Evaluation of the recumbent esophagogram in the early detection of left atrial enlargement.

Abstract

The use of the recumbent esophagogram as a means of early detection of an enlarged left atrium has been reported previously (4, 8). It was assumed that such a view might afford an early-possibly the earliest-sign of left atrial enlargement. Demonstration of a straight esophagus with the patient erect is considered by many clinicians to exclude a diagnosis of mitral valvular disease. It has been our experience, however, that in mild cases the esophagus may appear straight (negative) in the upright position but may show some deviation (positive) on the recumbent esophagogram. On the other hand, we are well aware that such a finding may lead to over-reading of roentgenograms, with diagnosis of mitral valvular disease where none is present. Consequently errors in interpretation may occur in both directions (5). In the present study we shall report further experiences with this procedure and evaluate its reliability in a larger series of cases. Method Fluoroscopy of the chest was performed, and postero-anterior teleroentgenograms and left and right anterior oblique films were obtained. The erect esophagogram was taken most often in the right lateral projection, and part of the same film was used for the right lateral recumbent esophagogram. The right lateral view was preferred to the right anterior oblique, since comparison of films is difficult when the angle of obliquity varies even slightly. All esophagograms were obtained under fluoroscopic control, after most of the barium-swallow had passed down the esophagus. The roentgenograms were taken in mid-inspiration, but fluoroscopy was performed both in deep inspiration and expiration. Fluoroscopy in expiration was done to rule out the possibility that changes in the height of the diaphragm in the recumbent position might cause a localized, well defined imprint in the lower third of the esophagus. The presumptive clinical diagnosis was formulated in all cases before the x-ray examination. Material and Results This study is based on 311 cases in which complete clinical and roentgenological data were available, including 173 cases with definite clinical evidence of mitral valvular disease, 17 with probable mitral valvular disease, 7 with various types of congenital heart disease, and a control group of 114 patients without clinical evidence of heart disease of any kind. Among the controls were patients with a high right diaphragm due to various causes, such as pregnancy, kyphoscoliosis, amebiasis of the liver, and phrenic crush. In 105 of this group the erect as well as the recumbent esophagogram showed a straight esophagus, with no localized, well defined indentation. In 18 of these cases a straightening of the left border of the heart, in 2 cases a prominent pulmonary segment, and in 3 straightening of the left heart border together with a prominent pulmonary segment were demonstrable on the postero-anterior and right oblique views (Figs. 1 and 2).