Radiologic Diagnosis of Heart

Diseases
An Atlas of Cardiac X-rays

PART 4
Radiological features of acquired valvular diseases
Heart failure and cardiomyopathies

Dr. Khairy Abdel Dayem

Professor of Cardiology
Ain Shams University
PART 4
Radiological features of acquired valvular diseases
 Mitral stenosis
 Mitral regurgitation
 Aortic stenosis
 Aortic regurgitation
 Tricuspid valve disease

Heart failure and cardiomyopathies

 Radiological Features of
Acquired Valvular Diseases
1. Mitral Stenosis

Stenosis of the mitral valve causes resistance to the flow of

blood from the LA to LV. The LA dilates. Blood will then
accumulate in the lungs causing pulmonary congestion. The
pulmonary vessel will then respond to long standing congestion
by arteriolar vasoconstriction. This will cause rise in pulmonary
artery pressure (pulmonary hypertension) and will partly relieve
pulmonary congestion. Pulmonary hypertension may – if severe –
cause severe right ventricular, hypertrophy, dilatation and failure,
and right atrial dilatation and may end in congestive heart failure.
X-ray Picture
 Mild stenosis of the mitral valve causes dilatation of the left
atrial appendage and straightening and mitralization of the left
border of the heart.

 As the stenosis becomes more severe pulmonary congestion

will start to appear and left atrial dilatation will progress until the
right border of the left atrium extends beyond the right border of
the heart. However, extreme left atrial enlargement is rarely
seen except if there is associated mitral regurgitation. Severe
cases will show Kerley A lines in the lungs which are straight,
dense lines up to 4 cm in length running toward the hilum.
Kerley’s B lines are also seen as dense short horizontal lines
most commonly present in the costophrenic angles and are
caused by edema and thickening of interlobular septa.
 The pulmonary hypertension will then set in causing severe
dilatation of the main pulmonary artery and its branches. The
left border of the heart will show small aortic knob due to
reduced cardiac output followed by a convexity representing
the enlarged pulmonary artery then another convexity due to
the dilatation of left atrial appendage followed by the cardiac
apex which may be displaced outwards by right ventricular
enlargement, (Fig. 72).

Fig. (72): Left: mild, Right: moderately severe mitral stenosis

causing increasing enlargement of the LA
 2. Mitral Regurgitation
(MR)
Initially the MR will cause dilatation of the LV and LA. Severe
and prolonged MR will result in LV failure, pulmonary congestion
and finally pulmonary hypertension, right ventricular enlargement
and right atrial enlargement.
X-ray Picture (Fig. 78 & 79):
The X-ray signs depend on the severity of the regurgitation and
the presence of complications. They include the following:
1. Signs of left atrial enlargement, i.e. straightening (mitralization)
of the left border of the heart and prominence in the third
intercostal space to the left of the sternum, backwards
displacement of the esophagus in barium swallow seen the
lateral projection and in severe cases the enlarged left atrium
appears as a prominence in the middle segment of right border
of the left heart. The LA may become aneurysmal and its walls
may be calcified.
2. Signs of left ventricular enlargement, i.e downwards and
outwards displacement of the apex crossing the diaphragm.
3. Advanced cases show X-rays signs of pulmonary congestion,
pulmonary hypertension and congestive heart failure.

Fig. (73): MR: left atrial and left Fig. (74): Aneurysmal dilatation of the left
ventricular dilatation and pulmonary atrium which extends beyond the border
congestion of right atrium almost to the right border
of the chest. LV is dilated
4. Calcification of the mitral valve
annulus is a common cause of
mitral regurgitation especially
in elderly females. It is best
seen in the lateral view as a C
shaped density posterior to the
mitral valve, (Fig. 75).
 In general, mitral stenosis
results in conspicuous
changes in the lungs with
few changes in the heart
(mainly mitralization or
straightening of the left
border of the heart). On the
other hand, MR results in
Fig. (75): Calcified mitral valve annulus
marked changes in the
seen as C shape density
heart, changes in the lungs
are less conspicuous.
 3. Aortic Stenosis (AS)

The most common cause of aortic stenosis in the elderly is

sclerocalcific aging of the aortic valve. Here thickening rigidity
and calcification of the valve cusps interfere with blood flow.

In the young, AS can be either rheumatic or congenital.

