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An approach to cardiac xray Dr. Muhammad Bin Zulfiqar

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This presentation is almost a complete Pictoral view of Radiograph chest.
This presentation will help radiologist in daily reporting.
This presentation will help physicians, surgeons, anesthetist and almost all medical professionals in diagnosing commonly presenting cardiac diseases.
This will also help all in preparaing TOACS examination.

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An approach to cardiac xray Dr. Muhammad Bin Zulfiqar

  1. 1. AN APPROACH TO CARDIAC XRAY Dr. Muhammad Bin Zulfiqar PGR IV FCPS Services Institute of Medical Sciences / Hospital Lahore radiombz@gmail.com
  2. 2. AIMS Basic Approach to Radiograph Chest Basic Anatomy Cardiac Pathologies
  3. 3. TOPICS DISCUSSED  1. BASICS OF CXR  2.STRUCTURES IN ANTERIOR VIEW  3.STRUCTURES IN LATERAL VIEW  4.CHAMBER ENLARGEMENT  5.PULMONARY CIRCULATION  6.CONGENITAL HEART DISEASE  7.PERICARDIAL DISEASE  8.PACEMAKER & ICD  9.CARDIAC CALCIFICATION  10.PROSTHETIC HEART VALVE  11.DISEASES OF AORTA  12. MISCELLENOUS
  4. 4. BASICS OF X-RAY TECHNICAL QUALITY R – ROTATION I -- INSPIRATION P -- PROJECTION E -- EXPOSURE
  5. 5. ROTATION The medial ends of both clavicles should be equidistant from the spinous process of the vertebral body projected between the clavicles
  6. 6. The increase in blackness (radiolucency) of one hemithorax is always on the side to which the patient is rotated, irrespective of whether the CXR has been taken PA or AP
  7. 7. DEGREE OF INSPIRATION It is ascertained by counting either the number of visible anterior or posterior ribs Adequate inspiratory effort – five to seven complete anterior or ten posterior ribs are visible Poor inspiratory effort - fewer than five anterior ribs Hyperinflated lung-more than seven anterior ribs
  8. 8. IMPORTANCE OF AN INSPIRATORY FILM POOR INSPIRATORY FILM NORMAL INSPIRATORY FILM 1 2 3 1. Mediastinal Widening 2.Cardiomegaly 3.Lower lobe patchy opacification
  9. 9. PROJECTION OF X-RAY Projection is defined as the direction of x-ray with relation to the patient If the direction of x-ray projection is from front – AP projection If the direction of x-ray projection is from behind –PA projection
  10. 10. AP VIEW PA VIEW
  11. 11. PA VIEW AP VIEW In erect patients Vertebral spines more prominent Scapulae clear of lungs Clavicles are horizontal In supine patients Vertebral bodies clear Apparent cardiomegaly Scapulae overlap Clavicles are oblique
  12. 12. ERECT SUPINE  Gas bubble in fundus with a clear air fluid level  Gas bubble in antrum  Apparent cardiomegaly
  13. 13. EXPOSURE OF X-RAY Normal exposure - the vertebral bodies should just be visible at the lower part of cardiac shadow Underexposed -If the vertebral bodies are not visible , insufficient number of x-ray photons have passed through the patient to reach the x-ray film Similarly, if the film appears too ‘black’, then too many photons have resulted in overexposure of the x-ray film.
