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D-Shaped Left Ventricle Seen on Gated Single-photon Emission Computed Tomography Is Suggestive of Right Ventricular Overload: The So-called Movahed's Sign

      To the Editor:
      In the article by De Lorenzo et al
      • De Lorenzo A.
      • Lessa C.
      • Camargo G.
      • Gottlieb I.
      • Lima R.S.
      A not so obvious cause of chest pain: pulmonary hypertension.
      entitled “A Not So Obvious Cause of Chest Pain: Pulmonary Hypertension,” they describe an image showing right ventricular enlargement that was seen on gated single-photon emission computed tomography (SPECT) images in a patient with pulmonary hypertension.
      However, they failed to recognize the classic D-shaped left ventricle in their images and the fact that this phenomenon has been well described as a very specific sign of right ventricular overload,
      • Movahed M.R.
      • Hepner A.
      • Lizotte P.
      • Milne N.
      Flattening of the interventricular septum (D-shaped left ventricle) in addition to high right ventricular tracer uptake and increased right ventricular volume found on gated SPECT studies strongly correlates with right ventricular overload.
      is now accepted as the so-called Movahed's sign,
      • Murarka S.
      • Movahed M.R.
      Review of Movahed's sign (D shaped left ventricle seen on gated SPECT) suggestive of right ventricular overload.
      and should be routinely assessed during interpretation of gated SPECT studies. In the initial publication of this phenomenon,
      • Movahed M.R.
      • Hepner A.
      • Lizotte P.
      • Milne N.
      Flattening of the interventricular septum (D-shaped left ventricle) in addition to high right ventricular tracer uptake and increased right ventricular volume found on gated SPECT studies strongly correlates with right ventricular overload.
      this sign was found to be very specific for right ventricular overload and was even more common than echocardiography in visualizing the D-shaped left ventricle. We believe that assessment of the septum shape during gated SPECT should be routinely performed to avoid missing a not so obvious cause of potentially treatable life-threatening chest pain, such as pulmonary hypertension or pulmonary embolism.

      References

        • De Lorenzo A.
        • Lessa C.
        • Camargo G.
        • Gottlieb I.
        • Lima R.S.
        A not so obvious cause of chest pain: pulmonary hypertension.
        Am J Med. 2014; 127: 605-607
        • Movahed M.R.
        • Hepner A.
        • Lizotte P.
        • Milne N.
        Flattening of the interventricular septum (D-shaped left ventricle) in addition to high right ventricular tracer uptake and increased right ventricular volume found on gated SPECT studies strongly correlates with right ventricular overload.
        J Nucl Cardiol. 2005; 12: 428-434
        • Murarka S.
        • Movahed M.R.
        Review of Movahed's sign (D shaped left ventricle seen on gated SPECT) suggestive of right ventricular overload.
        Int J Cardiovasc Imaging. 2010; 26: 553-557

      Linked Article

      • A Not so Obvious Cause of Chest Pain: Pulmonary Hypertension
        The American Journal of MedicineVol. 127Issue 7
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          A 63-year-old man was clearly a candidate for coronary artery disease, but comprehensive imaging studies led to an unexpected diagnosis. The patient presented with a 3-month history of oppressive exercise-induced chest pain and associated shortness of breath. He was a heavy smoker with hypertension and hypercholesterolemia.
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      • The Reply
        The American Journal of MedicineVol. 127Issue 12
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          In regard to the letter by Movahed, we recognize that there were no comments on the so-called Movahed's sign in our Images in Radiology publication.1 However, we note that the American Society of Nuclear Cardiology 2010 Guidelines for Nuclear Cardiology procedures state that in myocardial perfusion single photon emission computed tomography reporting, “the size of the right ventricle should be noted, as right ventricle dilation can provide a clue to the presence of right heart volume overload,”2 but have not yet incorporated the description of Movahed's sign.
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