Acquired Valvular Diseases of the heart different imaging techniques

2.  Muscular organ that pumps blood
throughout the circulatory system.
 Situated between two lungs in the
mediastinum

3. 4 chambers – 2 atria / 2
ventricles
Right and Left atria are
separated from one another
by a fibrous septum
Interatrial Septum
Right and Left ventricles- by
Interventricular Septum
Upper part – memberanous
Lower part - Muscular

5.  4 Valves
2 Atrioventricular Valves
Mitral and Tricuspid
between Atria and Ventricles
2 Semilunar Valves
Aortic and Pulmonary
placed at opening of blood vessels arising
from ventricles

7. Left AV valve
Mitral Valve or Biscuspid Valve
Right AV valve
Tricuspid Valve
has 3cusps (anterior, superior,inferior)

8. Composed of
 saddle-shaped fibrous annulus
 2 leaflets (a semicircular anterior leaflet and a
rectangular posterior leaflet)
 2 commissures
 2 papillary muscles (anterolateral and
posteromedial)
 chordae tendineae, which are fibrous tendons
that arise from the papillary muscles and insert on
the free edges of the leaflets

11.  Half moon shaped
 Made up of 3 flaps
 Aortic Valve and
Pulmonary Valve
 Open only towards aorta
and pulmonary artery and
prevent backflow of blood
into the ventricles.

13.  is composed of a fibrous annulus,
 3 cusps (right coronary cusp, left coronary
cusp, posterior or non-coronary cusp)
 3 commissures that separate the cusps

14.  fibrous annulus,
 3 cusps
 3 commissures separating the cusps.

15.  Inspection – Apical impulse/pulsations
 Palpation-apical impulse/thrills/palpable
heart sounds
 Percussion-asses cardiac borders
 Auscultation - murmurs

17.  Plain Chest X Ray
 Fluroscopy
 2D Echocardiograpy
 CT Scan
 MRI
 Radionuclide Imaging
 Angiography

18.  Teleroentgenogram

19.  6 feet distance
 Shoulders rotated forwards and downwards
 Centering T7 verterbrae
 High KvP technique

22. Left Atrium
Left Ventricle
Right Ventricle

23. Aorta
Main pulmonary artery
Inferior Vena Cava

24.  Cardiac apex
 Cardia - Site/Shape/Size/Borders
 Enlargement of chambers
 Aortic arch/pulmonary art
 Pulmonary vascularity
 Shift of Mediastinum
 Diaphragm – level/tenting/flattening
 CP Angles

25. CardioThoracic Ratio:
Internal diameter of the thoracic
cavity from the Medial border of
the ribs at the level of Right
hemidiaphragm
Transverse cardiac measurement
as the horizontal distance the
most Lateral aspects of the left
and right margins of the heart
Normal CT Ratio
Adults – 50%
Newborns - 57%
Infants – 55 %

26.  Pure stenosis or Regurgitation or Both

27. Dilated aortic shadows
Aortic stenosis
Aortic Regurgitation
HTN
Coaractation of aorta
Aneurism of aorta
Dilated Pulmonary
artery
Pulmonary stenosis
PA HTN
idiopathic

28.  Double density
 Enlargement of LA
appendage
 Upliftment of left
mainstem bronchus
 Widening of carinal
angle

29.  Lateral view:
 Prominent
posterosuperior
cardiac border
 Posterior
displacement and
upliftment of left
mainstem
bronchus

30.  Usually subtle and
difficult to determine
in mild and moderate
cases
 Lateral prominence of
right heart border
often associated with
increase in convexity
 In severe chronic
cases right heart
border can become
massively distended
towards right side

31.  The ventricle enlarges
towards the lateral
wall of the thorax in a
downward direction,
displacing the apex
laterally and inferiorly

32. Lateral View:
 posterior
displacement of the
posterior inferior
border of the heart
 Hoffman-Rigler Sign:
measured 2 cm above
the intersection of the
diaphragm & IVC;
 (+) if posterior border
extends more than 1.8
cm of IVC

33. Rounding and
upliftment of cardiac apex

34. Lateral view
Retrosternal
fullness
contact of anterior
cardiac border
greater than 1/3 of
the sternal length

35. Volume Overload Pressure Overload
Right Atrium Tricuspid
Regurgitation
Tricuspid Stenosis
Left Atrium Mitral Regurgitation Mitral Stenosis
Right Ventricle Tricuspid
Regurgitation
Pulmonary
Regurgitation
Pulmonary Stenosis
Left Ventricle Mitral Regurgitation Aortic Stenosis

36.  Levocardia:
 the heart is predominantly in the left chest, and the
cadiac apex points leftward
 Dextrocardia:
 the heart is predominantly in the right chest, and the
cardiac apex points rightward
 Mesocardia:
 the heart is positioned in the midline, and the cardiac
apex points directly inferiorly
 Dextroposition (dextroversion):
 the cardiac apex points leftward, but the heart is
located predominantly in the right chest (typically due
to extrinsic forces)

37.  “SITUS” - pattern of anatomic arrangement.
 atrial situs is usually concordant with
visceral situs (stomach on left, liver on
right); hence these two are described
together