  14. 14. UNDERPENETRATION NORMAL OVERPENETRATION
  15. 15. SYSTEMATIC APPROACH Technical factors Skeletal abnormalities and hardware Situs: gastric air bubble, cardiac apex, and aortic knob Heart: position, size, and shape Great vessels: position, size, and shape Lung fields and vascularity by zone Search for calcifications
  16. 16. STRUCTURES SEEN IN ANTERIOR VIEW
  17. 17. STRUCTURES IN LATERAL VIEW RV PT AA LA LV
  18. 18. Gastric air bubble Left upper lobe bronchus IVC Right hemidiaphragm LV LARV Pulmonary outflow tract Aorta Right upper lobe bronchusRPA LPA Confluence of pulmonary veins Brachiocephalic vessels Trachea Left hemidiaphrag m
  19. 19. Aortic knob is the junction formed by the arch and descending aorta
  20. 20. MAIN PULMONARY ARTERY LPA
  21. 21. HOW TO MEASURE MAIN PULMONARY ARTERY If we draw a tangent line from the apex of the left ventricle to the aortic knob(red line) and measure along a perpendicular to that tangent line (yellow line) The distance between the tangent and the main pulmonary artery (between two small green arrows) falls in a range between 0 mm (touching the tangent line) to as much as 15 mm away from the tangent line
  22. 22. PROMINENT MPA Main pulmonary artery projects more than the tangent Causes: 1. Increased pressure 2. Increased flow
  23. 23. HYPOPLASTIC PA MPA > 15 mm from the tangent Concave PA segment Causes: 1. TOF 2. TRUNCUS ARTERIOSUS
  24. 24. LEFT ATRIAL APPENDAGE L LA ENLARGEMENT HYPERTROPHIED LA APPENDAGE
  25. 25. LEFT VENTRICLE
  26. 26. CARDIOMEGALY The cardiothoracic ratio should be less than 0.55 on PA view. i.e. A+B/C<0.55  A cardiothoracic ratio > 0.55 suggests cardiomegaly in adults A cardiothoracic ratio > 0.6 suggests cardiomegaly in newborn
  27. 27. CTR is more than 50% but heart is normal Spurious causes of cardiac enlargement  Portable AP films  Obesity  Pregnant  Ascites  Straight back syndrome Pectus excavatum
  28. 28.  CTR is less than 50% but heart is abnormal Obstruction to outflow of the ventricles  Ventricular hypertrophy Must look at cardiac contours < 50% ASCENDING AORTA DILATED LV CONTOUR
  29. 29. CRITERIA'S FOR CARDIOMEGALY Cardiothoracic ratio >0.55 in adults on PA view Cardiothoracic ratio >0.6 in newborn on PA view Any increase in transcardiac diameter > 2 cm compared to old x-ray In old age and emphysema a transcardiac diameter more than 15.5 cm in males &>12.5 cm in females
  30. 30. CHAMBER ENLARGEMENT RA enlargement LA enlargement RV enlargement LV enlargement
  31. 31. CRITERIA FOR RA ENLARGEMENT Rt. Cardiac border becomes more convex > 50% of right border Rt. Atrial border extends >3 intercostal spaces Measurement from mid vertical line to max. convexity in rt. Border>5 cm in adult & >4cm in children Lateral view – fullness in space between sternum and front of upper part of cardiac silhouette
  32. 32. CRITERIA FOR LA ENLARGEMENT  Widening of carina( normal 45-75 degree)  Elevation of left bronchus  Straightening of left border  Double atrial shadow( shadow within shadow)  Grade 1 –double cardiac contour  Grade2 - LA touches RA border  Grade 3 – LA overshoots the Rt. Cardiac border  Displaces the descending aorta to the left and esophagus to right seen in barium swallow
  33. 33. LA ENLARGEMENT HYPERTROPHIED LA APPENDAGE
  34. 34. LEFT ATRIAL ENLARGEMENT DOUBLE ATRIAL SHADOW WIDENING OF CARINA ELEVATION OF LEFT BRONCHUS Left atrial appendage enlargement
  35. 35. Widening of carina Elevation of lt. bronchusAneurysmal LA Aneurysmal LA – When La enlarges to left and right and approaches within an inch of lateral chest wall
  36. 36. LATERAL VIEW-LA ENLARGEMENT LA pushing the Esophagus posterior
  37. 37. LEFT VENTRICULAR ENLARGEMENT  PA view  (a)Left cardiac border gets enlarged and becomes more convex resulting in cardiomegaly  (b)Lt. cardiac border dips into lt. dome of diaphragm  (c) rounded apical segment  (d) cardiophrenic angle is obtuse
  38. 38. LEFT VENTRICULAR ENLARGEMENT Lateral view (a) Left ventricle enlarges inferiorly and posteriorly (b)Rigler’s measurement A is >17 mm (c)Rigler,s measurement B is< 7.5 mm (d) Eyeler’s ratio becomes > 0.42
  39. 39. RIGLER’S MEASUREMENT Rigler’s A & B used to differentiate left ventricular and right ventricular enlargement  Possible only when IVC shadow is present Jn. Of IVC with Lt. Atrium – J point Rigler’s A- from J point along line of IVC draw a line of 2 cm above and mark the point X.
