statdx/docs_md/articles/left-ventricular-enlargement_fbb972de-3e13-4c67-b7a4-f8901aa2efb8.md

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Left Ventricular Enlargement	fbb972de-3e13-4c67-b7a4-f8901aa2efb8	key value df804626-c042-4296-96e3-836a6da50fd6 Gregory Kicska, MD, PhD	name slug treeNodeId Cardiac cardiac fa90100b-619c-430e-8074-b5b9789bab39 name slug treeNodeId Differential Diagnosis differential-diagnosis 952326a0-b3ea-4a21-aa7a-d796cc9325ed name slug treeNodeId Left Ventricular Enlargement left-ventricular-enlargement null	Cardiac	e8a63b4a-914d-475a-8dd1-cce5feaf7fec	15	03/17/22	Left Ventricular Enlargement	Cardiac, Differential Diagnosis, Left Ventricular Enlargement	Left Ventricular Enlargement | STATdx	Left Ventricular Enlargement	DDX	Cardiac Differential Diagnosis Left Ventricular Enlargement

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title: "Left Ventricular Enlargement" docid: "fbb972de-3e13-4c67-b7a4-f8901aa2efb8" authors:

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ESSENTIAL INFORMATION

• Key Differential Diagnosis Issues

  • Determination of LV chamber enlargement - Radiographic - Normal cardiothoracic ratio ≤ 0.5 on PA and ≤ 0.6 on AP at deep inspiration and proper positioning - Expiratory and lordotic or rotated projections can change appearance of cardiac silhouette shape and size - Leftward and downward displacement of left heart border - LV extending 2 cm posterior to IVC border (Hoffman-Rigler sign) on lateral view - Cross sectional - LV volume may be measured qualitatively, not quantitatively, when only axial planes are available - Reliable measurements require double oblique planes, usually short axis, and knowledge of phase within cardiac cycle - Normal internal LV diameter at base is 3.9-5.3 cm for female and 4.2-5.9 cm for male patients - 2-dimensional Simpson rule of discs in short axis or 3D auto-segmented are most reproducible - Less reliable: Biplane method of Simpson rule and area length rule - End-diastolic volume (EDV) > 170 mL in female and > 200 mL in male patients is indicative for enlargement - 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
  • Determination of LV wall thickness - End-diastolic radial LV wall thickness > 1.2 cm is abnormal - LV mass > 104 gm/m² in female or 119 gm/m² in male patients is specific for pathology
  • Pitfalls - Radiographic LV enlargement may be mimicked by pericardial effusion, expiration, poor lateral positioning or projection angle, or pericardial fat pad - Misidentification of end diastole most frequent cause of erroneous left ventricular size measurement - Cardiac volume may be affected by preimaging administration of β blockers or nitroglycerin

• Helpful Clues for Common Diagnoses

  • Heart Failure - Ischemic cardiomyopathy most common etiology, followed by diabetes and hypertension - EF < 40% - Multivessel coronary artery calcifications or stenosis - Evidence of prior infarct, subendocardial fat - If retrospective gated CT or MR performed, myocardium can be evaluated for evidence of hibernation - Subendocardial or transmural delayed enhancement present in coronary artery distribution indicates ischemia - If delayed enhancement excludes subendocardial layer, nonischemic etiologies should be considered
  • Aortic Regurgitation - Bicuspid valve or calcified aortic valve - Incomplete coaptation of cusps during diastole - Regurgitant jet present on bright-blood MR
  • Mitral Regurgitation - Mitral valve calcifications - Dilated left atrium - Isolated right upper lobe edema is rare manifestation resulting from regurgitant jet
  • Acute M****yocardial Infarction - Enlarged cardiac silhouette compared to recent prior - Supporting clinical information, troponin leak, ECG changes, or typical chest pain

