X-Ray Chest PA View in Severe PAH

Transcript of the video: Here is an X-ray chest PA view. The striking finding is the huge enlargement of the right pulmonary artery, almost aneurysmal dilatation of right pulmonary artery. Main pulmonary artery is also grossly dilated. And you can see left pulmonary artery shadow and rest of it is not seen here. It will be behind the main pulmonary artery shadow, because left pulmonary artery descends behind the main pulmonary artery and it will be a retrocardiac shadow. It is not visible here. This is the aortic knuckle. And you are seeing some end on views probably. This could be an end on view. This also could be, but you cannot be very sure about it because this is the region of the overlap between these two ribs. So you will not be very sure whether this an end on view and there is peripheral pruning or centralized pulmonary flow. The flow is mainly in the central region. Periphery it is dark. Peripheral pruning can be seen. So massive enlargement of pulmonary arteries. Cardiomegaly is not very striking. But if you trace the right border of the spine, right atrial shadow is extending beyond that. So it is possible that there is right atrial enlargement in this case. It can occur in severe pulmonary hypertension, there can be right atrial enlargement, as the severe hypertrophy of the right ventricle causes elevation of right ventricular end diastolic pressure, and later on right atrial enlargement. The possibillities here would be severe primary pulmonary hypertension versus atrial septal defect with severe pulmonary hypertension. As these are not definite end on views, this could be an end on view, of a pulmonary artery, branch pulmonary artery. If end on views, multiple end on views are seen, then it is strongly in favour of atrial septal defect with large shunt later going on for pulmonary hypertension. In VSD Eisenmenger and PDA Eisenmenger, you would not expect right atrial enlargement. In VSD and PDA Eisenmenger, the heart size decreases when pulmonary hypertension develops, due to decrease in the shunt. In ASD, shunt is decreasing in Eisenmenger but right atrial enlargement is a component for cardiomegaly. But, overall it doesn’t look like a great cardiomegaly. In PDA Eisenmenger, there will be more prominence of aortic knuckle shadow is expected in PDA Eisenmenger and another finding which you would expect in long standing PDA Eisenmenger would be calcification of the ductus, as an inverted Y shadow in this region. The ductus would be here, but that is also not seen here. Only definite finding here is gross severe pulmonary hypertension and some right atrial enlargement, the cause of course would have to be investigated by echocardiography, though there is some suggestion of ASD with pulmonary hypertension.