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The Differentiation of Dextroversion from Dextroposition

of the Heart and Their Relation to


Pulmonary Abnormalities*
S. ROGEL, M.D., A. ScHWARTZ, M.D. AND J. RAKoWER, M.D., F.C.C.P.
Jerusalem, Israel

D EXT ROVE RS ION OF THE HEART 'IS A The patient was well-developed, without
subgroup of dextrocardias. It in- cyanosis or dyspnea. The right anterior hemi-
thorax was prominent. The apex was felt in
cludes the-location of the heart in the right the fifth intercostal space about 3 em, to the
hemithorax without inversion of the car- right of the sternum. Systolic thrill was palpable
diac chambers. This congenital anomaly in the second and third intercostal spaces on
is the result of a counter-clockwise rotation both sides of the sternum. On percussion the
of a normally developed heart in the right heart was found in the right hemithorax. The
heart sounds were well audible and regular. The
hemithorax. This condition has been de- second sound in the left second intercostal space
scribed as an isolated phenomenon." as was accentuated and split. A rough, long, grade
well as associated with different intracar- 3 systolic murmur was heard all over the pre-
diac and/or pulmonary anomalies .... The cordium, in the right hemithorax, but maximally
heart, however, may be positioned in the in the second and third interspaces on the left
side of the sternum. The remainder of the
right hemithorax due to intrinsic factors, physical examination was non-contributory. The
such as major pathology of the right lung electrocardiogram exhibited upward P waves in
or pleura. There is no rotation of the L l _2 _3 , and negative P with R in a YR. In L 1
heart in such cases, and the heart is simply deeply inverted T waves and intraventricular
drawn into the right hemithorax. This conduction disturbance were seen. The unipolar
chest leads showed high R waves around the
condition is mostly acquired and .named sternum with decreasing potentials laterally.
dextroposition.t"
X-ray examination of the chest (Fig. 1)
The terms dextroversion and dextro- showed a symmetric bony thorax, with the
position are sometimes interchanged, and greater part of the heart shadow in the right
different conditions are denoted by the hemithorax. The pulmonary segment was prom-
same name, or vice versa-different terms inent on the left, below the aortic knob. The
hilar pulmonary arteries were enlarged. The
are used for the same condition....1a vascular markings in the lungs were greatly
The .purpose of this paper is to present increased. The aorta appeared normal. The
cases with dextroversion and dextroposition stomach was on the left side. Angiocardiography
of the heart accompanied by cardiac and/ (Fig. 2), with the catheter placed in the right
atrium, gave the following results: the superior
or pulmonary anomalies, and to discuss
vena cava was on the right. The right atrium
their relation to .pulmonary pathology. was on the right and posterior to the right ven-
tricle which lay in a right paramedial position.
CASE 1. The main pulmonary artery was to the right
A. W., 23-year-old student. Soon after birth of the midline and it divided at the midline.
non- cyanotic congenial heart disease wa s The left atrium appeared in normal position.
diagnosed. At the age of six years, an attack of The left ventricle was located anterior to the
paroxysmal supraventricular tachycardia occurred, right ventricle. No abnormalities were visible in
followed by similar attacks wit h increasing the course of the aorta or the pulmonary veins.
frequency. Cardiac catheterization, attempted Right heart catheterization was interrupted
elsewhere, could not be completed because of because of recurrence of paroxysmal supraven-
paroxysmal .tachycardia.
tricular tachyarrhythmia. The pressure in the
right atrium was normal, and the oxygen satura-
*From the Cardiovascular Unit, Department of tion was 70 per cent, as in the superior vena
Internal Medicine B, Diagnostic X-ray Depart- cava. The brachial arterial oxygen saturation
ment and Department of Chest Diseases, Hadas-
sah Univenity Hospital. was 96 per cent.
186
Volume .
No .2
DIFFERENTIATION OF DEXTROVERSION FROM DEXTROPOSmON
August 1963

