VOL.

110,

No.

TRANSPOSITION
DETERMINATION
IN

OF
OF THE

THE
CHEST

GREAT
OF THE
ROENTGENOGRAMS

ARTERIES*
GREAT ARTERIES

POSITION

CONVENTIONAL GUERIN, JOHN W. M.D.,t

KIRKLIN,

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By

RONALD

BENIGNO
M.D.,
BIRMINGHAM,

SOTO,
and
ALABAMA

M.D.,

ROBERT
BARCIA,

B. KARP,
M.D.

M.D.,

ALBERTO

HE heart of patients with transposition of the great arteries is classically described as having a narrow vascular pedicle placed in front of the vertebral column as seen in conventional posteroanterior chest roentgenograms. The mediastinum is narrow because the aorta and pulmonary artery are superimposed in the anteroposterior plane.4 It was our experience in a series of 114
cases previously studied at the Mayo Clinic

tions. artery chest

The positions and the aorta roentgenogram

of the pulmonary on the posteroantenior were reproduced

on
with

transparent paper the angiographic

prior to comparison findings.

Our series plete transposi

and type double in which

includes cases tion, corrected

outlet the right aorta is

of classic corntransposition,
ventricle transposed of the in

that the great arteries are not always located in the same anteropostenior plane. With the purpose of analyzing the different possible positions of the great arteries in all types of transpositions, we correlated the conventional roentgenograms and angiocandiographic findings from 70 patients
studied at the University of Alabama

relation to the pulmonary artery. The generalizations concerning localization of the positions of the great arteries are applicable to both transpositions and double outlet right ventricle, and on conventional roentgenograms the two cannot be distinguished. tion is present A classic when complete the aorta transposiarises from

Medical
METHOD

Center.
OF STUDY AND DEFINITIONS

the morphologic pulmonary artery left ventricle and

are or concordant, inversus. that Most

right ventricle and the from the morphologic the atria and ventricles
is, both frequently, in situs sohitus complete

The taken jections

of io

conventional in posteroanterior using a high

roentgenograms were and lateral prokilovoltage technique

x-ray studies generators. were done

transposition atria, situs ventricular conus and pulmonary

occurs with solitus of the loop), the aorta artery at to the

situs solitus of the ventricles (dextrosubaortic of the valve the right semilunar

right-sided

The with
by

kv. and 3 phase angiocardiographic

biplane
injecting the

large
contrast

roll

film
media

technique
selectively

level. when
to the

A corrected the location

atria of

transposition of the ventricles

Most

is present relative
frequently,

into both ventricular chambers. The roentgenograms were taken at a rate of 12 per second in each plane during the first 2
seconds of the by cineangiography series. Patients studied were excluded only due to

is discordant.

corrected
solitus tricles,

transposition
the atnia, left-sided subaontic

occurs
inversion conus,

with
of the and at

situs
venaorta the loop

lack

of

detail
artery

and
analysis. and above

the

impossibility
size was of

of
the pulmeasured

to the left semilunar

of the pulmonary valve level. Van

artery Praaghs68

quantitative monary immediately

The aorta the

sinuses

of Valsalva

rule states tricles can the aorta.

right
School

that the be identified An aortic

the pulmonary
University

position of the venby the location of valve located to the

valve indicates
Birming-

in
*

the
From

anteropostenior
the Departments

and
of Diagnostic

lateral
Radiology and

projecSurgery,

of

of Medicine,

of Alabama

in Birmingham,

ham,

Alabama.

t Research

Associate

in Radiology.

Presently

at LH#{244}pital Ste.

Justine,

Montreal,

Quebec,

Canada.

747

748

Guenin,

Soto,

Karp,

Kirklin

and

Barcia

DECEMBER,

1970

TYPESOF INTERRELATION BETWEEN THE GREAT ARTERIES AT THESEMILUNAR VALVELEVEL.

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position the aorta was almost always antenor to the right or anterior to the left of the pulmonary artery. In only i case was the aorta posterior to the pulmonary artery.

