Congestive Heart Failure

Describe the characteristic pathologic features of heart and lungs found in congestive heart failure. 

• The heart is enlarged.
• Changes in cardiac chambers and myocardium depend on the etiology of heart failure.
• Irregular fibrosis replaces the myocardium.  
• The lung shows severe, chronic passive congestion.  
• Vessels, including the alveolar capillaries, are congested as a result of pulmonary venous hypertension.
• Alveoli contain numerous hemosiderin laden macrophages.

	This photograph depicts a large, globular heart of dilated cardiomyopathy.
	The frothy liquid oozing from the cut surface of the lung is caused by air moving through water in the respiratory tree.

What are the anticipated findings in chest x-ray in a patient with congestive heart failure:

• Cardiomegaly: 
  • Cardiac width is larger than half trans-thoracic diameter. 
  • You can encounter normal size heart in acute myocardial infarction or in volume overload.
• Vascular phase
  • Cephalization: Vessels in upper chest is more prominent as a manifestation of pulmonary venous hypertension.
  • Hilar fullness with haziness: Enlarge pulmonary veins with perivascular fluid collection leads to full hazy hilum.
• Interstitial phase
  • Kerley lines: 2-3 cm long lines in bases perpendicular to pleural surface. Due to increased lymphatic flow and fluid in interstitium.
• Alveolar phase
  • Basal congestion
  • Pulmonary edema: Bilateral diffuse alveolar findings with butterfly distribution, air bronchograms and soft coalescing densities.
• Pleural effusions
• Rapid changes in CXR.

How do you measure heart size? When do you consider the heart as enlarged?

	What are the findings of heart failure seen in this chest x-ray?
	Note normal sized heart. Heart failure is due to acute myocardial infarction.