  40. 40. Draw a horizontal line from pt. A to posterior Cardiac border and mark that pt. y Distance between points x & y is Rigler’s measurement A NORMAL<17 mm Rigler’s B-from the pt. J drop a perpendicular line to the dome and this distance is Rigler’s measurement B NORMAL>7.5 mm RIGLER’S MEASUREMENT
  41. 41. When LV enlarges, Posterior cardiac border gets displaced posteriorly & IVC shadow gets included in cardiac shadow, without getting displaced posteriorly  Rigler’s measurement A >17 mm in lt. ventricular enlargement RIGLER’S MEASUREMENT
  42. 42. EYELER’S RATIO To differentiate lt. & rt. Ventricular enlargement  Valid when IVC shadow is absent or cannot be visualised Mark the point of jn. where postero inferior cardiac border meets the dome as B  From this point B draw a horizontal line to the posterior border of sternum-AB
  43. 43. From pt.B - draw another horizontal line posteriorly to the inner border of the rib- BC Ratio of AB/BC is Eyeler’s ratio < 0.42 EYELER’S RATIO
  44. 44. LA Oblique view  There is a retrocardiac space( prevertebral) (a)Mild lt. Ventricular enlargement-obliteration of retrocardiac space (b) mod. Lt.ventricular enlargement-cardiac shadow overlaps vertebral column (c)Marked Lt.ventricular enlargement-cardiac shadow overshoots vertebral column
  45. 45. Chest X ray shows left ventricular enlargement. Left heart border is displaced leftward, inferior and posteriorly. Rounding of the cardiac apex.
  46. 46. RV ENLARGEMENT PA VIEW Cardiophrenic angle is acute Clockwise rotation of heart causes RV to form the middle portion of the left heart border. RIGHT LATERAL VIEW Obliteration of retrosternal spac
  47. 47. RV ENLARGEMENT LEFT LATERAL VIEW Rigler’s measurement will be17mm or less Rigler’s measurement will be 7.5mm or more Eyeler’s ratio is 0.42 or less
  48. 48. PERICARDIAL EFFUSION Narrow vascular pedicle Cardiomegaly directly proportional to severity of pericardial effusion This shadow has a rounded, globular appearance with no particular chamber enlargement Cardiophrenic angle become more and more acute Oligaemic pulmonary vascular markings Marked change in cardiac silhouette in decubitus posture ‘Epicardial fat pad sign’- anterior pericardial strip bordered by epicardial fat post. and mediastinal fat ant.>2mm
  49. 49. Narrow vascular pedicle Acute cardiophre nic angle ‘Water bottle’ appearence Pulmonary oligaemia
  50. 50. DILATED CARDIOMYOPATHY VS PERICARDIAL EFFUSION Chambers can be identified Cardiophrenic angle is obtuse Increased pulmonary venous hypertension No change in cardiac silhouette in decubitus Vascular pedicle is dilated or normal Fluoro shows cardiac pulsation
  51. 51. CONSTRICTIVE PERICARDITIS 1.Straightening of the right border 2.Pericardial thickening > 4 mm 3.Pericardial calcification (50% cases) 4.Dilatation of SVC and azygous vein Pericardial calcification
  52. 52. CONGENITAL ABSENCE OF PERICARDIUM Focal bulge in area of main pulmonary artery  Sharply marginated  Absent right cardiac border  Increased distance between sternum and heart due to absence of sterno pericardial ligament
  53. 53. PULMONARY VASCULARITY 1.RDPA<17MM NORMAL PULMONARY CIRCULATION – 3 FEATURES
  54. 54. PULMONARY VASCULARITY
  55. 55. PULMONARY VENOUS HYPERTENSION
  56. 56. PULMONARY VENOUS HYPERTENSION LARRY ELLIOT’S CLASSIFICATION OF PVH RADIOGRAPHIC GRADE OF PVH ACUTE DISEASE PCWP CHRONIC DISEASE PCWP 1 13-17 MMHG 13-17 MMHG 2 18-25 MMHG 18-30 MMHG 3 >25 MMHG >30 MM HG 4 HEMOSIDEROSIS AND OSSIFICATION LONG STANDING PVH
