Evaluation of Left Ventricular Enlargement

in the Lateral Projection of the Chest'

RICHARD B. HOFFMAN, M.D., and LEO G. RIGLER, M.D.

T EFT VENTRICULAR enlargement is prob-

L ably the most frequent chamber en-
largement in the adult heart, yet its detec-
tion is often difficult. According to
Parkinson (3) the enlargement is more
posterior than lateral in most patients. In
all probability the left ventricle is en-
larged in both directions in the majority of
cases, but there are so many exceptions
that roentgen studies in both postero-
anterior and lateral views are commonly
used. Eyler and his associates in 1959 (1)
made an original and ingenious suggestion
for the determination of left ventricular
enlargement in the lateral view. They
described an abnormal change in the rela- Fig. 1. Cross section of the heart at the level of the
junction of the inferior vena cava and posterior wall
tionship of the left ventricle to the inferior of the right atrium. Note that if the left ventricle
vena cava and the left leaf of the dia- enlarges posteriorly (broken line), its posterior margin
will be displaced behind the inferior vena cava. LV =
phragm. They noted that if the left left ventricle; RV = right ventricle; RA = right
ventricle extended posteriorly beyond the atrium; lVC = inferior vena cava.
upper end of the vena cava more than 1.5
em, it probably was a sign of left ventricu- It is the purpose of this paper to define
lar enlargement. It has been our ex- two measurements easily obtained from
perience, however, that the junction of the the lateral chest film and to determine
inferior vena cava and the right atrium is their degree of efficacy in evaluating left
poorly defined in a great many cases. ventricular size.
More recently, the incorporation of the
METHODS AND MATERIALS
shadow of the inferior vena cava into that
of the left ventricle in the lateral view has Figure 1 is a diagrammatic cross section
been recommended as a sign of left ven- of the heart at the level of the junction
tricular enlargement, specifically for the of the inferior vena cava and the posterior
differentiation of interatrial from inter- wall of the right atrium. It is apparent
ventricular septal defects (2). that enlargement of the left ventricle
The determination of left ventricular posteriorly will displace its posterior mar-
enlargement is likewise of great importance gin behind the inferior vena cava. If the
in the differentiation of mitral stenosis right atrium enlarges posteriorly the
from mitral insufficiency and for the es- inferior vena cava will move with it. The
timation of the degree of aortic insuffi- normal relationships of the inferior vena
ciency associated with aortic stenosis. cava, left ventricle, and left leaf of the
In a few cases the demonstration of en- diaphragm on lateral view are shown in
largement of the left ventricle may be the Figure 2. Injection of contrast material
most important diagnostic sign of cardiac into the inferior vena cava (Fig. 3) demon-
disease. strates that the linear shadow seen on the
1 From the Department of Radiology, University of California, the Center for the Health Sciences, Los Angeles,
Calif. Accepted for publication in February 1965.
93
94 RICHARD B. HOFFMAN AND LEO G. RIGLER July 1965

TABLE I: DATA ON SUBJECTS SELECTED FOR STUDY

Group No. Diagnosis Established by Age Range

(yr. ) Male Female

l. Normal students 100 College routine entrance 18-36 50 50

chest roentgenogram
2. Normals at autopsy 22 Heart showed no dilatation at 16-90 9 13
autopsy, weighed less than
270 g for females and 330 g
for males, and left ventricu-
lar wall less than 1.5 em
thick.
3. Aortic stenosis 75 Surgically proved 14-73 52 23
4. Aortic insufficiency 18 Surgically or angiographically 17-54 12 6
proved
5. Mitral stenosis 25 Surgically proved 22-65 3 22
6. Mitral insufficiency 18 Surgically proved 17-55 9 9
7. Moderate- to-severe 12 Clinically proved 20-73 8 4
hypertension

TABLE II: PERCENTAGE OF SUBJECTS IN WHOM CROSSING OF THE INFERIOR VENA CAVA AND LEFT
VENTRICLE COULD BE IDENTIFIED

Group No. Cases No. Cases in Which Percentage of

Reviewed Crossing Was Seen Identified Crossings
l. Normal students 100 83 83
2. Normals at autopsy 22 19 87
3. Aortic stenosis 75 56 75
4. Aortic insufficiency 18 10 55
5. Mitral stenosis (pure) 25 17 68
6. Mitral insufficiency
(predominantly) 18 11 61
7. Hypertension 12 9 75

