0:00

So I think an abnormal cardiac silhouette is super

0:03

frustrating because, um, there's lots

0:06

of different ways the cardiac silhouette can look abnormal.

0:08

And all of these patients go on to echocardiography.

0:11

So I don't like to go crazy being like, oh, it has this sort

0:15

of morphology or, you know, going crazy about, um,

0:17

calling it abnormal because they go on to echocardiography.

0:21

Um, there are a few morphologies that I, um,

0:23

do pay attention to on a newborn chest x-ray,

0:26

and the, the most common one is the wall-to-wall heart.

0:29

So that's a good, uh, kind of abnormal cardiac morphology

0:32

where it's massively enlarged.

0:34

It's good to have a differential to give your

0:37

neonatology colleagues.

0:39

So Epstein anomaly is one

0:41

of the more common pulmonary atresia

0:43

with intact ventricular septum.

0:45

You might have a huge pericardial effusion, um,

0:48

and that will be well diagnosed on echocardiography as well.

0:51

Or if you have a patient with tuberous sclerosis,

0:53

you can have a very large rhabdo myoma.

0:56

So rhabdo myomas are a cardiac tumor

0:58

that are largest when the patient is born

1:00

and that can give you that wall to wall heart morphology.

1:03

And here's just an example of a patient

1:05

with Epstein anomaly.

1:07

Here's another example of a wall to wall heart, if you will.

1:10

Um, and this was another patient with Epstein anomaly, um,

1:13

just pointing out some of the support devices

1:15

and this infant, which all look appropriate.

1:17

We have an endotracheal tube.

1:19

Um, in the, uh, upper to mid trachea,

1:22

we have an umbilical venous catheter at the, uh,

1:24

T 90 10 vertebral body level.

1:26

So actually a little bit low line. I misspoke.

1:28

And then this is an umbilical venous catheter.

1:30

So the umbilical arterial catheter takes that curve

1:33

as it's entering from the umbilicus

1:35

and joins up with the iliac arteries.

1:38

The umbilical vein will go straight into the umbilical vein

1:41

towards the ductus 1 0 7.

1:43

So this is actually a little bit high lying position

1:45

of this umbilical venous catheter tip.

1:47

We would ask 'em to retract it just a little bit

1:49

to the low right atrium level.

1:52

Um, just a quick differential for etiologies

1:55

of congestive heart failure in a newborn infant.

1:59

Um, you can see this list here.

2:01

I want to point out just two of the etiologies

2:03

that are not cardiac in nature.

2:06

So extra cardiac etiologies

2:07

of congestive heart failure in a newborn.

2:10

So you'll have a chest x-ray where it sure does look like,

2:12

um, a big heart, uh, pulmonary edema, like lots

2:16

of pulmonary vessels.

2:17

Uh, so plethora pulmonary vasculature,

2:20

and then the echocardiography of that infant will be normal.

2:24

So structurally normal heart, there are two things you need

2:26

to recommend when you see this, uh, radiographic picture

2:29

and then, um, get that history.

2:32

And the first is this structure here.

2:34

So I know we already talked earlier about head ultrasounds,

2:37

but this is one of the things you want to ask for

2:39

and rule out, um, when you have an infant

2:42

with congestive heart failure.

2:43

So this is, uh, a head ultrasound

2:46

where we are showing this very dilated, very tortuous, um,

2:51

vascular structure with lots of aliasing.

2:53

This is the vein of galin aneurysmal malformation

2:56

or, or Vega. Um,

2:58

And this is actually a little bit of a misnomer

3:01

because the vein of galin doesn't actually form.

3:04

It is an, uh, arterial venous fistula

3:06

of the median pros cephalic vein,

3:08

everybody still calls it the vein

3:10

of galin aneurysmal malformation.

3:12

And the etiology of congestive heart failure is

3:15

wholly hats vascular shunting intracranial.

3:18

So that left right shunting causes congestive heart failure

3:21

on a chest x-ray appearance.

3:23

The second clinical scenario

3:24

where you're had gonna have a chest x-ray

3:26

that looks like congestive heart failure,

3:28

but has a structurally normal heart, um,

3:31

on echocardiography is a second extra cardiac shunt,

3:36

and that is the congenital hepatic anoma.

3:38

So congenital hemangiomas involving the liver can be

3:42

ginormous and they can have tons of shunting of blood.

3:46

So it is again, a left

3:47

to right shunt causing over

3:48

circulation at the level of the heart.

