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The chest x-ray in congenital heart disease 5
Article · July 2013
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2. Somerville J, Grech V. The chest x-ray in congenital heart disease 5. Images Paediatr Cardiol Volume 15(2);2013:1-2
1
IMAGES
in
PAEDIATRIC
CARDIOLOGY
Somerville J, Grech V. The chest x-ray in congenital heart disease 5. Images Paediatr Cardiol
Volume 15(2);2013:1-2
Grown Up Congenital Heart Clinic, Mater Dei Hospital, Malta
The patient in question was a woman aged 56 years who was sent to a cardiologist with left chest
pain that was of non-cardiac origin.
Apart from a loud P2, for which there was no obvious reason, nothing was found on clinical
examination. The chest X-ray was reported as normal (figure 1).
Closer scrutiny by the clinician shows normal sized heart with an unusual bulge on the left cardiac
border.
Figure 1: CXR

3. Somerville J, Grech V. The chest x-ray in congenital heart disease 5. Images Paediatr Cardiol Volume 15(2);2013:1-2
2
A closer look shows the left pulmonary artery higher and larger than the right but no sign of the
main pulmonary artery which should be bulging in the pulmonary. In fact, too much left pulmonary
artery is seen. This raises the possibility that the main pulmonary artery is in the wrong place, either
medial to the aorta or behind it.
When looking for the ascending aorta on the left border of the upper mediastinum on the left, one
sees a second shadow parallel to the denser mediastinal edge. This runs in to the left aortic knuckle
in the normal position.
Could this patient have congenitally corrected transposition, perhaps with trivial pulmonary valve
stenosis (bicuspid valve)?
The electrocardiogram is helpful having seen the chest X-ray. There is a QS pattern in V1 with an
upright T wave in lead V1 (figure 2). This can occur in infarction but would extend across the
anterior chest leads. But in this case this inferior deflection appears in leads III and aVF. With
infarction, the striking and diagnostic lead aVL has an rsr such as one sees in V1 normally.
Figure 2: ECG
This is classical congenital corrected transposition without other anomalies. If one sees the ECG
first, one is suspicious of the diagnosis and it explains the chest X-ray, but it is easier when the X-
ray seen first.
Contact Information
Victor Grech
victor.e.grech@gov.mt
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