  57. 57. GRADE 0 -PCWP< 12 MM HG  Upper lobe pulmonary veins are less prominent than lower lobe veins GRADE 1- PCWP 13-17MMHG Redistribution of blood flow with cephalization-’ANTLER SIGN’  1) increased resistance to flow due to interstitial odema  2) alveolar hypoxia in lower lobes causes reflex vasoconstriction  3) vasoconstriction of the arterioles due to LA or pulmonary vein reflex PULMONARY VENOUS HYPERTENSION
  58. 58. GRADE 2- PCWP 18-25mm hg  Interstitial edema  Peribronchial cuffing  Kerley A,B,C lines  Interlobular effusion  Pleural effusion  Hilar haze Peribronchial cuffing PULMONARY VENOUS HYPERTENSION
  59. 59. KERLEY A LINES Distended lymphatic channels within edematous septa coursing from peripheral lymphatics to central hilar nodes  Towards the hilum  Less specific for Pulmonary venous hypertension KERLEY A LINES
  60. 60. KERLEY B LINES Horizontal lines 1-3 mm thick Perpendicular to pleural surface Towards the costophrenic angle Accumulation of fluid in interlobular septa and lymphatics Highly specific for PVH KERLEY B
  61. 61. Crisscross lines seen between A &B GRADE 3 – pcwp > 25mm hg Alveolar odema Bilateral diffuse patchy cotton wool opacities KERLEY C LINES
  62. 62. Pulmonary circulation Pulmonary plethora – features  Enlargement of central pulmonary artery , lobar and segmental artery  Prominent nodular vascular shadows in frontal CXR- shunt vessels that course ventral to dorsal  Upper & lower lobe vessels prominent  RPDA > 17mm  Right descending pulmonary artery> tracheal diameter Ratio of RPDA to diameter of trachea > 1  Plethora seen if shunt size >2:1
  63. 63. PLETHORA
  64. 64. Decreased flow proximal to orgin of main pulmonary artery Small pulmonary artery Empty pulmonary bay Pulmonary vessels small Lung hypertranslucent Lateral view shows diminution of hilar vessels Pulmonary oligaemia
  65. 65. OLIGAEMIA Empty pulmonary bay
  66. 66. High pressure left to right shunts are associated with obliterative changes in the smaller pulmonary arteries & arterioles Large main & large central pulmonary arteries taper down rapidly to very small vessels Seen in Eisenmenger’s syndrome Precapillary PAH Pruning
  67. 67. PRUNING
  68. 68. PULMONARY EMBOLISM Hamptons hump Wedge opacity Westermark sign Hampton’s hump Fleischner’s sign- prominent central pulmonary artery Palla’s sign-dilated rt. Descending pulmonary artery Chang’s sign – dilatation and abrupt change in calibre of the rt. Descending PA
  69. 69. VALVULAR HEART DISEASE MITRAL STENOSIS Small aortic knob from decreased cardiac output Features of left atrial enlargement Right atrial enlargement from tricuspid insufficiency Pulmonary venous hypertension Enlarged MPA Calcified mitral valve
  70. 70. Mitral regurgitation LA enlargement LV enlargement Pulmonary venous hypertension
  71. 71. Ascending aorta dilated Left ventricular hypertrophy Aortic valve calcification AORTIC STENOSIS
  72. 72. Dilated ascending aorta LV enlargement AORTIC REGURGITATION
  73. 73. No obvious cardiomegaly Enlarged PA Dilated left pulmonary artery Normal to decreased pulmonary vasculature VALVULAR PS
  74. 74. Concave PA segment RVH Infundibular Pulmonary stenosis
  75. 75. MPA DILATED RPA DILATED RV APEX PULMONARY PLETHORAASD CONGENITAL HEART DISEASE
  76. 76. HOW TO DIFFERENTIATE ASD VSD PDA
  77. 77. MPA DILATED RPA DILATED LV APEX PLETHORA VSD