FIGURE 1 FIGURE 2
FIGURE 1: The greater part of an enlarged heart lies in the right hemithorax. The apex is not. dis-
cemible. The aortic knob is in its usual location, and a large pulmonary segment is seen below it.
The hilar and peripheral pulmonary arteries are wide. The lungs are normal (Case 1). FIGURE 2:
This exposure shows the right ventricle in front of the right atrium . Both these chambers are to the
right of the midline. Note the direction of the outflow tract of the right ventricle, and that of the
main pulmonary artery ascending from the right to left (Case 1).
On the basis of these data, the diagnosis of X-ray examination of .the chest (Fig. 3)
dextroversion of the heart, corrected transposition showed a symmetrical thorax. The greater part
of the great vessels, probably accompanied by of the enlarged heart was in the right hemi-
ventricular septal defect was made. The diag- thorax. The right border of the heart was
nosis was confirmed at operation. straight. The aortic knob was prominent to the
left. The pulmonary segment was concave. The
CASE 2. lungs showed increased translucency. The stom-
S. T ., 18 months old, poorly developed blue ach was on the left side. .
baby. The maximal pulsation of the heart was Venous angiocardiogram showed the superior
in the fifth intercostal space, to the right of the vena cava on the right, with simultaneous visual-
sternum. No murmurs were audible. There were ization of an enlarged right heart and the aorta.
signs of peripheral congestion. The pulmonary. arteries were not filled.
The electrocardiogram showed left axis shift, Postmortem examination showed a .complex
upward P,qR and negative T in Ls, high R congenital cardiac malformation, consisting of
waves in V 1-2 and equiphasic RIS deflections in dextroversion of the heart, corrected transposition
v, R. of the great vessels, stenosis of the pulmonary
artery, hypoplastic left pulmonary artery, multi.
pie ventricular septal defects, maldeveloped right
ventricle. ..
Dextroversion of the heart 'existed in this case,
accompanying multiple congenital cardiac an-
omalies without pathology of the pulmonary
parenchyma or pulmonary veins, but with a
hypoplastic left pulmonary artery.
CASE 3.
M. T., a 49-year-old woman, was admitted be-
cause of shortness of breath on exertion. During
the past 18 years, she had occasionally noted
blood stained sputum, and was once hospital-
ized with suspected pulmonary tuberculosis. At
that time she was told that her heart was in
FIGURE 3 : The greater pari of an enlarged heart the right chest. .
lies in the right hemithorax, with the apex above
the right diaphragm. The dilated aorta is on the On physical examination, the patient was in
left. The lungs are qligemic (Case 2) . good general condition, without dyspnea .or
Diseases of
188 ROGEL, SCHWARTZ AND RAKOWER the Chest

111
L. La. L.. ..\lit .. ..VF

~I\ v,1l. "It Va ~ \\ " '4


FIGURE 4: Electrocardiogram of Case 3. Note the high R waves around the sternum and the decreasing
voltage in the other chest leads taken from the left and right precordium .
cyanosis. The heart was found in the right tributaries were even better visualized on Bucky
hemithorax, and no murmurs could be heard. films (Fig. 6) . On fluoroscopy a normal con-
Examination of the lungs did not reveal patho- figuration of the heart and the great vessels was
logic findings. seen in the right anterior oblique position. The
The electrocardiogram (Fig. 4) revealed up- bronchogram showed (Fig. 7) a bifid, right main
ward P in the standard bipolar leads, qR and bronchus, the upper one terminating in a blind
inverted T in L and aVL, and tall R waves diverticulum; the middle lobe bronchus was
around the sternum with ST-T changes, and absent, and the bronchus of Nelson extended
decreasing voltage in VI" and V.-. R. into the apex, thus showing that the whole right
lung consisted of a single lobe. No bronchiec-
Roentgenogram of the chest showed the heart
tasis was seen.
in a small right hemithorax. The aorta was
hidden behind the sternum. The left pulmonary Right heart catheterization showed that the
artery and its branches were very small (Fig. 5) . right ventricule was located to the right and
From the right upper lung field originated a anterior to the right atrium. The main pulmo-
vessel which coursed downward and in medial nary artery was in an oblique, right-to-midline
direction, increasing in diameter and receiving
numerous tributaries, disappearing below the
diphragm, near the spine. This vessel and its

