The patient’s heart has been removed!

He is a heart transplant patient about to receive his new heart, and of course the surgeons had to remove his old failing heart first. The film was taken after his native heart had been removed but before the transplanted new heart was placed. Again, here is the abnormal film and a comparison normal film.

Abnormal:

Normal:

When I’ve shown the abnormal film to medical students, they usually know that something is amiss, but they can’t quite put their finger on what’s wrong.

Many med students learning introductory radiology find it much harder to recognize the absence of a normal structure than to recognize the presence of an abnormal structure. Or as one of my former professors used to put it, “The hardest thing to see is something that isn’t there.”

This principle is not unique to medicine, of course. For instance, the “dog that didn’t bark” (when it should have) was the key to a Sherlock Holmes mystery story.

And part of radiology residency training is to develop the appropriate mental checklists so that when one analyzing any radiology exam (ranging from a chest x-ray to a brain MRI scan), one is methodically looking both for “things that should be here but aren’t” as well as “things that shouldn’t be there but are”.

A few comments on some secondary findings:

The lungs are “dirtier” than usual (i.e., with more white), because of fluid build-up from his prior congestive heart failure. There are also various life-support lines and tubes that project over different portions of his chest. The dark vertical stripe in the midline is the incision used to remove the heart.