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VASCULAR IMAGING Table of Contents   
Year : 2005  |  Volume : 15  |  Issue : 1  |  Page : 99-102
Plan radiographic anticipation of adequacy of left ventricular size in patients with tetralogy of fallot by studying the level of diaphragmatic domes a new sign. A catheter correlated study of hundred patients.


Barnard Institute of Radiology and Cancer Institute of Cardiology and Cardiothoracic Surgery, Government General Hospital, Madras - 600 003, Tamil Nadu, India

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   Abstract 

A simple plain Radiographic method for anticipating the adequacy of left ventricular size in Tetralogy of Fallot (T.O.F.) by studying the level of cardiac dome (i.e.) the dome in contact with cardiaic apex is described. Out of eighty one patients with good sized left ventricle, seventy had low placed cardiac dome and eleven had equal domes. In nineteen patients with small left ventricle, the cardiac dome was high placed. In Tetralogy of Fallot, equal domes and low placed cardiac dome suggest good sized left ventricle. A high placed cardiac dome indicates small sized left ventricle. This information is useful to anticipate adequacy of left ventricular size to cope up with systemic circulation post-operatively. While the plain Radiographic indication of adequate sized left ventricle in Tetralogy migh obviate the need for left ventriculogram, a small sized left ventricle anticipated on plain radiograph will, in fact, indicate left ventricular angiographic corroboration and evaluation.

Keywords: Tetralogy of Fallot, New sign for L.V. Size, Cardiac dome in T.O.F., Plain Radiograph in T.O.F.

How to cite this article:
Rajaram P C, Lakshmikanthan, Thanikachalam S, Vaidyanathan S, Subramanian N. Plan radiographic anticipation of adequacy of left ventricular size in patients with tetralogy of fallot by studying the level of diaphragmatic domes a new sign. A catheter correlated study of hundred patients. Indian J Radiol Imaging 2005;15:99-102

How to cite this URL:
Rajaram P C, Lakshmikanthan, Thanikachalam S, Vaidyanathan S, Subramanian N. Plan radiographic anticipation of adequacy of left ventricular size in patients with tetralogy of fallot by studying the level of diaphragmatic domes a new sign. A catheter correlated study of hundred patients. Indian J Radiol Imaging [serial online] 2005 [cited 2019 Jul 20];15:99-102. Available from: http://www.ijri.org/text.asp?2005/15/1/99/28757

   Introduction Top


The frontal plain chest Radiographic finding in the normal individual revealing lower level of the left diaphragmatic dome (the dome that lies in contact with the cardiac apex - viz., the cardiac dome) due to the left ventricular mass and action depressing the cardiac dome has been utilized to study the level of the cardiac dome in patients with Tetralogy of Fallot. The low placed cardiac dome in the normal, lying in contact with good sized left ventricle could be corroborated on the laevo-phase of pulmonary angiograms [Figure - 1]. Similar left ventricular angiographic confirmation of a good sized L.V. depressing the cardiac dome could be obtained in conditions associated with L.V. depressing the cardiac dome could be obtained in conditions associated with L.V. enlargement and/or hypertrophy. The cause for low placed cardiac dome is best exemplified in patients with dextroversion (isolated dextrocardia) [Figure - 2] in whom the heart is one the right, liver is on the right and stomach is on the left. The right dome is at a lower level in spite of the liver being on the right. So, irrespective of the side of the liver, the dome which is in contact with the cardiac apex will be at a lower level because left ventricular action and mass depress it. We have designated this dome which is in contact with the cardiac apex as "Cardiac Dome". While studying the cine angio-cardiograms of patients with Tetralogy of Fallot, it was observed that, whenever the size of the left ventricle was either equal to or slightlyu less than that of right ventricle (i.e. two thirds of the sixe of right ventricle thereby indicating an adequate sized left ventricle), the cardiac dome was found to be at a lower level or at the same level of the opposite dome. It was also observed, that, whenever the left ventricular size was markedly less than that of right ventricle (i.e. less than two thirds of the size of Right ventricle thereby indicating a small sized left ventricle), the cardiac dome was at a higher level than that of opposite dome.

This could be explained as the result of a small sized left ventricle failing to reach downwards and depress the cardiac dome.


   Material and methods Top


Utilising and applying the above observations on frontal plain chest. Radiographs and cine angio-cardiograms of twenty-five patients with Tetralogy of Fallot as a preliminary control study, we studiedii subsequently the pre-cath frontal plain chest Radiographs of seventy five patients with Tetralogy of Fallot for assessment of anticipated size of left ventricle (for its adequacy of size) and the results were correlated with cine angio cardiographic findings.