• Helpful Clues for Less Common Diagnoses

  • Patent Ductus Arteriosus - Initially, enlarged main pulmonary arteries; later, LV, LA, and ascending aortic enlargement - LV enlargement with dilated ascending aorta in absence of valvular disease - Best seen in gated CT or 3D MRA - MR Qp:Qs ratio < 1:1
  • Coarctation of Aorta - Associated with bicuspid valve - Hemodynamic narrowing represented by dilated intercostal collaterals - Not to be confused with pseudocoarctation (tortuous arch without hemodynamic narrowing) - Undiagnosed cases in adults often occur when narrowing distal to left subclavian take-off
  • Idiopathic Dilated Cardiomyopathy - Patients often < 60 years of age - Diagnosis of exclusion - Significant coronary artery occlusion or myocarditis to be excluded - MR delayed enhancement present in ~ 40% of cases, most commonly mid-myocardial - EF < 40% &/or fractional shortening < 25%
  • Hypertrophic Cardiomyopathy - LVOT view shows MR with systolic anterior motion of mitral valve leaflet - Asymmetric septal, apical, and concentric variants exist - In concentric variant, differential includes hypertensive heart disease/aortic stenosis, amyloidosis, and sarcoidosis - Patchy mid myocardial enhancement in areas of LV thickening and RV insertion into LV
  • Amyloidosis - Patients typically > 65 years of age - Increased LV wall thickness with poor or normal contractility - Diffuse subendocardial perfusion defect - Delayed enhancement inversion recovery sequences show equal relaxation times between blood pool and myocardium

• Helpful Clues for Rare Diagnoses

  • Athlete's Heart - Occurs in athletes who engage in prolonged aerobic activity - End-diastolic wall thickness > 15 mm in young patient with dilated heart can be seen in athlete's heart - LV volume will decrease following 3 months of deconditioning
  • Pregnancy-Induced Dilated Cardiomyopathy - Postpartum LV enlargement and hypokinesis - Follow-up imaging in 3 months may show resolution
  • Alcohol-Induced Dilated Cardiomyopathy - Accompanying clinical history - Follow-up imaging will show resolution if acute

Images

Selected Images

Heart Failure Coronal oblique NECT of ischemic heart failure shows LV enlargement with subepicardial fat , predominantly in an LAD distribution, representing prior infract.

Heart Failure Coronal oblique NECT of ischemic heart failure shows LV enlargement with subepicardial fat , predominantly in an LAD distribution, representing prior infract.

Heart Failure Short-axis inversion recovery MR through the LV mid-chamber shows dilated LV with late enhancement in a LAD distribution , compatible with ischemic cardiomyopathy.

Heart Failure 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.

Heart Failure 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.

Aortic Regurgitation Coronal cine MR shows a turbulent jet originating at the aortic valve, directed toward the LV chamber .

Mitral Regurgitation Systolic phase LVOT cine MR of mitral regurgitation shows low signal corresponding to regurgitation due to mitral valve prolapse. The prolapsing leaflet is seen with a regurgitant jet directed at the septum.

Acute Myocardial Infarction Short-axis inversion recovery FSE MR through the LV mid-chamber shows mid-myocardial LAD distribution late enhancement . Hypointense subendocardium indicates acute MI associated microvascular obstruction .

Patent Ductus Arteriosus 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).

Patent Ductus Arteriosus Axial oblique CTA shows a connection between the proximal descending aorta and the pulmonary artery, diagnostic of a patent ductus arteriosus. Left-to-right shunt resulted in LV enlargement.

Coarctation of Aorta Sagittal T1 C+ FS MR shows focal narrowing distal to the left subclavian take-off . Presence of intercostal collaterals and LV enlargement indicated a hemodynamically significant stenosis, differentiating it from pseudocoarctation.

Dilated Cardiomyopathy 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.

Dilated Cardiomyopathy Short-axis inversion recovery FSE MR shows septal mid-myocardial enhancement in a patient with dilated cardiomyopathy .

Hypertrophic Cardiomyopathy Diastolic phase LVOT bright-blood cine MR of asymmetric variant hypertrophic cardiomyopathy shows asymmetric thickening of interventricular septum at base . Study should be interrogated for fibrosis and SAM.

Amyloidosis 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.

Additional Images

Aortic Regurgitation Diastolic phase LVOT bright-blood cine MR of aortic regurgitation shows a turbulent jet originating at the aortic valve, directed toward the LV chamber .