The

percentage
of

distribution

of
the

the
great

I ANTEROPOSTERIOR II AORTA ANTERIOR, 33 %

--

types arteries

interrelation between is shown in Figure i . The 3

typeS in complete

frequency
outlet

of these
corrected right

transposition,

transposition ventricle is detailed

and in

double Figure

SIDEBY SIDE

AORTA TO RIGHT,5 %

AORTA TO LEFT,10 %

OBLIQUE

AORTATO RIGHT,30 % AORTA RIGHT 35%

FIG. s.

AORTA TO LEFT,22 % AORTA LEFT 32%

bein-

2. In classic complete transposition, the most common i nterrelationships were the oblique with the aorta to the right (Fig. 3, C and D; and 4, A and B), and the anteroposterior (Fig. 3, ii and B). In 5 cases of complete transposition, the aorta was located anteriorly and to the left in relation to the pulmonary artery. These exceptions to Van Praaghs loop rule were due in each case to the marked right-to-left rotation of the heart produced by right ventricular

ANTERO POSTERIOR 33%

hypertrophy osis. In

and corrected (Fig.

dextroconvex transposition 5, zl-D)

dorsal the

scolimost

common
side-by-side

interrelationship and B), in both to the left. The was less frequent
(Fig.

tween cidence

Summary of the types of interrelation the great arteries, and their relative in this series of 70 patients.

6, 1 aorta lation

was either the or oblique (Fig. instances with the anteropostenior re-

transposition

than in complete #{231}, C and D). In double

outlet right ventricle was a side-by-side

(d-

right-sided

morphologic

right

ventricle

ventricular
left indicates

loop). (1-ventricular

An

aortic loop).8

valve

to

the
right

a left-sided

morphologic

and B) or oblique relationship. As shown in Figure 2, the aorta was to the left in 6 (i +5) cases and to the right in 5 (3+2). Of the 3 pa-

there also (Fig. 3, ii

frequently

ventricle

RE 5 U LTS

tients with anteroposterior relation, pulmonary atresia. Figure 7 shows the position of the
arteries be in 3 at the arteries at the semilunar valve the level

had

great
re-

We semilunar positions

found in

that valve patients

the level

great may with

main

transposition

and related malformations: (i) anteropostenor; (2) side-by-side; and (3) oblique. We had previously described these positions in double outlet right ventricle.2 In the first group the aorta was always located anterior to the pulmonary artery. In the second group, the aorta was to the right or to the left of the pulmonary artery. When the great arteries were in an oblique

lated to the visceroatrial situs, lar loop, the size of the great the heart axis. The visceroatnial
solitus in in
90 10

ventricu-

arteries situs
patients patients situs

and was
and with were loop

per

cent

of

the No

inversus indeterminate

per

cent.
The

visceroatrial

studied in our series. and the position of

ventricular

was concordant transposition loop, in which

the ascending aorta in all cases of complete except in patients with dthe aorta to the left of the

VOL.

110,

No.

Transposition

of the

Great

Arteries

749

TYPESOF INTERRELATION BETMEENTHE GREATARTERIES IN TRANSPOSITIONS AND DOUBLE OUTLETRIGHTVENTRICLE. 10 CASES

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I
ANTERO POSTERIOR

II
SIDE BY SIDE AD TA RIGHT LEFT

III
OBLIQUE RIGHT AORTA LEFT

COMPLETETRANSPOSITION 38 CORRECTED TRANSPOSITION 18 DOUBLE OUTLET RIGHTVENTRICLE 14

FIG. 2.

0 0

19

Detail

of

the frequency

transposition,

of the 3 types of complete transposition, and double outlet right ventricle.

corrected

pulmonary artery was an exception to the loop rule. The position of the great arteries and their interrelationship could be predicted accurately in the majority of the cases from chest roentgenograms done with high kilovoltage technique. Difficulties arose when there was a marked discrepancy in the size of the vessels, particularly when the aorta was small and the pulmonary artery large.
DISCUSSION

