Valvular heart disease affects the mitral, aortic, tricuspid, and pulmonary valves. Imaging plays an important role in assessing valve stenosis and regurgitation, effects on ventricular function, and associated pulmonary pathologies. Echocardiography is the main imaging modality and can evaluate valve structure and function, ventricular size, and pressures. Chest x-ray is also useful and can show valve calcification and chamber enlargement. Imaging is used to assess disease severity and guide management.
2. VALVULAR HEART DISEASES
One of the most common groups of cardiac disorders in India
Disease affects
Mitral valve
Aortic valve
Tricuspid valve
Pulmonary valve
3. Imaging Modalities
Chest radiograph – Initial screening modality.
Echocardiography
Real time evaluation of heart chambers
Evaluate the stenosis and regurgitation
Ventricular function ( Size, wall thickness)
Trans stenotic pressure gradient/ Regurgitant volume
CT
MRI
4. Objectives of Imaging
Assessment of valves.
Effects of disease on pulmonary vasculature and ventricular
function.
Detection of associated pulmonary pathologies.
Follow up
5. Assessing the chamber enlargement :
Left atrium
Has smooth walls
Receives pulmonary veins
Forms most of the base of the
heart
10. Distance between
middle of double
density and left main
bronchus of >7 cm
indicates LA
enlargement in >90 %
11. Right atrium
Forms the right heart
border
Interior of right atrium is
separated by the crista
terminalis(smooth
muscular ridge)
Space anterior to crista is
covered by ridges called
pectinate muscle
12. Crista
terminalis
right atrium lies the crista
terminalis, a muscular ridge
that runs from the entrance
of the superior- to that of
the inferior vena cava.
This structure separates the
smooth part of the right
atrium - the sinus venosus -
from the trabecularized
right atrium.
15. LEFT VENTRICLE
Elliptical / Oval shape
Wall thickness is >1 cm in mid
diastole. Thickest at the base.
Endocardium is lined by fine
lattice like trabeculations
except in the basal half of iv
septum which is smooth.
Papillary muscles attach to
free wall only and not septum.
19. LEFT VENTRICULAR
ENLARGEMENT
Increased cardiothoracic ratio.
left heart border/ apex is
displaced laterally, inferiorly or
posteriorly
rounding of the cardiac apex
Hoffman-Rigler sign
20. Hoffman-
Rigler sign
distance from the
posterior aspect of the
IVC to the posterior
border of the heart
horizontally at the level 2
cm above the intersection
of the diaphragm and the
IVC.
A distance of greater than
1.8 cm indicates left
ventricular enlargement.
24. localized by drawing a
longitudinal line through
the mid sternal body. Use
this line to bisect the
sternum in the sagittal
plane and then draw a
perpendicular line dividing
the heart horizontally.
25.
26. Normal Anatomy of the
Aortic Valve
Valve consists of three semilunar
cusps
Between the cusps and wall there
are pocket like sinuses
27.
28. Aortic valve
This is the sinus of Valsalva.
It fills with blood during diastole,
supplying the coronary arteries
29.
30. Aortic Stenosis
Narrowing of the aortic valve
Main causes:
Congenital bicuspid aortic
valve (younger)
Degenerative Calcification of
aortic valve (Elder)
Rheumatic inflammatory
fusion of aortic valve
31. Pathophysiology
Stiffening/Narrowing of Aortic
Valve
Incomplete emptying of
left atrium
Left ventricular hypertrophy
Pulmonary congestion
Compression of
coronary arteries
Right-sided heart failure
CO
Myocardial
O2 needs
Myocardial ischemia
(chest pain)
O2 supply
35. Pathophysiology
Incomplete closure of the
aortic valve
Backflow of blood to Left
ventricle
Left ventricular hypertrophy
& dilation
Left atrial pressure
Left-sided heart failure
(late stage)
Left atrium hypertrophy
CO
Pulmonary pressure
Right-sided heart failure Right ventricular
pressure
37. MITRAL VALVE (Left atrioventricular valve)
Bicuspid valve
Two leaflets anterior and posterior
Leaflets are attached to chordae
tendinae
Arise from two large papillary muscles
(anterolateral and posteromedial)
38.
39. MITRAL STENOSIS
Almost always rheumatic in
origin
Older people: can be caused
by heavy calcification of
mitral valve congestion
Congenital (rare)
40. Pathophysiology
Narrowing of mitral valve
CO
O2/CO2 exchange
(fatigue, dyspnea,
orthopnea)
Left ventricular
atrophy
pulmonary
congestion
pulmonary
pressure
left atrial
pressure
Hypertrophy left
atrium
blood flow to
left ventricle
Right-sided
failure
Fatigue
41. Signs of a mitral heart:
Cardiomegaly
Double right heart border - due to
enlargement of the left atrium.
Prominent left atrial appendage.
Severe splaying of the subcarinal
angle (150 degrees) - due to
compression from enlarged left
atrium.
43. Mitral valve
annulus
calcification
1. No gross evidence of
left atrial enlargement.
2. The pulmonary trunk
is clearly
demonstrated and not
enlarged.
