,Chest Radiographic Interpretation
in Pediatric Cardiac Patients
,
,Chest Radiographic Interpretation
in Pediatric Cardiac Patients
Shi-Joon Yoo, MD, PhD, FRCPC
Section Head of Cardiac Imaging
Department of Diagnostic Imaging
Hospital for Sick Children
Professor
Departments of Medical Imaging and Paediatrics
University of Toronto
Toronto, Canada
Cathy MacDonald, MD, FRCPC
Radiologist
Department of Diagnostic Imaging
Hospital for Sick Children
Assistant Professor
Department of Medical Imaging
University of Toronto
Toronto, Canada
Paul Babyn, MD, FRCPC
Radiologist-in-Chief
Department of Diagnostic Imaging
Hospital for Sick Children
Associate Professor
Department of Medical Imaging
University of Toronto
Toronto, Canada
Thieme
New York • Stuttgart
,Thieme Medical Publishers, Inc.
333 Seventh Ave.
New York, NY 10001
Editorial Director: Michael Wachinger
Managing Editor: Timothy Y. Hiscock
Editorial Assistant: Jacquelyn DeSanti
International Production Director: Andreas Schabert
Production Editor: Kenneth L. Chumbley, Publication Services
Vice President, International Marketing and Sales: Cornelia Schulze
Chief Financial Officer: James W. Mitos
President: Brian D. Scanlan
Compositor: Thomson Digital
Printer: Sheridan Books, Inc.
Library of Congress Cataloging-in-Publication Data
Chest radiographic interpretation in pediatric cardiac patients / [edited by] Shi-Joon Yoo, Cathy MacDonald, Paul Babyn.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-60406-036-2 (alk. paper)
1. Pediatric cardiology—Diagnosis. 2. Pediatric radiography. I. Yoo, Shi-Joon. II. MacDonald, Cathy, MD. III. Babyn, Paul S.
[DNLM: 1. Heart Diseases—radiography. 2. Child. 3. Infant. 4. Radiography, Thoracic. WS 290 C525 2010]
RJ423.C44 2010
618.92’1207572—dc22
2009043190
Copyright ©2010 by Thieme Medical Publishers, Inc. This book, including all parts thereof, is legally protected by copyright. Any use,
exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal
and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind,
translating, preparation of microfilms, and electronic data processing and storage.
Important note: Medical knowledge is ever-changing. As new research and clinical experience broaden our knowledge, changes in
treatment and drug therapy may be required. The authors and editors of the material herein have consulted sources believed to be
reliable in their efforts to provide information that is complete and in accord with the standards accepted at the time of publication.
However, in view of the possibility of human error by the authors, editors, or publisher of the work herein or changes in medical
knowledge, neither the authors, editors, nor publisher, nor any other party who has been involved in the preparation of this work,
warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or
omissions or for the results obtained from use of such information. Readers are encouraged to confirm the information contained herein
with other sources. For example, readers are advised to check the product information sheet included in the package of each drug they
plan to administer to be certain that the information contained in this publication is accurate and that changes have not been made in
the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection
with new or infrequently used drugs.
Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary
names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without
designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.
Printed in the United States of America
54321
ISBN 978-1-60406-036-2
,Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Alan Daneman, MD
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Andrew Redington, MD
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Section I Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1. Normal Cardiovascular Anatomy for Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Shi-Joon Yoo and Donald G. Perrin
2. Sequential Segmental Approach to Congenital Heart Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
3. Basic Cardiac Function and Hemodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Derek Wong and Shi-Joon Yoo
4. Glossary of Pediatric Cardiovascular Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Shi-Joon Yoo and Christopher A. Caldarone
5. The Best Radiographs with the Least Radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Ellen Charkot and Shi-Joon Yoo
Section II Systematic Approach to Chest Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6. Identification, Clinical History, and Radiographic Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
7. Visceral Situs, Heart Position, and Aortic Arch Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
8. Heart Size, Overall Configuration, and Specific Chamber Enlargement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
9. Pulmonary Vascularity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
10. Aorta and Systemic Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
11. Airways, Lungs, Pleurae, Mediastinum, Diaphragm, and Chest Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Section III Individual Heart Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
12. Lesions with Left-to-Right Shunt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
With Christian J. Kellenberger
13. Truncus Arteriosus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
With Christian J. Kellenberger
14. Ebstein’s Malformation and Other Forms of Congenital Tricuspid Regurgitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
With Christian J. Kellenberger
v
,vi Contents
15. Tetralogy of Fallot and Related Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
With Christian J. Kellenberger
16. Pulmonary Valvar Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
With Christian J. Kellenberger
17. Pulmonary Atresia with Intact Ventricular Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
With Christian J. Kellenberger
18. Partial and Total Anomalous Pulmonary Venous Connections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
With Monica Epelman
19. Congenital Stenosis and Atresia of the Individual Pulmonary Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
With Anne Geoffray
20. Abnormalities of the Mitral Valve and Related Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
With Anne Geoffray
21. Obstructive Lesions of the Left Ventricular Outflow Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
With Monica Epelman