38. Situs solitus:
 the morphologic right atrium is to the right
of the morphologic left atrium
 the gastric air bubble is on the left side, and
the liver is on the right

39. Situs inversus:
 the morphologic right atrium is to the left of
the morphologic left atrium
 the gastric air bubble is on the right side,
and the liver is on the left

40. Situs ambiguous:
 this term is used when identification of
visceroatrial situs is not possible due to
paucity of anatomic markers

41. Normal Arborization
Pattern
• tapering from medial to
lateral
• outer 1 cm of lungs has no
markings
• tapering from bottom to up
• preferential flow to lung
bases
• increase in caliber of vessels
inferiorly
• Blood vessel accompanying
bronchi should be 1:1

42. Increase in perfusion may be seen as an
increase in the calibre of the blood
vessels
Decrease in perfusion is seen as
darker lungs and very few
appreciable vessels

43. Pulmonary Oligemia
• Vascular shadows reduced
• Occurs in TOF
• pulmonary artery HTN
• Critical Pulmonary Stenosis with reversal of
shunt

44. Pulmonary Plethora
• Vascular shadows are numerous
• Seen in lateral 1/3 rd of lung fields
• End on vessels are more in no (>5)
• Left atrial or right atrial enlargement usually

45. Pulmonary Venous hypertension
• in PVH equalization of vascualrity
>12mm Hg – upper lobe veins=lower lobe
Cephalization
upper lobe veins more prominent
>15mm Hg – Kerley B lines(lateral,septal)
Kerley A lines(longer,linear
reaching hilum)
>25mm Hg – frank alveolar edema
Seen in Mitral Valve disease

46. • Perihilar haziness
• Bronchial cuffing (signet ring and thick outline)
• Redistribution of blood flow

47. Pulmonary Edema
Pulmonary venous pressure > 25-28mm Hg
Typical Batwing appearance seen
Seen in Mitral valve diseases

48. AORTIC STENOSIS
Causes:
• Calcification of Congenitally deformed
bicuspid valve in Men > 30yrs
• Degenerative calcific disease in middle
aged/elderly patients
• Rheumatic Heart Disease
• Degeneration of a normal trileaflet aortic
valve

49.  Calcification of valve usually indicates gradient
across valve of > 50mm Hg
Symptoms
Chest pain/shortness of breath/syncope
Mechanism
Deposition of Calcium on aortic cusps obstruct
the outflow by their bulk as well as by stiffening
of cusps – Stenosis

50. Area (cm2 ) Mean Gradient
(mm Hg)
NORMAL 3 Few
Mild 1.5-2 <25
Moderate 1-1.5 25-40
Severe 0.6-1.0 >40
Critical <0.6 >70

51.  Normal-sized heart or mild cardiomegaly
 Left ventricular hypertrophy (muscular)
 +/- pulmonary venous hypertension
 Dilated ascending aorta only (the rest of the
aorta normal) due to jet of blood from
stenosis
 +/- calcification

53. Calcification of aortic valve

54.  Thickening
 Increased echogenecity
 Reduced mobility of the valve leaflets
 Acoustic shadowing behind the calcification

55.  Coronal
gradient-echo
MRI image
 Calcification of
aortic valve
produces a
signal void

56. Causes
Damage to valvular cusps
• Rheumatic heart disease
• Endocarditis
• Marfan’s syndrome – dilatation of aortic root
• Syphilis
• Luetic aortitis
• Aortic dissection
• Connective tissue diseases

57.  Volume overload on
LV
 Cardiomegaly
 Left ventricular
enlargement
 Dilated ascending
aorta and aortic
arch due to large
blood volume
 Normal pulmonary
vascularity
Sitting Dove sign

58.  Color Doppler – jet of regurgitation
 Continuous wave doppler interrogation of
the regurgitant jet in LV
 Pulse wave doppler sampling of flow in
aortic arch to detect any abnormal reversal
flow

59. Doppler images taken in the parasternal long-axis view.
(A) A very small central regurgitant jet indicating mild aortic regurgitation.
(B) (B) A much broader based jet in a patient with severe aortic regurgitation

60. MITRAL STENOSIS
Cause: Rheumatic fever
Multiple episodes of
Acute Rheumatic Fever
causes PanCarditis

61. Other causes: (Rare)
 congenital anomalies,
 prior exposure to chest radiation,
 mucopolysaccharidosis,
 severe mitral annular calcification,
 left atrial myxoma
 Infective endocarditis
 Carcinoid syndrome
 Fabray’s Disease
 Hurler’s syndrome
 Whipple’s Disease

62. • Fusion of the leaflet commisure
• Shortening and thickening of chorda
tendinae
Reduction of flow

63. Mitral stenosis occurs
•Left atrial pressure ↑
•Left atrium enlarges
•Cephalization
•Pulmonary Interstitial Edema
•Pulmonary Artery Hypertension develops
•Pulmonary Vascular Resistance increases
•Right Ventricle enlarges
•Pulmonic regurgitation develops
•Tricuspid annulus dilates
•Tricuspid insufficiency
•RV failure