j
J. ~
:~

FIGURE 6 : AP Ducky film shows the anomalous


pulmonary vein receiving numerous tributaries in
FIGURE 5: Note the pronounced asymmetry of the its caudad course. This vein apparently drains
chest. The heart shadow is entirely in the right the whole hypoplastic right lung. No other pul-
hemithorax (Case 3). . monary vessels are visible (Case 3) .
X~ua:el~~ No.2 DIFFERENTIATION OF DEXTROVERSION FROM DEXTROPOSmON 18 9
CASE 4.
N. Ch., a 61-year-old clerk, was hospitalized
because of shortness of breath of increasing
severity and productive cough during the past
two years. On admission, the patient was in
good general condition. There was marked
dyspnea on slight effort. Except for accentuated
second aortic sound there were no pathologic
findings in the heart. The blood pressure was
200/100 mm . Hg. The right hemithorax ex-
panded less than the left, and on auscultation
rhonchi and moist rales could be heard at the
right base. The liver was on the right side.
There were no other relevant physical findings.
Electrocardiogram showed flat and isoelectric
T waves in most leads.
FIGURE 7: Bronchogram. The right upper Roentgenogram of the chest (Fig . 8) showed
bronchus terminates in a blind end. The lower
lobe bronchus shows irregular contour. No middle a small right thorax, and the mediastinum was
lobe is visible. The bronchus of Nelson is stretched markedly shifted to the right . The heart shadow
and branches in the upper lung field (Case 3) . was enlarged with indistinct right border and its
apex located above the middle of the left dia-
direction and posteriorly to the ascending aorta. phragm. The aorta was normal. The left pul-
The left pulmonary artery was entered, but the monary artery was enlarged, and the right
right pulmonary artery could not be catheterized. pulmonary artery was obscured. The vascular
The pressure values in all these places were markings of the right lung seemed markedly
normal. The . anomalous pulmonary vein was reduced. A vascular shadow originating in the
entered from the inferior vena cava, about 5 em. right middle lung field, near the heart border,
was seen running in a downward direction. On
below the diaphragm.
tomograms (Fig. 9) this vessel made a medial
This patient had a dextroversion of the heart curve and then turned towards the diaphragm
with a large anomalous pulmonary vein, draining and disappeared below it.
a hypoplastic right lung into the inferior vena Right heart catheterization disclosed normal
cava. In addition, significant bronchial anomalies course of the catheter, and normal pressure and
and hypoplastic right pulmonary artery were oxygen saturation values.
found . In this case, anomalous venous drainage of a
hypoplastic right lung, with a hypoplastic pul-
monary artery, was accompanied by dextroposi-
tion of the heart into a small right hemithorax,
but there was no rotation of the heart.
CASE 5.
T. G., a 22-year-old healthy woman. On
routine examination, the heart was found to
be in the right hemithorax. The maximal im-

r
,f) r

FIGURE 8 : The right hemithorax is smaller than


the left. The heart and the mediastinum are
shifted to the right . The apex is on the left.
An anomalous pulmonary vein is visible near the FIGURE 9: AP tomograma show the I~ anomal-
right heart border, disappearing beyond the heart ous pulmonary vein runninl{ in a seuucircle and
shadow (Case 4) . disappearing below the diaphragm (Cue 4).
Diseasesof
19 ROGEL, SCHWARTZ AND RAKOWER the Chest

