Echocardiography and More Recently With CT and MRI. However, The Chest Film

Introduction
Cardiac chamber enlargement is best assessed volumetrically with

echocardiography and more recently with CT and MRI. However, The chest film
is very frequently obtained when heart disease is suspected, and formed the
mainstay of chest imaging for decades that a great deal has been written about the
characteristic appearances of chamber enlargement. (1,2)
The treating physician in less equipped setup can get loads of information by
carefully looking at the black and white image of chest x-rays, This cheap imaging
tool may show double density sign, enlarged carinal angle and the lateral view may
depict a walking man The Chest X Ray can thus act as preliminary tool to give the
clue for left atrium enlargement. (3) And a clinically silent heart disease may also
be detected on a chest film taken for other reasons. (2)
Left atrial enlargement (LAE) is not a disease itself but rather a manifestation of

many conditions, they can be congenital causes (e.g. ventricular septal defect
(VSD), patent ductus arteriosus (PDA) or acquired (e.g. mitral stenosis, mitral
regurgitation, left ventricular failure, left atrial myxoma). These conditions
increase atrial wall tension due to increased filling pressures, causing atrial
enlargement. (1)
Enlargement of left atrium acts as a predictor of cardiovascular outcomes such as

atrial fibrillation, stroke, and congestive heart failure, and mortality after
myocardial infarction. (1,3) With a reduced incidence of mitral valve disease from
rheumatic fever, the incidence of left atrial enlargement has also decreased. (1)
An enlarged left atrium can have many clinical implications such as:
Ortner syndrome (left recurrent laryngeal nerve palsy due to compression by
enlarged left atrium), dysphagia megalatriensis (compression of oesophagus
between the enlarged left atrium and vertebral bodies), atrial fibrillation via a
multiple wavelet mechanism, thromboembolic events (e.g. ischaemic stroke) due
to stasis of blood in the enlarged left atrium -especially the appendage- or atrial
fibrillation (1)
Left Atrial Enlargement
-The left atrium is a smooth-walled chamber which gives rise to a narrow-based

and anteriorly pointing finger-like left atrial appendage that contains trabeculation.
It lies slightly higher than the right atrium and this can be clearly demonstrated in
transverse sectional imaging techniques.
-The pulmonary veins drain into the posterior part of the left atrium, usually in four
separate openings from the left and right upper and lower pulmonary veins.
-The left atrium usually (4)
-To detect cardiac abnormalities on a chest film, it’s crucial to have a detailed
understanding of the structures that make up the normal contours of the heart and
mediastinum (card iomediastinal contour).
-(1) On a PA film, a normal sized left atrium should not be visible except for its
auricle (appendge) on the left cardiac contour. While on the lateral film, the left
atrium makes most of the posterior cardiac contour. (1)
(
1)
As the left atrium enlarges, it may become directly visible, or displace adjacent
structures.(1) Direct visualization of the enlarged atrium includes:
Double density sign (double atrial shadow (double atrial contour, shadow in
shadow, double density) (5):
one of the earliest signs of slight enlargement is the appearance of the double
density sign (2) On frontal chest radiographs, this sign presents as a curvilinear
soft-tissue density projecting over the right retrocardiac region (6)
inferolateral margin of the left atrium pushes into the adjacent lung, and becomes
visible along with the right atrium opacity (1,6)
an exaggerated version of the double density sign occurs when there is massive left

atrial enlargement, the curvilinear density may even project beyond the right
atrium border, this is called the atrial escape (1,6) which may suggest an aneurysm.
(5) Another reported cause of giant left atrium is long standing rheumatic mitral
valve disease (2)
Giant left atrium. Rheumatic mitral valve disease (2)
Once Double density sign is visualized, one should also look for other signs of left
atrial enlargement like carinal widening, elevation of the left main bronchus, and
enlargement of the left atrial appendage (6)
The double density sign may be observed in patients without cardiac disease (7) a
similar appearance to the double density sign can be caused by the right superior
pulmonary vein in patients without atrial enlargement (1) for these reasons, there
is a semiquantitative measurement to estimate the left atrial diameter and better
estimate whether it is a real finding or not.(1,7)
2- oblique measurement of greater than 7 cm

