Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ THE CHEST X-RAY IN THE ECHO LAB ++ A phone call may come to the lab asking for an echo because of a finding on a chest x-ray. The following is a very simple but practical guide. Lungs: The vascular markings of the lungs may become more prominent. Echo looks for cardiac shunts or causes of left heart failure. Cardiac size: The cardiac silhouette may change in size and contour. Echo looks for cardiac chamber size, wall thickness, and function. An echocardiographer should be familiar with the rules for normal lung markings on the chest x-ray: The pulmonary vessels branch out in symmetric fashion. They are sharply defined. As they branch out to the periphery, each successive set of branches is slightly smaller—just like in a tree. Normal pulmonary vessels are larger in the lower lobes than in the upper lobes. Pericardial calcifications can be found on the chest x-ray of patients with pericardial constriction. The calcifications may be easier to spot in the lateral films. The calcifications may appear as a hoop, as a band, or as a sheet of calcium. Cardiac fluoroscopy can be used to study the function of mechanical prosthetic valves. +++ X-RAY SIGNS AND EPONYMS ++ Vertical heart borders, clear lungs, prominent left pulmonary artery: pulmonic valve stenosis (easily confirmed on echo). Pulmonary vessel pruning in pulmonary hypertension. There is a sharp decrease in the size of the vascular shadows in the outer regions of the lung fields. Rib notching: coarctation of the aorta. Waterfall hilum: dilated pulmonary trunk with elevation of the right pulmonary artery due to increased pulmonary flow in a congenital shunt (transposition, tricuspid atresia, truncus arteriosus). Shmoo-shaped cardiac silhouette: Left ventricular hypertrophy or enlargement (easy to confirm with echo). The Shmoo was a comic strip creature drawn by cartoonist Al Capp. Boot-shaped heart: tetralogy of Fallot—the dilated right ventricle curves around the small left ventricle. The apex of the heart is pushed out and elevated. The cardiac shadow resembles a boot. +++ Source ++ Aziz F, Abed M. Coeur en sabot. Cardiovasc J Afr. 2010;21:229–231. ++ Right aortic arch: tetralogy of Fallot, or a vascular ring. +++ Source ++ Etesami M, Ashwath R, Kanne J, et al. Computed tomography in the evaluation of vascular rings and slings. Insights Imaging. 2014;5:507–521. ++ Butterfly or bat wing density of the lung fields: pulmonary edema. +++ Source ++ Herrnheiser G, Hinson KF. An anatomical explanation of the formation of butterfly shadows. Thorax. 1954;9:198–210. ++ Egg-on-a-string heart: In some patients with transposition of the great vessels, the cardiac shadow resembles an egg that is tilted so that its long axis lies in an oblique position. +++ Source ++ Carey LS, Elliott LP. Complete transposition of the great vessels. Roentgenographic ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth