acquired valvular heart disease, mr,tr,ar,as,ms, rheumatic valvulitis, radiology perspectives, cardiac valves, imaging findings on valvular diseases

1. ACQUIRED
VALVULAR
HEART DISEASE
Dr Kamal Adhikari
2nd year resident
Radiodiagnosis, NAMS

2. • Cardiac valvular disease causes significant morbidity and
mortality, particularly the aortic and mitral valves.
• Echocardiography is generally considered the first line of
investigation.
• However , both CT and MRI play important roles in
evaluation of valvular heart disease.

3. • CT scan can precisely assess valve morphology and if
retrospective ECG gating is used, functional assessment
can be performed,
including direct assessment of valve morphology
and the effects of valvular disease on cardiac dimensions
,mass ,
and ejection fraction.

4. • MRI can also evaluate valve morphology using cine bright
–blood SSFP(steady-state free precision) sequences
• and phase contrast imaging is valuable to quantify flow
across the valve.
• Stenosis and regurgitation is visible on SSFP sequences
and is visualized as an area of signal dropout.
• However , qualitative assessment of flow on SSFP
sequences often overestimates the degree of
regurgitation or stenosis.
• Imaging of valvular vegetations or masses and
postoperative valvular assessment can be achieved with
CT or MRI.

5. Mitral valve
• The bicuspid mitral valve
Posterior cusp :crescentic
Anterior cusp : semicircular
• The anterior leaflet covers more of the mitral orifice than
the posterior leaflet and forms a portion of the left
ventricular outflow tract (LVOT).

6. Mitral stenosis
• Left Atrial Outflow Obstruction
• Causes
Rheumatic fever (most common cause)
Congenital anomalies with parachute deformity.
Prior exposure to chest radiation.
Mucopolysaccharidosis.
Severe mitral annular calcification
Ball valve thrombus
Left atrial myxoma

7. Mitral Stenosis
Rheumatic Valvular Heart Disease
• Rheumatic heart disease causes mitral stenosis in 99.8%
of cases.
• In rheumatic mitral stenosis ,
fusion of the leaflet edges occurs along the commissures,
Accompanied by the thickening of the chordae tendinae
• Fibrosis and calcification associated with thickening and
tethering of the mitral valve apparatus lead to
Elevation of atrial pressure.
Atrial fibrillation.
Pulmonary venous hypertension.

9. Acute Rheumatic Valvulitis
Pathophysiology
• Multiple episode of Acute rheumatic fever(ARF) first-
pericarditis.
• Valves affected
-Most often mitral valve alone
-Then most often mitral and aortic together
-Lastly aortic valve

11. Chronic Mitral Stenosis
Pathophysiology
• Mitral orifice becomes smaller
- Two circulatory changes
- To maintain LV filling across narrowed valve, left atrial
pressure increases
- Blood flow across mitral valve decreases which to
decrease cardiac output.

12. Effects Of Mitral Stenosis
On Heart
• Left atrium hypertrophies and dilates secondary to
increased pressure
- Atrial fibrillation and mural thrombosis follow
• Left ventricle is “protected” by stenotic mitral valve
-LV usually normal in size and contour
• Pulmonary arterial pressure increases
- Intimal and medial hypertrophy of pulmonary arteries
increased pulmonary vascular resistance.

13. • Right ventricle dilates from pressure overload
- Main pulmonary artery dilates pulmonary valve
regurgitation
• Tricuspid regurgitation develops
- secondary dilated RV
• Right atrium dilates secondary to volume overload
- Right heart failure

15. Effect of Mitral Stenosis
On Lungs
• Pulmonary arterial hypertension develops
- first passively
• Then secondary muscular hypertrophy and hyperplasia
increased pulmonary vascular resistance
• Chronic edema of alveolar walls fibrosis
-pulmonary hemosiderin deposited in lungs
-pulmonary ossification may occur

16. • Increased venous and capillary pressure
Normal 5-10 mm Hg
Cephalization 10-15 mm Hg
Kerley B lines 15-20 mm Hg
Pulmonary interstitial
edema
20-25 mm Hg

17. Effects of Mitral Stenosis
On Right Ventricle
• RV hypertrophies in response to increased afterload
• Eventually RV fails and dilates
-causes dilatation of tricuspid annulus  tricuspid
regurgitation

18. X-ray findings of MS
Cardiac findings
• Usually normal or slightly enlarged heart
- enlarged atria do not produce cardiac enlargement, only
enlarged ventricles.
• Straightening of left heart border.
• Or , convexity along left heart border secondary to
enlarged atrial appendage
- only in rheumatic heart disease

22. X-ray findings of MS
Cardiac findings
• Small aortic knob from decreased cardiac output
• Double density of left atrial enlargement
• Rarely, right atrial enlargement from tricuspid insufficiency

25. X-ray findings of MS
Calcifications
• Calcification of valve- not annulus- seen best on lateral
film and at angio.
• Rarely , calcification of left atrial wall secondary to fibrosis
from long standing disease.
• Rarely , calcification of pulmonary arteries from PAH.

27. X-ray findings of MS
pulmonary findings
• Cephalization
• Elevation of left main stem bronchus
(especially if 90 to trachea)
• Enlargement of main pulmonary artery
secondary pulmonary arterial hypertension
• severe , chronic disease
-Multiple small hemorrhages in lung
-Pulmonary hemosiderosis

31. Echocardiography findings
• Leaflet thickening, nodularity
• Commissural fusion
• Narrowing of the valve to the shape of a fish mouth
• Calcification of leaflets (hockeystick deformity), chords fusion
and shortening
• Calculation of the mitral valve area and pressure gradient
across mitral valve (severity assessment)

32. Severity assessment on Echo
S.No. MVA Pressure
gradient across
Mitral Valve
Severity
1 >1.5 cm2 <5 mmHg Mild
2 1.0-1.5 cm2 5-10 mmHg Moderate
3 <1.0 cm2 >10 mmHg Severe

34. Role of CT/MRI
• Cine-MRI is helpful with good visualization of the restricted mitral
leaflets and the anterograde jet due to turbulent flow across stenotic
valve orifice (2 chambers view or LV outflow tract views).
• Direct measurement of orifice area can be performed with good
correlation with Echo.
• MDCT can also calculate MVA (usually larger than that measured by
Echo).
• Mitral valve leaflet calcification can be identified.
• Other causes of MS like ball valve thrombus or left atrial myxoma
can be identified.

35. CT and MRI findings
• Valve leaflets are thickened
• Characteristics fishmouth appearance is visible on the
two-chamber view.
• Left atrial size can be quantified
• Mitral orifice can be measured
• MRI shows a stenotic jet extending from the valve into the
LV and permits quantification of the severity of mitral
stenosis by measurement of the mean diastolic gradient
across the valve during diastole.

36. MS and MR
• Rheumatic mitral stenosis occurs with varying degrees of
mitral regurgitation
• When MS is severe, MR is relatively unimportant.

37. Mitral Regurgitation
• Mitral regurgitation is the most common of all valvular
lesions.
• Primary regurgitation directly affects the valve apparatus
and include rheumatic heart disease , mitral valve
prolapse , and infectious endocarditis.
• Secondary etiologies of mitral regurgitation are due to
changes in left ventricle geometry or function of the
papillary muscle and are frequently a result of ischemic or
hypertrophic cardiomyopathy.

38. Causes
• Rheumatic heart disease
• Non-rheumatic heart disease
• Mitral Leaflets disease:
• Prolapse
• Endocarditis
• Mucopolysaccharidosis
• Lupus
• RA

39. • Subvalvular apparatus:
Annular dilatation
Chordae tendineae rupture
Annular calcification
MI
Hypertrophic cardiomyopathy

40. • Acute Regurgitation:
• Infective endocarditis
• Rupture of chordae tendinae/papillary muscles
• Sudden volume loading into non-complaint left atrium
• Markedly elevated left atrial pressure
• Acute pulmonary edema and cardiac failure

41. Chronic Regurgitation
• Chronic mitral regurgitation
• Chronic volume load of both left ventricle and left atrium
• Dilatation of left ventricle and atrium
• Pulmonary vascular pressure may not be raised until
decompensation leads to cardiac failure

42. Chest X-ray
• Appearance depends on chronicity and severity of
MR/associated heart disease
• Acute MR:
Pulmonary edema
Virtually normal heart size and shape

44. • Chronic MR
• Cardiomegaly with left ventricular configuration
(enlargement of left ventricular contour with a larger
radius curve).
• Left atrial enlargement is less prominent with left atrial
appendage enlargement occurring rarely (contrast with
MS).
• However, in longstanding cases, marked left atrial
enlargement can occur.
• No calcification.