3:50

Congenital hemangiomas are largest at the time of birth,

3:55

so we can see them on fetal imaging.

3:57

And this is just one of the phases

3:59

of a a biphasic CT in this infant postnatally.

4:03

And you can see how crazy vascular these are.

4:06

Um, they have lots of shunting within the liver

4:09

and so that can give you a, a chest x-ray, uh, picture

4:12

of congestive heart failure.

4:16

Moving on to a different topic altogether.

4:18

Um, and that is the esophageal atresia trachea

4:22

esophageal fistula spectrum.

4:24

So, um, with trache, esophageal fistulas

4:27

or esophageal atresia, the classic radiographic appearance,

4:30

it's gonna be that they can't pass a ogle tube, um,

4:34

pass the upper, uh, thoracic esophagus.

4:37

And so on an x-ray you're gonna see a ogle tube stuck

4:41

above the level of the thoracic inlet.

4:43

And in this example, we can see gaseous distension

4:45

of this upper esophagus.

4:47

And so this is esophageal atresia.

4:49

There are types of esophageal atresia with

4:52

and without trache esophageal fistulas that I,

4:54

I will let you Google, but uh, it's important

4:57

to tell your clinical team is there a fistula

5:00

or is there not a fistula?

5:01

So I don't go through type one, type two,

5:03

type two, type type five.

5:04

I just say this is esophageal atresia.

5:07

And then if you don't have anything in your stomach,

5:09

if you don't have distal bowel gas, there is no fistula

5:13

because there was no way for bowel gas

5:15

to bypass the atretic upper esophagus

5:17

to get into the stomach and into bowel.

5:20

The good news is most of the patients

5:21

who have esophageal atresia with

5:23

or without a fistula, they have an idea

5:26

that it exists on prenatal imaging

5:28

because they, if there's no fistula,

5:30

they don't see a stomach full of fluid, um,

5:32

on fetal ultrasound

5:34

or if it's a patient with a fistula,

5:37

they will see a distended upper esophagus.

5:40

Typically, if not, it will be an infant who presents

5:43

with respiratory distress

5:44

and they have failure to pass a repo type enteric two

5:48

or any type of an enteric tube pass the

5:50

upper, um, esophagus.

5:52

When you see a patient

5:53

that you're concerned about esophageal

5:55

atresia, either with or

5:56

Without a fistula, I want you to stop

5:58

and ask yourself where is the vertebral body anomaly?

6:02

And so this one is subtle in this infant.

6:04

All of these vertebral bodies look okay until we get

6:07

to the inferior sacrum.

6:08

So this is a vertebral anomaly associated with a es,

6:13

an esophageal atresia.

6:14

So now we're dealing with the ral spectrum.

6:17

So this infant will undergo, uh, screening echocardiography,

6:21

plus this patient will get a spine ultrasound

6:23

to rule out spine malformations.

6:25

And then last but not least,

6:26

they will also get a renal ultrasound

6:28

to rule out renal anomalies.

6:31

So that is the ral spectrum.

6:33

Um, all diagnosed on one little

6:35

chest and abdomen radiograph.

6:37

Okay, how about this other type of fistula?

6:39

Um, so this is a grainy example.

6:42

I'm sorry, but you can tell this is a ogle type enteric

6:45

tube, not an endotracheal tube

6:46

because it has these radiolucent bands in the catheter.

6:50

So this is an enteric tube, not an endotracheal tube.

6:53

This one will say there is a fistula

6:55

because there is gas that has been able to pass through

6:58

that, uh, esophageal atresia

7:01

through the tracheal esophageal fistula.

7:03

So gas is now in the stomach.

7:05

Yes, this is a very distended stomach for whatever reason,

7:07

sometimes these patients, uh, preoperatively, we'll go

7:11

to esophagus to try to delineate that fistula.

7:15

More often than that than not, they go straight to the

7:17

or in our experience,

7:18

but we see them postoperatively looking

7:20

for either a recurrent fistula

7:22

or a postoperative leak as in this example.

7:25

So you can see this, um, abnormal communication between, uh,

7:29

this is our enteric tube that we have dropped to the level

7:32

of the aortic arch approximately.

7:34

We, um, pretty forcefully inject contrast to try

7:37

to get contrast to pacify this fistula communication

7:40

between the airway and the esophagus.

7:42

So this is a trache esophageal fistula that, um,

7:45

persisted postoperatively.