Role of chest x-ray in Acquired valvular heart

diseases

• There is a wide variety of structural change that can affect the heart valves, but in terms of their function valvular disease can either be pure stenosis or pure regurgitation, or more likely a combination of both.

• The appreciation of the dynamics of flow through the cardiac chambers is important and allows the interpreter to assess from the features on the radiograph exactly what changes are occurring at the valvular level.

AORTIC STENOSIS

Aortic StenosisFrequency of Causes

Most often as result of degeneration of bicuspid aortic valve

Less commonly, 2° to degeneration of tricuspid aortic valve in person > 65

Even less commonly, 2° rheumatic heart disease in tricuspid aortic valve

Aortic StenosisX-Ray Findings

Depends on age patient/severity of disease• In infants, AS CHF/pulmonary edema• In adults

– Normal heart size Until cardiac muscle decompensates LVH

– Enlarged ascending aorta 2° post-stenotic dilatation 2° turbulent flow

– Normal pulmonary vasculature

Post-stenotic Dilatation of Aorta

Results due to the impact of the stenotic jet on the vessel wall

Variable as the jet itself vary in direction from patient to patient

Does not correlate with the degree of stenosis

Difficult to be detected in older patients

aorta becomes unfolded and slightly dilated

Prominence of ascending aorta from post stenotic dilatation

Prominence of ascending aorta from post stenotic dilatation

Calcification in the position of Aortic valve

An important sign On lateral film

Usually indicates hemodynamically significant AS

Calcification of valve usually indicates gradient across valve of > 50mm Hg

In most cases Pulmonary vascularity is normal

But in advanced cases Left ventricular impairment and associated changes of heart failure

AORTIC REGURGITATION

Aortic RegurgitationCauses

Rheumatic heart disease

Marfan’s

Luetic aortitis

Ehlers-Danlos syndrome

Endocarditis

Aortic dissection

Aortic RegurgitationX-Ray Findings

A large heart with predominantly left ventricular configuration

The ascending aorta and often the aortic arch are large and can sometimes be visualized as a bulge on the right of the mediastinum

No Calcification in pure aortic regurgitation unless there is combination of stenosis and regurgitation

Combination of a large left ventricle, no other chamber enlargement and normal pulmonary vessels is very suggestive of severe chronic aortic regurgitation

Enlarged left ventricle + enlargement of entire aorta in AR

LVH and dilated ascending aorta(dilated aortic configuration)

MITRAL STENOSISLEFT ATRIAL OUTFLOW OBSTRUCTION

Rheumatic heart disease causes mitral stenosis in 99.8% of cases

The reduction of flow occurs as a result of fusion of leaflet commisures

In addition, thickening of the valve leaflets occurs with shortening and thickening of the chordae tendinae which further restricts valve movement

The symptoms of flow restriction (dyspnea and heart failure) may be few until the valve become critically narrowed

The condition leads to thrombus formation in left atrium and consequent systemic embolus.

Course of Mitral Stenosis

Mitral stenosis occurs

Left atrial pressure ↑

Left atrium enlarges

Cephalization

PIE

PAH develops

PVR increases

RV enlarges

Pulmonic regurg develops

Tricuspid annulus dilates

Tricuspid insufficiency

RV failure

Chest X-Ray Findings in Mitral Stenosis

Usually normal or slightly enlarged heart

Straightening of left heart border

convexity along left heart border 2° to enlarged atrial appendage

Small aortic knob from decreased cardiac output

Double density of left atrial enlargement

Rarely, right atrial enlargement from tricuspid insufficiency

Chest X-Ray Findings in MS…Calcifications

Calcification of valve-not annulus-seen best on lateral film

Rarely, calcification of left atrial wall 2° fibrosis from long-standing disease

Rarely, calcification of pulmonary arteries from PAH

Chest X-Ray Findings in MS…Pulmonary findings

Cephalization

Elevation of left mainstem bronchus

Enlargement of main pulmonary artery 2° pulmonary arterial hypertension– Severe, chronic disease

Multiple small hemorrhages in lung– Pulmonary hemosiderosis

Straightening of the left heart border

Convexity from enlarged left atrial appendage

Small aortic knob

Right atrial enlargement from TR and enlarged Left atrial appendage from MS

cephalization

cephalization

Enlarged MPA and straightening of left heart border due to enlarged left atrium

Mitral annulus Calcification

Calcification of mitral annulus does not signify presence of mitral valve disease

• Occurs in older women• Usually asymptomatic

MITRAL REGURGITATION

Mitral Regurgitation Causes

Thickening of valve leaflets 2°rheumatic disease

Rupture of the chordae– Posterior leaflet more often-Trauma,

Marfan’s

Papillary muscle rupture or dysfunction– Acute myocardial infarction

LV enlargement dilatation of mitral annulus– Any cause of LV enlargement

LV aneurysm valvular dysfunction– Acute myocardial infarction

The acute lesion of rheumatic fever is mitral regurgitation, not stenosis

The largest left atria ever are produced by mitral regurgitation, not mitral stenosis

X-Ray Findings in MR

In acute MR

– Pulmonary edema

– Heart is not enlarged

In chronic MR

• LA and LV are markedly enlarged– Volume overload

• Pulmonary vasculature is usually normal– LA volume but not pressure is elevated

Markedly enlarged heart and large LA

MS MR

PULMONARY VALVE STENOSIS

It is very rare to see acquired disease of the pulmonary valve

Carcinoid disease and endocarditis can occasionally affect the valve

X-Ray Findings in pulmonic valve stenosis

Enlarged main pulmonary artery

Enlarged left pulmonary artery (jet effect)

Normal to decreased peripheral pulmonary vasculature

Rare calcification of pulmonary valve in older adults

Enlarged LPA and MPA and normal size heart---PS

TRICUSPID VALVE DISEASE

• Tricuspid stenosis (TS) is usually due to rheumatic fever and is usually seen in association with left heart valve disease

• TS is also sometimes associated with carcinoid syndrome

• Tricuspid regurgitation (TR) is usually secondary to right ventricular dilatation as in pulmonary vascular disease.

• Primary TR is less common and usually caused by rheumatic heart disease or infective endocarditis (heart valve infection).

• Chest x-ray may show right atrial bulge in either condition

TS-prominent right heart border

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