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---
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title: "Left Ventricular Enlargement"
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docid: "fbb972de-3e13-4c67-b7a4-f8901aa2efb8"
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authors:
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- key: "df804626-c042-4296-96e3-836a6da50fd6"
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value: "Gregory Kicska, MD, PhD"
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breadcrumbs:
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-
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name: "Cardiac"
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slug: "cardiac"
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treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "952326a0-b3ea-4a21-aa7a-d796cc9325ed"
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-
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name: "Left Ventricular Enlargement"
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slug: "left-ventricular-enlargement"
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treeNodeId: null
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category: "Cardiac"
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documentVersionId: "e8a63b4a-914d-475a-8dd1-cce5feaf7fec"
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imageCount: 15
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lastUpdated: "03/17/22"
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pageDescription: "Left Ventricular Enlargement"
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pageKeywords: "Cardiac, Differential Diagnosis, Left Ventricular Enlargement"
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pageTitle: "Left Ventricular Enlargement | STATdx"
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enhancedTitle: "Left Ventricular Enlargement"
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type: "DDX"
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breadcrumbs:
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- "Cardiac"
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- "Differential Diagnosis"
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- "Left Ventricular Enlargement"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Determination of LV chamber enlargement
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- Radiographic
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- Normal cardiothoracic ratio ≤ 0.5 on PA and ≤ 0.6 on AP at deep inspiration and proper positioning
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- Expiratory and lordotic or rotated projections can change appearance of cardiac silhouette shape and size
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- Leftward and downward displacement of left heart border
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- LV extending 2 cm posterior to IVC border (Hoffman-Rigler sign) on lateral view
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- Cross sectional
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- LV volume may be measured qualitatively, not quantitatively, when only axial planes are available
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- Reliable measurements require double oblique planes, usually short axis, and knowledge of phase within cardiac cycle
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- Normal internal LV diameter at base is 3.9-5.3 cm for female and 4.2-5.9 cm for male patients
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- 2-dimensional Simpson rule of discs in short axis or 3D auto-segmented are most reproducible
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- Less reliable: Biplane method of Simpson rule and area length rule
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- End-diastolic volume (EDV) > 170 mL in female and > 200 mL in male patients is indicative for enlargement
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- EDV normalized by body surface area (EDV/BSA) are 2 standard deviations above mean if > 100 mL/m² in male and above 95 mL/m² in female patients
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- Determination of LV wall thickness
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- End-diastolic radial LV wall thickness > 1.2 cm is abnormal
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- LV mass > 104 gm/m² in female or 119 gm/m² in male patients is specific for pathology
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- Pitfalls
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- Radiographic LV enlargement may be mimicked by pericardial effusion, expiration, poor lateral positioning or projection angle, or pericardial fat pad
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- Misidentification of end diastole most frequent cause of erroneous left ventricular size measurement
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- Cardiac volume may be affected by preimaging administration of β blockers or nitroglycerin
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- ## Helpful Clues for Common Diagnoses
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- **Heart Failure**
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- Ischemic cardiomyopathy most common etiology, followed by diabetes and hypertension
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- EF < 40%
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- Multivessel coronary artery calcifications or stenosis
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- Evidence of prior infarct, subendocardial fat
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- If retrospective gated CT or MR performed, myocardium can be evaluated for evidence of hibernation
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- Subendocardial or transmural delayed enhancement present in coronary artery distribution indicates ischemia
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- If delayed enhancement excludes subendocardial layer, nonischemic etiologies should be considered
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- **Aortic Regurgitation**
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- Bicuspid valve or calcified aortic valve
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- Incomplete coaptation of cusps during diastole
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- Regurgitant jet present on bright-blood MR
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- **Mitral Regurgitation**
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- Mitral valve calcifications
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- Dilated left atrium
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- Isolated right upper lobe edema is rare manifestation resulting from regurgitant jet
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- **Acute M****yocardial Infarction**
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- Enlarged cardiac silhouette compared to recent prior
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- Supporting clinical information, troponin leak, ECG changes, or typical chest pain
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- ## Helpful Clues for Less Common Diagnoses
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- **Patent Ductus Arteriosus**
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- Initially, enlarged main pulmonary arteries; later, LV, LA, and ascending aortic enlargement
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- LV enlargement with dilated ascending aorta in absence of valvular disease
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- Best seen in gated CT or 3D MRA
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- MR Qp:Qs ratio < 1:1
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- **Coarctation of Aorta**
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- Associated with bicuspid valve
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- Hemodynamic narrowing represented by dilated intercostal collaterals
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- Not to be confused with pseudocoarctation (tortuous arch without hemodynamic narrowing)
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- Undiagnosed cases in adults often occur when narrowing distal to left subclavian take-off
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- **Idiopathic Dilated Cardiomyopathy**
