 Hey everybody, it's Mark and we're moving on with our radiographic approach to the heart old school and now we're going to shift gears a little bit and looking at the radiograph in the setting of unequal chamber enlargement. So unequal chamber enlargement when you see it. And you're able to decipher that from the radiograph it usually indicates a valvular abnormality and occasionally a septal defect. And the pulmonary vascular changes are going to be really crucial in this setting of unequal enlargement. So understanding how these chambers enlarge in the pulmonary vascular you can actually come up with a pretty narrow differential or even the diagnosis. So we go back to our concept map, small heart disease, large heart disease, and it refers to outside the end pericardial myocardial and valvular. The small heart disease with valvular we're often talking about stenosis. And with large heart disease with valvular and septal we're often talking about volume overload or insufficiency. So today, or in this one, we're going to look at unequal chamber enlargement. So this is the kind of heart we're going to be talking about the right ventricles enlarged about half. The left atrium is mildly dilated, the left ventricle is normal, unequal heart enlargement usually indicates valvular. So to figure this out, you start trying to figure out which chambers are enlarged and very importantly, what do the pulmonary vessels look like. There tends to be massive dilation of the right or left atria in the setting of insufficiency because of the volume. The ventricles on the other side will also tend to be dilated because volume induces dilation. In the setting of stenosis, there will be mild dilation of the atria because they're less compliant. And the ventricles do not tend to dilate until they tend to get failure. Now, the right ventricle with hypertrophy has nowhere to go, so it tends to crawl up sternum. That's why you get the so-called sternal heave in the setting of right ventricular hypertrophy. Enlarged aorta and pulmonary arteries are also useful in the setting of post-anotic dilation or insufficiency. But when you start, you've got to look at the pulmonary vessels. Is this sephalization or is this shunt vascularity? Now these mean the exact opposite because shunt is just a plethora of blood flow and sephalization is minimal. But you know what? It's really subtle. So where do you look? Well, both of them have upper-low vessels that are dilated. They're enlarged. But when you look at the lower-low vessels, that will help you distinguish. If the lower-low vessels are constricted and small, that is sephalization and chronic compensated heart failure. If the vessels are the same size all the way through, that is shunt vascularity. There's an increased amount of flow. That's your starting point. Then you've got to know where the valves and the chambers are. Well, where are the valves? We haven't really talked about that. Lateral projection? Again, very helpful. So the lateral, you take a look and the anterior heart is going to be the right. The posterior heart is going to be the left. Now, for the right, the anterior-inferior is tricuspid and up here is the pulmonic. They are separate in their anterior. In the back, the aortic and mitral are very closely aligned and almost connected at the annulus. This is how you separate. Look at the sternum, diaphragm border, drawn imaginary line to the hyalum. If the valve plane lies above it, that's the aortic. If it lies below it, that's the mitral. This is the pulmonic valve. Again, it tends to be separated up high in the anterior. Valves can be tough to tell on the AP, so the lateral projection is kind of your go-to on trying to figure that out. So we take a look at this patient. There's no history. You take, well, let's start with the vessels. The vessels are a bit dilated here, and they're constricted here. You can see they're a bit dilated here, but not super, and then they're very constricted here. This is not shunt vascularity. It is an evidence of some sephalization. The main pulmonary artery is large. The pulmonary arteries on the lateral are large. There is pulmonary hypertension. You don't say in gorge vessels or plump, they are large pulmonary arteries, pulmonary hypertension. You look here at the aortic arch, main pulmonary artery, there's your left atrial appendage, double density. You look in the lateral projection, there's your left ventricle, which looks normal, and then you have the left atrial budding out a little bit. On top, that's left atrial enlargement that's mild. The right ventricle is over halfway up on the sternum, and you know this person has a sternum leave. How do you put this all together? This is a patient with a valve in the aortic area, because it's all pushed forward. The mitral would be right here, draw your line, but there is probably a valve there. This is actually going to be mitral stenosis and probably has aortic valve stenosis, chronic pulmonary venous hypertension, pulmonary artery hypertension, core pulmonary. It's all there. What can you say about her childhood? She had rheumatic fever because she had her aortic valve and mitral valve. Pretty good stuff, huh? All on a radiograph. 33-year-old female. Well, first thing you notice, hey, sternotomy wires, and look how small they are. That means that she had surgery when she was young. The right atrial chamber markedly dilated, marked dilation of a usually suggesting sufficiency. Look at the right ventricle. Yep, that's dilated too. So right and left chambers are dilated in sufficiency. The left ventricle and left atrium have a normal convexity and they're normal. One other thing, whenever you see the convexity of the left heart border, that's real gradual. That's not the left ventricle anymore. That's the right ventricle, which tends to rotate because it has no room behind the sternum and it rotates around. What would you say here? This is Epstein's anomaly. This is tricuspid regurgitation. I mean, you can just say it. So very powerful when you know what chambers to look for and how to deduce this. Again, when you see this convex border, that usually means the right ventricle is dilated enough that the heart has rotated and now that forms the left heart border. How about this person? Remember the aortic arch, descending aorta, supravenic cable? Whoops, what's that? The ascending aorta. Remember, you should not see the ascending aorta normally. If you see it and it's tortuous, that's fine, but this doesn't look unfolded. And then when you look in the lateral, you see there's calcification there. What valve is that? Draw a line from the hylum to the sternum, the sternal diaphragmatic border. It lies predominantly above. That's aortic. Aortic valve calcification is strongly associated with aortic stenosis. That's post-denotic dilation of the ascending aorta. 27-year-old. This patient has shunt vascularity. The vessels are all large, no matter where you look. The pulmonary artery is enlarged. The right ventricle is markedly enlarged with a probable sternal heave. The left atrium and ventricle are normal. This is a patient with pulmonary artery hypertension from shunt. Well, where is the shunt, do you think? This is your hint. You look at the left atrial chamber and it's normal. Why is it normal? With all that blood flow coming back, you can see that the left atrium should dilate, but it's not. Why? Because there's an ASD and all of this extra flow coming in the left atrium is just pushed right through the ASD into the right atrium. This patient, pulmonary hypertension, there are his vessels enlargement that's all throughout the left atrium is normal. This is an ASD. If this was a VSD, you would see the left atrial chamber a bit dilated because it has to accommodate all that flow. So, unequal cardiac enlargement. If you see it, play close attention to the pulmonary vasculature, shunt versus sephalization versus normal, and try to deduce based on chamber enlargement what valve or septal defect is probably present. Okay, remember now this is an old school puzzle where you taking the clues and trying to deduce the patient's cardiopulmonary status.