When there is a double density sign on PA radiographs, measurement of the left
atrial dimension (defined as the distance from the midpoint of the right border of
left atrium to the midpoint of the left mainstem bronchus) greater than 7 cm was
consistent with a diagnosis of left atrial enlargement, confirmed on
echocardiography. (1,7)
This oblique measurement is thought to be the most reliable sign on chest
radiography in adult patients (1) However, this measurement was found to be an
unreliable sign in the evaluation of pediatric patients with a double density sign on
PA radiographs. (7)
(1)
3-Third Mogul Sign (convex left atrial appendage)

The term “Moguls” refers to projections of snow seen on a ski slope. First mogul
on chest X-ray is the aortic knuckle, second mogul the main pulmonary artery,
third mogul the left atrial appendage and fourth mogul the left ventricular apex.(8)
normally on PA chest X-ray, the left heart border just below the pulmonary
outflow track should be flat or slightly concave (9), third mogul sign refers to a
prominent left atrial appendage appearing as an extra mogul or bump along the
upper left cardiac silhouette just below the left main bronchus. (9)
(9) third mogul sign in a case of LAE

The third mogul sign can be seen on frontal chest radiograph in the presence of left
atrial enlargement (9) or a similar shadow due to other causes, Masses in the same
location can also cause a third mogul. (8) it commonly represents the enlarged left
atrial appendage, particularly in patients with rheumatic heart disease Other causes
that may also appear as a third mogul on the cardiomediastinal contour include:
cardiac aneurysm, pericardial cyst, coronary artery aneurysm, mediastinal tumour,
pericardial defect, sinus of Valsalva aneurysm, dilated right ventricular outflow
tract (9) and due to post mitral valve replacement (8)
left ventricular pseudoaneurysms have also been described to give a third mogul
appearance. Detection of third mogul sign in such cases is of great significance as
left ventricular pseudoaneurysms are more prone for rupture than true aneurysms,
with potential catastrophic results. (8)
Indirect signs include:
1-splaying of the carina, with the increase of the tracheal bifurcation angle to over
90 degrees
The carina is the sagittally-orientated cartilaginous ridge that represents the inferior

bifurcation of the trachea into the right and left main bronchi. and is an important
reference point in chest imaging (10) the carina usually sits at the level of the
sternal angle and the T4/T5 vertebral level in the thoracic plane. (10)
the tracheal bifurcation angle refers to both the interbronchial angle (the angle

formed by the central axis of the left and right main bronchi) and the subcarinal
angle (the angle of divergence between the right and left main stem bronchi
measured along their inferior borders ) and it may be measured as either. (11)
The tracheal bifurcation angle is regarded as inaccurate and of poor diagnostic

value due to its lack of sensitivity and specificity in identifying the underlying
pathology. it is dependent on radiographer technique, inspiration and body habitus
and can have a wide range of normal values in patients and vary significantly in
serial radiograph, and therefore must be interpreted only in correlation with the
clinical presentation. (11)
interbronchial angle: normal mean 67-77° (range 34-109°)
subcarinal angle: normal mean 62-73° (range 34-90°)
The angle of tracheal bifurcation value is not related to age and gender, however,
there is a weak correlation with the shape of the chest (11)
The angle of tracheal bifurcation may be widened in the following conditions due
to the mechanical splaying of the bronchi: subcarinal masses, lobar collapse, left
atrial enlargement, generalized cardiomegaly, pericardial effusion. (11)
(11)
2-Walking man sign

The normal trachea, right and left upper lobe bronchi, and lower lobe bronchi are
vertically aligned on a normal lateral chest radiograph (12) The walking man
sign is seen on a lateral chest radiograph. when there is posterior displacement of
the left main bronchus such that it no longer overlaps the right bronchus. The left
and right bronchus thus appear as an inverted 'V', mimicking the legs of a walking
man. (1,3,12) Posterior displacement of the left bronchi is typically the result of
mass effect on the bronchi by a markedly enlarged left atrium but is not
pathognomic of an enlarged atrium. (1,12) It may also occur in the setting of
subcarinal lymphadenopathy, mediastinal masses, left lower lobe volume loss,
large hiatal hernias, and thoracolumbar scoliosis. (12)
(1)
3- superior displacement of the left mainstem bronchus on frontal view(1)
4- posterior displacement of a barium-filled oesophagus or nasogastric tube(1)