47. Echocardiography
• Detection of MR and grading of severity.
• Left atrial dilatation
• Increased atrial emptying volume
• Gradual closure of aortic valve during systole
• Systolic regurgitant color coded flow within the left
atrium.
• Pulsed Doppler sensitive to detect even small amounts
of regurgitant flow, can estimate the severity of MR
based on regurgitant jet

49. MRI
• Turbulent flow across mitral valve in MR causes spin
dephasing, thus detected in cine MRI.
• Quantification can be done as the difference between
ventricle stroke volumes (LVSV and RVSV).
• Regurgitant flow = RVSV-LVSV provided no TR/AR.
• Phase contrast MRI can differentiate antegrade and
retrograde flow.
• Regurgitant fraction = Mitral regurgitant volume/LVSV

50. Mitral regurgitation. Axial CMR shows a jet-
like signal void in the left
atrium due to moderate mitral regurgitation.
LA ¼ left atrium, LV ¼ left
ventricle, RA ¼ right atrium, RV ¼ right
ventricle.*

51. • Severity grading in MRI
Mild RV
<30 ml
RF
<30%
Moderate 30-59 ml 30-49%
Severe >60 ml >50%

52. Mitral Valve Prolapse
• m/c cause of severe non-ischemic MR
• Systolic bowing of the mitral leaflet >2 mm beyond the
annular plane into the atrium due to rupture or elongation
of the chordae tendinae
• Posterior leaflet most affected
• Isolated or associated with Marfan’s syndrome and ASD
• Diagnose on echo leaflet thickening >5 mm and flail
leaflet.
• Cardiac CT can detect MVP, small vegetations or rupture
of chordae.

53. Aortic stenosis
• Normal aortic valve consists of three cusps with semilunar
attachments to the annular ring.
• The area of normal aortic valve is 2.5 to 3.5cm2 .

54. Aortic stenosis
• Western world: Degenerative calcific disease of
aortic valve in middle aged or elderly
• Rheumatic heart disease: inflammatory fusion of the
commissures

55. Chest x-ray
• Rounding of the cardiac apex – Left ventricular hypertrophy
• Prominence of the ascending aorta due to post-stenotic
dilatation. (does not correlate with severity of stenosis).
• Calcification of the aortic valve, best viewed in lateral view.
• Calcification in x-ray indicates significant aortic stenosis
suggesting gradient of at least 50 mmHg.
• Pulmonary vascularity remains normal unless left ventricular
impairment leading to heart failure.

59. Echocardiography
• Recognition of bicuspid aortic valve
• Features of AS:
Thickening of valve
Increased echogenicity
Reduced mobility of the valve leaflets
Fibrotic thickening – increased echo
Calcification – highly echogenic with acoustic
shadowing

60. Role of Cardiac CT
Demonstration of LVH
Mild-moderate post-stenotic dilatation of ascending
aorta
Calcification of aortic valve
Limited motion of valve
Reduced area of aortic valve
Direct planimetry of the aortic valve orifice helps in
quantification of stenosis severity. (CT and MRI).

61. Role of Cardiac MRI
• Demonstrates
Impaired aortic valve opening
Morphology of the valve
Stenosis severity assessment
Differentiates subvalvular or supravalvular stenosis
Assessment of the ascending aorta
Left ventricular hypertrophy or dilatation/function

62. Rheumatic aortic stenosis
• Fusion of the commissures of the aortic valve cusps
• Associated with AR and MV
• CXR shows signs of MV involvement and left atrial
enlargement
• Post stenotic dilatation is rare.
• Gross aortic calcification is rare.

63. Aortic Regurgitation
• Causes
• Disease of cusps:
Bicuspid, Endocarditis, Rheumatic disease
• Disease of the aortic roots:
Systemic hypertension, Aortic dissection, Takayasu,
Marfan, RA, Elhers-Danlos syndrome, trauma

64. • Chronic AR: Left ventricular dilatation, increase
compliance, later cardiac failure
• Acute AR: No ventricular dilatation, Pulmonary edema

65. Chest X-ray
• Chronic:
Enlargement of left ventricle in both lateral and PA view.
Heart size reflects the severity of the disease.
Calcification - not a feature in pure AR.
Thoracic aorta may be moderately enlarged – bulge on the right
of the mediastinum.
Pure AR, excellent compensation for the increased flow in the
left ventricle, so normal pulmonary vasculature.
Large left ventricle, no other chamber enlargement, normal
pulmonary vessels – severe chronic AR.

68. Echocardiography
• Color flow Doppler: Jet of regurgitation, assess the
size, shape, distribution and intensity of jet appearance
• Continuous wave Doppler: assess the regurgitant jet in
left ventricle and Pulsed wave Doppler sampling of flow
in the aortic arch to detect reversal of flow.
• Assessment of left ventricular function.

71. CT and MRI
• CT or MRI obtained during diastole shows lack of
coaptation of the aortic leaflets and permits calculation of
the size of the regurgitant orifice.
• The characteristics of the LV and ascending aorta can be
accurately assessed.
• On MRI , a diastolic flow jet is visible emanating from the
valve into the LV. Regurgitant volume and fraction can be
calculated.

