 you as a doctor give hope and health to many each day there are many more to give hope and health to and with fuji film we are doing that together so chest x-ray behavior integrating full inspiration we will now see the cellopes so the cardiac cellope border is formed mainly by the right atrium superiorly there is a contribution of the superior vena cava and inferiorly there is contribution from the inferior vena cava while the left heart border is basically formed by the left ventricle with a superior contribution of the aortic knuckle and a small in concavity formed by the known as the pulmonary bay formed by the main pulmonary trunk the left ventricle forms the left heart border including the apex while the base of the heart is formed by the right ventricle in lateral projection if you see the anterior cellot is mainly contribution of the right heart border inferiorly by the right ventricle and superiorly by the right atrium while posteriorly it's mainly by the left chambers superiorly by the left atrium and inferiorly by the left ventricle you can see the left bronchus just posterior to the left atrium now talking of a circularity changes before birth at neonatal the deoxyne blood is carried by the two umbilical arteries to placenta for oxygenation the oxygenate blood from the placenta is carried by a single large umbilical vein through the ductus venousis which shunts the blood into two circuits the inferior vena cava circuit and the portal venous circuit from the portal venous system it again entered the inferior vena cava through the hepatic veins as it goes to the right atrium it is guarded by a instruction valve which is directs this uh oxygenate blood to the inter ethyl septum in the region of foramen oval it is the flat communication between the right atrium and the right left atrium and it goes the oxygenate blood goes from the right atrium to the left atrium from the left atrium it goes to the left ventricle and it makes it wait to the aorta for systemic circulation to supply through its branches the coronary artery and the carotid and the inamen artery for the further development for the brain and the myocardium the deoxyne blood or the desaturated blood from the right atrium also reaches the right ventricle and goes the through the pulmonary circuit to the pulmonary circulation but the pulmonary arterials are in a state of severe vasoconstriction anoxic vasoconstriction in a state of fetal physiological pulmonary arterial hypertension and they don't participate in oxygenation so the deoxyne blood is shunted to the ductus arteriosis to the descending thoracic aorta from which fervor in it is again connected by the umbilical arteries from oxygenation which makes it wait to the placenta at birth what happens is this there is as the placenta is shaded its sole supply of oxygenation there is fall in the pulmonary arterial pressure as there is fall in the pulmonary arterial pressure the pulmonary arterioles are now relatively participate in oxygenation so the desaturated blood from the right ventricle goes to the pulmonary circuit through the pulmonary artery for oxygenation the oxygenated blood reaches the left atrium through the pulmonary veins and there is a rise in pressure in the left atrium and that forces the ferment over to close from the left atrium it goes to the left ventricle makes it wait to the aorta for systemic circulation the desaturated blood from the right ventricle no longer goes to the ductus arteriosis to the descending thoracic aorta rather it makes most of them makes it wait to the pulmonary circulation so the ductus arteriosis also closes from a ligament arteriosome so the resultant is this that we have got two independent circuits the right heart and the left heart connected by pulmonary circulation giving a figure of eight pattern the primitive cardiac tube the fetal cardiac tube is a small tube but fixed at both ends it can consist of five dilatations the sinus venous dilatation the common primitive atrium the common primitive ventricle the bulbous cordies and the most cranial the common truncus arteriosis they are fixed and either the both ends actually but it's a fast developing tube so it is bound to rotate loop and twist the in common fetus it goes for dextro rotation or dextro loop the dextro looping is also seen in uncorrected transposition of great arteries while the lever loop is seen in corrected transposition of great arteries in normal population the cardiac tube rotates in such a way making the right ventricle the most anterior chamber and the left atrium the most posterior chamber the left ventricle forming the most of the left heart border and the right atrium forming the most of the right heart border so in this lecture we'll be seeing the asinotic heart disease of the congenital heart spectrum the left to right shunt the right heart obstruction and the left heart obstruction in the cyanotic spectrum we'll be seeing the tricuspid atresia the tetralogy of phallus the pulmonary arteriolar obstruction that is