The high kilovoltage chest roentgenographic technique allows better visualization of the heart and mediastinum by increasing the contrast between air and soft tissue and decreasing the contrast between soft tissue and bones.5 With this technique it is possible to outline the ascending aorta (Fig. 3-6) in the majority of the cases even when the artery is not border-forming. The ascending aorta may be directly localized on conventional chest roentgenograms made in this way when it is identified on the right (Fig. 3, z1-D; and 4, 1 and B)

or left (Fig. 5, A-D; and 6, A and B) mediastinal border. When the ascending aorta is not outlined, we try to identify the main pulmonary artery. The main pulmonary artery directly visualized on the left mediastinal border (Fig. , A and B) indicates a right-sided aorta. To locate the main pulmonary artery when it is not directly outlined in hearts with a wide vascular pedicle, one identifies the right and left pulmonary branches. If the pulmonary branches are at the same level and of the same length, the main pulmonary artery was medially placed indicating a left-sided aorta (Fig. , zl-D). When the right pulmonary artery is higher than the left (Fig. 6, A and B), the ascending aorta was likewise located in the left upper mediastinum. All except of the patients with these arrangements had corrected transposition. When there is a narrow vascular pedicle and one cannot identify the ascending aorta or the pulmonary artery, the relative position of the left and right main branches may help to locate the main pulmonary artery. If the left pulmonary branch is

750

Guerin,

Soto,

Karp,

Kirklin

and

Barcia

DECEMBER,

1970

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11G.

3. (In this and subsequent Figures, (A) and (C) are frontal conventional chest roentgenograms, and B and D are schematic diagrams of corresponding angiocardiograms.) (4 and B) Double outlet right ventricle with both subaortic and subpulmonary conus and ventricular septal defect. The gastric air bubble to the left indicates that the visceroatrial situs is solitus. The vascular pedicle is wide as the great arteries are side-by-side. The ascending aorta to the right of the prominent main pulmonary artery identifies the normal (solitus) position of the right ventricle, according to the ioop rule. (C and D) Complete transposi-

tion of the great

arteries

with

ventricular

septal

defect

and oblique

interrelation

between

the great

arteries.
and

The wide vascular pedicle is due to prominence to the main pulmonary artery on the left. There

of the ascending is situs solitus

=

PA

pulmonary

artery;

RA

right atrium; RV

right

aorta on the right mediastinal of viscera, atria and ventricles. ventricle; LV = left ventricle.

border AO =

aorta;

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0
POST.
751

es. The

ediastihe Vas-

na and

752

Guerin,

Soto,

Karp,

Kirklin

and

Barcia

DECEMBER,

1970

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hG.

.
tween

(A and
the aorta great

B)

Corrected
arteries. The

transposition dilated

with aorta

ventricular is prominent

septal defect and side-by-side on the left mediastinai border.

interrelation The main

bepul-

monary
the
ventricles

artery
are

is medially
in discordant

placed
position.

with
right

right

and

left branches

at the same

level.

The

left-sided

location

of

indicates

a left-sided

sinus with
atrium;

and large right-sided the ascending aorta

I
=

morphologic

to the left

ventricle. The viscera and atria are in situs solitus. The atria and (C and D) Common ventricle with underdeveloped right ventricular left ventricle. The great arteries are transposed and side-by-side of the pulmonary artery, forming a wide vascular pedicle. LA=left

infundibuium.

VOL.

no,

No.

Transposition

of

the

Great

Arteries

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FIG.

transposition with oblique interrelation between the great arteries. The ascendthe left mediastinal border. The main pulmonary artery is medially placed and the right branch is higher than the left. (C and D) Corrected transposition with anteroposterior interrelation between the great arteries. The vascular pedicle is narrow with both great arteries medially placed. The right and left pulmonary arteries are at the same level. There is situs solitus of the viscera and atria with discordant position of the ventricles.
6. (A
ing aorta is located pulmonary on

and B) Corrected

754

Guerin,

Soto,

Karp,

Kirklin

and

Barcia

DECEMBER,

1970

POSITION OF GREAT ARTERIES IN RELATION TO VISCERO#{149}ATRIAL SITUS, VENTRICULAR LOOP, GREAT ARTERY SIZE,ANDHEART AXIS. 10 CASES
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I
ANTEROPOSTERIOR

II
SIDEBY SIDE
AORTA RIGHT LEFT RIGHT

III
OBLIQUE AORTA
LEFT

23 I VISCERO

&21

16

ATRIAL

SOLITUS

631

21 2 16

3 0
3

SITUSLINVERSUS

iJ
46 24
30

20

13
3

VENTRICULARfD. LOOP LOOP LOOP

L1.

