Silhouette sign, right middle lobe pneumonia. Initial frontal (A) and lateral (B) radiographs in a patient with clinical suspicion of pneumonia demonstrate obliteration of the right heart border. Follow-up radiographs the next day (C, D) illustrate dense opacification on the lateral view and persisting loss of the right heart border, confirming the presence of a right middle lobe pneumococcal pneumonia. Source Signs in Thoracic Imaging Journal of Thoracic Imaging 21(1):76-90, March 2006.
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Air Bronchograms Ashley Davidoff thecommonvein.net
How to approach the Field of Radiology
My Story – Curiosity
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Sherlock Holmes Not invisible but unnoticed Watson…. Ashley Davidoff thecommonvein.net
In the pursuit of excellence of piano playing … principles are
Notes Scales and Music
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THE ART OF PERFECTING MUSIC Ashley Davidoff Scales from MusicNotes.com thecommonvein.net
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THE ART OF PERFECTING DANCE Ashley Davidoff thecommonvein.net
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THE ART OF PERFECTING TENNIS Ashley Davidoff thecommonvein.net
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TIGER WOODS AND TOM BRADY
NOTES SCALES AND MUSIC IN THE PURSUIT OF PERFECTION
Both images are in the public domain
Story of Dr Jerry Balikian
Application to Radiology
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Where to look, how to look and
what to look for
Ashley Davidoff thecommonvein.net
Identifying the Units
=
Notes
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Lungs and The Common Vein The image shows some of the major components of the lung that when bonded create a new and powerful unit – a vital organ. In the center is an example of the airways and parenchyma making up the 2 lungs. At 12 oclock the tracheo-bronchial tree with segmental and subsegmental airways. At 1 o?cloclock, is a cross section of the lungs showing some of the segments of the lung. At 5o?clock a cross section shows the arteries and veins of the lungs. At 7o?clock the drawing shows the pleura and pleural space of the lungs. At 9o?clock, a coronal reformat of the tracheobronchial tree shows the lymph node stations of the lungs. At 11 o?clock is the golden alveolus, the epicentral unit where gas exchange takes place Ashley Davidoff MD TheCommonVein.net lungs-0696
U SSPCT C
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Anatomy of the Lungs
Frontal Examination of the Lungs
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THE HEART, LUNGS, PLEURA, DIAPHRAGM, ARTERIES, VEINS, PROXIMAL TRACHEOBRONCHIAL TREE and SKELETON
Ashley Davidoff MD
Parts of the Lungs- Basics
Left Lung ? Left Upper Lobe ? Frontal Projection
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LEFT UPPER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Frontal Projection Left Lower Lobe
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LEFT LOWER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Lung ? Right Upper Lobe ? Frontal Projection
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RIGHT UPPER LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Middle Lobe ? Frontal Projection
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RIGHT MIDDLE LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Right Lower Lobe ? Frontal Projection
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RIGHT MIDDLE LOBE IN THE FRONTAL PROJECTION
Ashley Davidoff MD
Lateral Examination of the Lungs
Major Fissure on the Left
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LATERAL PROJECTION ? FISSURE DIVIDES THE LEFT UPPER LOBE (INCLUDING LINGULA) AND LEFT LOWER LOBE
Ashley Davidoff MD
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MAJOR FISSURE ON THE LEFT
Ashley Davidoff MD
Lateral Projection ? Left Upper Lobe
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LATERAL PROJECTION, LEFT UPPER LOBE
Ashley Davidoff MD
Lateral Projection left Lower Lobe
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LATERAL CXR SHOWING LEFT LOWER LOBE
Ashley Davidoff MD
Major and Minor Fissures on the Right
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ANATOMIC SPECIMEN SHOWING MAJOR and MINOR FISSURES DIVIDING THE RIGHT LUNG INTO 3 LOBES
The right lung has a small right upper lobe (RUL) separated from the middle lobe (RML) by the minor fissure (pink,lower image) . Both the RUL and RML are anterior and are separated from the lower lobe by the major fissure (orange line)
Ashley Davidoff MD
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LATERAL X-RAY SHOWING MAJOR and MINOR FISSURES DIVIDING THE RIGHT LUNG INTO 3 LOBES
The right lung has a relatively small right upper lobe (RUL) separated from the middle lobe (RML) by the minor fissure (pink,lower image). Both the RUL and RML are anterior and are separated from the lower lobe by the major fissure (orange line)
Ashley Davidoff MD
Right Upper Lobe ? Lateral Projection
