The Differentiation of Dextroversion from Dextroposition
of the Heart and Their Relation to
Pulmonary Abnormalities*
S. ROGEL, M.D., A. ScHWARTZ, M.D. AND
Jerusalem, Israel
D EXT ROVE RS ION OF THE HEART 'IS A
subgroup of dextrocardias. It in-
cludes the-location of the heart in the right
hemithorax without inversion of the car-
diac chambers. This congenital anomaly
is the result of a counter-clockwise rotation
of a normally developed heart in the right
hemithorax. This condition has been de-
scribed as an isolated phenomenon." as
well as associated with different intracar-
diac and/or pulmonary anomalies .... The
heart, however, may be positioned in the
right hemithorax due to intrinsic factors,
such as major pathology of the right lung
or pleura. There is no rotation of the
heart in such cases, and the heart is simply
drawn into the right hemithorax. This
condition is mostly acquired and .named
dextroposition.t"
The terms dextroversion and dextro-
position are sometimes interchanged, and
different conditions are denoted by the
same name, or vice versa-different terms
are used for the same condition....1a
The .purpose of this paper is to present
cases with dextroversion and dextroposition
of the heart accompanied by cardiac and/
or pulmonary anomalies, and to discuss
their relation to .pulmonary pathology.
CASE 1.
A. W., 23-year-old student. Soon after birth
non- cyanotic congenial heart disease wa s
diagnosed. At the age of six years, an attack of
paroxysmal supraventricular tachycardia occurred,
followed by similar attacks wit h increasing
frequency. Cardiac catheterization, attempted
elsewhere, could not be completed because of
paroxysmal .tachycardia.
*From the Cardiovascular Unit, Department of
Internal Medicine B, Diagnostic X-ray Depart-
ment and Department of Chest Diseases, Hadas-
sah Univenity Hospital.
186
J. RAKoWER, M.D., F.C.C.P.
The patient was well-developed, without
cyanosis or dyspnea. The right anterior hemi-
thorax was prominent. The apex was felt in
the fifth intercostal space about 3 em, to the
right of the sternum. Systolic thrill was palpable
in the second and third intercostal spaces on
both sides of the sternum. On percussion the
heart was found in the right hemithorax. The
heart sounds were well audible and regular. The
second sound in the left second intercostal space
was accentuated and split. A rough, long, grade
3 systolic murmur was heard all over the pre-
cordium, in the right hemithorax, but maximally
in the second and third interspaces on the left
side of the sternum. The remainder of the
physical examination was non-contributory. The
electrocardiogram exhibited upward P waves in
L l _2 _3 , and negative P with R in a YR. In L 1
deeply inverted T waves and intraventricular
conduction disturbance were seen. The unipolar
chest leads showed high R waves around the
sternum with decreasing potentials laterally.
X-ray examination of the chest (Fig. 1)
showed a symmetric bony thorax, with the
greater part of the heart shadow in the right
hemithorax. The pulmonary segment was prom-
inent on the left, below the aortic knob. The
hilar pulmonary arteries were enlarged. The
vascular markings in the lungs were greatly
increased. The aorta appeared normal. The
stomach was on the left side. Angiocardiography
(Fig. 2), with the catheter placed in the right
atrium, gave the following results: the superior
vena cava was on the right. The right atrium
was on the right and posterior to the right ven-
tricle which lay in a right paramedial position.
The main pulmonary artery was to the right
of the midline and it divided at the midline.
The left atrium appeared in normal position.
The left ventricle was located anterior to the
right ventricle. No abnormalities were visible in
the course of the aorta or the pulmonary veins.
Right heart catheterization was interrupted
because of recurrence of paroxysmal supraven-
tricular tachyarrhythmia. The pressure in the
right atrium was normal, and the oxygen satura-
tion was 70 per cent, as in the superior vena
cava. The brachial arterial oxygen saturation
was 96 per cent.
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
hemithorax, and no murmurs could be heard.
Examination of the lungs did not reveal patho-
logic findings.