0 1
6

21

1
12

0 0 2
3 0

0
5

10 1
2

GREAT ARTERY

SIZE I AO<PA

AO>PA [AO=PA

1 33

2
9 18 5

0
5 2

15

1
8 8
situs,

LEVOCARDIA 55
HEARTAXIS [DEXTROCARDIA 15
IIG.

21 0

7.

Position of the great the ventricular

arteries at the semilunar loop, the size of the great

valve level related to viscero-atrial arteries and the heart axis.

higher artery

than

the

right,

the

main and

pulmonary the aorta

on conventional
possible viscera, to the atria,

chest
determine and the

roentgenograms
the the cases. in the position great There position of arteries

it is the in

is usually

left-sided

right-sided. All such cases which we reviewed were complete transpositions. If both pulmonary branches are at the same level and there is an anteroposterior relationship of the great arteries, complete
transposi tion occu rred more frequ en tl

the majority of ways correspondence

was alof the

viscera and atria in our cases. From the loop rule, knowing the position of the aorta, we can suspect the ventricular
interrelation. confirm the location the On the position of the angiocardiograms of the great morphologic we arteries, right and

than corrected transposition. The identification of the position of the great arteries in patients with complex forms of congenital heart disease is a step in the segmental approach described by Van Praagh.79#{176} The major cardiac segments to be analyzed are: (i) the visceroatrial situs; (2) the ventricular segment; (3) the conus or infundibulum; and
(4) the great arteries. From a practical

left ventricle, of development

bulum.

and

the position of the conus

and degree or infundito

sideby be-

There Praaghs
side and

were no exceptions loop rule in our cases

anteroposterior

Van

of interrelation

standpoint, it is helpful to obtain as much of this information as is possible from simple studies. It is important, then, that

tween to the
complete tricular

the great loop rule

transposi loop and

arteries. occurred
tions oblique

Five exceptions in patients with

wi th interrelated dextrovengreat

VOL.

iso,

No.

Transposition

of the

Great

Arteries

755

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arteries with the aorta anterior and to the left. The other exception was a case of double outlet right ventricle, situs solitus of atria and ventricles, and left-sided aorta. Thus it is of prime importance to locate the ascending aorta on the conventional chest roentgenograms to establish the interrelation between the great arteries and the position of the ventricles. The following are the factors affecting the identification of the ascending aorta in the conventional chest roentgenograms: (i) the position of the aorta in relation to the main pulmonary artery; (2) the relative size of the great arteries; (,) the position of the heart axis; and () the rotation of the heart and degree of right ventricular hypertrophy.
When an an teroposterior interrelation-

was made in 70 cases of transposition of the great arteries, including 14 cases of double outlet right ventricle of the transposition type. We found 3 main types of interrelation
between the great arteries: anteroposterior,

oblique and side-by-side. From the interpretation of the conventional high kilovoltage roentgenogram it was possible to determine the position of the great arteries in the majority of the
cases sided with aorta. levoventricular In patients with loop and dextroventrileft-

cular loop and anteroposterior between the great arteries,

difficult arteries. to identify the

relationship
it position was of more the

Six in
70

ship of the great arteries occurs, the relative size of the arteries is the most important factor in the visualization of the aorta. In every case of pulmonary atresia and in most cases with severe pulmonary stenosis, the aorta was directly identified on the chest roentgenograms. When the great arteries are side-by-side, the position of the vessels is more important than their relative size in the identification of the aorta. In oblique interrelationship the aorta is more easily seen as a border-forming structure when it is on the left. This is a consequence of the degree of right ventricular hypertrophy and the clockwise rotation of the heart. Thus the aorta is prominent even when it is not enlarged and smaller than the pulmonary artery. The position of the heart axis (levocardia or dextrocardia) was not an important factor in the identification of the aorta. In dextrocardias with levoventricular loop, the aorta was more often directly identified to the left in 10 of 12 cases studied, because the side-by-side and extreme oblique positions were more frequent.
SUMMARY

exceptions cases.
Barcia,

to the

loop

rule

occurred

Alberto

Department University Birmingham,

M.D. of Diagnostic Radiology of Alabama Medical Center Alabama 35233

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0. W., DAVIS, G. D., and ONGLEY, P. A. Transposition of great arteries: angiocardiographic study. AM. J. ROENTGENOL., RAD. THERAPY &
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