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What valve has been replaced?

December 16, 2014


Here is a patient with a cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat helps with this dilemma:

If we apply the rules from to our patient, it appears he has an aortic valve:

Valve Lat EditedValve Lat

Valve AP editValve AP

AV = Aortic Valve*

TV = Tricuspid Valve*

MV = Mitral Valve*

PV = Pulmonic Valve*

*These are anticipated locations.  The locations could be altered if the patient has anatomic variations such as chamber enlargement, cardiac rotation, etc.

RadDaily also has additional information using flow directional clues from the shape of the valves.  Check it out!

Author:  Russell Jones, MD

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What valve has been replaced?

December 10, 2014


Here is a patient with a prosthetic cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

Answer to follow.

Author:  Russell Jones, MD

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How to identify a cardiac rhythm device with CXR…

September 25, 2014


How many times have you had trouble with figuring out what type of cardiac device (e.g. pacemaker/defibrillator) a patient has implanted?  A patient presented to our ED with chest pain, palpitations.  He did not have his device card with them, no prior visits to our ED, and did not know the manufacturer of the device.  How do you decide which company to call for interrogation?

Here is an article I found with radiologic characteristics of devices that can help identify which company produced the device.  It has a great identification algorithm they coined the CaRDIA-X algorithm:

There are 5 major manufacturers currently:  Medtronic, Boston Scientific, St. Jude, Biotronik, and Sorin Group.  Each device manufactured by these companies have certain differentiating characteristics of can shape, battery shape, alphanumeric codes, capacitor shadows, coil types, etc.  Turns out you can identify the manufacturer using the device characteristics on chest X-ray relatively easily.

In the case I was describing above the patient had an easily identifiable Medtronic device and we were able to get it interrogated.  Our ED now has the algorithm posted at our doctor’s station so we can utilize it for device identification.

Author:  Russell Jones, MD


Jacob S et al.  Cardiac Rhythm Device Identification Algorithm Using X-Rays: CaRDIA-X.  Heart Rhythm 2011; 8(6): 915-922.

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Heart in the Heart…Happy Valentine’s Day

February 14, 2014

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This patient had a transvenous pacemaker placed for severe bradycardia:

Heart in heart


This patient has a transvenous pacing wire which decided to loop around the right side of the heart.  It was working though!  Happy Valentine’s Day.

Image contributor:  James Chenoweth, MD

Author:  Russell Jones, MD

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What is this device?

October 26, 2013


What is this device?


This patient has two devices on Chest Xray and KUB:

1.  The large, radiodense structure just below the cardiac silhouette is a Left Ventricular Assist Device (LVAD).  Specifically it is a Heartmate II®.  LVADs are implanted in patients with severe cardiac depression for augmented left ventricular output.  Often these are implanted in patients awaiting cardiac transplant, however we are seeing more patients with implanted LVADs for “Destination Therapy.”  This is a long-term treatment for severe CHF with no intention of eventual cardiac transplantation.   The goal of these devices is to improve quality-of-life in severe CHF.  Complications most-often include thrombotic (ischemic stroke) or hemorrhagic (patients require anticoagulation with these devices which predisposes them to GI, CNS, other hemorrhagic events). 

2.  He has an Automatic Implantable Cardiverter Defibrillator (AICD) in the left upper chest.  It also functions as a pacemaker. 

A word of warning:  some of these patients will not have pulses because these devices provide a continuous left ventricular output.  A good way to obtain a blood pressure is to manually inflate the blood pressure cuff with a doppler transducer on the radial artery, as you release the blood pressure cuff you will obtain a doppler signal at some point.  This is your blood pressure (a single number).  Often they will have pulsatile flow if the intrinsic function of the heart provides enough stroke volume on top of the LVAD. 

Author:  Russell Jones, MD

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Massive cardiomegally…

September 30, 2013

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Patient with acromegally has this xray:

Massive cardiomegally 1 Massive cardiomegally 2 Massive cardiomegally 3

These images show some serious cardiomegally.  He incidentally has what appear to be retained metallic fragments that look suspicious for bullets.  Apparently his estimated cardiac “girth” is 2 liters!

Author:  Russell Jones, MD

Image Contributor:  Jay Williams, MD

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Holy Cardiomegally Batman…

November 18, 2012

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Just saw this guy, he presented with severe dyspnea:



This is severe cardiomegally!  He looked very bad, had HTN in the 220/120 range, and sounded wet even though his xray doesn’t appear particularly full of pulmonary edema.  IT IS CRUCIAL THAT YOU RULE OUT CARDIAC TAMPANODE WITH THIS XRAY!

Turns out this guy wasn’t that interesting.  Bedside ultrasound didn’t show an effusion.  He had a severely dilated cardiomyopathy and once we got his blood pressure under control with nitrates he improved dramatically. 

Author:  Russell Jones, MD

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