THE DETERMINATION OF INDIVIDUAL ENLARGEMENT OF THE VENTRICLES BY RADIOLOGIC METHODS

BASED UPON AUTOPSY AND ANGIOCARDIOGRAPHIC FINDINGS IN THE LEFT ANTERIOR OBLIQUE POSITION

JORGE CEBALLOS, M.D.,* ROBERTO CALDERON, M.D.,** AND OTTO KARGL, M.D.***

GALVESTON, TEXAS

T HE difficulty in evaluation of ventricular enlargement by fluoroscopy or routine films is well known and has been emphasized in a previous paper.i

Consequently, the method based upon measurement of the heart shadow in the left anterior oblique position has been used, and by this means more precise measurements are possible.

Studies by Fray” on autopsy cases and O’Kane and associates3 on clinical cases and our angiocardiographic studies in left anterior oblique position have shown the interventricular septum to be in the center of the cardiac silhouette except in its inferior portion. In this lowest segment, the septum makes a small curve downward and posteriorly to reach the well-known shallow identation which indicates the ending of the interventricular septum. By this line, the heart is divided into two parts; the anterior half is formed by the right ventricle and the posterior half corresponds to the left ventricle.

Following the interventricular septum line upward as described above it will show that it extends precisely to the posterior contour of the ascending aorta. On the bases of these features, we have the necessary data for finding the interventricular septum, either fluoroscopically or on the films in the left anterior oblique position. At fluoroscopy it will be sufficient to turn the patient enough to visualize the margins of the aorta. The posterior margin of the aorta cannot always be identified on the radiograms. In that event we have to meas- ure first the aortic diameter in the posteroanterior view using the method de- scribed by Kreuzfuchs4 from the barium-filled esophagus or the air-filled trachea to the outer border of the aortic knob. We may then locate the posterior border of the aorta on the left anterior oblique view by measuring its diameter from the anterior portion, which is always visible as it emerges from the anterior contour

Received for publication Sept. 12. 1954. *Roenteenolonist. Instituto National de Cardioloaia, Mexico D. F. (on leave) : at present. Assistant

Professor of Radiology, The University of Texas, Medical Branch. Galveston, Texas. - **Ex-Assistant Professor of Radiology, The University of Texas, Medical Branch; at present,

Radiologist at Managua, Nicaragua. ***Ex-Resident. Dept. of Radiology, The University of Texas, Medical Branch: at present, Radi-

ologist, University of Innsbruck, Austria.

606

CEBALLOS ET AL. : RADIOLOGY IN \‘lZNTKICIJLAK ENLAKGEMRXT 00;

of the cardiac shadow in this projection. The interventricular septum Cll correspond to a line which follows the heart axis and goes from the postct-ion margin of the aorta to the inferior portion of the heart shadow just above I ht. small curve which will reach the well-known shallow identation rel)resentinc the inferior portion of the septum. Once we have localized the septum, \vc‘ trace two perpendicular lines to extend to the cardiac shadow in its most rortve~ part. The anterior one will represent the width of the right ventricle, most]\- the in-flow tract according to Nemet and Schwedel,5 and the posterior that of the left ventricle (Figs. l-4).

The present paper is a study of this method and a review of the findings in one hundred and fifteen cases which have been checked with the clinical diq- nosis, electrocardiography, and in some instances with angiocardiography , surgery, or at autopsy.

Fig. I.--Posteroanterior and left anterior oblique views. B. E., 63-year-old white male with chief complaint of shortness of breath. B. P.. 175/90. E. C. G., Q-T upper limits OP normal; left-axis de- viation. Left ventricular hypertrophy. malit,y amterolaterally.

Incomplete left bundle branch block. Myocardial abnor- Diagnosis: hypertensive heart disease.

Table I gives a general idea of the types of cases used in this study.

Tables I I and III and Fig. 1 record the data in the hypertensive cases. The number of cases is too small to be taken in consideration for statistical purposes, yet our findings agree with the general knowledge of left ventricle changes in

608

Hypertensive heart disease Syphilitic aortic regurgi-

tation ik-teriosclerosis Mitral valve disease

‘Total

Anemia Heart in pregnancy

‘Total

AMERICAN HEART JOI~RNAI,

K.\I)IOI,O(;IC FINI)INGS COKClSKNIN(; so. 01%’ ‘TIlli \‘l<NTKICI,I<S C.ZSES

Predominance of enlargement of the left \-entricle I 55

Enlargement of the left ventricle None or slight enlargement of left ventricle

; 1:

None or predominance of the enlargement of the right 1 ventricle 35

110

Moderate globular enlargement of the heart Slight globular enlargement of the heart

TABLE II. HYPERTENSIVE HEART DISEASE (55 CASES)

I RACE AND SEX I I SIZE AVERAGE (CM.) h’o. OF _--_--- CASES

N.F.