Rheumatic fever causes thickening, fusion and later calcification
of the aortic valve cusps. Rheumatic AS is more common in
males. Congenital AS results from thickening and calcification of
a congenitally bicuspid aortic valve.

AS causes concentric hypertrophy of the LV. The wall of the

ventricle becomes thick at the expense of the cavity. The overall
size of the ventricle is not changed.
1. Signs of mild AS in the X-ray are subtle and may consist of only
accentuated curvature of the chunky left lower cardiac border.

2. Later severe and longstanding aortic stenosis causes left

ventricular dilatation that can be detected in the X-ray by
displacement of the cardiac apex downwards and outwards
(Fig. 79).

3. Aortic valve calcification occurs and is seen as dense opacity

within the cardiac border. Calcification of the aortic valve
occurs in almost all adults with significant AS. It is difficult to
demonstrate in the routine film but better seen in fluoroscopy
(Figs. 76 & 77).

The absence of calcium after careful examination excludes

significant AS. However, heavy calcification can occur in old
age in the aortic valve with no significant stenosis.
Fig. (76): Case of aortic stenosis with Fig. (77): Calcification of the aortic valve
calcification of aortic valve and post (black arrow head) in the lateral view
stenotic dilatation of ascending aorta
 4. Post stenotic dilatation of the ascending aorta occurs as result
of the jet of blood ejected from the stenotic valve hitting the
wall of the aorta (Figs. 78 & 79).

Fig. (78): Mild aortic stenosis showing Fig. (79): Aortic stenosis. The X-ray shows
post stenotic dilatation of the post stenotic dilatation of the aorta and
ascending aorta dilatation of the LV

5. In severe and longstanding cases the LV dilates and ultimately

fails (Fig. 79).
 4. Aortic Regurgitation (AR)
The vast majority of cases of AR are due to rheumatic affection
of the valve. Rarely it may be due to:
 Congenital heart disease
 Infective endocarditits on top of AS or bicuspid aortic valve,
 Trauma
 Dissecting aneurysm of the aorta
 Ankylosing spondylitis
 Marphan Syndrome: Here cystic medionecrosis causes
weakening of the aortic wall and aortic annulus resulting in
annulo-aortic ectasia.
During diastole the blood in the aorta regurgitates in the LV
causing its dilatation then hypertrophy. During systole the
ventricle pumps a larger than normal amount of blood in the aorta
which dilates.
The X-ray shows, Figs. (80 & 81):

 Left ventricular enlargement

 Dilatation of the ascending aorta and the aortic arch

The combination of these 2 effects results in a peculiar boot

shaped heart called aortic configuration.

 The aorta may be aneurysmally dilated in cases of Marphan

Syndrome or Syphilis.
Fig. (80): AR with dilated ascending aorta, Fig. (81): Aneurysmally dilated
aortic arch and left ventricle resulting in ascending aorta in a case of AR
“boot shaped” “aortic configuration”
 5. Tricuspid Stenosis (TS)
In TS the most characteristic radiographic finding is prominence
of the RA without significant pulmonary arterial enlargement or
changes due to pulmonary hypertension, (Fig. 82).

Fig. (82): Prominence on the lower third of the right cardiac border caused by
dilated right atrium due to tricuspid stenosis.
 Heart Failure and cardiomyopathies
Heart Failure
Heart failure is the end result of many cardiac diseases
including ischemic heart disease, severe hypertension, severe
valvular heart disease, cardiomyopathies and some congenital
heart disease.

Radiologically it’s characterized by dilatation of left, right or

both ventricles and atria and pulmonary congestion. The cardiac
silhouette is enlarged and there may be both pericardial and
pleural effusion. In addition, radiological signs of the original
disease that caused the failure may also be apparent.
 Cardiomyopathies
Cardiomyopathy may be:

1. Hypertrophic

2. Dilated or

3. Restrictive

Dilated cardiomyopathy is the most common and presents

radiologically as dilated one or both ventricle. The left ventricle is
more commonly affected. Advanced cases show manifestations
of heart failure.

Hypertrophic myopathy starts by severe hypertrophy of the LV

that usually maximal in the outflow tract but may predominate in
the mid cavity or apex. The X-ray shows signs of concentric
hypertrophy of the LV: accentuation of the curvature of the lower
two thirds of the left cardiac border.
Fig. (83): Hypertrophic cardiomyopathy with
concentric LV hypertrophy.