RADIOLOGY

HEARD FAILURE PULMONARY EDEMA

Year 5 Group 5, 2011/2012

CONGESTIVE HEART FAILURE

Introduction
Congestive heart failure (CHF) is the result of insufficient output because of cardiac failure, high resistance in the circulation or fluid overload. Causes of CHF
Coronary artery disease Hypertension Cardiomyopathy Cardiac valvular lesions Arrhythmias Hyperthyroidism Severe anemia Left to right shunts

CONGESTIVE HEART FAILURE

Introduction
Left ventricle (LV) failure Most common and results in decreased cardiac output and increased pulmonary venous pressure. In the lungs, LV failure will lead to dilatation of pulmonary vessels, leakage of fluid into the interstitium and the pleural space and finally into the alveoli resulting in pulmonary edema. Right ventricle (RV) failure Usually the result of long standing LV failure or pulmonary disease and causes increased systemic venous pressure resulting in edema in dependent tissues and abdominal viscera.

CONGESTIVE HEART FAILURE

Clinical Features
1.

2.

Left Heart Failure Shortness of breath Paroxysmal nocturnal dypsnea Orthopnea Cough Right Heart Failure Edema

CONGESTIVE HEART FAILURE

Illustration of features in CHF

CONGESTIVE HEART FAILURE

Pathophysiology of CHF
Left Ventricular Failure

CO decreases and pulmonary venous pressure increases

Pulmonary capillary pressure exceeds the oncotic pressure of plasma proteins Fluid accumulates in and around the capillaries in the interlobular septa Further accumulation occurs in interstitial tissues of the lungs Finally with increasing fluids alveolar fill with edema fluid

CONGESTIVE HEART FAILURE

Stage I : Redistribution
1. Redistribution of pulmonary blood flow 2. Increase in width of the vascular pedicle 3. Increased artery-to-bronchus ratio in the upper and middle lobes 4. Cardiomegaly 5. Dilatation of azygos vein

Stage I Redistribution
Redistribution of pulmonary blood flow

Views of the upper lobe vessels of a patient in good condition (left) and during a period of CHF (right). Notice also the increased width of the vascular pedicle (red arrows).

 Bordered on the right by the superior vena cava and on the left by the left subclavian artery origin Indicator of the intravascular volume

Stage I Redistribution
Increased artery-to-bronchus ratio in the upper and middle lobes (normal 0.85)

On the left a patient with cardiomegaly and redistribution. The upper lobe vessels have a diameter > 3 mm (normal 1-2 mm). Notice the increased artery-to-bronchus ratio at hilar level (arrows).

Stage I Redistribution
Cardiomegaly (Cardiothoracic ratio, CTR) Ratio of the transverse diameter of the heart to the internal diameter of the chest at its widest point just above the dome of the diaphragm Cardiomegaly CTR is > 50%

a c

Stage I Redistribution
Dilatation of azygos vein (Sign of increased right atrial pressure )

Standing position - > 7 mm is most likely abnormal & a diameter > 10 mm is definitely abnormal. Supine patient > 15 mm is abnormal

Stage II: Pulmonary interstitial edema

4 key radiographic signs

a) Thickening of the interlobular septa (Kerley-B, Kerley-A) b) Peribronchial cuffing c) Fluid in the fissures d) Pleural effusions

a) Thickening of the interlobular septa: The Kerley B line

B = distended interlobular septa Location and appearance Bases 1-2 cm long Horizontal in direction Perpendicular to pleural surface

Kerley A line
A = connective tissue near bronchoarterial bundle distends Location and appearance Near hilum Run obliquely Longer than B lines

Kerley B lines (red arrows) Kerley A lines (yellow arrows)

Kerley B lines (red arrows) Kerley A lines (yellow arrows)

Kerley C = reticular network of lines

b) Peribronchial cuffing
Interstitial fluid accumulates around bronchi Causes thickening of bronchial wall When seen on end, looks like little doughnuts

Peribronchial cuffing appears as numerous, small, ringlike shadows that look like little doughnut

c) Fluid in the fissures

Fluid may collects in the subpleural space which is between visceral pleura and lung parenchyma Normal fissure is thickness of a sharpened pencil line Fluid may collect in any fissure including major(horizontal), minor(oblique), accessory fissures, azygous fissure

d) Pleural effusion
As a result of either increased production or decreased absorption of pleural fluid, fluid in excess of 2-5 ml can collect in the pleural space, typically at a pulmonary capillary wedge pressure of 20 mmHg. Features of pleural effusion:
Subpulmonic effusion Blunting of costophrenic angles Meniscal sign Opacified hemithorax

Subpulmonic effusion Fluid is first collected in area beneath the lung btw the parietal pleura lining the sup. surface of diaphragm and the visceral pleura under the lower lobe

Stage III: Pulmonary alveolar edema

When pulmonary venous pressure is sufficiently elevated (about 25 mmHg), fluid spills out of the interstitial tissues of the lung into the airspaces. This results in pulmonary edema

 Fluffy, indistinct, patchy airspace densities that are usually centrally located. Outer third of the lung is usually spared, and the LZ > UZ, giving rise to bat-wing, angel wing or butterfly configuration of pulmonary edema Presence of pleural effusion (cardiogenic)

PULMONARY EDEMA Classification

Pulmonary edema

Cardiogenic

Noncardiogenic

Pulmonary interstitial edema

Pulmonary alveolar edema

- ARDS - V. Overload - Malignancy

NON-CARDIOGENIC PULMONARY EDEMA

1. Increase capillary permeability Acute Respiratory Distress Syndrome (ARDS) Sepsis Uremia DIC Smoke inhalation Near drowning 2. Volume overload 3. Lymphangitic spread of malignancy 4. Others High-altitude pulmonary edema Neurogenic pulmonary edema Reexpansion pulmonary edema Heroin or other overdose

NON-CARDIOGENIC PULMONARY EDEMA

The vascular pedicle width (VPW) can help in differentiating these different forms of pulmonary edema (6): Normal VPW: most common in capillary permeability or acute cardiac failure. Widened VPW: most common in overhydration/renal failure and chronic cardiac failure. Narrowed VPW: most common in capillary permeability. Other features less demonstrate pleural effusion and Kerley B line normal heart size more patchy and peripheral

NON-CARDIOGENIC PULMONARY EDEMA

On the left a patient with ARDS. There is alveolar edema in both lungs. Notice that the VPW is normal. The vessels in the upper lobes are not dilated and no cardiomegaly.

Chest radiograph shows bilateral perihilar airspace shadowing with normal heart size and no pleural effusion.

Differentitating cardiac from noncardiac pulmonary edema

Imaging finding Pleural effusions Kerley B lines Heart size
PCWP

Cardiogenic Common
Common Frequently enlarged Elevated

Noncardiogenic Infrequent
Infrequent May be normal Normal