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LATERAL CXR SHOWING RIGHT UPPER LOBE
Ashley Davidoff MD
Right Middle Lobe ? Lateral Projection
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LATERAL CXR SHOWING RIGHT MIDDLE LOBE
Ashley Davidoff MD
Right Lower Lobe ? Lateral Projection
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LATERAL CXR SHOWING RIGHT LOWER LOBE
Ashley Davidoff MD
Summary
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CXR of LEFT LUNG
Ashley Davidoff MD
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Lungs and The Common Vein The image shows some of the major components of the lung that when bonded create a new and powerful unit – a vital organ. In the center is an example of the airways and parenchyma making up the 2 lungs. At 12 oclock the tracheo-bronchial tree with segmental and subsegmental airways. At 1 o?cloclock, is a cross section of the lungs showing some of the segments of the lung. At 5o?clock a cross section shows the arteries and veins of the lungs. At 7o?clock the drawing shows the pleura and pleural space of the lungs. At 9o?clock, a coronal reformat of the tracheobronchial tree shows the lymph node stations of the lungs. At 11 o?clock is the golden alveolus, the epicentral unit where gas exchange takes place Ashley Davidoff MD TheCommonVein.net lungs-0696CXR of RIGHT LUNG
Ashley Davidoff MD
Trachea, Main Stem Bronchi, and Carina
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NORMAL FRONTAL CXR NORMAL ASYMMETRIC BRANCHING OF MAINSTEM BRONCHI The normal CXR shows the characteristic asymmetric branching of the main stem bronchi. The right is short and stout and slightly more vertical while the left is long and thin and slightly more obtuse. The normal carinal angle is between 40-80 degrees. Ashley Davidoff MD
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ASYMMETRIC BRANCHING PATTERN ? RIGHT SHORT AND STOUT AND THE LEFT LONG AND THIN
CARINAL ANGLE ? 40-80 degrees
Ashley Davidoff MD
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THE RIGHT ? SHORT STOUT AND CUTE
THE LEFT ? TALL THIN AND GRACILE
The carinal angle
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OLIVER HARDY AND STAN LAUREL IN THE 1939 FILM ? THE FLYING DEUCES
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SCREW IN THE RIGHT MAIN STEM
http://www.wikiradiography.net/
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N-G TUBE IN RIGHT MAIN STEM BRONCHUS
Courtesy Radiopaedia
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ET TUBE IN RIGHT MAIN STEM BRONCHUS
Courtesy Radiopaedia
Another “Unit”
The Heart
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U SSPCT C
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Chambers that are Border Forming on the PA Examination
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FRONTAL CXR AND PARTS OF THE HEART
If we were to ?crack open? the chest of the chest X-ray, the structures that would dominate this bloody, black and white scene, would be the right sided chambers. The right ventricle (RV) would be the dominant anterior chamber, and would form the dominant interface with the diaphragm. The right atrium (RA) would form the border with the right lung. The RA would of course be slightly posterior to the RV. The left border would be formed by the left ventricle. Most the left ventricle is hidden posteriorly in this view. The left anterior descending artery would be visible from this anterior view. It marks the position of the interventricular septum.
Ashley Davidoff MD
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CARDIOMEGALY – THE CARDIOTHORACIC RATIO The maximum transverse length of the heart is expressed as a percentage of the maximum length of the internal diameter of the chest. When this ratio – the cardiothoracic ratio (c t r) is greater than 50% cardiomegaly is present. The top image is normal and the bottom reflects cardiomegaly Ashley Davidoff MD
There are Two Basic Common Shapes of Cardiomegaly
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CARDIOMEGALY ? TWO BASIC TYPES -OVOID and TRIANGULAR The ovoid form which suggests left ventricular dominance and triangular form which suggests right ventricular dominance. Ashley Davidoff MD
The Ovoid Form of Cardiomegaly ? Consider LVE
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SHAPE OF THE LEFT VENTRICLE
The enlarged LV (a,b) is shaped like an oval and it is likened to a rugby ball or an American football placed on the field at kick off time. LVE on CXR is mostly assessed by an increased cardiothoracic ratio as well as the accentuation of the ovoid shape. (lower images c, d,e, f)
Ashley Davidoff MD
Vector of the Enlarging LV ? Rotate Down and to the Left
VECTOR FOR LV ENLARGEMENT DOWN AND OUT The left ventricle (LV) enlarges in a posterior, downward and lateral direction resulting in the characteristic changes of LVE on CXR Ashley Davidoff MD
CLINICAL EVALUATION OF LVE ? DOWN AND OUT
The left ventricle (LV) enlarges in a downward and lateral direction resulting in the apical impulse displacement and increase forcefulness of the apical tap.