lateral chest roentgenogram is in fact the TABLE III: MEAN VALUES FOR MEASUREMENTS
A AND B
posterior margin of the inferior vena cava.
Measurement A is defined as the distance Mean Mean
Group Measurement Measurement
which the left ventricle extends posteriorly A (cm) B (ern)
to the posterior border of the inferior 1. Normal students 1.12 2.51
vena cava at a point 2 em cephalad to the 2. Normals at autopsy 1.25 1.7
3. Normals, groups 1
crossing of the cava and the left ventricle. and 2 1.15 2.35
This measurement is made on a plane 4. Aortic stenosis 2.16 0.2
5. Aortic insufficiency 2.29 0.3
extending posteriorly which parallels the 6. Mitral stenosis (pure) 1.29 1.8
horizontal plane of the vertebral bodies. 7. Mitral insufficiency
(predominantly) 2.33 0
Measurement B is the distance of the 8. Hypertension 1. 75 0.45
crossing, referred to above, caudad to the 9. Abnormals, Groups
4,5,7,8 2.19 0.21
left leaf of the diaphragm (Fig. 2,B).
Seven groups of patients were studied, a
total of 270. Only those with true lateral cent. This is broken down into each of
chest films who were over fourteen years of the groups in Table II. In the other 24
age were included. A 6-foot target-film per cent several reasons may be responsi-
distance and either left or right lateral ble: Barium in the esophagus obscured
positions were used. The method of the crossing in many instances; pleural
selection of the subjects, age ranges, and fluid or parenchymal disease overlying the
sex are shown in Table I. lower lung fields accounted for some;
and underpenetrated films proved to be
RESULTS the third major cause.
Of the 270 cases studied we were able to It is significant that in only 55 per cent
see the crossing of the inferior vena cava of the cases of aortic and 61 per cent of
and left ventricle in 205 subjects or 76 per mitral insufficiency were the films satis-
Vol. 85 EVALUATION OF LEFT VENTRICULAR ENLARGEMENT 95

LD

Fig. 2. Right lateral projection of a normal heart. A. Radiograph with dots designating limits of measure-
ments A and B.
B. Diagram of the posterior inferior cardiac border of the same case with measurements A and B designated.
LV = left ventricle; IVC = inferior vena cava; RD = right diaphragm; LD = left diaphragm.

Fig. 3. Right lateral projection of the posterior inferior cardiac border. A. Film obtained before the injec-
tion of contrast material shows linear shadow presumed to represent the inferior vena cava.
B. Same patient after contrast medium has been injected into the inferior vena cava, This film proves that
the linear shadow is, in fact, the posterior margin of the inferior vena cava.

factory for this type of measurement. The
fact that the examinations were not made
with this method in mind accounts in large
part for the high percentage of unsatis-
factory films.
Table III illustrates the mean values for
measurements A and B for the 7 groups
defined above. Of note is the value of
measurement A for the normal students
and the autopsy-proved normals, 1.12 and
1.25 em respectively. In Figure 4 both
normal groups were combined and plotted
96 RICHARD B. HOFFMAN AND LEO G. RIGLER July 1965

MEASUREMENT A

14
:3 12
'" 1

r;;: 10 NORMAL
ol-l
:. 8
: 6
III

~ 4
~
,.Q
§
z
0
2
I
2 4 6
1/
8
I I I
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40
mm. of Overlap
14
'D
00
.....
12
<!l
ol-l 10 LESIONS CAUSING
0
f-<
LEFT VENTRICULAR
8 ENLARGEMENT
6
4
2
0
2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40

14
.....
..... 12
.....
III
ol-l 10 MITRAL STENOSIS
0
f-t
8
6
4
2
0

Fig. 4.

on a distribution curve. This shows a or borderline. Yet the lateral projection

mean for measurement A of 1.15 cm and a
standard deviation of 0.47 ern. A typical
normal heart with a small overlap measure-
ment is demonstrated in Figure 2.
The cases with aortic valvular lesions,
mitral insufficiency, and hypertension show
mean measurements from 1.75 to 2.33 cm
(Table III). These were grouped together
as cases clinically showing left ventricular
enlargement and also plotted on a distribu-
tion curve in Figure 4. The mean for
measurement A was 2.19 em with a
standard deviation of 0.50 em. A typical
example of the large posterior overlap
seen in left ventricular enlargement is
illustrated in Figure 5. It is notable that
the postero-anterior view shows relatively
little mediolateral enlargement. In fact,
if viewed without knowledge of the clinical
findings, it might well be considered normal
with measurement of diameter A gives
the unequivocal finding of left ventricular
enlargement which was borne out by the
surgical findings.
When the cases of mitral stenosis are
plotted, as shown in Figure 4, the mean for
measurement A is 1.29 em, which is what
would be expected since there is no sig-
nificant left ventricular enlargement in
cases of pure mitral stenosis. This normal
figure also indicates that enlargement of
the left atrium or right ventricle does not
invalidate the measurement. An illustra-
tion of this point is exhibited in Figure 6,
a case of mitral stenosis without insuffi-
ciency in which no posterior enlargement of
the left ventricle is disclosed.
By similarly plotting the data from
measurement B (Fig. 7), the combined
normals show a mean of 2.35 em distance
Vol. 85 EVALUATION OF LEFT VENTRICULAR ENLARGEMENT 97

