Cardiophile MD

This X-ray is suggestive of:

a) Multivalvular heart disease
b) Pericardial effusion
c) Ebstein’s anomaly of tricuspid valve
d) None of the above

Answer: b) Gross enlargement of cardiac outline due to pericardial effusion.

In this case there was underlying severe right ventricular endomyocardial fibrosis as well.

Differential diagnosis of gross enlargment of cardiac size on x-ray include:

1. Large pericardial effusion

2. Ebsteins’s anomaly of tricuspid valve

3. Multivalvular heart disease

4. Endomyocardial fibrosis

In pericardial effusion the shadow is globular with no lobulations. In valvular heart disease different bulges in the cardiac contour will be seen due to asymmetric enlargement of various cardiac chambers. In Ebstien’s anomaly of tricuspid valve and endomyocardial fibrosis, it is mainly right atrial enlargement (including atrialized portion of right ventricle in Ebstein’s anomaly). An example of cardiomegaly not due to pericardial effusion: http://cardiophile.org/2010/09/gross-cardiomegaly-on-cxr/

What is seen on this chest X-ray?

a) Prosthetic aortic valve
b) Prosthetic pulmonary valve
c) Prosthetic mitral valve
d) Prosthetic tricuspid valve

Answer: c) Prosthetic mitral valve

Prosthetic mitral valve – Starr Edward Prosthesis (SEP). Mitral position of the prosthesis is identified by the location below the line joining the left hilum and right cardiophrenic angle. The sewing ring is above and the cage pointing downwards. There are four struts for a mitral prosthesis while an aortic prosthesis has only three. The position of the aortic prosthesis will be above the reference line mentioned above and the cage will be pointing upwards. A double atrial shadow or ‘shadow in shadow’ indicating left atrial enlargement is seen along the right heart border. At the same time, left atrial appendage shadow is not prominent on the left border, possibly indicating previous closed mitral valvotomy with amputation of the left atrial appendage. Sternal wires used for fixing the sternum after sternotomy are also seen.
Annotated image at: http://cardiophile.org/2009/08/prosthetic-mitral-valve-starr-edward-prosthesis-sep/

What is the diagnosis?

a) Pericardial cyst

b) Right atrial enlargement

c) Aortic aneurysm

d) Mediastinal mass

Answer: c) Aortic aneurysm.

Other conditions do come in the differential diagnosis of a similar appearance. In this case, previous X-rays were available, to support the diagnosis: http://cardiophile.org/2010/07/serial-x-rays-of-aortic-aneurysm/

This X-ray is suggestive of:

a) Pneumothorax

b) Pneumomidastinum

c) Penumoperiocardium

d) Hydropneumopericardium

Answer: d) Hydropneumopericardium

X-ray chest PA view illustrating air fluid level in the pericardial cavity. In the yester years, air used to deliberately introduced into the pericardial cavity after partial aspiration of pericardial fluid to visualise intra pericardial structures by their contour and to assess the pericaridal thickening. Now a days, with the availability of multiple imaging modalities like echocardiography, CT scanning and MRI scanning, it is seldom necessary. Hydropneumopericardium can occur if an oesaphageal malignancy invades the pericardial cavity and produces an oesphageopericaridal fistula. In such case hydropneumopericardium is rapidly converted into a pyopneumopericardium.