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The “tricolore” sign of heart failure
  1. H Liptau,
  2. J Gellissen,
  3. H Schunkert
  1. heribert.schunkertinnere2.uni-luebeck.de

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A 73 year old male patient with ischaemic cardiomyopathy and congestive heart failure (New York Heart Association functional class IV) presented with cachexia and chronic pleural effusion. He was sent for abdominal and thoracic computed tomography (CT) scans to rule out malignancy. Aside from cardiomegaly and pleural effusion the CT showed few developmental cysts of the liver but no suspicion of a malignant tumour.

The images were unusual for a distinctive trilaminar contrast density in the inferior vena cava (panel A) that was found 70 seconds after dye injection into the right cubital vein. The opaque bottom layer was explained by a substantial retrograde flow of almost undiluted contrast medium below the level of the right atrium. The middle layer consisted of contrasted blood returning from both renal veins into the inferior vena cava after first passing through the kidneys. The top layer represented poorly contrasted blood mainly returning from the lower extremities.

This study is remarkable because there was almost no admixture between these three distinctly contrasted layers. We attribute this “tricolore phenomenon” of heart failure to the physicochemical properties of the contrast medium in coherence with slow laminar flow secondary to low cardiac output.


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Abdominal CT scan 70 s after antecubital intravenous administration of 70 ml contrast medium (flow 2 ml/s) in a patient with low output heart failure. Note the inferior vena cava displays three distinct layers of contrasted blood (61 HU, 126 HU, and 785 HU, arrowheads), indicating slow laminar blood flow.


Embedded Image

Thoracic CT scan depicting basal parts of the enlarged heart. A seemingly turbulent influx of contrast medium is seen in the right atrium while the other cardiac cavities display a homogeneous density.

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