BRIEF REPORTS

A Simple Method to Interpret Cardiac and Aortic Anatomy

From Chest Radiographs

T. JAMES WATERS, MD RICHARD E. RUBIN, MD

WILLIAM C. ROBERTS, MD

In the training of cardiologists, considerable emphasis is placed on learning proper precordial examination and how to obtain and interpret electrocardiograms, echo- cardiograms, hemodynamics and contrast and radio- nuclide angiograms. In contrast, relatively little em- phasis is placed on learning how to interpret “routine” radiographs of the chest, This report describes a simple technique to aid in the interpretation of the cardiac and aortic silhouette on the chest roentgenogram.

A 3 X 5 inch (7.6 f 12.7mm) card is cut so that it is square (3 X 3 inches) (7.6 X 7.6 mm). On the card, 4 equal-sized circles are drawn, as demonstrated in Figure 1, upper left. The circle closest to the bottom of the card represents the right ventricle (RV), the 1 to the right the right atrium (RA), the 1 toward the top the left atrium (LA) and the 1 to the left the left ventricle (LV). Between the RA and RV, of course, is the tricuspid valve (TV), and between the LA and LV is

From the Division of Cardiology, Department of Medicine, Georgetown University, and the Pathology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Manuscript received and accepted May 23, 1983.

Coxsackie Viral Myocarditis Causing Transmural Right and Left Ventricular Infarction Without Coronary Narrowing

JEFFREY E. SAFFITZ, MD, PhD DAVID J. SCHWARTZ, MD

WILLIAM SOUTHWORTH, MD SIDNEY MURPHREE, MD

E. RENE RODRIGUEZ, MD VICTOR J. FERRANS, MD, PhD

WILLIAM C. ROBERTS, MD

Although in adults Coxsackie viral myocarditis is usu- ally an acute, self-limited, benign illness, it can pursue a subacute or chronic course leading to permanent

From the Pathology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, and the Departments of Pathology and Medicine, The Jewish Hospital of St. Louis and Washington University School of Medicine, St. Louis, Missouri. Manu- script received and accepted June 3, 1983.

the mitral valve (MV). The aortic valve (AV) lies in the center surrounded by the circles representing each of the 4 cardiac chambers. The descending thoracic aorta (A) is lo- cated to the left of the mitral valve. The esophagus (E) is located between the LA and vertebral bodies.

After these structures are drawn on the 3 X 3 inch card, the ends of a pipe-cleaning wick are placed through the aortic valve and descending aorta and secured by bending the wire on the back of the card. The wick then represents the as- cending, transverse and proximal descending thoracic aorta. The bottom of the card represents the anterior chest wall, the right (R) edge the right side of the chest, the top the posterior wall and the left (L) edge the left lateral wall of the chest. The card can now be viewed from the front (Fig. 1, upper left), left lateral position (Fig. 1, upper right), left anterior oblique (LAO) position (Fig. 1) lower left) and right anterior oblique (RAO) position (Fig. 1, lower right) simply by rotating the card.

In the left lateral (LL) position (Fig. 1, upper right) the RV is the most anterior chamber and the LA the most pos- teriorly located chamber. The LV and RA are midway in between. In the LAO position (Fig. 1, lower left), the RA and RVare to the left and the LA and LV to the right. This is the best view for seeing the ascending and descending thoracic aorta (Ao). In the RAO position (Fig. 1, lower right), the RA and LA form the right lateral border and the RVand LV the left lateral border. The ascending and descending thoracic aorta are superimposed.

This simple 3 X 3 inch index card with the pipe wick can be kept in the wallet or purse until these chamber locations in each of the 4 standard radiographic views are engrained. This simplified approach has made the teaching of radiographic anatomy easy.

cardiac dysfunction or death.1 Such was the case in the man described here.

During 1 week, a previously healthly 38-year-old white man had progressively severe dyspnea on minimal exertion without chest pain, fever, recent flu-like syndrome, systemic hypertension, palpitations, orthopnea, paroxysmal dyspnea or heavy alcohol consumption. Examination disclosed com- plete heart block with a ventricular rate of 40 beatslmin, Q waves in the anterior precordial leads, a markedly dilated left ventricle with segmental wall motion abnormalities (Fig. 1), and angiographically normal coronary arteries. Periph- eral blood counts and thyroid function study results were normal and serologic test findings for collagen vascular dis- eases were negative. The erythrocyte sedimentation rate was 21 mm in 1 hour. Antibodies against Coxsackie B-l were detected in serum at dilutions <l:lO at 1 and 4 weeks after onset of symptoms. After minimal improvement with di- goxin, diuretics and permanent pacemaker implantation, symptoms of congestive heart failure (CHF) worsened, and signs of right-sided CHF became severe. The peripheral leukocyte count increased to 19,000/mm3. Repeat serologic