c
Fig. 5. Aortic insufficiency. A. Normal appearing heart in postero-anterior projection. B. Right lateral
view demonstrates large measurement A. C. Diagram illustrating measurements.

from the left leaf of the diaphragm cepha-
lad to the crossing of the inferior vena
cava and left ventricle. The groups in
which left ventricular enlargement is ex-
pected display a mean measurement of
There was no significant difference be-
tween males and females for either meas-
urement in any of the 7 groups.
DISCUSSION

0.21 em. The cases of mitral stenosis
show a mean of 1.80 em for the B measure-
ment, a slight variance from the normals
which might be accounted for by some
downward displacement of the left atrium
on the left ventricle.
We feel that if measurement A is 1.8
cm or above, there is a strong probability
that the left ventricle is enlarged. With
this value, 11 out of 102 normals or 11 per
cent would be false positives and 17 of our
86 patients or 19 per cent who should have
98 RICHARD B. HOFFMAN AND LEO G. RIGLER July 1965

Fig. 6. Pure mitral stenosis. A. Postero-anterior view demonstrates large "mitral" heart, but significant
insufficiency with a large left ventricle cannot be excluded.
B. Left lateral view reveals small measurement A despite enlarged left atrium and right ventricle. Dots indicate
points for measurement.
C. Diagram illustrating measurements. Small left ventricle helps to rule out mitral insufficiency.

had large left ventricles would be false
negatives. Two of the 11 cases of mitral
stenosis or 13 per cent would have been
wrongly reported as left ventricular en-
largement. The data indicate the value
and reliability of this simple measurement
for estimating left ventricular enlarge-
ment.
If a good inspiratory film is obtained
and measurement B is 0.75 em or less, one
must consider left ventricular enlarge-
ment. With this figure for measurement
B we would have reported left ventricular
enlargement in 6 out of 102 normals or
6 per cent false positives. Twenty-eight
of the 86 patients with left ventricular
enlargement would have been considered
normal, a false negative rate of 32 per cent.
Seven of the 17 cases of mitral stenosis, or
41 per cent, would have been falsely re-
ported as left ventricular enlargement.
This figure most likely reflects the en-
largement of the left atrium and right
ventricle and shows the ineffectiveness of
this measurement when there is other
chamber enlargement.
The degree of correlation between lateral
enlargement of the heart and the posterior
measurement is important. Of the 124
cases with conclusive evidence of left
Vol. 85 EVALUATION OF LEFT VENTRICULAR ENLARGEMENT 99

ventricular enlargement, 11 showed what

appeared to be a normal heart in the
postero-anterior view, while in the same
cases the A measurement was well over 1.5
em. In the same group there were 4 cases
in which the A measurement was normal
while the postero-anterior view showed
clear-cut evidence of left ventricular en-
largement.
MEASUREMENT B

N 30
;; 27
-; 24 NORMAL
~ 21
~ 18
<:l 15
] 12
~ 9
6 Fig. 8. Right lateral projection shows how barium in
3 the esophagus obscures measurements A and B.
o L-~~~~---}--+-~=---*--+:--~'=-+:::-+::-~