Frontal and lateral right ventricular angio-cardiograms were studied in all the hundred patients (including twenty five control patients). Left ventricular angiocardiogram was performed only in twelve patients which facilitated more accurate comparative study of the sizes of left ventricle and right ventricle.


   Illustrative Patients and Results Top


Patient No.1 [Figure - 3]. This is a patient with Tetralogy of Fallot with infundibular, valvular and peripheral pulmonary stenoses with situs solitus abdominis. The left dome is at a lower level than the right. Normally the left dome which is in contact with cardiac apex formed by left ventricle is at a lower level because left ventricular action and mass depress it. [Figure - 3].

Patient No.2 [Figure - 4]: This is right ventricular angiocardiogram in Tetralogy of Fallot with right aortic arch. The left dome is at a lower level. The soft tissue shadow of left ventricle shows that left ventricle is normal in size [Figure - 4]a. The left ventricular angiocardiogram of the same patient [Figure - 4]b, shows the large left ventricle depressing the cardiac dome. Note that the left dome (i.e. the cardiac dome) is at a lower level than the right.

Patient No. 3 [Figure - 5]. This is Tetralogy of Fallot with left aortic arch and situs solitus abdominis. Right ventricular angio-cardiogram [Figure - 6] show good sized ventricle. Both the domes are at the same level. When both the domes are at the same level. When both the domes are at the same level in patients with Tetralogy of Fallot, one can anticipate a good-sized left ventricle.

Patient No. 4 [Figure - 6] : This is right ventricular angio cardiogram in a patient with Tetralogy of Fallot [Figure - 6]a showing large right ventricle. Note that the left dome, i.e. the cardiac dome is at a higher level than the right dome. In the same patient, the laevo-phase shows the small left ventricle [Figure - 6] b. The catheter is in the large right ventricle through which the small left ventricle is seen. Note that the large right ventricle has not depressed the cardiac dome. When the cardiac dome is at a higher level, as is seen in this patient, one can anticipate a small sized left ventricle. Note that the left ventricle lies well away from the dome and hence it has not depressed it.

Patient No. 5 [Figure - 7] : This is left ventricular angiocardiogram in a patient with Tetralogy of Fallot [Figure - 7] showing a small left ventricle. The cardiac dome is at a higher level and is also away from the left ventricle. This is why the small left ventricle has not depressed the left dome. This explains how one can anticipate on plain chest Radiograph a small sized left ventricle when the cardiac dome lies at a higher level in patients with Tetralogy of Fallot.

Other non-cardiac conditions causing elevation of cardiac dome such as pleural and pulmonary pathology, large gastric gas bubble, interposed colon and abdominal organomegaly as well as depression of either or both domes by overinflated lung should, of course, be taken note of and excluded.


   Results and Conclusions Top


In our present study, in eighty one out of one hundred patients, seventy showed low placed cardiac dome and eleven showed equal domes with good sized left ventricle on the cine angiocardiograms.

In Nineteen patients with elevated cardiac dome, the cine angiocardiograms demonstrated small sized left ventricle. Thus our cine angiocardiographic correlated study of cardiac dome on frontal plain chest Radiograph of patents with Tetralogy of Fallot has brought home the conclusion that elevated cardiac dome in tetralogy of fallot suggests small sized left ventricle and low placed cardiac dome or equal domes in tetralogy of fallot suggest good sized left ventricle.

This information regarding adequacy of left ventricular size on plain chest Radiograph is important in patients considered for intra-cardiac repair to predict good sized left ventricle to cope up with systemic circulation post-operatively. While this simple, non-invasive plain Radiographic method could provide useful information about adequacy of left ventricular size thus obviating the need for routine L.V. angiography in Tetralogy patients, it would, in fact emphasize the need for it when a small sized left ventricle is anticipated. The purpose of this communication is to stress on the diagnostic potential of plain. Radiograph in Tetralogy of Fallot and not to claim its superiority over angiographic evaluation.

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Correspondence Address:
P C Rajaram
F-139, Anna Nagar East, Madras 600 102. Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.28757

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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]

This article has been cited by
1 Unusual Cardiac Associations with Tetralogy of Fallot—A Descriptive Study
Vishal Changela, Colin John, Sunita Maheshwari
Pediatric Cardiology. 2010; 31(6): 785
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