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Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 279-280
Cardiomegaly due to left atrial enlargement mimicking dextrocardia in chest radiograph


1 Department of Cardiac Anaesthesiology, Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
2 Department of Cardiac Surgery, Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India

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Date of Web Publication1-Oct-2013
 

How to cite this article:
Kapoor MC, Sarupria A, Gupta K, Kumar AS. Cardiomegaly due to left atrial enlargement mimicking dextrocardia in chest radiograph. Ann Card Anaesth 2013;16:279-80

How to cite this URL:
Kapoor MC, Sarupria A, Gupta K, Kumar AS. Cardiomegaly due to left atrial enlargement mimicking dextrocardia in chest radiograph. Ann Card Anaesth [serial online] 2013 [cited 2020 Aug 5];16:279-80. Available from: http://www.annals.in/text.asp?2013/16/4/279/119178


X-ray chest is an important diagnostic tool to determine left atrial enlargement (LAE). The left atrium (LA) usually enlarges in the path of least resistance, that is, posteriorly, superiorly and to the right. [1] We managed an interesting case of rheumatic mitral stenosis in which cardiomegaly, due to LAE, presented as an image mimicking dextrocardia in the chest radiograph.

A 15-year-old boy presented with palpitation of 6 years duration, which was aggravated by physical exercise. Patient also had dyspnea (New York Heart Association functional class IV) and swelling of legs from 2 years. On examination, patient had dyspnea at rest, icterus, raised jugular venous pressure, and pedal edema. Pulse rate was 110/min and the blood pressure was 90/50 mmHg. On chest auscultation, crepitations were heard bilaterally. Chest X-ray revealed kyphosis, massive cardiomegaly (cardio-thoracic ratio 1:0.85) with biatrial enlargement, fullness of the left pulmonary bay, and massive right-sided pleural effusion. Two-dimensional transthoracic echocardiography revealed severe mitral stenosis (mitral valve area 0.58 cm 2 by pressure half time and 0.6 cm 2 by planimetry method) with moderately severe tricuspid regurgitation, severe pulmonary hypertension (pulmonary artery systolic pressure 124 mmHg) and a giant LA 9 cm) with a LA clot with multiple extensions (largest dimension 8.7 cm × 6.5 cm). Mitral valve replacement with evacuation of LA clot was carried out. Post-operative chest radiograph image resembled a dextro-rotated boot-shaped heart [Figure 1].
Figure 1: Post-operative chest radiograph showing cardiomegaly with massive enlargement of the left atrium projecting to the right and upwards, resembling a dextro-rotated cardiac apex

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Dextrocardia is a condition in which the apex of the heart is pointed toward the right of the chest instead of pointing toward left. Although LAE has been defined in patients with dextrocardia, there are no reports of LAE mimicking dextrocardia in patients with normocardia. LA appendage enlargement is seen as fullness beneath the pulmonary artery with straightening of the left heart border. Posteriorly, LAE pushes the esophagus toward the spine (as seen on barium swallow) and is the most sensitive indicator of LAE. [2] Superiorly, LAE elevates the left main bronchus splaying the carinal angle (>75%). However, a change in the carinal angle is an insensitive indicator of LAE. [3],[4] Anteriorly, LAE is resisted by the right ventricle (RV), but rarely the RV may yield to the LA push to produce a left parasternal lift, which could be mistaken for RV enlargement. Inferiorly, LAE is limited by the atrio-ventricular groove and the strong fibrous skeleton. LAE can occur both to the left and right (usually towards right) and may over shoot the right heart border late in the course of the LAE. A disproportionate LAE along the right heart border, with a cardiac apex like configuration, resembled dextrocardia in this case. In true dextrocardia, the heart is located in the right hemithorax with its base-to-apex axis directed to the right and caudad. In this case, the direction of the apex was to the right and lateral. Such a positional abnormality may be seen in a radiological boot-shaped heart as seen in Fallot's tetralogy, with dextrocardia. However, the presence of a double density apical shadow, in this radiograph, indicates that this was a pseudo-apex and not a true apex.

 
   References Top

1.Desanctis RW, Dean DC, Bland EF. Extreme left atrial enlargement. Some characteristic features. Circulation 1964;29:14-23.  Back to cited text no. 1
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2.Neufang KF, Carstens V. Left atrial enlargement in mitral valve disease: A comparison of conventional roentgen signs and methods of roentgenographic measurement (author's transl). Rontgenblatter 1981;34:280-7.  Back to cited text no. 2
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3.Murray JG, Brown AL, Anagnostou EA, Senior R. Widening of the tracheal bifurcation on chest radiographs: Value as a sign of left atrial enlargement. AJR Am J Roentgenol 1995;164:1089-92.  Back to cited text no. 3
[PUBMED]    
4.Karabulut N. CT assessment of tracheal carinal angle and its determinants. Br J Radiol 2005;78:787-90.  Back to cited text no. 4
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Correspondence Address:
Mukul C Kapoor
6 Dayanand Vihar, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.119178

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