Signs of Congestive Heart
Failure on the Chest
Radiograph
Molly Lalor MS4
OHSU Radiology Rotation November 2006
When should you use the Chest x-ray in CHF?
► The
Chest Radiograph is a valuable tool for
confirming signs of congestive heart failure and
should be considered in patients with new or
newly exacerbated clinical signs and symptoms of
CHF1.
► Can
you name signs and symptoms of CHF?
CHF clinical symptoms and signs
►Symptoms: dyspnea on exertion, orthopnea,
paroxysmal nocturnal dyspnea, peripheral edema,
fatigue. (Palpitations, chest pain, diaphoresis etc.
may occur depending on etiology).
►Signs:
 Left: bibasilar rales (crackles), S3 or S4, signs of
peripheral hypoperfusion.
 Right: jugular venous distention, large pulsatile
liver, abdominojugular reflex, peripheral edema.
CXR in CHF: what can it show me?
There are four main pieces of information to be gleaned from a chest
radiograph regarding heart failure.
► Is
► Is
there Pulmonary Edema?
there evidence of long term pulmonary venous
hypertension?
► What is my patient’s intravascular volume status?
► Is there heart chamber enlargement? depends
on etiology of CHF. This presentation will not cover
this topic.
CXR: What can it show me?
►
►
►
►
►
So first let’s consider pulmonary edema.
Pulmonary edema is abnormal accumulation of
extravascular lung water2,3.
There are two major types/ mechanisms: hydrostatic
edema and alveolar damage edema.
There are other more rare mechanisms like endothelial
damage edema, but we’ll consider the two most common.
Mixed types can occur but we’ll keep them separate for
simplicity.
Pulmonary Edema = Abnormal
Extravascular Lung Water*
► Again,
because this is important: pulmonary
edema can be caused by elevated hydrostatic
pressure (CHF is in this category).
► Or,
it can be caused by alveolar damage like in
Adult Respiratory Distress Syndrome.
►
On the following slide, look at the cartoon showing
physiologic barriers against edema formation.
Pulmonary Edema Barriers
Alveolar air space
alveolar
epithelium
with tight
junctions
Interstitium
capillary
endothemium
with “loose”
junctions
lymphatics
Capillary
RBC
lumen
RBC
Hydrostatic Pulmonary Edema
high capillary pressure forces water molecules across endothelium
(through loose junctions) into the interstitium and sometimes into the air
space.
Alveolar air space
alveolar
epithelium
with intact
tight
junctions
H2O
Interstitium
capillary
endothemium
with “loose”
junctions
lymphatics
Increased
RBC
capillary
Pressure
RBC
Hydrostatic Pulmonary edema: In this section of lung, septal capillaries are congested and
the alveoli are filled with pink-staining proteinaceous edema fluid. Within the edema fluid
there are macrophages, many of which contain hemosiderin pigment. These changes result
from increased hydrostatic pressure in the pulmonary circulation, as is seen in left-sided
heart failure or mitral stenosis.
From www.pathology.vcu.edu/.../cardio/lab2.c.html
Pulmonary Edema
faculty.southwest.tn.edu/wray/images/
Hydrostatic Pulmonary Edema:
Can you think of the causes of increased capillary hydrostatic
pressure?
Increased
Arterial
Pressure: more
blood to push
through the
tube:
Increased Venous
Pressure:
Capillary pressure
•Left Heart
(pump) failure
with pressure
backup
*Left to right
shunts
•Hypertension
(systemic)
*Renal Failure
•Veno-occlusive
disease
*etc
•Etc.
Alveolar Damage Pulmonary Edema:
Not from CHF
Water in
the air
space
Alveolar air space
Broken tight
junctions
alveolar
epithelium
with
BROKEN
tight
junctions
Interstitium
lymphatics
RBC
RBC
Pulmonary Edema continued
► So
in considering your patient who may have CHF,
evaluate his/her chest film for the mechanism of
pulmonary edema: is it cardiogenic (hydrostatic)
or is it from diffuse alveolar damage (ie there’s
another process besides CHF going on.)
► Let’s
look at some examples.
Hydrostatic vs Alveolar Damage: you can
usually tell them apart on chest radiograph!
CHF: More whiteness (water) in
lower lung areas due to higher
capillary pressures lower down.
