Which chest radiograph finding is classically associated with Tetralogy of Fallot?

• A. Boot-shaped heart
• B. Normal heart size
• C. Calcified aortic valve
• D. Left atrial enlargement

Answer: (A)

Tetralogy of Fallot produces a distinctive chest radiograph appearance because the right ventricle enlarges from outflow tract obstruction, pulling the heart’s apex upward and giving the silhouette a boot-shaped contour. This boot-shaped heart is the classic clue on X-ray for TOF, reflecting the combination of a VSD, right ventricular outflow obstruction, overriding aorta, and resulting right ventricular hypertrophy. Heart size can be normal or mildly enlarged, but the key feature is the characteristic shape. Other findings listed—such as calcified aortic valve or left atrial enlargement—are associated with different conditions and do not produce this radiographic appearance.