Cardiophile MD

Dextrocardia with situs inversus

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Dextrocardia is evident as the apex is pointing to the right and the right atrial contour is on the left. The gastric air bubble is on the right (below the diaphragm) and liver shadow on the left, indicating situs inversus. The ascending aortic shadow on the left is a little prominent. There is mild scoliosis with convexity to the left which could be partly positional. Crowding of upper ribs on the right side could be due to the scoliosis.

Left sided pleural effusion with dextroposition

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There is massive pleural effusion on the left side pushing the heart along with the mediastinum to the right side producing a dextroposition. The higher level of the effusion in the axilla is evident.

Low atrial rhythm and IVCD

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ECG showing negative P waves in inferior leads – II, III and aVF. A superior P wave axis means that the atrial activation is proceeding from below upwards. This occurs when the focus is in the low atrium (low atrial rhythm or coronary sinus rhythm). In addition the ECG also shows an intraventricular conduction defect (IVCD) in the form of notched R wave in lead II and aVF and an rSR’ pattern in lead III. Sometimes this pattern occurs in atrial septal defect and it is known as chrochetage sign. The QRS width seems to be a little more than that in usual chrochetage sign. (Low atrial rhythm can occur in sinus venosus ASD as the region of the sinus node is defective and an ectopic atrial focus takes over.

X-ray chest PA view showing biatrial enlargement

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X-ray chest PA view showing biatrial enlargement. Right atrial enlargement is manifest as the enlargement of the cardiac outline towards the right side. Left atrial enlargement is seen as a double atrial contour (shadow within shadow) within the right heart border. Straightening of the left heart border is also partly due to the enlargement of the appendage of left atrium.

X-ray Chest PA view showing prominent ascending aortic dilatation

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X-ray chest PA view showing prominent dilatation of ascending aorta appearing as a right paracardiac shadow. Other possibilities which may be considered are paracardiac mass lesion or cyst.

X-ray taken one year earlier – Significant aortic dilatation

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X-ray chest PA view taken one year earlier shows significant dilatation of ascending aorta as well as the descending aorta. There is an apparent similarity to the shadow of right atrial enlargement. But the presence of associated dilatation of descending aorta suggests that the shadow on the right cardiac border is most probably the ascending aortic dilatation. In right atrial enlargement, the ‘cardiophrenic angle’ may not be so acute. There is an apparent cardiomegaly, though the heart as such may not be dilated.

Initial X-ray – mild aortic dilatation

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The first available x-ray chest PA view taken five years earlier, showing mild only prominence of the ascending aortic shadow. Arch of aorta appears unfolded. There is no cardiomegaly.

X-ray chest PA view in heart failure

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X-ray chest PA view in heart failure, showing cardiomegaly with bilateral pleural effusion, which is more on the right side. The lung fields show pulmonary congestion.Pleural effusion in heart failure, if unilateral, is more likely to occur on the right side. The proposed mechanisms are the larger surface area of the right lung leading to transudation of more fluid and the preference of patients with heart failure to lie on the right side. The latter is thought to be due to the presence of an enlarged heart on the left side, producing more discomfort in the left lateral position. In one study, unilateral right-sided effusions were twice as common as left-sided effusions in congestive heart failure (CHF) (28% vs 15%). This data also shows that bilateral pleural effusion is more common than unilateral pleural effusion in CHF.