References:
1- Lukies, M. and Gaillard, F. et al. Left Atrial Enlargement. [online]

radiopedia.org. Available at: <https://radiopaedia.org/articles/left-atrial-
enlargement> [Accessed 28 June 2020].
2- Miller, S., 2015. The Elements Of Cardiac Imaging. [online] Radiology Key.
Available at: <https://radiologykey.com/the-elements-of-cardiac-imaging/>
[Accessed 28 June 2020].
3- Bhat, R., Kodan, P. and Shetty, M., 2015. Walking Man with A Large
Heart. nternational Journal of Anatomy, Radiology and Surgery, 4(2),
pp.16-17
4- Sutton, D., 2005. A Textbook Of Radiology And Imaging. Edinburgh: Churchill

Livingstone, p.266.
5- Francis, P., 2018. Double Atrial Shadow And Prominent Upper Lobe Vessels.
[online] All About Cardiovascular System and Disorders. Available at:
<https://johnsonfrancis.org/professional/double-atrial-shadow/> [Accessed 28 June
2020].
6- Kumaresh, Athiyappan et al. “Back to Basics - 'Must Know' Classical Signs in

Thoracic Radiology.” Journal of clinical imaging science vol. 5 43. 31 Jul. 2015
7- Marshall, G., Farnquist, B., MacGregor, J. and Burrowes, P., mar 2006. Signs in
Thoracic Imaging. Journal of Thoracic Imaging, 21(1), pp.76-90.
8- Francis, P., 2018. Third Mogul Sign: Prominent Left Atrial Appendage On Left
Cardiac Border. [online] All About Cardiovascular System and Disorders.
Available at: <https://johnsonfrancis.org/professional/third-mogul-sign/>
9- Tatco, V., Third Mogul Sign | Radiology Reference Article |
Radiopaedia.Org. [online] Radiopaedia.org. Available at:
<https://radiopaedia.org/articles/third-mogul-sign?lang=gb> [Accessed 28
June 2020].
10- Smith, D., 2020. Carina | Radiology Reference Article |

Radiopaedia.Org. [online] Radiopaedia.org. Available at:
<https://radiopaedia.org/articles/carina?lang=gb> [Accessed 28 June 2020].
11- Anderson, J., 2020. Tracheal Bifurcation Angle | Radiology Reference

Article | Radiopaedia.Org. [online] Radiopaedia.org. Available at:
<https://radiopaedia.org/articles/tracheal-bifurcation-angle?lang=gb>
12-Parker, M., Chasen, M. and Paul, N., 2009. Radiologic Signs in Thoracic
Imaging:Case-Based Review and Self-Assessment Module. American
Journal of Roentgenology, 192(3_supplement), pp.S34-S48

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Echocardiography and More Recently With CT and MRI. However, The Chest Film

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Introduction

Cardiac chamber enlargement is best assessed volumetrically with

Left atrial enlargement (LAE) is not a disease itself but rather a manifestation of

Enlargement of left atrium acts as a predictor of cardiovascular outcomes such as

-The left atrium is a smooth-walled chamber which gives rise to a narrow-based

-The left atrium usually (4)

an exaggerated version of the double density sign occurs when there is massive left

2- oblique measurement of greater than 7 cm

3-Third Mogul Sign (convex left atrial appendage)

(9) third mogul sign in a case of LAE

Indirect signs include:

The carina is the sagittally-orientated cartilaginous ridge that represents the inferior

the tracheal bifurcation angle refers to both the interbronchial angle (the angle

The tracheal bifurcation angle is regarded as inaccurate and of poor diagnostic

2-Walking man sign

3- superior displacement of the left mainstem bronchus on frontal view(1)

4- posterior displacement of a barium-filled oesophagus or nasogastric tube(1)

1- Lukies, M. and Gaillard, F. et al. Left Atrial Enlargement. [online]

4- Sutton, D., 2005. A Textbook Of Radiology And Imaging. Edinburgh: Churchill

6- Kumaresh, Athiyappan et al. “Back to Basics - 'Must Know' Classical Signs in

10- Smith, D., 2020. Carina | Radiology Reference Article |

11- Anderson, J., 2020. Tracheal Bifurcation Angle | Radiology Reference

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