pulse was felt in the fifth intercostal space, 3 with the apex lying close to the left of the
em. to the right of the sternum. The heart sternum.
sounds were normal and no murmurs were aud- Electrocardiogram exhibited signs of hyper-
ible. The rest of the physical examination was trophy of the right heart, without marked
irrelevant . change in the electrical position of the heart.
Roentgenogram of the chest revealed a small The P waves were in the expected direction in
right hemithorax. The heart shadow was com- the different leads.
pletely to the right of the midline. The aorta This case showed. an acquired dextroposition
was not visible, being in a retrosternal position. of the heart due to extensive pulmonary path-
No pulmonary vessels were visible in that part ology. There was no rotation of the heart around
of the right lung which was not obscured by the its longitudinal axis.
heart. No abnormal vascular shadows were dis-
cernible in the lungs. The gastric air bubble DISCUSSION
was under the left hemidiaphragm.
When the heart is mainly in the right
Electrocardiogram showed almost normal pat-
tern except' for small q and negative T in L, and hemithorax, the diagnosis between the dif-
highest positive deflections in V,-o with decreas- ferent subgroups of dextrocardia has to be
ing potentials of the ventricular complexes both made. True dextrocardia is easily recog-
to the left and right of the sternum. nized, while the other subgroups are more
In this healthy patient, dextroversion of the difficult to differentiate, mainly because of
heart was present with a right hypoplastic lung
in a small hemithorax, without evidence of ad- the confused terminology used by different
ditional cardiac or pulmonary disease. authors. It is not within the scope of this
paper to discuss the terminology used in
CASE 6.
the various types of dextrocardias. An at-
N. S., a 23-year-<>ld patient was treated by tempt is made only to emphasize the fea-
artificial pneumothorax because of advanced
right sided pulmonary tuberculosis during a tures of right sided heart due to dextro-
period of six years. At the conclusion of this version and that due to dextroposition.
therapy, the patient recovered, but fibrothorax The diagnosis of dextroversion of the
developed. heart is based on the clinical, roentgeno-
The chest roentgenogram six years after cessa- logic, electrocardiographic or catheteriza-
tion of the treatment (Fig. 10) showed a pro-
nounced shift of the mediastinum to the right, tion findings. On physical examination, in
small righ t hemithorax; markedly thickened addition to the right-sided heart, the maxi-
pleura and elevated right diaphragm. The mum impulse is felt near the sternum, and
greater part of the heart shadow was in the right is caused by the anteriorly placed left ven-
chest, but its configuration appeared normal , tricle and by the parasternal, anterior,
ascending aorta. Abnormal auscultatory
findings are present only when dextrover-
sion .is complicated by intracardiac anoma-
lies.
Radiologic examination, including an-
giocardiography, shows a peculiar config-
uration, without evident apex, since this
lies behind the sternum; the left atrium
forms the left heart border, and the right
ventricle the right border. The right atrium
is in a posterior position. The aortic knob
is in its normal, left-sided position, and the
pulmonary artery bifurcation is preverte-
bral. On fluoroscopy, a normal configura-
U '/ 7
tion is seen with the patient in the right
Ftouaa 10: The right hemithorax it shrunken, anterior oblique position.
The right pleura is markedly thickened. The
mediastinum and the heart are shifted to the In dextroposition of the heart normal
right. The apex is on the left side. The appear-
ance it typical for a fibrothorax (Case 6). ' cardiac chamber arrangement is present
X~~~1~3No. 2 DIFFERENTIATION OF DEXTROVERSION FROM DEXTROPOSITION 19 1