The electrocardiogram (Fig. 4) revealed up-
ward P in the standard bipolar leads, qR and
inverted T in L and aVL, and tall R waves
around the sternum with ST-T changes, and
decreasing voltage in VI" and V.-. R.
Roentgenogram of the chest showed the heart
in a small right hemithorax. The aorta was
hidden behind the sternum. The left pulmonary
artery and its branches were very small (Fig. 5) .
From the right upper lung field originated a
vessel which coursed downward and in medial
direction, increasing in diameter and receiving
numerous tributaries, disappearing below the
diphragm, near the spine. This vessel and its
tributaries were even better visualized on Bucky
films (Fig. 6) . On fluoroscopy a normal con-
figuration of the heart and the great vessels was
seen in the right anterior oblique position. The
bronchogram showed (Fig. 7) a bifid, right main
bronchus, the upper one terminating in a blind
diverticulum; the middle lobe bronchus was
absent, and the bronchus of Nelson extended
into the apex, thus showing that the whole right
lung consisted of a single lobe. No bronchiec-
tasis was seen.
Right heart catheterization showed that the
right ventricule was located to the right and
anterior to the right atrium. The main pulmo-
nary artery was in an oblique, right-to-midline

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
FIGURE 7: Bronchogram. The right upper
bronchus terminates in a blind end. The lower
lobe bronchus shows irregular contour. No middle
lobe is visible. The bronchus of Nelson is stretched
and branches in the upper lung field (Case 3) .
direction and posteriorly to the ascending aorta.
The left pulmonary artery was entered, but the
right pulmonary artery could not be catheterized.
The pressure values in all these places were
normal. The . anomalous pulmonary vein was
entered from the inferior vena cava, about 5 em.
below the diaphragm.
This patient had a dextroversion of the heart
with a large anomalous pulmonary vein, draining
a hypoplastic right lung into the inferior vena
cava. In addition, significant bronchial anomalies
and hypoplastic right pulmonary artery were
found .
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
right heart border, disappearing beyond the heart
shadow (Case 4) .
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.
Roentgenogram of the chest (Fig . 8) showed
a small right thorax, and the mediastinum was
markedly shifted to the right . The heart shadow
was enlarged with indistinct right border and its
apex located above the middle of the left dia-
phragm. The aorta was normal. The left pul-
monary artery was enlarged, and the right
pulmonary artery was obscured. The vascular
markings of the right lung seemed markedly
reduced. A vascular shadow originating in the
right middle lung field, near the heart border,
was seen running in a downward direction. On
tomograms (Fig. 9) this vessel made a medial
curve and then turned towards the diaphragm
and disappeared below it.
Right heart catheterization disclosed normal
course of the catheter, and normal pressure and
oxygen saturation values.
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-
FIGURE 9: AP tomograma show the I~ anomal-
ous pulmonary vein runninl{ in a seuucircle and
disappearing below the diaphragm (Cue 4).

19 ROGEL, SCHWARTZ AND RAKOWER
pulse was felt in the fifth intercostal space, 3
em. to the right of the sternum. The heart
sounds were normal and no murmurs were aud-
ible. The rest of the physical examination was
irrelevant .
Roentgenogram of the chest revealed a small
right hemithorax. The heart shadow was com-
pletely to the right of the midline. The aorta
was not visible, being in a retrosternal position.
No pulmonary vessels were visible in that part
of the right lung which was not obscured by the
heart. No abnormal vascular shadows were dis-
cernible in the lungs. The gastric air bubble
was under the left hemidiaphragm.
Electrocardiogram showed almost normal pat-
tern except' for small q and negative T in L, and
highest positive deflections in V,-o with decreas-
ing potentials of the ventricular complexes both
to the left and right of the sternum.
In this healthy patient, dextroversion of the
heart was present with a right hypoplastic lung
in a small hemithorax, without evidence of ad-
ditional cardiac or pulmonary disease.
CASE 6.
N. S., a 23-year-<>ld patient was treated by
artificial pneumothorax because of advanced
right sided pulmonary tuberculosis during a
period of six years. At the conclusion of this
therapy, the patient recovered, but fibrothorax
developed.