3 2 1

__-_-----

22 2 7

__-A_-----

30 4

! ’

7

_____- A-‘&RgP j----------:__--__ U'.M. AORTA LEFT VENT. RIGHT VENT.

0 0 Ei% 2.40 to 3.00 4.80 to 9.00 4.50 to 7.00

_-_ --- ----__- ------ -----:--- --

8 5 Group 2 2.50 to 5.90 6.00 to 13.00 3.75 to 7.00 31 to 50

7 Group 3 2.70 to 5.20 / 6.00 to 13.00 4.20 to 9.50 51 or more

I

W. F. = white female; N. F. = Negro female; W. 11. = nhite male; S. 31. = Negro male

TABLE III. HYPERTENSIVE HEART. INCREASE IN SIZEOFLEFTVENTRICLE ema WHEN COMPARED WITH RIGHT VENTRICLE

St

P 6

r_ 5

30 40 60

AQE IN YEAR6

70

h\yertensive heart disease. (A) Most of the patients were more than 30 !xxrrs of age. (Bj There were more Negroes than Caucasians, more males than iv- m;\les. CC‘) As it was previously reported,’ in no f‘;tse were the left and right

ventrirular measurements the same. The difference in size between the right and kit measurements increased with the numtx,r of c‘ases studied, ;intl this was a!n;~!-s more than 1.5 cm.

Pig, 2. -Post,eroanterior and left anterior oblique views. J. W., fig-year-old Negro male with ctriel cwmplairrt. of pain on left side of chest. Dyspnea on exertion. B. P., 172/108. Diast.olic shock Frll. in aortiv area. Aortic systolic rumbling mwmw and aortic diastolic mm-mm-. Kahn positive. E (‘. (:.. left-axis deviation, semihorizontal electrical position. Left, ventricular hyperbrophy. Multifrwal wntrirular prrmaturrs. Diagnosis: syphilitic aortic rrgurgitation.

Tables IV and V and Fig. 2 summarize the findings in the cases of syphilitic aortic regurgitation. Our findings in these cases were very similar ro those in our hypertensive cases.

W. F. = white female; N. F. = Negro female; W. 51. = white male; pu’. 1%. = Negro male

610 AsMERICAN HEART JOURNAL

TABLE V. SYPHILITIC AORTIC REGURGITATION INCREASE IN SIZE OF THK LEFT VENTRICLE WHEN COMPARED~ITHTHE RIGHTVENTRICLE

______ ____-

DIFFERENCE INTHESIZEOFVENTRICLES NO.OFCASES (CM.1

____- --~-

0 None or in favor of the right ventricle

1 0 to 0.50

1 0.50 to 1.00 -----------__-----~-------_-------~~--

3 1.00 to 2.00

3 2.00 to 3.00 ---_---_----------------------------------

7 More than 3.00

~- ____--

Tables VI and VII, arteriosclerotic cases, were made up mostly of patients 50 years old or more, and there was only a minimal enlargement of the left ven- tricle.

TABLE VI. ARTERIOSCLEROSIS (5 CASES) ____---____

RACEANDSEX I ! SIZE AVERAGE (CM.) NO.OF AGEGROUP - CASES (YEARS)

W.F. N.F. W.M. N.M. AORTA

~__

0 Gortooup301

------____ ___-________

1 1 Group 2 3.30 31 to 50

------ 4 1 1 1 1 Group 3 3.00 io 4.50

51 or more

LEFTVENT. RIGHT VENT. --__-

6.20 ) 6.90

6.20 to 7.50 5.50 to 7.00

TABLE VII. INCREASE INSIZEOF LEFTVENTRICLEWHEN COMPARED WITH RIGHTVENTRICLE

DIFFERENCE IN SIZE OF VENTRICLES NO.OF CASES (CM.)

1

2

None or in favor of right ventricle __~

0 to 0.50

2 I 0.51to 1.00

0 I

More than 1.00

Tables VIII and IX and Figs. 3 and 4 showed findings which were opposed to the previous cases; the predominant chamber enlarged was the right ventricle.

CEBALLOS ET AL.: RADIOLOGY IN VENTKICI’LhK ENLhKGEMI‘;S’I 611

Fig. 3:-Posteroanterior and left anterior oblique. C. 11. L., 26-year-old white female. lih~\I- matic fever when 6 years of age: progressive shortness of breath on exertion and orthopnea II. I’., 120/70. No palpable thrill, no enlargement to percussion. Loud hard Grade 3 harsh blowing systolic murmur from mitral area and to apex and axilla. Diast,olic murmur over mit,ral area. E. (‘. <;.. ripht- axis deviation, left atria1 abnormality. hlinor S-T depressions which could he due to digitalis. I)iag nosis: mitral lesion, predominance of mitral stenosis. Surgical procedure: The mitral orifiw was palpated with the finger tip, the opening was about thr: size of a kitchen match. Dilatat,iw rvit II IIII~ finger, no commissurotomy.