Ashley Davidoff MD
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ISCHEMIC CARDIOMYOPATHY S/P RCA OCCLUSION 62 year old female with acute chest pain atrial fibrillation, hypotension admitted to ICU. Clinical evaluation was considered to be non-ischemic cardiomyopathy with EF by echo of about 20%. She was hypotensive and, in the ICU, and CXR showed acute CHF with cardiomegaly. The TEE was more in keeping with segmental dyssynergy, Cardiac cath showed occluded RCA bot good collateralization from the LAD. MRI showed subendocardial LGE in the inferior and inferolateral portions of the LV consistent with a prior infarction and EF of 20% Ashley Davidoff MD
The Triangular Form of Cardiomegaly
Consider RVE or any disease from the left side that may cause RVE eg mitral stenosis
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TRIANGULAR SHAPED HEART ? SUGGESTING RIGHT VENTRICULAR DOMINANCE. MITRAL STENOSIS PULMONARY HYPERTENSION 71 year old Asian female with rheumatic heart disease dominated by calcific mitral stenosis mild MR, moderate tricuspid regurgitation and secondary pulmonary hypertension. Ashley Davidoff MD
Note the Basic Shape of the RV is Triangular in almost all Views
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SHAPE OF THE LEFT VENTRICLE
The enlarged LV (a,b) is shaped like an oval and it is likened to a rugby ball or an American football placed on the field at kick off time. LVE on CXR is mostly assessed by an increased cardiothoracic ratio as well as the accentuation of the ovoid shap. (lower images c, d,e, f)
Ashley Davidoff MD
Vector of the Enlarging RV ? Rotate Laterally to the Right
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VECTOR FOR RV ENLARGEMENT
ANTERIOR LEFTWARD
The right ventricle (RV) enlarges with a clockwise rotation resulting in an upward turning of the apex and enlargement in a anterior and leftward lateral direction.
Ashley Davidoff MD
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UPTURNED APEX AND THE PROUD BREAST APPEARANCE OF RIGHT VENTRICULAR ENLARGEMENT
As the right ventricle (RV) enlarges with a clockwise rotation the apex of the small ventricle succumbs to the larger silhouette of the RV which pints upward and to the left and has been called the ?proud breast? appearance.
Ashley Davidoff MD
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PROUD BREASTS
Ashley Davidoff MD
Clinical Exam of the RV ? Diffuse Anterior Parasternal Heave
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CLINICAL EVALUATION OF RVE ? PARASTERNAL HEAVE
The right ventricle (RV) enlarges in a anterior, upward and lateral direction resulting in the broad based parasternal pulsation which on clinical examination is identified as a parasternal heave identified with the base of the extended hand
Ashley Davidoff MD
PULMONARY HYPERTENSION Frontal x-ray with triangular shaped heart due to pulmonary hypertension with enlarged MPA and enlarged descending RPA . Ashley Davidoff MD
What about the Right Atrium (RA) and Right Heart Border?
The RA does not make much a statement on the frontal CXR unless very large
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FRONTAL CXR AND PARTS OF THE HEART
If we were to ?crack open? the chest of the chest X-ray, the structures that would dominate this bloody, black and white scene, would be the right sided chambers. The right ventricle (RV) would be the dominant anterior chamber, and would form the dominant interface with the diaphragm. The right atrium (RA) would form the border with the right lung. The RA would of course be slightly posterior to the RV. The left border would be formed by the left ventricle. Most the left ventricle is hidden posteriorly in this view. The left anterior descending artery would be visible from this anterior view. It marks the position of the interventricular septum.
Ashley Davidoff MD
The Enlarged Right Atrium
The right atrium is the most difficult chamber to assess unless it is very large in which case it will manifest on the frontal CXR with a very large right paravertebral border.
enlarged, globular heart
narrow pedicle
gross enlargement of the right atrial shadow, i.e. increased convexity in the lower half of the right cardiac border
right atrial convexity is more than 50% of the cardiovascular height
right atrial margin is more than 5.5 cm from the midline
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RIGHT ATRIAL ENLARGEMENT ON FRONTAL X-RAY
The right atrium is the most difficult chamber to assess unless it is very large in which case it will present on the frontal CXR with a very large right paravertebral border. This is a 71 year old female person with rheumatic heart disease with pulmonary hypertension and tricuspid regurgitation hence resulting in a large right atrium (RAE)
Ashley Davidoff MD
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RIGHT ATRIAL ENLARGEMENT ON FRONTAL X-RAY
The right atrium is the most difficult chamber to assess unless it is very large in which case it will present on the frontal CXR with a very large right paravertebral border. The frontal CXR and coronal CT through the RA is from a 71 year old female with rheumatic heart disease with pulmonary hypertension and tricuspid regurgitation resulting in a giant right atrium (RAE). The RA accounts for the large bulge of the right border of the cardiac silhouette. The black arrowhead in the loer image points to the calcified mitral valve.
