1. Role of chest x-ray in
Acquired valvular heart
diseases

2. • 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.

3. • 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.

4. AORTIC STENOSIS

5. Aortic Stenosis
Frequency 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

6. Aortic Stenosis
X-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

7. 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

8. Does not correlate with the degree of
stenosis
Difficult to be detected in older patients
aorta becomes unfolded and slightly
dilated

9. Prominence of ascending aorta from post stenotic dilatation

10. Prominence of ascending aorta from post stenotic dilatation

11. 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

16. In most cases Pulmonary
vascularity is normal
But in advanced cases Left
ventricular impairment and associated
changes of heart failure

17. AORTIC REGURGITATION

18. Aortic Regurgitation
Causes
 Rheumatic heart disease
 Marfan’s
 Luetic aortitis
 Ehlers-Danlos syndrome
 Endocarditis
 Aortic dissection

19. Aortic Regurgitation
X-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

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

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

22. Enlarged left ventricle + enlargement of entire aorta in AR

23. LVH and dilated ascending aorta(dilated aortic
configuration)

24. MITRAL STENOSIS
LEFT ATRIAL OUTFLOW OBSTRUCTION

25. Rheumatic heart disease causes mitral
stenosis in 99.8% of cases

26. 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

27. 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.

28. Course of Mitral Stenosis
 Mitral stenosis occurs
 Left atrial pressure ↑
 Left atrium enlarges
 Cephalization
 PIE
 PAH develops

29.  PVR increases
 RV enlarges
 Pulmonic regurg develops
 Tricuspid annulus dilates
 Tricuspid insufficiency
 RV failure

30. 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

31. Small aortic knob from decreased
cardiac output
Double density of left atrial
enlargement
Rarely, right atrial enlargement from
tricuspid insufficiency

32. 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

33. 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

34. Straightening of the left heart border

35. Convexity from enlarged left atrial appendage

36. Small aortic knob

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

38. cephalization

39. cephalization

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

41. Mitral annulus Calcification
Calcification of mitral annulus does not
signify presence of mitral valve disease
• Occurs in older women
• Usually asymptomatic

43. MITRAL REGURGITATION

44. 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

45. LV enlargement dilatation of mitral
annulus
– Any cause of LV enlargement
LV aneurysm valvular
dysfunction
– Acute myocardial infarction

46. The acute lesion of rheumatic fever is
mitral regurgitation, not stenosis
The largest left atria ever are produced
by mitral regurgitation, not mitral
stenosis

47. X-Ray Findings in MR
In acute MR
– Pulmonary edema
– Heart is not enlarged

48. In chronic MR
• LA and LV are markedly enlarged
– Volume overload
• Pulmonary vasculature is usually
normal
– LA volume but not pressure is elevated

49. Markedly enlarged heart and large LA

50. MS MR

51. PULMONARY VALVE STENOSIS

52. It is very rare to see acquired disease
of the pulmonary valve
Carcinoid disease and endocarditis can
occasionally affect the valve

53. 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

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

55. TRICUSPID VALVE DISEASE

56. • 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

57. • 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).

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

59. TS-prominent right heart border

60. THANKS