The chest roentgenogram six years after cessa-
tion of the treatment (Fig. 10) showed a pro-
nounced shift of the mediastinum to the right,
small righ t hemithorax; markedly thickened
pleura and elevated right diaphragm. The
greater part of the heart shadow was in the right
chest, but its configuration appeared normal ,
U '/ 7
Ftouaa 10: The right hemithorax it shrunken,
The right pleura is markedly thickened. The
mediastinum and the heart are shifted to the
right. The apex is on the left side. The appear-
ance it typical for a fibrothorax (Case 6). '
Diseasesof
the Chest
with the apex lying close to the left of the
sternum.
Electrocardiogram exhibited signs of hyper-
trophy of the right heart, without marked
change in the electrical position of the heart.
The P waves were in the expected direction in
the different leads.
This case showed. an acquired dextroposition
of the heart due to extensive pulmonary path-
ology. There was no rotation of the heart around
its longitudinal axis.
DISCUSSION
When the heart is mainly in the right
hemithorax, the diagnosis between the dif-
ferent subgroups of dextrocardia has to be
made. True dextrocardia is easily recog-
nized, while the other subgroups are more
difficult to differentiate, mainly because of
the confused terminology used by different
authors. It is not within the scope of this
paper to discuss the terminology used in
the various types of dextrocardias. An at-
tempt is made only to emphasize the fea-
tures of right sided heart due to dextro-
version and that due to dextroposition.
The diagnosis of dextroversion of the
heart is based on the clinical, roentgeno-
logic, electrocardiographic or catheteriza-
tion findings. On physical examination, in
addition to the right-sided heart, the maxi-
mum impulse is felt near the sternum, and
is caused by the anteriorly placed left ven-
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-
tion is seen with the patient in the right
anterior oblique position.
In dextroposition of the heart normal
cardiac chamber arrangement is present
X~~~1~3No. 2 DIFFERENTIATION OF DEXTROVERSION FROM DEXTROPOSITION
with more or less normal silhouette. The
heart may be somewhat distorted by an un-
derlying lung pathology. The apex of the
heart is discernible to the left of the ster-
num or behind it, since the pulmonary or
pleural pathology may pull the heart in
toto, but does not rotate its apex and left
ventricle anteriorly.
In dextroversion of the heart the electro-
cardiogram exhibits upright P waves in Li,
indicating normal positioning of the atria.
The anterior location of the left ventricle
is evidenced by high R waves above and
near the sternum. The mainly negative
deflections of the right ventricle are in-
scribed on the right. postero-Iateral chest
wall. The first standard lead usually shows
qR and negative T waves. These findings
can be interpreted as extreme counter-
clockwise rotation of the heart with nor-
mally placed atria.
The electrocardiogram in dextroposition
of the heart does not show this type of
ventricular rotation and approaches nor-
mal.
Cardiac catheterization is helpful in
proving the normal position of the caval
veins, the marked rotation of the ventricles
by the right turn of the catheter from the
right atrium into the right ventricle, and by
the right to left direction of the main pul-
monary artery. These features are not
found in dextroposition of the heart.
All the above mentioned clinical, radio..
logic, electrocardiographic and catheteriza-
tion findings may be changed and compli-
cated by additional congenital anomalies
of the heart or lungs, which-though not
infrequent-are not necessarily present.
The differentiation between dextrover-
sion and dextroposition of the heart does
not seem to be difficult on the basis of the
above described criteria. Surprisingly
enough, dextroversion of the heart remains
frequently unrecognized, and is erroneous-
ly called "simple dextroposition," "dextro-
displacement of the heart" or "shift to the
right," because of a coexisting lung
anornaly.t'"
19 1
The present series of cases demonstrates
the lack of etiologic relationship between
dextroversion of the heart and accompany-
ing thoracic, bronchial, vascular and intra-
cardiac anomalies.
Cases 1 and 2 are the examples in this
series that dextroversion of the heart may
be present in patients with additional single
or multiple congenital cardiac malforma-
tions, but with no evidence of chest de-
formity or pulmonary anomalies. Case 2
even shows that hypoplasia of the pulmo-
nary artery on the left side does not prevent
the rotation' of the heart into the right
hemithorax.
