1. Adult Cardiac Valvular Disease for the General Radiologist
Mark M. Hammer, MD
Kareem Mawad, MD
Fernando R. Gutierrez, MD
Sanjeev Bhalla, MD
All authors have disclosed no relevant financial relationships.
Address correspondence to: S.B., Cardiothoracic Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Box 8131, 510 S Kingshighway Blvd, St Louis, MO (

2. Contents Learning objectives Introduction
Overview of cardiac valvular anatomy
Mitral disease: regurgitation, annular calcifications, stenosis
Aortic disease: stenosis, regurgitation, calcifications
Tricuspid disease: regurgitation
Pulmonic disease: stenosis
Endocarditis and vegetations

3. Learning Objectives
Recognize the normal anatomic position of cardiac valves on frontal and lateral chest radiographs.
Describe the changes in cardiac chamber size that are related to aortic, mitral, and tricuspid valve stenosis and the changes that are related to regurgitation.
List features of aortic, mitral, and tricuspid valvular disease that are visible at chest radiography and computed tomography (CT).

4. Introduction
Valvular abnormalities underlie a large fraction of cardiac disease cases
Moderate to severe valvular disease is present in 8.5% of adults aged 65–74 years and 13.2% of adults 75 years or older
Presence of a valvular abnormality may affect how other medical conditions (eg, cancer) should be treated
Although cardiac function and valvular abnormalities are best evaluated with echocardiography or cardiac magnetic resonance (MR) imaging, many features of valvular disease are apparent at chest radiography and CT
Radiologists may be the first to discover cardiac valvular disease and can help in its evaluation
Diseases affecting each cardiac valve, from the most to the least commonly affected, are discussed in this presentation

5. Normal Valvular AnatomyP P A M T
Posteroanterior (PA) and lateral chest radiographs in a patient with normal cardiac valve anatomy show the locations of the tricuspid (T), mitral (M), aortic (A), and pulmonic (P, dotted-dashed circle) valves.
Click to view animation

6. Mitral Regurgitation Has multiple causes, most commonly:
Mitral valve prolapse
Infarct involving a papillary muscle
Dilated cardiomyopathy
Rheumatic heart disease
Imaging demonstrates sequelae of mitral regurgitation:
Left-heart failure
Left-sided chamber dilatation
Enlargement of pulmonary arteries because of venous hypertension I II
III IV
Schematics demonstrate normal mitral valve function (I) and the effects of mitral regurgi-tation (II–IV). Regurgitant volume (II) expands the left atrium (III) and recirculates into the left ventricle, which becomes dilated (IV). Red arrows = direction of flow.

7. Mitral Regurgitation
PA radiograph obtained in a 60-year-old woman with congestive heart failure shows an enlarged left atrium lifting the left mainstem bronchus, and enlarged pul-monary arteries (within blue-shaded ovals). These findings are characteristic of severe mitral regurgitation.
Click to view animation

8. Mitral Regurgitation LA RA LV
PA chest radiograph shows asymmetric edema in the upper lobe of the right lung, a feature resulting from acute mitral regurgitation. The asymmetric edema is related to the regurgitant jet directed toward the right superior pulmonary vein. Acute mitral regurgitation is often seen in the setting of myocardial infarction with papillary muscle rupture.
Axial CT images in a patient with chronic mitral regurgitation show dilatation of the left atrium (LA, top) and left ventricle (LV, bottom). The right atrium (RA, bottom) is also dilated from tricuspid regurgitation.

9. Mitral Annular Calcifications
Calcific deposition within the fibrous mitral valve annulus is a common finding due to aging.
It is thought to be produced by a mechanism similar to that leading to athero-sclerosis.
It is typically not associated with mitral valve dysfunction.
Lateral chest radiograph shows mitral annular calcifications in a 76-year-old man.

10. Mitral Annular Calcifications
PA (top left) and lateral (top right) radiographs and axial CT image (bottom left) show calcifi-cations of the mitral annulus, coronary artery, and aortic valve.