  78. 78. Linear or railroad track calcification at site of ductus may be seen in adults with PDA PROMINENT MPA LV APEX PLETHORA AORTIC KNOB PDA
  79. 79. • “FIGURE OF 3” in CXR • “REVERSE 3” or “E sign” in Barium meal COARCTATION OF AORTA
  80. 80. DD OF INFERIOR RIB NOTCHING 1)Aortic obstruction- Takayasu arteritis Coarctation of aorta 2) Subclavian artery obstruction –Classic BT shunt Takayasu arteritis 3)Chronic Svc obstruction 4)Intercostal Av fistula 5)Neurofibromatosis
  81. 81.  Cyanosis With Decreased Vascularity Tetralogy of Fallot Truncus-type IV Tricuspid atresia Transposition of great arteries Ebstein’s anomaly  Cyanosis With Increased Vascularity Truncus types I, II, III TAPVC Tricuspid atresia Transposition Single ventricle Cyanotic Congenital Heart Disease
  82. 82. CYANOTIC CHD—TOF • Rv apex • Underfilled LV • Concave pulmonary artery • Pulmonary oligaemia
  83. 83.  ‘Egg on string’  1)Narrow pedicle  2)Rt. Border RA  3)Lt. border LV  4)Increased vascularity  5)Hypoplastic thymus CYANOTIC CHD—TGA
  84. 84. ‘figure of 8’ “snowman” Rt border-SVC Upper border-left innominate Left border-left vertical vein Body of snowman-RA CYANOTIC CHD—TAPVC (supracardiac)
  85. 85. The scimitar sign is produced by an anomalous pulmonary vein that drains any or all of the lobes of the right lung.  Scimitar vein empties into the inferior vena cava CYANOTIC CHD—PAPVC(Scimitar sign)
  86. 86. ‘Box shaped heart Enlarged RA Hypoplastic pulmonary trunk  Decreased vascularity CYANOTIC CHD—EBSTEIN
  87. 87. LV apex Rt pulmonary artery has a superior orgin (20%) ‘waterfall sign’ ‘Hilar comma sign’ Associated right aortic arch (33%) Concave PA segment ELEVATED RIGHT HILUM CYANOTIC CHD—TRUNCUS ARTERIOSUS
  88. 88. CYANOTIC CHD Eisenmenger’s syndrome • Chest xray show dilation of central pulmonary arteries and pruning of peripheral pulmonary arteries, right ventricular and atrial enlargement. Left heart would return to normal size. • Left to right shunts such as atrial septal defect, ventricular septal defect and patent ductus arteriosus, cause increased pulmonary blood flow. With time, high pulmonary vascular resistance will develop, ultimately causing right to left shunt.
  89. 89. PACEMAKER
  90. 90. BIVENTRICULAR PACING
  91. 91. RA LEADRV LEAD
  92. 92. PACEMAKER PROBLEMS LEAD FRACTURE DISPLACED RA LEAD DISPLACED RV LEAD
  93. 93. ICD
  94. 94. A) Valvular – Mitral , aortic valve B) Pericardial – constrictive pericarditis C) Myocardial – left atrial wall, LV aneurysm D) Endocardial – Endomyocardial fibrosis E) Intraluminal – La thrombus , La myxoma , Lv thrombus F) Vascular – aortic calcification , coronary artery CARDIAC CALCIFICATIONS
  95. 95. CARDIAC CALCIFICATION MITRAL VALVE CALCIFICATION
  96. 96. MYOCARDIAL CALCIFICATION CALCIFIED LV APICAL ANEURYSM
  97. 97. CONSTICTIVE PERICARDITIS CALCIFIED PERICARDIUM
  98. 98. PERICARDIAL VS MYOCARDIAL CALCIFICATION PERICARDIAL  SEEN IN BOTH SIDES OF HEART MOST COMMONLY IN AV GROOVE  DIFFUSE CALCIFICATION AROUND THE HEART  CALCIFICATION IS CHUNKY & UGLY MYOCARDIAL  SEEN IN ONLY LEFT SIDE  MOST COMMON SITE IS ANT. WALL  LOCALIZED TO THE LEFT  CALCIFICATION IS FINE & CURVILINEAR
  99. 99. GIANT LA CALCIFICATION
  100. 100. ATRIAL MYXOMA
  101. 101. TILTING DISK VALVE PROSTHETIC HEART VALVE
  102. 102. STARR EDWARD BALL VALVE
  103. 103. STARR EDWARD PROSTHETIC VALVE MITRAL PROSTHESIS
  104. 104. ST. JUDE VALVE
  105. 105. Aneurysm of ascending & Descending aorta Diseases of aorta