the isomagnetic reaction the uncorrected transposition of great arteries the total anomalous pulmonary venous drainage and the persistent common truncus arteriosus and in other spectrum we'll see the transposition of great arteries again which here we'll deal again with the corrected transposition of the great arteries the right heart abnormalities like the epsin's anomaly and accurate pulmonary heart disease like the rheumatic mitral pulmonary disease the most commonest one so we go to the ASD in ASD we see that the cardiac appears enlarged involving the right atrium and the ventricle and the heart is mildly displaced to the left there is enlargement of the main pulmonary artery with variable degrees of pulmonary pithora the costophenic septal edema is manifested as curly b-lines now you can see in chest p-radigra so we can see the enlarged cardiac this cardiomegaly with enlarged right atrial chambers and the ventricle chambers that is dilated pulmonary arteries the main pulmonary artery which I saw which we saw already forming the flow of the pulmonary bay is dilated and there is dilatation of the central lower segmental as well as peripheral pulmonary arteries with dilated right heart chamber and most importantly you rounded upward cardiac apex so talking about ASD there are three types of ASD the commonest type is the ostium secondum defect which is seen in 85 percent of the population the second type is the endocardial cushion defect seen in 10 percent of the population it is again divided into septum primum and the severe type is the persistent artery of ventricle canal defect the third type the least commonest type is the sinus venousus defect so in septum ostium primum defect the endocardial cushion defect is the milder variety the more severe variety as I told you it's a persistent atrial ventricle canal defect in this septum ostium primum defect what happens there is a misplaced often there is a misplaced mitral valve so this is a four-year-old boy this is a frontal left ventricular cardiogram showing the left ventricle with a distorted upper right lateral border of the left ventricle because of this misplaced mitral valve and the anterior left ventricle goes on to attach to the crista of the intravendicular spectrum giving rise to goo's neck deformity of the left ventricle so what happens is this is the head the rigid end flow because of this mild position mitral valve goes on the rigid end flow not only goes not it does not go to the left atrium but it goes to the right ventricle forming a goo's neck deformity one year later after this is a postoperative film all one year later when the left angiogram ventricular angiogram begin was done we see that the all the cardiac chambers here which was enlarged before has reduced in size you can see the prostatic mitral valve here in its characteristic location but the goo's neck deformity of the left ventricle still persists. Coming talking of ventricular septal defect this is the commonest of the conical anomalies occurring in isolation or as a essential component of the failure technology or a concomitant of any other cardiac anomalies like transposition of great arteries the radiographic features are the there is enlargement enlarged heart proportional to volume overload there is enlarged pulmonary arteries and in proportion to increased pulmonary blood flow to note unless the left atrium is noticeably enlarged it is very it is not possible and very difficult to differentiate the cardiac shape from ASD. So what we see here in this frontal radiograph chest x-ray we can see a dilated heart there is cadaomegaly and there is dilated pulmonary arteries there is pulmonary prithora is as well the right heart chamber is enlarged there is a convex right heart border and here what we see because of the cardiac size enlargement right right heart border enlargement we can see the retrospermorphilium and more increased contact with the sternum so this is the right ventricle enlarged right ventricle this is the right atrium the left atrium is also enlarged because we can see the left bronchus is displaced posteriorly so there is dilated left atrium and also the dilated right heart chamber. Talking of PDA the persistence of pregnancy of the doctor's results in varied manifestation being isolation or in association with VSD or co-op patient of aorta now what is this PDA it is a short conical tubular connection without faults linking the concavity of the aortic arch immediately below the origin of the left subclavian artery to the upper aspect of the main pulmonary artery at its bifurcation. The radiographic features are there is filling of the normal angle between the aortic arch and the main pulmonary artery the central pulmonary artery and the lower arteries enlarges but the segmental arteries are not as large as in ASD so we can see a vivid pulmonary plethora the enlarged lung and the dilated left main pulmonary artery which is forming the pulmonary bay here it should be concavity but we can see a prominent pulmonary