Cases 3 and 4, on the other hand, both
exhibit congenital malformation of the
bony thorax, bronchial anomalies of severe
degree, and anomalous venous drainage of
the right hypoplastic lung into the inferior
vena cava, with hypoplastic pulmonary
artery on the same side. Yet, in Case 3
there was definite dextroversion of the
heart, while in Case 4, with the same
pathologic process, only dextroposition took
place. Dextroversion of the heart cannot
then be explained by the mediastinal shift
occasioned by the small lung, as it is often
stated, since the latter was present in both
cases, while dextroversion of the heart
occurred only in one of them. The same
is true for the coexisting vascular anomalies
of the right lung which were also similar in
both patients. Case 5 differs from Case 3
only by the absence of anomalous drainage
of the right lung, and here, too, dextrover-
sion was present. On the other hand, in
Case 5 there was chest deformity and small
lung similar to Case 4 which exhibited dex-
troposition' only.
Severe pulmonary pathology with small
sized thorax and lung, of the acquired type
(Case 6), or small thorax with hypoplastic
lung and bronchial anomalies, of the con-
genital type. (Case 4), were not accom-
panied by dextroversion of the heart, in-
dicating that for the presence of this con-
dition more than pulmonary pathology of
advanced degree is needed. Pulmonary
abnormalities, with or without anomalous

19 2 ROGEL, SCHWARTZ AND RAKOWER
pulmonary veins (Cases 3 andS) were,
however, accompanied by dextroversion,
showing the existence of this malrotation
in such cases. Cases 1 and 2~ congenital
cardiac abnormalities without lung disease,
also exhibited right-sided heart without
chamber inversion, proving that no pul-
monary abnormality and small sized lung
is necessary for development of dextrover-
sion.
The conclusion from these observations
is that dextroversion. of the heart is a con-
genital malformation which has' no etio-
logic relation to pulmonary pathology,
and thus may be present independently of
accompanying lung disease, congenital or
acquired, parenchymal or vascular. The
characteristic features of dextroversion,
shown by the different diagnostic methods,
make it possible to reach a correct diagnosis
in most cases and to differentiate this con-
dition from the much more frequent dex-
troposition of the heart.
SUMMARY
The diagnosis of dextroversion of the
heart is sometimes missed and erroneously
interchanged with dextroposition, because
of frequent, coexisting lung disease. By pre-
senting six cases with different cardiac and/
or pulmonary abnormalities, it is shown
that dextroversion is a congenital -malrota-
tion of the heart with no etiologic relation
to any associated cardiac or pulmonary,
vascular or bronchial anomalies.
RESUMEN
. EI diagn6stico de. dextroversion del coraz6n
algunas veces es pasado por alto y erroneamente
tornado por dextroposici6n a causa' de las enfer-
medades pulmonares con frecuencia coexistentes.
Al presentar seis casos con diferentes anormali-
dades cardiacas y pulmonares se muestra que la
dextroversi6n es una malformacion congenita del
coraz6n, sin relaci6n etiol6gica con cualquiera
anomalia concomitante, sea cardiaca, pulmonar,
vascular 0 bronquial.
Diseases of
the Chest
ZUSAMMENFASSUNG
Die Diagnose der Rechtslage des Herzens wird
gelegentlich versaumt und irrtiimlich verwechselt
mit einer Rechtsverziehung dank der haufigen
gleichzeitig bestehenden Lungenerkrankung. Un-
ter Vorweisung von 6 Fallen mit verschiedenen
cardialen und/oder pulmonalen Anomalien wird
gezeigt; dab. die Rechtslage eine kongenitale
Fehlbildung des Herzens dargtellt ohne atio-
logish Beziehung zu irgend einer damit verkniipf-
ten kardialen oder pulmonalen, vaskularen oder
bronchialen Anomalien.
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For reprints, please write Dr. Rogel at 'Hadassah
Medical Organization, Box 499, Jerusalem, Israel.