Radiological sign of left ventricular enlargement based on the distance between the inferior vena cava (IVC) and left ventricle (LV).​

Left ventricular enlargement is suggested on lateral chest radiograph if the distance (A) between the LV border border and the posterior border of IVC is more than 1.8 cm at a level 2 cm above the intersection of diaphragm and IVC.

Hoffman-Rigler sign measured
Hoffman and Rigler index measurement (A).

History of the Hoffman-Rigler sign

1959 – Eyler et al made an original and ingenious suggestion for the determination of left ventricular enlargement in the lateral view. They described an abnormal change in the relationship of the left ventricle to the inferior vena cava and the left leaf of the diaphragm. They noted that if the left ventricle extended posteriorly beyond the upper end of the vena cava more than 1.5cm, it probably was a sign of left ventricular enlargement.

In patients with rheumatic lesions of the mitral valve, the detection of left ventricular enlargement in the lateral view has been the most reliable single roentgen indication of the presence of mitral insufficiency or of an aortic valve lesion. All four views as well as fluoroscopy should be used.

When the left ventricle was enlarged, it has in most cases projected behind the shadow of the inferior vena cava for a distance of 15 mm. or more.

Eyler et al, Radiology 1959

1965Richard Bashefkin Hoffman (1937-2011) and Leo George Rigler (1896-1979) published their paper defining two measurements easily obtained from the lateral chest film and to determine their degree of efficacy in evaluating left ventricular size.

Measurement A is defined as the distance which the left ventricle extends posteriorly to the posterior border of the inferior vena cava at a point 2 em cephalad to the crossing of the cava and the left ventricle. Measurement is made on a plane extending posteriorly which parallels the horizontal plane of the vertebral bodies.

Measurement B is the distance of the crossing, referred to above, caudad to the left leaf of the diaphragm

When the posterior border of the left ventricle extends posteriorly to the posterior border of the inferior vena cava more than 1.8cm at a level 2cm cephalad to their crossing, on a lateral projection of the chest in the adult, one can postulate left ventricular enlargement with a considerable degree of certainty

Hoffman, Rigler Radiology 1965
Hoffman-Rigler sign 1965 Normal

Fig. 2. Right lateral projection of a normal heart
A. Radiograph with dots designating limits of measurements A and B.
B. Diagram of the posterior inferior cardiac border of the same case with measurements A and B designated.
LV = left ventricle; IVC = inferior vena cava; RD = right diaphragm; LD = left diaphragm
Hoffman-Rigler sign 1965 Aortic insufficiency
Fig. 5. Aortic insufficiency with Left Ventricular Hypertrophy
B. Right lateral view demonstrates large measurement A
C. Diagram illustrating measurements

2008Serna et al evaluated the validity of the H&R sign against the echocardiographic LV end-diastolic diameter in 200 patients and showed a sensitivity of 92.5%, a specificity of 83.3%, a positive predictive value of 78.7%, and a negative predictive value of 94.3%. They conclude that the Hoffman-Rigler sign is a valuable alternative in the evaluation of left ventricular enlargement when cardiac ultrasound is not readily available

2016Spaziano et al investigated the sensitivity and specificity of the H&R sign in a modern population. A sample of 145 patients with LV dilatation was matched for age and sex with 145
patients without LV dilatation. The H&R sign and the cardiothoracic index were assessed on the radiograph independently by 2 blinded physicians.

They found that the sign was only measurable in about two thirds of patients and that its diagnostic performance was low for detecting LV dilatation

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Third year M.D. student at the University of Notre Dame Fremantle. Passionate about emergency and retrieval medicine, rural practice and clinical research

BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

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