Diffuse Alveolar Damage: all over
whiteness from all over alveolar
damage.
► Now
that we’re clear that CHF manifests as
hydrostatic pulmonary edema, what does
that look like?
*Vascular Indistinctness
*Interlobular Fissure Thickening
* Peri-bronchial Cuffing
*Septal Lines (Kerleys)
Pulmonary edema= abnormal
extravascular lung water
Note: peri-bronchovascular fluid cuff
(imagine how this would blur the
vessel margins on radiograph!)
No edema
Interstitial Edema
Vascular Indistinctness
Water is the same density as vessels, and so as it leaves
vasculature for interstitium the margins become fuzzy.
Crisp vessel margins, no edema
Edema
Vascular Indistinctness
Crisp margins, no edema
Edema
Interlobular Fissure Thickening
Edema in the lung along the fissure
Peri-Bronchial Cuffing
Peribronchial cuffing represents extravasated water surrounding the
bronchus.
Pre-diuresis: note the
cuffing (large arrow)
Post diuresis
Septal Lines
Thickened interlobular septae
What about Cephalization?
► Cephalization
means that the upper lung
zone vessels look bigger than the lower lung
zone vessels because more blood is flowing
through the higher vessels. This is also
called flow inversion.
► This
phenomenon is the opposite of the
normal gravity-dependent regional
pulmonary blood flow.
Cephalization
The upper lobe vascular caliber is greater than lower vessels.
Cephalization
► Many
sources teach that cephalization (flow
inversion) is an early and sensitive sign of acute
pulmonary edema or acute CHF4-7. This teaching is
likely based on studies of chronic mitral stenosis
patients.
► However, studies have shown that cephalization is
not well correlated with acute pulmonary
hypertension in acute MI3,9,10, and that flow
inversion remains after diuresis8.
► Ketai and Godwin in a review conclude that
cephalization is almost never seen unless there is
chronic pulmonary venous hypertension3 .
Cephalization
► Pistolesi
et al (1988) found that flow inversion
correlated positively with pulmonary vascular
resistance and not with wedge pressure, edema,
or arterial oxygen tension8.
► Therefore, cephalization likely reflects chronic
structural changes in the dependent lung
vasculature (like reduction of cross sectional
area)3,8.
Cephalization
► So
what does that all mean?
►
If you see cephalization it means your patient likely has a chronic
process causing pulmonary venous hypertension.
►
Cephalization is not a sign of pulmonary edema.
Intravascular Volume Status
The vascular pedicle (mediastinal width above top of aortic
arch) represents the superior vena cava on the patient’s
right and the left subclavian artery on the left.
If it is wide, that indicates greater intravascular volume.
Look at the example on the following slide.
Intravascular Volume Status
Pre-dialysis
Post-dialysis
Quiz Time!
► For
the following chest xrays, practice
deciding if you think there is pulmonary
edema-hydrostatic or alveolar damage.
► Answers
at the end.
#1
#2
#3
#4
#5
#6
#7
Quiz Answers
► #3
and #5 show hydrostatic pulmonary
edema.
► #6 shows alveolar damage pulmonary
edema.
► Bonus:
#7 demonstrates cephalization.
References
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1. American College of Radiology Committee on Appropriateness Criteria for Congestive Heart Failure, 2006.
2. Reading the Chest Radiograph; A Physiologic Approach. Milne and Pistolesi, 1993.
3. Ketai and Godwin, A New View of Pulmonary Edema and Acute Respiratory Distress Syndrome. Journal of Thoracic Imaging 13: 147-171.
1998.
4. UpToDate. Acute Decompensated Heart Failure (Cardiogenic Pulmonary Edema). Accessed 11/02/06.
5. EMedicine “Congestive Heart Failure and Pulmonary Edema”
6. Loyola University teaching website: www.meddean.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/CXR/atlas/pulmonaryedema.htm
7. Sumer’s Radiology website:http://www.sumerdoc.blogspot.com/
8. Pistolesi M et al. Factors Affecting Regional Pulmonary Blood Flow in Chronic Ischemic Heart Disease. Journal of Thoracic Imaging 3(3): 6572. 1988.
9. Kostuk WJ. Circulation 1973 48: 624.
10. Goodman and Morgan. Pulmonary Edema and adult respiratory distress syndrome. Radiologic Clinics of North America 1991; 29: 943-963.