The 'boot-shaped heart' (coeur en sabot) on chest X-ray is the classic appearance of which congenital heart disease, and what anatomical feature accounts for this shape?

• A Transposition of great arteries — narrow superior mediastinum
• B Ebstein anomaly — massively enlarged right atrium
• C Total anomalous pulmonary venous connection — snowman sign
• D Tetralogy of Fallot — upturned right ventricular apex due to RVH and absent pulmonary artery segment ✓

Explanation

The coeur en sabot (boot-shaped heart) in Tetralogy of Fallot results from right ventricular hypertrophy (boot toe = upturned RV apex) and hypoplastic pulmonary artery (concave main pulmonary artery segment = absence of the boot instep). Lung fields show oligaemia. TGA shows an egg-on-side heart and narrow pedicle. Ebstein shows a globular enlarged heart. TAPVC (supracardiac) shows snowman/figure-of-8 due to enlarged vertical vein.

Reference: Grainger & Allison's Diagnostic Radiology, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.