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8/3/2019 CCF Radiology
http://slidepdf.com/reader/full/ccf-radiology 1/33
Congestive HeartFailure
Congestive Heart
Failure
William Herring, M.D. © 2002
In Slide Show mode, to advance slides, press spacebaror click left mouse button
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Congestive Heart FailureCauses of
Coronary artery disease
Hypertension
Cardiomyopathy
Valvular lesions
AS, MS
L to R shunts
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Congestive Heart FailureClinical
Usually from left heart failure
Shortness of breath
Paroxysmal nocturnal dyspnea Orthopnea
Cough
Right heart failure
Edema
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Left Atrial PressuresCorrelated With Pathologic Findings
Normal 5-10 mm Hg
Cephalization 10-15 mm
Kerley B Lines 15-20
Pulmonary Interstitial Edema 20-25
Pulmonary Alveolar Edema > 25
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Pulmonary CirculationPhysiology
Very low pressure circuit
Pulmonary capillary bed only has 70cc
blood
Yet, it could occupy the space of a
tennis court if unfolded Therefore, millions of capillaries are
“resting,” waiting to be recruited
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Keeping the Lungs Dry
Pulmonary capillaryhydrostatic pressure islow — about 7 mm Hg
Plasma colloid oncoticpressure is high —about 28 mm Hg
Normalosmotictendency to
dehydrate theinterstitiumand alveoli
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Pressure and Flow
Pressure = Flow x ResistanceNormally, resistance is so low that flow
can be increased up to 3x normal withoutincrease in pressure
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Pulmonary Interstitial EdemaX-ray Findings
Thickening of the interlobular septa
Kerley B lines
Peribronchial cuffing Wall is normally hairline thin
Thickening of the fissures
Fluid in the subpleural space in continuity with
interlobular septa
Pleural effusions
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Pulmonary Interstitial Edema
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Kerley B Lines
B=distended interlobular septa
Location and appearance
Bases
1-2 cm long
Horizontal in direction Perpendicular to pleural surface
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Kerley B Lines are short, white lines perpendicularto the pleural surface at the lung base.
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Kerley A and C Lines
A=connective tissue near bronchoarterial
bundle distends
Location and appearance Near hilum
Run obliquely
Longer than B lines
C=reticular network of lines
C Lines probably don’t exist
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Kerley A and C Lines form a patternof interlacing lines in the lung
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Peribronchial Cuffing
Interstitial fluid accumulates around
bronchi
Causes thickening of bronchial wall
When seen on end, looks like little
“doughnuts”
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Peribronchial cuffing results when fluid-thickenedbronchial walls become visible producing”doughnut-like” densities in the lung parenchyma
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Fluid in The Fissures
Fluid collects in the subpleural space
Between visceral pleura and lungparenchyma
Normal fissure is thickness of asharpened pencil line
Fluid may collect in any fissure Major, minor, accessory fissures, azygous
fissure
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Fluid in the major or minor fissure (shown here)produces thickening of the fissure beyond the pencil-point thickness it can normally attain
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Pleural Effusion
Laminar effusions collect beneath
visceral pleura In loose connective tissue between
lung and pleura Same location for “pseudotumors”
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Inner margin of the
rib starts here
Aerated lung stops
here
Laminar pleural effusions can be difficult to see. Aerated lungshould normally extend to the inner margin of the ribs. The white
band of fluid seen here (white arrow) is a laminar effusion,separating aerated lung from the inner rib margin.
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CephalizationA Proposed Mechanism
If hydrostatic pressure >10 mm Hg, fluidleaks in to interstitium of lung
Compresses lower lobe vessels first Perhaps because of gravity
Resting upper lobe vessels “recruited”
to carry more blood Upper lobes vessels increase in size
relative to lower lobe
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Cephalization means pulmonary venous hypertension,so long as the person is erect when the chest x-ray is obtained.
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Left Atrial PressuresCorrelated With Pathologic Findings
Normal 5-10 mm Hg
Cephalization 10-15 mm
Kerley B Lines 15-20
Pulmonary Interstitial Edema 20-25
Pulmonary Alveolar Edema > 25
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Pulmonary EdemaTypes
Cardiogenic
Neurogenic
Increased capillary permeability
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Congestive Heart FailureX-ray patterns
Interstitial Alveolar
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Congestive Heart FailurePulmonary interstitial edema
Thickening of the interlobular septa
Kerley B lines
Peribronchial cuffing Wall is normally hairline thin
Thickening of the fissures
Fluid in the subpleural space incontinuity with interlobular septa
Pleural effusions
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Congestive Heart FailurePulmonary alveolar edema
Acinar shadow
Outer third of lung frequently spared Bat-wing or butterfly configuration
Lower lung zones more affected than
upper
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Pulmonary Alveolar EdemaPulmonary Interstitial Edema
In pulmonary alveolar edema, fluid presumably spills over from theinterstitium to the air spaces of the lung producing a fluffy, confluent
“bat-wing” like pattern of disease.
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Pulmonary Alveolar EdemaClearing
Generally clears in 3 days or less Resolution usually begins peripherally
and moves centrally
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Differential DiagnosisKerley B lines and Peribronchial cuffing
Cardiac 30%
Renal 30%
ARDS None
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Differential DiagnosisDistribution of Pulmonary Edema
Cardiac Even 90%
Renal Central 70%
ARDS Peripheral in 45%
Even in 35%
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Differential DiagnosisAir Bronchograms
Cardiac 20%
Renal 20%
ARDS 70%
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Differential DiagnosisPleural Effusions
Cardiac 40%
Renal 30%
ARDS 10%
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Left Atrial PressuresCorrelated With Pathologic Findings
Normal 5-10 mm Hg
Cephalization 10-15 mm
Kerley B Lines 15-20
Pulmonary Interstitial Edema 20-25
Pulmonary Alveolar Edema > 25