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- Patients often < 60 years of age
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- Diagnosis of exclusion
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- Significant coronary artery occlusion or myocarditis to be excluded
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- MR delayed enhancement present in ~ 40% of cases, most commonly mid-myocardial
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- EF < 40% &/or fractional shortening < 25%
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- **Hypertrophic Cardiomyopathy**
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- LVOT view shows MR with systolic anterior motion of mitral valve leaflet
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- Asymmetric septal, apical, and concentric variants exist
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- In concentric variant, differential includes hypertensive heart disease/aortic stenosis, amyloidosis, and sarcoidosis
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- Patchy mid myocardial enhancement in areas of LV thickening and RV insertion into LV
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- **Amyloidosis**
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- Patients typically > 65 years of age
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- Increased LV wall thickness with poor or normal contractility
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- Diffuse subendocardial perfusion defect
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- Delayed enhancement inversion recovery sequences show equal relaxation times between blood pool and myocardium
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- ## Helpful Clues for Rare Diagnoses
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- **Athlete's Heart**
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- Occurs in athletes who engage in prolonged aerobic activity
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- End-diastolic wall thickness > 15 mm in young patient with dilated heart can be seen in athlete's heart
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- LV volume will decrease following 3 months of deconditioning
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- **Pregnancy-Induced Dilated Cardiomyopathy**
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- Postpartum LV enlargement and hypokinesis
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- Follow-up imaging in 3 months may show resolution
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- **Alcohol-Induced Dilated Cardiomyopathy**
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- Accompanying clinical history
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- Follow-up imaging will show resolution if acute
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## Images
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### Selected Images
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**Heart Failure**
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*Coronal oblique NECT of ischemic heart failure shows LV enlargement with subepicardial fat <img src='img/arrows/WO.png'/>, predominantly in an LAD distribution, representing prior infract.*
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**Heart Failure**
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*Coronal oblique NECT of ischemic heart failure shows LV enlargement with subepicardial fat <img src='img/arrows/WO.png'/>, predominantly in an LAD distribution, representing prior infract.*
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**Heart Failure**
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*Short-axis inversion recovery MR through the LV mid-chamber shows dilated LV with late enhancement in a LAD distribution <img src='img/arrows/WO.png'/>, compatible with ischemic cardiomyopathy.*
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**Heart Failure**
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*Four-chamber bright-blood MR in a patient with history of long, uncontrolled, standing hypertension shows a mildly dilated LV with diffuse wall thickening. This will eventually progress to an appearance indistinguishable from other dilated CM.*
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**Heart Failure**
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*Diastolic phase LVOT CECT shows markedly dilated LV without aortic valve disease. This patient had depressed EF and densely calcified coronary arteries, indicating ischemic cardiomyopathy.*
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**Aortic Regurgitation**
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*Coronal cine MR shows a turbulent jet originating at the aortic valve, directed toward the LV chamber <img src='img/arrows/WO.png'/>.*
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**Mitral Regurgitation**
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*Systolic phase LVOT cine MR of mitral regurgitation shows low signal corresponding to regurgitation <img src='img/arrows/WS.png'/> due to mitral valve prolapse. The prolapsing leaflet is seen <img src='img/arrows/WO.png'/> with a regurgitant jet directed at the septum.*
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**Acute Myocardial Infarction**
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*Short-axis inversion recovery FSE MR through the LV mid-chamber shows mid-myocardial LAD distribution late enhancement <img src='img/arrows/WO.png'/>. Hypointense subendocardium indicates acute MI associated microvascular obstruction <img src='img/arrows/WS.png'/>.*
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**Patent Ductus Arteriosus**
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*Four-chamber CTA shows dilation of the left atrium and left ventricle from chronic volume overload due to left to right shunting across the patent ductus arteriosus (not shown).*
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**Patent Ductus Arteriosus**
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*Axial oblique CTA shows a connection <img src='img/arrows/WS.png'/> between the proximal descending aorta and the pulmonary artery, diagnostic of a patent ductus arteriosus. Left-to-right shunt resulted in LV enlargement.*
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**Coarctation of Aorta**
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*Sagittal T1 C+ FS MR shows focal narrowing distal to the left subclavian take-off <img src='img/arrows/WO.png'/>. Presence of intercostal collaterals and LV enlargement indicated a hemodynamically significant stenosis, differentiating it from pseudocoarctation.*
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**Dilated Cardiomyopathy**
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*Axial NECT in a 41-year-old man with symptoms of heart failure shows LV dilation without CAD. Cardiomyopathy etiology was not found, and a diagnosis of idiopathic dilated cardiomyopathy was made.*
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**Dilated Cardiomyopathy**
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*Short-axis inversion recovery FSE MR shows septal mid-myocardial enhancement in a patient with dilated cardiomyopathy <img src='img/arrows/WO.png'/>.*
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**Hypertrophic Cardiomyopathy**
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*Diastolic phase LVOT bright-blood cine MR of asymmetric variant hypertrophic cardiomyopathy shows asymmetric thickening of interventricular septum at base <img src='img/arrows/WO.png'/>. Study should be interrogated for fibrosis and SAM.*
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**Amyloidosis**
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*Short-axis inversion recovery FSE MR through LV mid-chamber 10 minutes post contrast shows near-equal relaxation of blood pool and myocardium. This finding is caused by altered contrast concentration kinetics due to presence of amyloid protein.*
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### Additional Images
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**Aortic Regurgitation**
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*Diastolic phase LVOT bright-blood cine MR of aortic regurgitation shows a turbulent jet originating at the aortic valve, directed toward the LV chamber <img src='img/arrows/WO.png'/>.*
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