Professional Documents
Culture Documents
, 43, 673-684
VOLUME 43 NUMBER 514
OCTOBER 1970
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FIG. 1.
Starr-Edwards mitral valve replacement. It is not possible
from this radiograph to decide, from the position of the
valve, whether it is a mitral or aortic valve replacement. The
thick collar (->) of the valve indicates the inflow and therefore this is a mitral valve.
CHAMBER ASSESSMENT
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LV
FIG. 2.
Aortic Starr-Edwards valve. Radio-opaque ball within a metal cage. The perforated collar is sewn to the aortic valve ring,
and is the inflow of the valve.
(A) The valve is closed in ventricular diastole as the ball is seated firmly and closes the collar.
(B) The valve is open in ventricular systole and blood passes through the aperture of the collar into the aorta.
(LV = left ventricle. Ao = ascending aorta.)
FIG. 3.
Calcification of left atrial wallmitral stenosis. Curvilinear
calcification (<) outlining a moderately enlarged left atrium.
The calcium is probably deposited in a layer of clot lining
the atrial endothelium.
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A
FIG. 4.
Calcification following myocardial infarction.
(A) A band of calcification (*) over the apex of the left ventricle. No aneurysm. No change in cardiac contour. Note pad of
fat at cardiac apex.
(B) Another patient. A large calcified aneurysm (<-) of left ventricle distorting cardiac contour.
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FIG. 5.
Giant left atrium. Note marked splaying of the carina with
elevation of both right and left main bronchi.
FIG. 6.
FIG. 7.
FIG. 6. Left ventricular enlargement. The apex is displaced outwards and downwards almost to the left chest wall. The
aorta is slightly enlarged. No enlargement of the pulmonary conus or main pulmonary arteries. Moderate enlargement
of left atrium (just visible at right heart border). The patient has stenosis and incompetence of both mitral and aortic
valves.
FIG. 7. Right ventricular enlargement. The cardiac apex is flattened and almost vertical. The pulmonary conus is verylarge and both main pulmonary arteries are prominent. Normal aorta. The patient has cor pulmonale.
OCTOBER 1970
FIG. 8.
FIG. 9.
FIG. 8. Relationship of ventricles. The right ventricle (R.V.) lies directly anterior to left ventricle (L.V.) They communicate via a V.S.D. (j). S. = Sternum. (From Cardiac Catheterization and Angiocardiography, by Verel and Grainger.
Livingstone Ltd.)
FIG. 9. Enlarged left ventricle. Left anterior oblique projection. Note curve of posterior inferior aspect of left ventricle
with an increased line of diaphragmatic contact (see text). The dotted line would be a typical curve for right ventricular
enlargement. (Same patient as Fig. 6).
confidence. Unfortunately, these signs are occasionally misleading: more often these features are
not distinctive enough to be of differential diagnostic value.
Radiological assessment of left ventricular size
can be facilitated by noting the relationship of the
posterior border of the inferior vena cava (I.V.C.)
on the lateral radiograph.
The posterior border of I.V.C. can usually be
identified on the lateral radiograph as a vertical,
almost straight line, extending upwards from about
the mid-point of the diagrammatic cupola (Fig. 10).
This identification is readily confirmed by selective
inferior vena cavography or right atrial injection
(Fig. 10). The posterior border of the left ventricle
bulges about 15-20 mm behind this line in the
normal lateral radiograph (Fig. 11).
If the left ventricle is enlarged and the right heart
is not enlarged (e.g. aortic valve disease), the posterior margin of the left ventricle bulges backwards
to a greater extent, often more than 20 mm behind
the I.V.C. line at its farthest point (Hoffman and
Rigler (1965) suggest more precise mensuration.)
This is in contrast to the situation when the right
heart is enlarged and displaces the left ventricle back-
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FIG. 10.
FIG. 11.
FIG. 10. Identification of the inferior vena cava (or right atrial) line. Lateral projection. Injection into right atrium (ra)
identifies its straight posterior wall. Behind this line, the left atrium can be faintly seen (la). The posterior border of the
inferior vena cava (<) is a downward continuation of the posterior border of the right atrium.
FIG. 11. Relationship of line of I.V.C. and left ventricle. Note the left ventricle (-<) bulges behind the line of I.V.C. (>).
Normally this distance is no more than 15-20 mm.
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FIG. 12.
Left ventricle obscured by the oesophagus. Barium in the lower oesophagus obscures the posterior border of left ventricle
(black line). The I.V.C.-L.V. distance cannot be measured. I.V.C. indicated by <-: L.V. indicated by black line. Patient
has aortic incompetence with large L.V.
FIG. 13.
The influence of rotation on the I.V.C. sign, same patient in (A) and (B). Note the marked difference in the I.V.C.-L.V.
distance (> -<-) when the X-ray beam is not in the mid-coronal plane. In (A) the I.V.C.-L.V. distance is much less than
normal: in (B) the distance is greatly increased. Both radiographs are "reasonable" laterals, but the geometry of the sign
is very sensitive to the smallest rotation (see text).
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FIG. 14.
Enlarged Left Atrium.
(A) Note the extreme limit of the right border of the left atrium (-) coincides exactly with right border of right atrium (>)
This coincidence is probably due to the pericardium (see Text).
(B) Simultaneous lateral angiogram. Marked mitral incompetence demonstrated by left ventriculogram which shows gross
reflux into the enlarged left atrium (LA).
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FIG. 15.
Giant right atrium in mitral stenosis.
(A) Large right atrium causing marked convexity of right heart border. The angle which it makes with the diaphragm
suggests right rather than left atrium. Note distended azygos vein (>) due to right heart failure.
(B) Penetrated antero-posterior film of same patient. Note outline of modestly enlarged left atrium (<-) which is far
smaller than the giant R.A. seen in (A). Note absence of displacement of oesophagus. If the large chamber seen in (A) were
L.A. it would displace the oesophagus, usually to the right but occasionally to the left. The carina cannot be seen in this
print, but it was not splayed and this also excludes a giant left atrium.
assessment of ventricular dominance, for the classic descriptions are frequently not applicable, nor sufficiently selective, for the individual patient under consideration.
REFERENCES
BRAUNWALD, E., 1969, New Engl.J. Med., 281, 425.
ACKNOWLEDGMENTS
ABSTRACT
1965,
31, 684.
ROBERTS, W. C , HUMPHRIES, J. O., and MORROW, A.
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G.