72. Coronal MRA. Oblique breath-hold cine-MRA in
a patient with mild aortic regurgitation indicated
by the black area of signal loss (black arrow).
The left atrial appendage (LAA) is embedded in
epicardial fat. There is mild dilatation of the
ascending aorta (aa) as a result of the aortic
regurgitation. Between curved arrows ¼ aortic
valve. lv ¼ left ventricle, pa ¼ pulmonary artery,
RA ¼ right atrium. Aortic valve calcification.
Axial CT at aortic valve level shows calcification

73. Tricuspid Valve Disease
Tricuspid Regurgitation:
m/c Functional; secondary to marked dilatation of tricuspid
annulus due to RVH in the presence of Pulmonary
Hypertension, mitral valve disease or replacement, IHD or
DCM.
Rheumatic heart disease
Endomyocardial fibrosis and Carcinoid syndrome (also
Stenosis) – Severe TR.
Ebstein’s anomaly
Bacterial endocarditis.
• Tricuspid stenosis
Causes- rheumatic heart disease (most common)
- carcinoid heart disease

74. Chest x-ray
Tricuspid regurgitation
• Right atrial enlargement
• PA: increased arch of right heart border
• Lateral: Increased retrosternal opacity between aortic
arch and outflow tract of right ventricle.
• Other subtle findings:
• right ventricular enlargement
• reduced prominence of pulmonary vascularity
• superior vena caval enlargement
• inferior vena caval enlargement
• features of congestive heart failure may also be presen

75. • Tricuspid stenosis chest x-ray findings
right atrial enlargement
superior vena caval enlargement
rarely, calcifications of the tricuspid valve may be seen
features of congestive heart failure may also be present

77. Echocardiography
• Most important diagnostic tool.
• TR
• Color Doppler: retrograde flow in the right atrium;
measurement of depth and area of jet penetration, the
severity can be graded.
• Pulsed Doppler: Pansystolic turbulent signal in the right
atrium; severe regurgitation if retrograde flow also noted
in IVC.
• TS:
• Thickened valve leaflets/limited motion
• Doppler: visualization and measurement of stenotic jet.

79. Pulmonic Stenosis
• Mostly asymptomatic
• When symptomatic
• Cyanosis and cardiac failure
• Cor pulmonale
• Loud systolic ejection murmur

80. Types
• Subvalvular
• Valvular
• Supravalvular

81. Valvular
• Classic pulmonic stenosis (95%)
• Congenital
• Metastatic carcinoid syndrome along with tricuspid disease
• Associated with Noonan syndrome
• ASD
• HOCM

82. X-ray findings
• Enlarged main pulmonary artery
• Enlarged left main pulmonary artery (jet effect)
 with a relatively normal caliber right pulmonary artery . This
configuration is due to the flow jet that is directed posteriorly into the
left pulmonary artery.
• Normal to decreased pulmonary vasculature
• Rare calcification of pulmonary valves in older

84. Subvalvular pulmonic stenosis
• Infundibular in TOF
• 50% have bicuspid PV
• 50% have valvular PS
• Subinfundibular
• Associated with VSD 85%

85. Supravalvular pulmonic stenosis
• May be either tubular hypoplasia or localized with post stenotic
dilatation
• Associated syndromes
• Williams syndrome
• Pulmonic stenosis
• Supravalvular AS
• Peculiar facies
• Post rubella syndrome
• Carcinoid syndrome with liver metastasis
• Ehlers-Danlos syndrome

86. Pulmonary regurgitation
Causes – conditions that dilate the pulmonary valve ring
e.g. pulmonary hypertension
surgical correction of congenital pulmonary stenosis
• Chest x-ray findings:
Signs of pulmonary regurgitation on chest radiograph are
often subtle, but include 1:
Right ventricular enlargement
prominent pulmonary trunk
features of tricuspid regurgitation may also be present
features of congestive heart failure may also be present

87. Prosthetic heart valves
• Identification on chest x-ray
• Right heart valves (TV/PV) separated by infundibulum.
• Left heart valves (MV/AV) immediately adjacent to each
other.
• Aortic valve points toward the arch.
• The adjacent mitral valve points anteriorly and inferiorly
on lateral radiograph (best seen with the prongs of the
bio-prosthetic valves).
• Pulmonic valve is the most superiorly-positioned valve
and it points more posteriorly on the lateral view.
• Tricuspid valve is the most anteriorly-positioned valve and
is seen en face on the lateral view.

88. Position of the valves

89. THANK YOU
References:
Textbook of Radiology and Imaging David
Sutton
Images from internet sources