  106. 106. Egg shell sign Aortic dissection
  107. 107. MISCELLENOUS X-RAYS LEFT SVC  Occurs in less than 0.5% of people  Failure of regression of L common and Ant. Cardinal veins  Drains left jugular and left subclavian vein  Most patients also have right sided SVC  Drains into dilated coronary sinus LEFT SVC
  108. 108. RIGHT AORTIC ARCH  Leftward displacement of barium filled esophagus Rt. Indentation of trachea  Aortic knob is absent from left side  Aorta descends on right Associated with TOF Truncus arteriosus
  109. 109. AORTIC NIPPLE Left superior intercostal vein  Seen in 5% of cases To be differentiated from a mass Also called pseudo dissection It drains into hemiazygous vein Hartman T .Pearls & Pitfalls in Thoracic imaging,Variants and other difficult diagnosis
  110. 110. CERVICAL AORTIC ARCH Left sided cervical aortic arch Aortic knob at apex of lung Descend on the left CERVICAL AORTIC ARCH
  111. 111. SITUS INVERSUS WITH DEXTROCARDIA SITUS INVERSUS WITH LEVOCARDIA
  112. 112. DEXTROCARDIA
  113. 113. HYDROPNEUMOPERICARDIUM
  114. 114. PDA CLIP
  115. 115. BIBLIOGRAPHY (1)Jefferson K, Rees S. Clinical cardiac radiology, 2nd edition Butterworths; 1980. (2) Lipton MJ. Plain film diagnosis of heart disease: cardiac enlargement. Contemporary Diagnostic Radiology 1988;11:1-6. (3) Boxt LM, Reagon K, Katz J. Normal plain film examination of the heart and great arteries in the adult. J Thorac Imaging 1994;9:208-18. (4)Murray G. Baron,Wendy M. Book .Congenital heart disease in the adult.North American Clinics of Radiology 2004;3 (5) Ramesh M. Gowda,Lawrence M. Boxt. Calcifications of the heart.North American Clinics of Radiology 2004;4 (6) Martin J. Lipton, Lawrence M. Boxt. How to approach cardiac diagnosis from the chest radiograph.North American Clinics Of Radiology 2004;5 (7) Murray G. Baron .PLAIN FILM DIAGNOSIS OF COMMON CARDIAC ANOMALIES IN THE ADULT.North American Clinics Of Radiology 2004;6 (8) Radiology imaging – sutton 6th edition (9) Pediatric cardiology- Perloff’s clinical recognition of congenital heart disease (10)Radiology of congenital heart disease-Amplatz (11)Grainger & Allisons- diagnostic radiology vol1 , 4th edition (12)Cardiac Xrays- v.Chockalingam (13)Braunwald heart diseases 9th edition (14) Emma C. Ferguson,Rajesh Krishnamurthy,Sandra A. A.Oldham. Classic Imaging Signs of Congenital Cardiovascular Abnormalities; RadioGraphics 2007; 27:1323–1334 (15)www.learningradiology.com
  116. 116. QUIZ
  117. 117. QUIZ
  118. 118. EBSTEIN’S ANOMALY
  119. 119. 8 YR OLD ACYANOTIC CHILD
  120. 120. ATRIAL SEPTAL DEFECT
  121. 121. 25 YR OLD LADY WITH DYSPNOEA
  122. 122. MITRAL STENOSIS
  123. 123. 65 YR OLD MAN WITH DYSPNOEA
  124. 124. PERICARDIAL EFFUSION
  125. 125. 35 YR OLD ACYANOTIC FEMALE
  126. 126. ASD WITH PAH
  127. 127. RT AORTIC ARCH WITH RT DESCENDING AORTA
  128. 128. 4 MO CYANOTIC CHILD
  129. 129. TAPVC SUPRACARDIAC
  130. 130. 3 MO CYANOTIC CHILD
  131. 131. D-TGA
  132. 132. 8 YR OLD ACYANOTIC CHILD
  133. 133. VSD
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This presentation is almost a complete Pictoral view of Radiograph chest. This presentation will help radiologist in daily reporting. This presentation will help physicians, surgeons, anesthetist and almost all medical professionals in diagnosing commonly presenting cardiac diseases. This will also help all in preparaing TOACS examination.

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