with more or less normal silhouette. The The present series of cases demonstrates
heart may be somewhat distorted by an un- the lack of etiologic relationship between
derlying lung pathology. The apex of the dextroversion of the heart and accompany-
heart is discernible to the left of the ster- ing thoracic, bronchial, vascular and intra-
num or behind it, since the pulmonary or cardiac anomalies.
pleural pathology may pull the heart in Cases 1 and 2 are the examples in this
toto, but does not rotate its apex and left series that dextroversion of the heart may
ventricle anteriorly. be present in patients with additional single
In dextroversion of the heart the electro- or multiple congenital cardiac malforma-
cardiogram exhibits upright P waves in Li, tions, but with no evidence of chest de-
indicating normal positioning of the atria. formity or pulmonary anomalies. Case 2
The anterior location of the left ventricle even shows that hypoplasia of the pulmo-
is evidenced by high R waves above and nary artery on the left side does not prevent
near the sternum. The mainly negative the rotation' of the heart into the right
deflections of the right ventricle are in- hemithorax.
scribed on the right. postero-Iateral chest Cases 3 and 4, on the other hand, both
wall. The first standard lead usually shows exhibit congenital malformation of the
qR and negative T waves. These findings bony thorax, bronchial anomalies of severe
can be interpreted as extreme counter- degree, and anomalous venous drainage of
clockwise rotation of the heart with nor- the right hypoplastic lung into the inferior
mally placed atria. vena cava, with hypoplastic pulmonary
The electrocardiogram in dextroposition artery on the same side. Yet, in Case 3
of the heart does not show this type of there was definite dextroversion of the
ventricular rotation and approaches nor- heart, while in Case 4, with the same
mal. pathologic process, only dextroposition took
place. Dextroversion of the heart cannot
Cardiac catheterization is helpful in
then be explained by the mediastinal shift
proving the normal position of the caval
occasioned by the small lung, as it is often
veins, the marked rotation of the ventricles
stated, since the latter was present in both
by the right turn of the catheter from the
cases, while dextroversion of the heart
right atrium into the right ventricle, and by
occurred only in one of them. The same
the right to left direction of the main pul-
is true for the coexisting vascular anomalies
monary artery. These features are not
of the right lung which were also similar in
found in dextroposition of the heart.
both patients. Case 5 differs from Case 3
All the above mentioned clinical, radio.. only by the absence of anomalous drainage
logic, electrocardiographic and catheteriza- of the right lung, and here, too, dextrover-
tion findings may be changed and compli- sion was present. On the other hand, in
cated by additional congenital anomalies Case 5 there was chest deformity and small
of the heart or lungs, which-though not lung similar to Case 4 which exhibited dex-
infrequent-are not necessarily present. troposition' only.
The differentiation between dextrover- Severe pulmonary pathology with small
sion and dextroposition of the heart does sized thorax and lung, of the acquired type
not seem to be difficult on the basis of the (Case 6), or small thorax with hypoplastic
above described criteria. Surprisingly lung and bronchial anomalies, of the con-
enough, dextroversion of the heart remains genital type. (Case 4), were not accom-
frequently unrecognized, and is erroneous- panied by dextroversion of the heart, in-
ly called "simple dextroposition," "dextro- dicating that for the presence of this con-
displacement of the heart" or "shift to the dition more than pulmonary pathology of
right," because of a coexisting lung advanced degree is needed. Pulmonary
anornaly.t'" abnormalities, with or without anomalous
Diseases of
19 2 ROGEL, SCHWARTZ AND RAKOWER the Chest

pulmonary veins (Cases 3 andS) were, ZUSAMMENFASSUNG

however, accompanied by dextroversion, Die Diagnose der Rechtslage des Herzens wird
showing the existence of this malrotation gelegentlich versaumt und irrtiimlich verwechselt
in such cases. Cases 1 and 2~ congenital mit einer Rechtsverziehung dank der haufigen
gleichzeitig bestehenden Lungenerkrankung. Un-
cardiac abnormalities without lung disease, ter Vorweisung von 6 Fallen mit verschiedenen
also exhibited right-sided heart without cardialen und/oder pulmonalen Anomalien wird
chamber inversion, proving that no pul- gezeigt; dab. die Rechtslage eine kongenitale
monary abnormality and small sized lung Fehlbildung des Herzens dargtellt ohne atio-
is necessary for development of dextrover- logish Beziehung zu irgend einer damit verkniipf-
ten kardialen oder pulmonalen, vaskularen oder
sion. bronchialen Anomalien.
The conclusion from these observations
REFERENCES
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1953. .
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senting six cases with different cardiac and/ 1961.
9 'HALASZ, N..A., HALLORAN, K. H. AND LIEBOW,
or pulmonary abnormalities, it is shown A. A.: ""Bronchial and Arterial .Anomalies with
that dextroversion is a congenital -malrota- Drainage of the Right Lung into the Inferior
Vena Cava;" Circulation 14: 826, 1956.
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11 STECKEN~ A.: "Beitrag zur Partiellen Lungen-
RESUMEN
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coraz6n, sin relaci6n etiol6gica con cualquiera ology, 74: 1, .1960. ,. . .
anomalia concomitante, sea cardiaca, pulmonar, For reprints, please write Dr. Rogel at 'Hadassah
vascular 0 bronquial. Medical Organization, Box 499, Jerusalem, Israel.