moderative findings on plane chest

radiography

which findings are present depends on

the severity of the patient's condition

on an erect posterior anterior chest

x-ray suggestive findings include

cardiomegaly which does not necessarily

need to be present

vascular redistribution that is the

syphilization of blood flow

pulmonary venous congestion pulmonary

interstitial edema

pleural effusions and in more severe

disease

alveolar edema which is not clearly

evident on this radiograph

cardiomegaly particularly in concert

with other findings

is a suggested feature of congestive

heart failure however

keep in mind that congestive heart

failure can occur in the presence of a

normal-sized heart

cardiomegaly is said to be present when

the cardiothoracic ratio is greater than

0.5

that is when the largest transverse

distance between the left and right

heart borders of the cardiac silhouette

is greater than half the width of the

thorax in this image

the cardiothoracic ratio is

approximately 0.6

now you should also be aware that on

ontario posterior films

the termination of heart size is

unreliable due to magnification

vascular redistribution is one of the

first signs of congestive heart failure

increased blood flow to pulmonary

vessels in the upper lung zones results

in an increase in size

relative to blood vessels in the lower

lung zones

this caudal to cranial redistribution of

blood flow should only be inspected for

an

erect x-ray since equalization of blood

flow may occur in the supine position

the finding of upper low blood diversion

however can be difficult to appreciate

on a plane radiograph

one other way that it can be identified

is by the discovery of a superior lobe

artery with a greater diameter than its

accompanying bronchus

now since it is hard to be certain on

this radiograph this example should be

taken for illustrative purposes

the bronchus is the ring-like structure

with a hollow center while the artery is

filled in

normally the upper lobe artery to

bronchus ratio is less than one to one

here the reverse is seen with a larger

artery than bronchus

you may have also noticed the prominence

of the hilar region and the widening of

the vascular particle in this radiograph

the fullness of the right hilum is

particularly evident whereas the left

eye element is predominantly obscured by

an enlarged cardiac silhouette

unlike with lymph node enlargement in

which case the highlight can appear as a

large lumpy mass

the hilar region in this x-ray has

irregular borders due to thickened

outward branching vessels

the increase in hilar size as well as

the vascular pedicle whitening in this

x-ray

are due to pulmonary venous congestion

an edematous interstitium is another

important feature of congestive heart

failure

three signs of thickened interstitial

tissue include curly beelines

peri-bronchial coughing and interlobal

fissure thickening

curly b lines are fine linear opacities

that are only one to two millimeters in

width

they are typically located peripherally

in the lower lung fields near the

cosmophrenic angles

when viewed close up they can be seen to

extend perpendicularly in words from the

pleura

and are up to three centimeters in

length these opacities can also be seen

head on

in which case they referred to as curly

sea lines or radiating outward from the

hila

in which case they are called curly

a-lines

peri-bronchial cuffing is another

discrete finding which occurs due to

edema of the bronchial wall

when viewed head on it appears as a

donut or a ring

when viewed tangentially that is from

the side it appears as two parallel

lines

which to some extent resemble tram

tracks

note that perry braghill coughing can

occur in other conditions as well

such as chronic bronchitis

also evident in this image is a

thickened minor that is horizontal

fissure

this finding is easier to detect on a

lateral radiograph where both the

oblique and horizontal figures may be

visible

collectively interstitial edema results

in widespread blurring of lung markings

the loss of definition results in a hazy

appearance of the lung fields in

highland bilaterally

now let's turn our attention to the

bottom right corner of the radiograph

note that there is a decrease in

definition of the left cosophenic angle

a finding that is consistent with a

plural effusion

here's another x-ray of congestive heart

failure in this case

there are bilateral pleural effusions

which can be identified by the loss of

phosphor neck angles and obscured

hemidiaphragms

below the left lung we see the meniscus

sign in which the opacity has a concave

upper border and is higher laterally

than immediately

alveolar edema is a more severe sign of

congestive heart feeler

and is not clearly evident in this

radiograph that we've thus far been

examining

in this image many of the aforementioned

findings of congestive heart failure

present

plus alveolar edema which classically

results in central and symmetrical

aerospace disease

the outer third of the lung is

frequently spared resulting in a

characteristic batwing configuration

however the patterns of pulmonary

pacification are variable

and can be more or less diffuse and

asymmetric or patchy

to quickly recap the plane radiographic

findings that can occur with congested

heart failure include

cardiomegaly signs of vascular

redistribution

such as cephalization and increased

artery to bronchus ratio in superior

segments

signs of pulmonary vascular congestion

such as hylar enlargement and a white

and vascular pedicle

signs of pulmonary interstitial edema

such as curly beelines peri-bronchial

coughing

and interlobal fissure thickening

pleural effusions

and in more severe cases alveolar edema

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