64. Effect of MS on Lungs
 Pulmonary arterial hypertension develops
 muscular hypertrophy and hyperplasia
increased pulmonary vascular resistance
 Chronic edema of alveolar walls -> fibrosis
 Pulmonary hemosiderin deposited in lungs
 Pulmonary ossification may occur

65. Area (cm2 ) Mean Gradient
(mm Hg)
NORMAL 4-6 Few
Mild >1.5 <5
Moderate 1-1.5 5-10
Severe <1.0 >10

66.  Enlargement of left
atrial appendage
 Early – normal heart
size and subtle signs
of left atrial
enlargement

67.  Straightening of
left heart border
 Small aortic knob
 Double density of
left atrial
enlargement

68. Severe and longstanding cases – calcification
of the valve

69.  Cephalization
 Elevation of
main stem
bronchus
 Widened carinal
angle

70.  Leaflet thickening or
 calcification
(hockey-stick
deformity of the
mitral valve
leaflets is typical)
 leaflet mobility
 commissural or
sub-valvular fusion
Echocardiography (parasternal
long axis) shows marked thickening of
mitral leaflets with restricted mitral valve
orifice (doming anterior leaflet). Left atrial
(LA) enlargement is evident.

72. MITRAL REGURGITATION
 Degenerative valve or chordal tissue
Prolapsed leaflet
Ruptured chordae
Myxomatous degeneration
 Secondary to ischaemic heart disease or cardiomyopathy
Dilated mitral annulus
Papillary muscle dysfunction
Papillary muscle rupture
 Rheumatic mitral disease
 Infective endocarditis
 Hypertrophic cardiomyopathy

73.  In acute MR
Acute 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
 In Marfan’s Syndrome
Enlargement of aortic root

74.  Acute non-rheumatic
mitral regurgitation.
(A) Frontal view in the
acute phase.
 Heart size – nomral
 even in the presence
of high left atrial
pressure as evidenced
by the preferential
dilatation of the
upper-lobe vessels
and interstitial
oedema

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

77.  2D Echo – morphological abnormality
 Doppler – assessment of regurgitation
 Prolapse of posterior leaflet- regurgitation
jet will be directed superiorly to the roof of
the left atrium near aortic root
 Proplapse of anterior leaflet – jet will be
directed inferiorly

79. Transoesophageal
Echocardiography
 Assess exact nature
and severity of the
lesion

80. Shows evidence of regurgitation secondary to
lesions of right heart or pulmonary
Hypertension
Normal area – 10.5 cm2 Mean gradient – 40-45mmHg
Causes:
 Bacterial Endocarditis -Staphlycoccal
 Late feature of Rheumatic Heart Disease
 Metastatic carcinoid Disease

81. Enlargement of Right atrium
 Prominent bulging or elongated right
heart border
 +/- SVC or IVC prominence

82.  Tricuspid stenosis.
(A) The right heart border has bulged to
the right and its radius of curvature
has increased.
(B) In the lateral view, the gap
between the front of the heart
and the sternum is filled in.

83.  Commonly aortic and mitral valves
 2Types – Mechanical / Biological
Mechanical
~Ball and cage type(rare)
~Tilting disc type
Single – Bjork-Shiley
Bileaflet- St Jude or carbomedic

84.  Biological
 Stentmounted porcine xenografts
(pig valve tissue mounted on a frame)
 or homograft valves (human tissue, usually
without additional mechanical support)
 Visible on Echocardiography
 Small orifice size than the original valve
 Doppler – slightly restrictive pattern

87. Structure Fracture
Structure fractures have been reported
in some types of mechanical valves;
CXR using microfocus,
Fluoroscopy and CT have been useful
in identifying fractures
Porcine Bioprosthesis
The major problem with porcine bioprostheses
is their poor durability.
5th post of year - Cusp tears, degeneration,
perforation,fibrosis and calcification appear
10th year 20% will fail and require
reimplantation

88.  Incidence - 0.9 to 4.4%,
 most frequent - within 6 months of valve
replacement
 Organisms – Streptococcus, Staph aureus,
Candida albicans

89.  Transoesophageal Echocardiography
 Vegetations
 Small(1-5mm) very large(2-3cm)
 Damaging free edge of leaflets or leaflet
perforation ->Valve regurgitation
 Abscess formation

90. Transoesophageal echocardiogram in
the long-axis plane.
The bicuspid aortic valve shows large
vegetations on opposing leaflets (A)
(arrow).
The shortaxis view confirms the bicuspid
anatomy and shows the
'kissing' vegetations on
opposing leaflets (B) (arrow).

91.  Helps in assessing post-op complications

92.  MRI is limited in vegetation detection
 because of the artefacts generated by
ferromagnetic components
 useful for assessing pseudoaneurysms

93.  produces a set of
images at different
stages of the cardiac
cycle that can be
viewed dynamically
 Any marked
turbulence of flow of
blood is
demonstrated as
black signal void
At the level of aortic valve in pt with
aortic valve stenosis

94.  Acquired is Very Rare
 May be due to Carcinoid Disease and
Endocarditis