A 48-year-old man is admitted with shoness of breath and signs of left ventricular failure. CXR is shown.The diagnosis based on the CXR is associated with
The cardiac silhouette is large, with prominent pulmonary vasculature and increased vascular markings in the lower and lateral poions of the hemithorax. Transverse lines can be seen in the lateral one-third of the lower right lung zone. These are Kerley B lines and are indicative of interstitial pulmonary edema. There is straightening of the left hea border from the aoic shadow, called mitralization of the hea. The carinal angle appears to be about 90deg which is wider than normal, also suggesting an enlarged subcarinal left atrial appendage. This chest x-ray is consistent with pulmonary edema and left atrial and left ventricular enlargement. The CXR shows acute pulmonary edema with cardiomegaly. Bilateral airspace densities are noted. Pulmonary edema is the result of increased pulmonary venous pressures, i.e., hydrostatic edema, which can be due to volume overload or congestive hea failure. This is usually associated with cardiomegaly, although the hea size may be normal in acute myocardial infarction or acute valvular dysfunction. Impaired pulmonary venous return due to left ventricular failure or mitral valve disease leads to increased pulmonary blood volume. Signs of cephalization of blood flow suggest enlargement of upper lobe pulmonary vessels. Mitral stenosis is one of the cardiac causes for elevated pulmonary venous pressure, although it has become relatively uncommon. The wellknown radiographic signs of pulmonary edema are cardiomegaly, pleural effusions, and vascular congestion. Interstitial edema can be seen with blurring of the margins of blood vessels around the bronchial wall--called peribronchial cuffing--and in the subpleural position--called Kerley B lines. As capillary pressure rises, accumulated fluid in the interstitium adds to the interstitial pressure, forcing fluid into the alveolar space. Differentiation between pulmonary edema due to increased circular blood volume and that due to a failing left ventricle can be made on the basis of measurement of the vascular pedicle if the technique is not flawed. The radiographic differentiation of hydrostatic pulmonary edema from increased capillary permeability is also difficult. The criteria used are cardiac size, vascular distribution, and measurement of the vascular pedicle; this test has a predictive value of 75%. Some authors believe that the best sign of hydrostatic pulmonary edema is an abnormal right costophrenic angle containing Kerley B lines, subpleural edema, and pleural effusion. Those patients who have increased capillary permeability frequently have normal right costophrenic angles. The other most useful sign is the presence of an air bronchogram in increased capillary permeability edema and its absence in hydrostatic edema. The diagnosis of mitral stenosis is associated with a diastolic rumble on physical exam. The first hea sound is loud and there is no clubbing or koilonychia. Mitral stenosis may be complicated by atrial arrhythmias, hemoptysis secondary to left ventricular failure, or endocarditis. Atrial myxoma is not a complication but may mimic signs and symptoms of mitral stenosis. The radiographic sign suggestive of an atrial enlargement is a widened carinal angle.
A diastolic rumble
Soft first hea sound
Clubbing
Koilonychia
Cardiovascular system