22. Hypoplastic Left Heart Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
With Monica Epelman
23. Obstructive Lesions of the Aortic Arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
With Monica Epelman
24. Transpositions of the Great Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
With Kevin S. Roman
25. Double-Outlet Ventricles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
With Kevin S. Roman
26. Hearts with Single-Ventricle Physiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
With Kevin S. Roman
27. Abnormal Situs and Cardiac Malposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
With Kevin S. Roman
28. Rheumatic Fever and Acquired Valvular Heart Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
With Christian J. Kellenberger and Kevin S. Roman
29. Cardiomyopathies and Related Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
With Kevin S. Roman
30. Kawasaki Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
With Kevin S. Roman
31. Pericardial Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
With Christian J. Kellenberger
32. Cardiac Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
With Christian J. Kellenberger
33. Pulmonary Thromboembolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
With Anne Geoffray
34. Pulmonary Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
With Anne Geoffray
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
,Foreword
Appropriate management of children with cardiovascular At the Hospital for Sick Children, Toronto, Canada,
disease in the 21st century relies heavily on an armamen- there has long been a close relationship between the
tarium of sophisticated imaging techniques, such as echo- pediatric radiologists, whose prime interest has been in
cardiography, computed tomography, magnetic resonance cardiovascular disease, and the pediatric cardiologists
imaging (including functional techniques), angiography, and cardiac surgeons. This close relationship began
and interventional procedures guided by angiography. No decades ago, when the cardiac radiologist Dr. Fred Moes
modern hospital can provide appropriate care for the forged a close collaboration with Drs. Rowe, Mustard,
child with cardiovascular disease without the availability and Freedom in cardiology and cardiovascular surgery.
of this full range of modalities. Over the years, other outstanding cardiac radiologists
Plain radiographs of the chest are still used in these have joined the staff, such as Gordon Culham and
children at the time of their initial presentation and Pat Burrows and more recently Shi-Joon Yoo and Cathy
during follow-up of medical management and after cor- MacDonald.
rective surgical or interventional procedures. Although This collaboration has led to the publication of many
the plain radiograph does not provide the definitive outstanding papers and books on the subject of pediatric
anatomic and functional information depicted by the cardiovascular disease. The present book on interpreta-
more sophisticated modalities, it serves as an initial part tion of the plain radiograph in these patients finds its
of the evaluation at the time of the diagnosis and is essen- niche by filling a specific area of interest among the other
tial (usually repeatedly) following surgical correction. books on pediatric cardiovascular diseases published
Accurate interpretation of the plain radiograph of the from this institution.
chest therefore remains vitally important. However, in The information in this book is important not only to
recent decades there has been tremendous interest in the pediatric cardiovascular radiologists but also to pediatric
newer, more exciting, sophisticated modalities, and more cardiologists and cardiac surgeons. The book will become
time has been spent learning how to derive maximum standard reading for all those training in these specialties.
information from these modalities. In this era, learning to The manner in which it has been written and illustrated
optimize the interpretation of plain radiographic findings will reignite interest in the interpretation of the plain
often assumes a less important role. chest radiograph even for those whose main interest is in
This book, authored by Drs. Yoo, MacDonald, and Babyn, the more sophisticated modalities.
highlights the plain radiographic interpretation in cardio-
vascular abnormalities manifesting in neonates, infants, Dr. Alan Daneman
and children. The information is presented in an organized Professor of Medical Imaging
and interesting manner. The quality of the illustrations is University of Toronto
outstanding, and they are accompanied by extremely clear Head of Body Imaging
and straightforward explanations of the findings. The text Department of Diagnostic Imaging
also describes the common cardiovascular surgical proce- Hospital for Sick Children
dures (past and present) in detail to facilitate the under- Toronto, Canada
standing of what can be expected to be found on the chest
radiograph in these conditions postoperatively.
vii
,
, Foreword
It is with great pleasure that I write this foreword to Drs. Yoo, the authors for their painstaking collection and analysis
MacDonald, and Babyn’s tour de force, Chest Radiographic on our behalf. Accrued over the course of five years, and
Interpretation in Pediatric Cardiac Patients. representing many thousands of hours of analysis, illus-
With the ever-increasing technology available to image tration, writing, and production, this book is a credit not
cardiovascular disease, it is sometimes easy to forget the only to Drs. Yoo, MacDonald, and Babyn, but also to the
value of basic clinical assessment and investigations. If combined Divisions of Cardiology and Radiology at the
ever there was an illustration that such an evolution was Hospital for Sick Children. I am proud to be associated
mistaken, it exists in this text. The extraordinary wealth with the authors and, in this small way, with the book
of diagnostic and therapeutic information that may exist itself.
within the chest radiograph shouts out from almost every
page of this extraordinary contribution. Replete with Andrew Redington, MD
up-to-the-minute examples of virtually every abnormality Head, Division of Cardiology
imaginable, I am convinced that this book will rapidly Department of Paediatrics
establish itself as a seminal work in the field. Hospital for Sick Children
On behalf of all of the potential readers of this text, University of Toronto
I would like to commend the extraordinary efforts of Toronto, Canada
ix