bridge so speaks of dilated main pulmonary trunk. Pulmonary valuable stenosis right ventricular hypertrophy consistent with the degrees of stenosis right ventricular dilation does not occur until the right ventricular failure develops to note post-tenotic dilation of the main pulmonary trunk usually extend into the left pulmonary artery not but not into the right pulmonary artery the radiographic features are large left high lung smaller than normal right high lung mildly enlarged heart with RV apex configuration a flattened apex raised above the diaphragm right HM may cause prominent convex right head border a right sided aortic arch in pulmonary venous stenosis usually implies an associated VSD so we can see the heart here is not that enlarged but there is dilated main pulmonary trunk but here it is not extending to the left main pulmonary artery rather the lungs are mildly oligemic it is because because here Eisenmengert's reaction is already taken in and there is reversal of the sun from the left to right from right to left so the heart is not that enlarged oligemia has set in but the main pulmonary trunk is still dilated because of post-tenotic dilation. Coming talking of co-optation of aorta it is an abnormality of aortic media presents as a disc in this discrete folding in the post-relatal wall of the aorta at the level of the legamentum or ductus arteriosus. The resultant present shape membrane causes obstruction to the flow forward flow just to the ductus appropriately termed as post ductal or adult co-optation when the membrane is proximal to the ductus in early life it is known as pre ductal or infantile co-optation. The post co-optation dilation or the proximal descending aorta significant co-optation impairs blood flow into the descending thoracic aorta resisting the presence of co-optals to re-establish the blood flow. The intercostal arteries play a major collateral role resulting in rib notching in the inferior margin of the posterior ribs extending from third to eighth rib in untreated patients usually by eight to ten years of age so we will see a high aortic arch in the left border of the posterior proximal descending thoracic aorta giving rise to the sign of three a rib notching inferior aspect unilateral or bilateral as the case may be. As the case may be suggested there is an aberrant right subclavian artery so it will act as a collateral and if it inserts distal to the co-optation and then in that case the rib notching will be on the left side. If the left subclavian artery inserts distal to the co-optation it may well serve as the co-laterals then in that case there will be only left sided rib notching. So here we can see a frontal chest radiograph with high aortic arch with a indentation or duration and aortic medial duration here and there is a posterior aortic dilatation giving rise to a sign of three. We can see also see the subtle rib notching here in the posterior ribs inferior margin and the co-optals pulsating and the engorged co-laterals are responsible for this the co-laterals which participates in this rib notching are the anterior spinal lateral thoracic internal memory epigastric arteries. So this is an MR angiogram societal section showing the co-optation and internal memory arteries are serving as co-laterals. Tertilogy of phallus a major cause of sciatic heart disease maldevelopment of the cunotrachal symptom is responsible for the development of the four cardinal features that is the right ventricular hypertrophy, a large subaerotic VSD, an overriding of the aortic margin over the VSD and pulmonary vulvular stenosis. If the VSD is absent the overriding is also usually absent with a fifth entity coming into play that is the ASD and that time it is known as the trilogy of phallus. If all these four cardinal features are present along with ASD it is known as Tertilogy of phallus. So the classic wood shape that there is the core and suba is attributed to the deep concavity pulmonary vein and elevation from the diaphragm of a well rounded cardiac apex. So we can see here the right side of the aortic arch there is cardiomegaly there is deep concave pulmonary vein there is an elevated upturned cardiac apex and oligemic lung fills giving rise to a core and suba or a wood shaped heart the signatory of Tertilogy of phallus. This is an cardiac amount oblique short axis view showing the right ventricular hypertrophy and you can see outer overriding the both the right ventricular outflow tract as well as the left ventricular outflow tract. A large subaerotic VSD is also vivid here. CT angiogram shows a classic pulmonary vulva stenosis with post stenotic dilatation of the right pulmonary artery and the left pulmonary artery. Tracheotracia right heart border tends to be flat rather than convex heart lines slightly more than towards the midline than normal. The pulmonary brain is markedly concave main pulmonary trunk and the higher artery are much smaller than normal in the pulmonary oligamy. So we can see a flat right heart border