Ashley Davidoff MD
NORMAL FRONTAL CXR NORMAL ASYMMETRIC BRANCHING OF MAINSTEM BRONCHI
The normal CXR shows the characteristic asymmetric branching of the main stem bronchi. The right is short and stout and slightly more vertical while the left is long and thin and slightly more obtuse.
The normal carinal angle is between 40-80 degrees.
Ashley Davidoff MD
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ASYMMETRIC BRANCHING PATTERN ? RIGHT SHORT AND STOUT AND THE LEFT LONG AND THIN
CARINAL ANGLE ? 40-80 degrees
Ashley Davidoff MD
The Abnormal Carinal Angle
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NORMAL AND WIDENED CARINAL ANGLE
A dancer demonstrates a normal carinal angle (upper image) and as she continues to extend her left leg, (lower images) the angle becomes greater than 80 degrees and in terms of the carinal angle becomes abnormal.
Ashley Davidoff MD
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MITRAL STENOSIS WITH ENLARGED LEFT ATRIUM ? WIDENED CARINAL ANGLE DOUBLE DENSITY ENLARGED LEFT ATRIAL APPENDAGE
The frontal CXR demonstrates findings consistent with mitral stenosis including a widened carinal angle (teal blue and black arc), a double density (red arc) and an enlarged left atrial appendage (maroon arc).
The overall shape of the heart is triangular suggesting right ventricular enlargement. A mitral valve prosthesis is in position
Courtesy of Radiopaedia
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PARTS OF THE ENLARGED HEART ON FRONTAL CXR in MITRAL STENOSIS PULMONARY HYPERTENSION AND COR BOVINUM
71 year old Asian female with rheumatic heart disease dominated by calcific mitral stenosis mild MR, moderate tricuspid regurgitation and secondary pulmonary hypertension.
The frontal view shows an enlarged RA (light blue) characterized by a prominent right heart border. The right ventricle is enlarged as noted by the triangular shape of the cardiac silhouette, an the upturned (?proud breast?) appearance of the left heart border, both reminiscent of RVE. The left atrium is also significantly enlarged characterised by the widened carina and the straight heart border caused by a combination of atrial appendage enlargement and pulmonary hypertension. The LV (maroon) is normal in size
Ashley Davidoff MD
SMALL APICAL PNEUMOTHORAX IN AN UPRIGHT CXR TAKEN IN EXPIRATION. In an upright position a pneumothorax rises to the apex of the lung and assumes the shape of the apex because it exerts pressure on the lung apex which yield to the greater pressure. The expiration film accentuates the pneumothorax because it further reduces the pressure in the lungs and increases the pressure difference between the PTX and the intraparenchymal pressure. The PTX is barely seen in (a) and is better seen in the magnified views (b and c) and with increasing contrast (c) the faint line of the the pleura becomes better visualized (white arrowheads). Ashley Davidoff MD
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DEEP SULCUS SIGN Portable supine examination in the ICU shows a pneumothorax in the right subpulmonic region Ashley Davidoff MD
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Spontaneous Tension Pneumothorax 49 year old male with a cough presents for a Chest Xray which showed a tension pneumothorax. Chest tube was placed emergently in the radiology department. Ashley Davidoff MD TheCommonVein.net 117300c
Pleural Effusion
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Fluid in the Upright and Supine Projection Ashley Davidoff thecommonvein.net
Small Effusion May Only Seen on the Lateral Exam
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SMALL EFFUSION ONLY IDENTIFIED ON THE LATERAL EXAMINATION A small effusion is not identified on the PA chest since it is hidden by the diaphragm and the effusion first fills the posterior recess because it is most inferior. The lateral examination is required to identify the effusion Courtesy How to Interpret CXR Strong Medicine https://www.youtube.com/watch?v=wOpDvUO5sD8
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Typical shape of a moderately large right pleural effusion Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 34401
Veiling Opacity
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Veiling Opacity left pleural effusion in the supine projection Case courtesy of RMH Core Conditions, Radiopaedia.org, rID: 34401
Scales
Learning how to look so that you can see
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How to look and what to look for Ashley Davidoff thecommonvein.net
Notes Scales and Music
Scales
Have a fluid and logical method of looking (search pattern) and
practice practice practice
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SCALES
4 Review Spaces relating to 4 areas of major disease
Pleura – PTX and Effusions
Lungs – Pneumonia and Masses
Hila – Masses and CHF
