Correlation of upper lobe vascularization with certain congenital intracardiac shunts.

Abstract

Dyspnea and cyanosis are diagnostic emergencies in the newborn. The most frequent clinical explanation is atelectasis or aspiration pneumonitis, and the radiologist is often hard pressed to make a preliminary diagnosis from the information available on the conventional film. In our experience, abnormal intracardiac shunts have been a frequent cause of alarming dyspnea and cyanosis, but the size and contour of the heart may be so normal at this period that the signs of anomalous blood flow through the lungs are overlooked or misinterpreted. Study of the distribution and the size of the peripheral vessels has greatly aided us in predicting the most probable type of anomaly, especially when serial films are obtained. The pediatrician is occupied with the acute problem of keeping the newborn child alive, so that the more calculated aids of electrocardiography, fluoroscopy, laboratory studies, angiocardiography, and precise physical examination are not employed until the immediate danger has passed. Often fluoroscopy is not possible, or, if it is done, oxygen and mask are brought to the x-ray department with the patient. Thus, the simple roentgenogram may be the only means for presumptive diagnosis, treatment, and prognosis. The following series of cases is presented from the point of view of the radiologist in a community hospital, who is called on to differentiate atelectasis and aspiration pneumonitis from congenital malformations of the heart and to make a presumptive anatomical diagnosis. Case I: P. K. was born Oct. 3, 1949, with poor color and appearance. Only slight cyanosis of the nail beds was noted. The heart was rapid, regular, and without murmurs. The clinical impression was congenital heart disease or atelectasis. Due to the patient's condition no laboratory studies were obtained. A roentgenogram (Fig. 1) shows an atypical left heart border and prominent hilar vessels. There is diminished aeration of the right upper lobe, apparently due to atelectasis. Bronchoscopy revealed no obstruction and no material in the bronchi. The child died Oct. 6. Autopsy showed transposition of the great vessels. The pulmonary artery was 2.8 cm. in circumference; the aorta 2.0 cm. Large dilated branches passed directly to the right upper lobe. There was extreme dilatation of the right ventricle. The ductus arteriosus was short and widely patent, the foramen ovale was patent and measured 2.1 cm., and a small 3.0-mm. interventricular septal defect was present. There was no atelectasis or pneumonitis. Case II: E. M. was born Jan. 14, 1951. No abnormality was noted, and she was discharged on Jan. 18. She was readmitted on Feb. 1 with dyspnea, dehydration, and cyanosis. There were no murmurs, and the heart was normal on physical examination. The red cell count was 4,250,000 and the hemoglobin 15 gm. A roentgenogram (Fig. 2) on April 2, at three months of age, shows a large right heart and bilateral upper lobe infiltration, more marked on the right.