which is caused by the right atrium but the right atrium is larger in size but it is not vivid here because it goes to take the place of a small right ventricular. So it is pushed medially and hence the flattening of the right heart border that is cardiomegaly and there is the oligemic lung fills virtually a classic of tricuspid atreus here. Now we will talk of Isomagros reaction pulmonary arterial obstruction. It is an important hemodynamic response to a large left to right shunt that I have already talked to you in pulmonary venous stenosis fortunately becoming much less frequent due to great success in surgical closure of the cardiac anaerotic shunts. So what we are seeing here we are seeing a dilated simple pulmonary arterials the main pulmonary trunk, the central pulmonary arteries and also the lower and the segmental arteries but the peripheral arterials are not that dilated that is because the reactive pulmonary arterial sclerosis had sets in and the shunt is reduced that is the left to right shunt is reduced and ultimately it is reversed and the heart size comes to normal. Now we will talk of total anomalous pulmonary venous trend. The more frequent variant of complete mixing of the systemic and pulmonary venous return to heart when all the pulmonary veins went directly or indirectly to the right atrium. Supracardic drainage of the pulmonary veins is the most common frequent pattern of total anomalous pulmonary venous drainage draining into the left inaminated vein. Enlarged supracardic veins alongside the enlarged pulmonary artery are contributed to the altered cardiac cellul and pulmonary plethora. Enlarged heart is due to enlarged right atrium and ventricle along with the bilateral convexity of the enlarged superior menostral cellul giving rise to snowman's figure of eight or cottage loaf of red heart which Dr. Jain has already shown me. So we will see the same x-ray giving rise to a figure of eight atmases on the heart cardiomegaly is there but a concurrent pulmonary venous stenosis is also occurring here killing a pulmonary oligamine. So what happens is this the right and left pulmonary vein they join behind the left atrium form an anomalous vertical vein which traverses and takes the left superior menostral cellul joints underneath the left inaminated vein which in turns drain into the superior vena cava. The superior vena cava is dilated and engorged which in turn drains into the right atrium causing a dilated right superior menostral cellul. The right atrium is engorged and dilated which in turn drains into the right ventricle. So the resulting picture you are getting an enlarged superior menostral cellul on either side one due to the pulmonary and anomalous vein another secondary to the engorged and dilated superior vena cava. Here there is again dilated contour because of the right atrium enlargement giving rise to a typically snowman appearance or a figure of heart appearance. Talking of persistent common truncus arteriosus a common truncus arteriosus arises collecting the total outflow from both the ventricles and invariable association is high VSD above which the truncus arises. The intercardic mixing of the blood flow results in synopsis. Enlarged heart with biventricular enlargement is the feature deep concave pulmonary bay with small hyla a rounded cardiac apex and elevated well above the diaphragm giving rise to a sitting duck appearance. So in persistent common truncus arteriosus what you see we see a enlarged heart with a deep concave pulmonary bay a rounded elevated apex small hyla and the truncal arch is on the right side a concurrent pulmonary venous stenosis is also occurring here giving rise to oligemic lung fills and ultimately the feature is this sitting duck appearance which is signatory of the persistent common truncus arteriosus. Uncorrected transposition of great arteries here that is by ventricular ventricle arterial discordance meaning right ventricle giving rise to aorta and left ventricle giving rise to pulmonary artery. Rest the systemic veins the pulmonary veins the right and the right ventricle and the right atrium left atrium on the left ventricle appears normal that is that is venous atrial concoctins and atrioventricular concoctins. This hemodynamic situation is not at all compatible with postnatal life as no oxygen will reach the aorta and the neonate will die immediately after birth. So shunt has to be established from right to left and left to right and should be established at equal volume and in all levels that is this is the normal circulation but the vena cava comes from the reaches the right atrium blood from the right atrium most right ventricle to the pulmonary circuit comes oxygenate blood to the pulmonary veins from the left atrium to the left ventricle ultimately makes it way to the aorta to systemic circulation. What happens in this incorrect position since the right ventricular ventricle gives rise to the aorta so the oxygenate blood never reaches the aorta while here the pulmonary veins reaches