'" 30
barium swallow so often obscures the
: 27 relationships of the inferior vena cava, left
~ 24 LESIONS CAUSING
I-t 21 LEFT VENTRICULAIl
ENLARGEMENT
ventricle, and left leaf of the diaphragm,
18 as in Figure 8, that another lateral projec-
15
12
tion without barium should be obtained
9 with each cardiac series.
6
3
We have also found that the measure-
ments lose their reliability in cases of
severe pectus deformity of the chest,
r-. 30
; 27
marked kyphosis, and anomalies involving
C; 24
... 21
MITRAL STENOSIS cardiac rotation.
18
The presence of abnormalities of the
15 lungs, pleurae, and diaphragms may in-
12
9
validate the procedure since increased
density or secondary changes in cardiac
position may obscure the shadow of the
inferior vena cava. In a small number of
Fig. 7. apparently normal subjects the contrast
factors are such that the inferior vena cava
The average measurement A in cases
is not clearly visible.
of mitral insufficiency is greater than in
The two measurements discussed above
aortic insufficiency. This result was sur-
are useful adjuncts in the diagnosis of
prising and not clearly understood.
cardiac chamber enlargement and should
COMMENTS be used in conjunction with postero-
anterior and oblique chest projections.
Several requirements in the technic of
the lateral chest film must be fulfilled be- SUMMARY
fore measurements A and B can be applied. Two easily obtained measurements for
The film must be a true lateral projection, determining left ventricular enlargement
in deep inspiration, and penetrated suffi- from the lateral chest roentgenogram have
ciently to see the retrocardiac space clearly. been presented and their efficacy tested.
The lateral projection of the heart with When the posterior border of the left
 100 RICHARD B. HOFFMAN AND LEO
ventricle extends posteriorly to the poste-
rior border of the inferior vena cava more
than 1.8 cm at a level 2 ern cephalad to
their crossing, on a lateral projection of the
chest in the adult, one can postulate left
ventricular enlargement with a consider-
able degree of certainty.
When the distance from the crossing of
the inferior vena cava with the left ventricle
to the left leaf of the diaphragm is less than
0.75 ern, one can suspect left ventricular
enlargement, but must be aware of other
chamber enlargement which can alter the
normal relationships of these structures.
Since the relationships in these measure-
ments are often obscured by a barium-
filled esophagus, it is suggested that a fifth
view be added to the standard four views
of the heart, the lateral projection of the
chest without barium.
SUMMARIO IN INTERLINGUA
Evalutation de Allargamento Sinistro-Ventricular in Ie Projection Lateral del Thorace
Es presentate duo facilemente obtenibile
mesurationes al uso in determinar al-
largamento sinistro-ventricular a base de
lateral roentgenogrammas thoracic. Le
efficacia del mesurationes ha essite testate.
Quando le margine posterior del ventriculo
sinistre se extende in direction posterior
verso le margine posterior del vena cave
inferior per plus que 1,8 ern a un nivello
2 em distante in direction cephalic ab
lor cruciamento in un projection lateral
del thorace de un patiente adulte, i1 es
possible postular le presentia de allar-
gamento sinistro-ventricular con un grado
considerabile de assecurantia. Quando le
distantia ab le cruciamento del vena cave
inferior con le ventriculo sinistre usque al
labio sinistre del diaphragma es minus que
0,75 ern on pote suspicer allargamento sinis-
G. RIGLER July 1965
The addition of these two measurements
to the conventional methods of assessing
cardiac chamber size will materially assist
in the determination of the presence or
absence of left ventricular enlargement
before the use of catheterization or angio-
cardiography.
The Center for the Health Sciences
Dniversity of California
Los Angeles, Calif. 90024
REFERENCES
1. EYLER, W. R., WAYNE, D. L., AND RHODEN-
BAUGH, J. E.: The Importance of the Lateral View in
the Evaluation of Left Ventricular Enlargement in
Rheumatic Heart Disease. Radiology 73: 56-61,
July 1959.
2. KEATS, T. E., RUDHE, D., AND Foo, G. W.:
Inferior Vena Caval Position in the Differential Diag-
nosis of Atrial and Ventricular Septal Defects. Radi-
ology 83: 616-621, October 1964.
3. PARKINSON, J.: The Radiology of Rheumatic
Heart Disease. (Carey Coombs Memorial Lecture).
Lancet~1 : :896-902, May 28, 1949.
troventricular sed debe esser conscie del
facto que altere allargamentos cameral
pote alterar le relationes normal de iste
structuras. Viste que le relationes del
mesurationes in question es frequente-
mente obscurate per un esophago replenate
de barium, i1 es recommendate que
un quinte projection sia addite al serie
standard de quatro projectiones del
corde, e que iste quinte projection sia un
projection lateral del thorace sin le uso de
barium.
Le addition del mentionate duo mesura-
tiones al methodos conventional pro evalu-
tar le dimensiones del cameras cardiac
va esser de assistentia in le determination
del presentia 0 absentia de allargamento
sinistro-ventricular ante le uso de cathete-
rismo 0 de angiocardiographia.