3. Normal cardiac size.
46. Tricuspid valve
disease
This valve has three leaflets
and three papillary
muscles, which partially
insert on the septum (in
contrast to the papillary
muscles of the mitral valve,
which do not)
47. Tricuspid Valve
Diseases
usually occurs together with aortic or
mitral stenosis
may be due to rheumatic heart
disease (<5%)
On CXR, the main radiological sign is
right atrial enlargement, which can be
appreciated on frontal view
48. blood flow from right atrium to right
ventricle
right ventricular output
left ventricular filling co
If it occurs in isolation, suspicion should be
made of a valve lesion: e.g. carcinoid cardiac
valve lesions
Tricuspid valve anomalies are associated with
congenital heart diseases
Mainly due to the prevalence of rheumatic heart disease in India. Disease most commonly involves
Provides information about cardiac size pulmonary vasculature, arterial and venous hypertension, secondary changes in lungs..
Real time evaluation in multiple planes,…valvular calcification CECT can help assess chamber and valves..Ecg gated CT can help in reconstructing cardiac motion
shape of an irregular ellipsoid, with the exception of the right atrial appendage, which arises anteriorly
Most superiorly located chamber Lies posteriorly in the midline and enlarges posterior and to the right(not anteriorly)
Normally left atrium does not form any cardiac border on PA view.. Lt atrial appendage is a finger like / tubular structure has a pointed end and is trabeculated. Originates supralaterally….. trapezoidal shape of the right atrial appendage
Stenotomy sutures and prosthetic valve implant are seen. The cardiac shadow is enlarged. A double right heart border is noted. Prominence of pulmonary vasculature in the upper zones which indicates cephalization. Widening of carinal angle >90 degrees aortic knuckle calcification is seen ...Prominence of mid part of left heart border suggesting enlarged left atrial appendage.
White line enlarged left atrium
Atria may be massively enlarged crossing the right atrial shadow k/a Atrial escape
LA is located just anterior to the mid part of thoracic oesopagus, Enlarges posteriorly. Barium Swallow
Recieves the SVC, IVC and the Coronary sinus
Distance between right cardiac border convexity and the right lateral vertebral border > 3cms
known history of tricuspid regurgitation.
Has high pressure function Most muscular chamber
conical in shape with an anteroinferiorly projecting apex and is longer with thicker walls than the right ventricle
Internally, there are smooth inflow and outflow tracks and the remainder of the left ventricle (mainly apical) is lined by fine trabeculae carnae.
The right ventricle also has a thinner wall which is more trabeculated, especially towards the apex.. moderator band is another distinguishing feature of the right ventricle. It runs from the septum to the lateral wall of the right ventricle, it caries the conducting system of the heart Right bundle branch
Multiplaner reconstructon(2d post processing techniques) re-formats images at different planes, defined by the operator, using the pixel data from a stack of planar images (base images). The digital value for each pixel is assigned to a virtual voxel with the same thickness as the slice thickness of the base image. Airways , pulmonary emboli
Cardiomegaly with a lifted up cardiac apex.Notice that it is especially the right ventricle that is dilated. This is well seen on the lateral film (yellow arrow).
There is a small aortic knob (blue arrow), while the pulmonary trunk and the right lower pulmonary artery are dilated. All these findings are probably the result of a left-to-right shunt with subsequent development of pulmonary hypertension.
The location of the cardiac valves is best determined on the lateral radiograph. A line is drawn on the lateral radiograph from the carina to the cardiac apex. The pulmonic and aortic valves generally sit above this line and the tricuspid and mitral valves sit below this line
Pulmonary valve is more horizontal others are more oblique..mitral and tricuspid valve are usually seen as rings a line drawn through the valve forms more acute angle with the base of heart..anterior and posterior borders of the aortic valve are superimposed on pa view
Edge of these cusps are projecting into the aa, Right left and posterior (also known a non coronary cusp)
Blood fills these aortic sinuses and fills the coronaries
oblique CT image at the level of the aortic valve demonstrates right (R), left (L), and noncoronary (N) cusps
CT image obtained at a slightly more cranial level shows the origins of the right (white arrow) and left (black arrow) main coronary arteries
Cardiac CT showing a bicuspid aortic valve ..only two semilunar valves are visible
CO fails to meet the demands of heart: syncopy dec blood to brain, angina due to increased demand to lv and dec co, and exertional dysnoea later stages
Chest X-ray of aortic stenosis shows rounded profile of left ventricle), with slight enlargement of ascending aorta due to the stenotic jet of blood flow having a pressure effect
Frontal and lateral views demonstrate left ventricle enlargement, lateral displacement of apex, as left third
cardiac arch widening in the frontal view, and second posterior arch in the lateral view
Mitral valve is surrounded by annulus (fibrous ring around mitral leaflets) helps in proper closure of valve.
Horizontal long-axis MPR image shows the LV (large black *), RV (large white *), LA (small black *), right atrium (RA) (small white *), MV (black arrow), tricuspid valve (white arrow), and pericardium (arrowheads). The latter structure is normally very thin.
Three-chamber MPR image shows the LV papillary muscles (arrow) and chordae tendineae (arrowheads).
Very prevalent in developing countries
Left atrium is filled with blood…Dysnoea, cough (pulmonary congestion), fatigue ,oedema
Rheumatic mitral stenosis. This frontal film shows marked enlargement of the left atrial appendage
band of coarse calcification projected over the expected location of the mitral valve, to the left of midline.. mitral annulus is not significantly associated with stenosis of the valve
Pulmonary hemosiderosis due to long-standing mitral stenosis show diffuse small, rounded, “miliary” nodular areas of increased opacity bilaterally 1-4 mm(t.b histo,sarco,silicosis,vp)
Myxomatous is pathological weakening of connective tissue
crista supraventricularis a thick muscle separates pulmonary valve, from the tricuspid valve by known as the (blue arrow