the left atrium goes to the left ventricle and goes to the pulmonary circuit again it is not compatible with life. So shunt has to be established either at the ductile level or at the ventricular level or at the atrial level and they should be equal and opposite. The right heart border is usually more convex and prominent than the normal due to enlargement of the right atrium. This produces an on-frontal projection a globular heart like in to an egg on its side or egg on string appearance. The superior media strand is narrow in frontal projection and wide on lateral view as both the ascending aorta anteriorly and the pulmonary artery posteriorly tend to be lie on the same midline. The pulmonary trunk here arises from the left ventricle and takes origin in the midline behind the ascending aorta and within the concavity of the aortic arch. So the it does not participate in border forming and so the highlight are hidden in the media stina instead of contributing prominent to the highlight as in normal anatomy. So here in frontal radiograph we see a lobulated a wide heart with enlarged lobulated contour of the right heart border secondary to enlarged right atrium. We can also see the narrowing of the superior media stina and we can see a bit oligomic lung fills like in to a egg on string or a egg lying on its side heart. Talking of corrected transposition of great arteries the abnormal circulation of uncorrected transposition of great arteries that is ventricular arterial discordance is corrected by a second development anomaly atrioventricular discordance. The atrioventricular discordance is due to displacement of the right ventricle to the left of left ventricle. This coronal position of two ventricles is termed as inversion of the ventricles. So what happens here from the blood from the vena cava reaches the right atrium of leoxynate blood it goes to the left ventricle from there it goes to the pulmonary artery. The pulmonary veins reaches the left atrium from there it goes to the right ventricle and it goes to the aorta. So purpose of life is established and it is compatible in real life because oxynated blood reaches the systemic circulation. Position of the ascending aorta is the take-home message here forming the slightly convex right border of the superior medial stymium forming a long convexity along the upper portion of the left cardiac border to reach the aortic arch which lies to the left of the trachea anomalous lungs usually plethora. So if you can see the cardiomegaly here in this frontal radiograph we can appreciate also a long convex border in the upper cardiac border formed by the ascending arch which is arising here and it goes to the to meet the aortic arch which lies left of the trachea forming a classic appearance of a corrected transposition of the great arteries. Talking of abstinence anomaly the septal and the posterior leaflets of the tricuspid valve are attached to the wall of the middle of the right ventricular chamber instead of the tricuspid ring at the atrium ventricular junction. Hence the proximal portion of the right cavity is atrialized. So what happens here we are seeing a enlarged glomular heart with narrow vascular pedicle and pulmonary oligene. High curved left heart border and squared apex is the hallmark of this condition producing a box shaped or a squared heart. In lateral projection there will be increased contact with the sternum and a very sharply defined almost etched cardiac outline due to reduced cardiac pulsation is the feature. So we can see our typically a box shaped heart glomular heart with sharp etched margin due to reduced cardiac pulsation and since there is utilization of the proximal right ventricle so only the distal right ventricle only can contract and there is since there is impeded ventricular contraction the there is stasis here giving rise to a box shaped heart and there is narrow vascular pedicle as well. Talking of acquired right vascular heart vascular disease that's a rheumatic vascular disease is the calmness there is selective left atrial enlargement with particular affection of the left atrial appendage. The chronology of events here the simple strengthening of the left heart border to very bulge in the characteristic characteristic side of the left atrial appendage to enlargement of the left atrium to the right. So what we see in this frontal radiograph we can see the left atrial appendage has there is enlargement there is a double contour of the heart right heart because of the left atrial chamber has dilate or enlarge to the right there is this playing of the carina and if you see nicely there is upper lower venous diversion which is the hallmark of rheumatic vascular vascular disease. Yet in another patient this is a postoperative case so where this picks up volume overdo it because of this hydrostatic pulmonary edema there is confined assina sharing in both lungs and also along with this there is the prominence of the left atrial appendage which is picks up rheumatic vascular disease.