Heart – Megalies and Failure
First Scale – Pleural Run
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PANORAMA WALK FOR PLEURAL ASSESSMENT Ashley Davidoff MD
Pattern – start at the white lines to the right and left of the thoracic vertebra running along the diaphragms into the pleural recesses, up the lateral walls to the apices
2nd Scale – Lung Loops
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LUNG LOOPS – UPPER MID AND LOWER Ashley Davidoff MD
Pattern –
Come down the trachea and and
loop the upper lung fields, then the
mid lung fields, and finally the
lower lung fields
looking for
symmetry,
masses,
infiltrates,
interstitial changes
3rd Scale – Skiing on the Moguls
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SKI TRIP DOWN THE MOGULS OF THE HEART A methodical approach to evaluation of the cardiac silhouette is likened to skiing down a mogul laden ski slope and then taking a trip on the ski lift back to the top of the mountain. The ski slope starts at the left subclavian artery (light brown) , followed by the mogul of the aortic knob (bright green) at the bottom of which is the A-P window (white) only to be presented with a second mogul of the main pulmonary artery(yellow), and then the bay of the left atrial appendage (pink)and finally free at last of moguls and an exciting and accelerating ski down the LV (red) We then have to take a walk back to the ski lift. At the junction of the LV (red) and the RV (blue) , if we take a right ward look up the mountain we can spot the LAD on top of the interventricular septum. The walk along the border of the RV is terminated at the junction of the RV (dark blue) and the right atrium (light blue). At this point we wait in line to get on to the ski lift. We ride up the right hand border of the right atrium (light blue) a little rough bump over the ascending aorta )maroon) and then straight to the top along the SVC (pink). Ashley Davidoff MD
Pattern of the Ski Run –
Start at the left apex at the left subclavian artery,
jump the aortic mogul and
land in the AP window, and then
jump the PA mogul,
land in the LA appendiceal bay, and then
ski all the way down the LV.
Walk back to the ski lift via the inferior border of the RV and then the RA.
At the bottom of the RA get on to the ski lift as the IVC enters the RA
and then take the lift up the mountain via the RA ,
portion of the ascending aorta and the
the SVC
4th Scale – Hilar Hoops
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PRESSURE PUZZLES Down the airways for the carinal angle Upper vs Lower Vessels Artery vs Bronchus Middle – Hilar Size and Shape Lower – Descending Bronchovascular Bundle and specifically RPA yellow arrow Ashley Davidoff MD
Pattern of the Hilar Hoops –
Trip down the trachea – Specifically to look at the carinal angle
Upper hoop specifically to look at pa- bronchus ratio
Middle Hoop – Specifically to look at hilar size and shape
Lower Hoop – Specifically to look for redistribution and clarity of RPA
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The Shapes of the Heart in Health and Disease
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From top left ti right and across the rows they are: The normal heart , the ?football? of LV enlargement the ?triangle? or ?proud breast? of RV enlargement, ?snowman? of total anomalous pulmonary venous return, big PA mogul of pulmonary hypertension, ?egg on its side? of D transposition of the great vessels, ?boot shaped? heart seen in both pulmonary atresia and Tetralogy of Fallot, the long smooth combined Ao and PA mogul that has a differential diagnosis of L transposition, absence of the pericardium, and juxtaposition of the atrial appendages, the box shaped large heart of Ebstein?s anomaly, dextrocardia , and the water bottle? heart of a large pericardial effusion.
07197 Images are a combination of images from a personal collection and borrowed from the internet for educational purposes only. Some of the sources are unknown and are used for educational purposes alone 86774b02
Normal Pulmonary Artery
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Normal Main Pulmonary Artery When a line is drawn from the aortic knob to the left edge of the heart, (red line) the pulmonary artery should lie medial to that line (ie along the line drawn to 1.5cms medial to the line) Ashley Davidoff MD TheCommonVein.net
Pulmonary Hypertension
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Pulmonary Arteries in Pulmonary Hypertension When a line is drawn from the aortic knob to the left edge of the heart, (red line) the pulmonary artery lies lateral to that line indicating an enlarged pulmonary artery most commonly caused by hypertension . In this instance the size of the descending right pulmonary artery is greater than 15 mms confirming the presence of pulmonary hypertension Ashley Davidoff MD TheCommonVein.net