acquired valvular heart diseases with x ray findings
TRANSCRIPT
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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