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.

1. IMAGING OF VALVULAR
HEART DISEASES
DEVKANT LAKHERA

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

6. LEFT ATRIUM
 At the level of 7th Thoracic
vertebra

7. Enlargement
 Splaying of carina.
 Double heart border/
Double density sign

9.  Posterior displacement of
esophagus

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.

13. RIGHT ATRIAL
ENLARGEMENT
 Features are more subtle
 Elongation of the right
heart border
 Increased convexity of
right heart border

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.

16. RIGHT VENTRICLE
• Rhomboid in shape
• Papillary muscles attached to both free wall
and septum.

18. Three-chamber MPR
image shows the RV
moderator band

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.

21. Right ventricular enlargement
 Frontal view demonstrates:
 rounded left heart border
 uplifted cardiac apex

22.  Lateral view
demonstrates:
 filling of the retrosternal space

23. Artificial heart valves

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.

26. Normal Anatomy of the
Aortic Valve
 Valve consists of three semilunar
cusps
 Between the cusps and wall there
are pocket like sinuses

28. Aortic valve
This is the sinus of Valsalva.
It fills with blood during diastole,
supplying the coronary arteries

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

32. X Ray findings
May present with normal sized heart
shadow

33. Valve calcification
 On a lateral film the
presence of calcification
in the position of aortic
valve is a sign indicating
aortic stenosis.

34. Aortic Regurgitation
 Congenital:
 Bicuspid valve or disproportionate cusps
 Acquired:
 Rheumatic disease
 Infective endocarditis
 Trauma
 Aortic dilatation (marfan’s syndrome, aneurysm, dissection,
syphilis)

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

36. On X-Ray

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)

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.

42. Prominent left
atrial appendage

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.

44. Pulmonary
hemosiderosis

45. Mitral regurgitation
CAUSES
Congenital anomalies
Degenerative myxomatous changes
Marfan’s syndrome
Left ventricular enlargement is
more common.
Calcification of valve is less
common

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

49. Pulmonary valve disease
 Very rare
 Occasionally seen in carcinoid disease and endocarditis