TABLE VIII. MITRAL HEART (35 CASES) _~~~-~. ..--_ -- -.-.

/ / I

RACE AND SEX SIZE AVERAGE (CM.‘)

13’6 2 2 3 No. 2 2.5 to 3 5 ~ 47tos.5 j .i .i to 0 31 to 50 /

__- - .__. I--- - ~~~ . . 1 _-__-__-__ 1 1 No. 3 j

51 or more /

3.75 j f~ ,i

W. F. = white female: N. F. = Negro female; W. &I. _ white male; N. >I. 5 Negro male.

612 AMERICAN HEART JOURNAL

Fig. 4.-Posteroanterior and left anterior oblique views. W. R., 45-year-old Negro female. Short- ness of breath on exertion. B. P., 130/90. No thrills. Heart enlarged to percussion. Soft apical systolic murmur, mid-diastolic murmur at apex. E. C!. G., right-axis deviation. Anterolateral sub- endocardial ischemia. Rapid auricular fibrillation. Angiocardiography: left atrium enlarged, delay in emptying through mitral valve. Diagnosis: mitral lesion, predominance of mitral stenosis. Pa- tient rejected surgical treatment.

TABLE IX. MITRAL HEART. INCREASE IN SIZE OF RIGHT VENTRICLE WHEN COMPARED WITH LEFT VENTRICLE

GMS.

IO

9 -I-= GROUP I l = GROUP 2

0 08 GROUP 3

2 7

; 6

z 5

.-. l . l T- . .

.- 0

I 0.

: .

0 IO 20 30 40 50

AGE IN YEARS

60 70 00

‘I’herc is, however, less tendency to different,cs than there was in t ht: cxscs 01 ~~redornin~u~t left ventricular enlargement. This is, of course, the rt5ult 0i thc* mitral contigura!-ion of the heart in which, if the stenosis is l)redomin;tllt O\‘VI the insufticiency, it shows enlargement of the right ventricle. On tl1c ottw

hand, if the lesion is “double mitral” there \%41 bc enlargement of both venl~rklrs. In the two cases of anemia and three of normA pregnancy, there WIS :I

mo(lcratt globular enlargement of the heart c‘ontour which is the usual tindill&.

A follow-up of a method for individual measurement of the ventricles is presented. It is based upon the localization of the interventricular septum in the left anterior oblique position. One hundred and fifteen additional cases were used. The results previously described show again the value of the method.

SUMMXRIO IN ISTERLINGI..\

1,e objective de iste studio, que es basat.e super 11.5 cases, es demonstrar lc valor de nostre method0 pro determinar le allargamento individual del Van- triculos per medios radiologic in le position oblique sinistro-anterior (0. S. .1. i del thorace. Le method0 se basa primarimente super le constat;ttion :mpio- cardiographic que in le perspectiva 0. S. A. le septo interventriculnr cs in It> c-entro del silhouette cardiac e divide lo per consequente in duo portiones. I s portion anterior corresponde al ventriculo dextere, le portion posterior al \~n- trirulo sinistre. Ambe ventriculos es normalmente equidimensional in le position 0. S. .A. In cases de predominante allargamcnto sinistro-ventricular--come per exemplo in morbo cardiac hypertensive e in insutkientia aortic --nos constat;lv;t qae le portion posterior esseva plus grande clue le anterior. In cases de morbo mitral le portion anterior esseva plus grande que le posterior.

Iste method0 es usabile in iluoroscopia e r:tdiophotogrnphia. 1110 cs lJus lltile in fluoroscopia.

Lye wish to gratefully acknowledge the assistance received from Dr. George IIrrrnti\nl~ in cYlilil1.q IlliS nrticlc.

REFERENCES

I. (‘el)allos, Jorge, and Isaza, Jairo: tricles.

Determination of Individual Enlargement (,I’ the \‘erl- Method Based on .-\ngiocardiography in the Left Anterior Oblique I’ouitioll.

Radiology 58:844, 1952. 1. Fray, W. \V.: Mensuration of Heart and Chest in the Left Postero-anterior Oblique I’osi-

tiun: Comparative Study, Determination of Type of Cardiac Enlargement I Right or Left), Am. J. Roentgenol. 27:363-372, 1932.

.i. O’liane, A., Andrew, F. D., and Warren, .A.: .A Standardization Koentgenologic Stutl~ 01 the Heart and Great Vessels in the Left Oblique \.iew, Am. J. Roentgenal. 2.7:,%7.3. 1930.

1. Kreuzfuchs, S.: Die Brustaorta in Kontgenilde, \\?en. klin. \Vchnschr. 29:701. 1Qlb: Aortometrie precise, Presse m&d. 4.4:2013. 1936.

5. Yemet. G., and Schwedel, J.: HEART J. 7:132, 1932.

Roentgenographic Stlldies of the Right \-rnt ric+, :\>I.