Pulmonary venous hypertension (PVH) results from elevated left atrial pressure secondary to left heart disease, mitral valve pathology, or LV dysfunction. Chest radiography remains a simple yet reliable first-line tool to suggest PVH.
🩻 1. Early Stage (Pulmonary Venous Pressure 12–18 mmHg)
➡️ Cephalization of pulmonary vessels
- Upper lobe veins become as prominent as or larger than lower lobe veins.
- Seen best on an erect PA film.
- Indicates redistribution of blood flow due to elevated left atrial pressure.
🩻 2. Intermediate Stage (Pressure 18–25 mmHg)
➡️ Interstitial edema
- Kerley B lines: Short (1–2 cm), horizontal lines at the lung bases near the costophrenic angles.
- Kerley A lines: Longer oblique lines in upper lobes.
- Peribronchial cuffing: “Donut” appearance due to thickened bronchial walls.
- Hazy vascular margins and blurred hilum from interstitial fluid.
🩻 3. Advanced Stage (>25 mmHg)
➡️ Alveolar edema (“bat-wing” pattern)
- Bilateral, perihilar airspace opacities spreading outward.
- Air bronchograms may be visible.
- Pleural effusions (often bilateral).
- Cardiomegaly commonly coexists in chronic LV failure.
📊 Summary Table
| Stage | Pressure (mmHg) | Key Radiographic Features |
|---|---|---|
| Early | 12–18 | Cephalization of upper lobe veins |
| Intermediate | 18–25 | Kerley lines, peribronchial cuffing, hazy hilum |
| Advanced | >25 | Bat-wing opacities, effusions, cardiomegaly |
🧠 Teaching Pearls
- Always assess patient position — supine films may falsely show cephalization.
- Combine with clinical signs and echocardiography for confirmation.
- Chronic PVH may cause pulmonary hemosiderosis and calcified pleural plaques over time.