11. Mitral Stenosis
Virtually always associated with a history of rheumatic heart disease
Rarely from endocarditis, congenital malformation, or mitral annular calcification
Consequent pulmonary venous hypertension
Left atrium enlarges because of pressure overload
Calcified left atrium seen in rheumatic heart disease
Calcifications in the left atrium can also be seen with chronic, calcified thrombus
Left ventricle is typically not affected, in contrast to mitral regurgitation
LAA
Axial CT images show calcified mitral valve leaflets (top, arrows) and a dilated left atrial appendage (bottom, LAA) in a 64-year-old woman with severe mitral stenosis.

12. Mitral Stenosis
Axial CT images (same patient as previous slide) show right ventricular hypertrophy and pulmonary arterial enlargement due to pulmonary hypertension. Pulmonary vascular redistribution is evident, with pulmonary arteries larger than corresponding bronchi. Left ventricular hypertrophy due to aortic stenosis is also seen.
Click to view animation

13. Severe Mitral Stenosis
PA and lateral chest radiographs obtained in a 44-year-old man with a history of mitral stenosis and rheumatic heart disease who presented with shortness of breath show an enlarged, calcified left atrium with splaying of the carina, mitral valve replacement, and pulmonary vascular redistribution (upper lobe vessels larger than lower lobe vessels).
Click to view animation

14. Aortic Stenosis Common in aging populations
Caused by calcification of leaflets in a similar mechanism to aortic atherosclerosis
A bicuspid aortic valve (1%–2% of population) is predisposed to early stenosis
Dense calcification of the aortic leaflets is closely associated with severe aortic stenosis
In one series, patients with moderate to severe calcifications at CT had a 60% chance of aortic stenosis, according to Koos et al (2006)
Calcifications seen at chest radiography are even more strongly indicative of severe stenosis
Axial contrast-enhanced CT images at the level of the aortic root in a 54-year-old woman (top) and a 67-year-old woman (bottom) show dense calcifications of the aortic valve (arrows).

15. Severe Aortic Stenosis
PA (above left) and lateral (above right) radiographs show a calcified aortic valve in a 63-year-old man with dyspnea on exertion.
Aortic valve calcifications (arrows) are seen also on coronal (above left) and sagittal (above right) chest CT images obtained in the same patient.
Click to view animations

16. Aortic Stenosis
Outflow obstruction produces hypertrophy of the left ventricle
Ventricular hypertrophy may be overestimated on non–cardiac- gated images obtained during systole
Left ventricle is not typically dilated until a late stage of disease
Ectasia or aneurysmal dilatation of the ascending aorta often occurs
In bicuspid valves, ectasia is related to underlying defects in the aorta—with an imaging appearance similar to that in patients with Marfan syndrome
Dilatation also occurs because of the eccentric post-stenotic jet
Axial chest CT images in a 68-year-old woman show dense calcification of the aortic valve (top, arrow) and left ventricular hypertrophy (bottom, arrowheads).

17. Aortic Regurgitation (Insufficiency)
Most commonly related to aortic root dilatation
Root dilatation may be idiopathic or may be related to atherosclerosis due to aging or to an aortopathic syndrome such as Marfan disease
Valvular causes, which are less common, include:
Bicuspid aortic valve
Rheumatic heart disease
Infective endocarditis
Severely calcified aortic valves are often regurgitant
Results in both left ventricular enlargement and left ventricular hypertrophy
Because of enlargement, the ventricular wall may appear thin even when hypertrophied

18. Aortic Regurgitation (Insufficiency)
PA radiograph (above) and coronal CT image (right) obtained in a 48-year-old woman show a dilated aortic root and left ventricular enlarge-ment owing to aortic regurgitation.

19. Aortic Regurgitation
PA (left) and lateral (right) chest radiographs show marked left ventricular enlargement (arrows) in a 34-year-old woman with aortic regurgitation.

20. Marfan Syndrome
Coronal oblique (above left) and volume-rendered (above right) chest CT images show an ascending aortic aneurysm in a 60-year-old woman. Note the annulo-aortic ectasia, a classic feature of Marfan syndrome. The sinotubular junction, which typically forms a waist in the ascending aorta, is effaced (flat). If the aortic root is dilated, aortic regurgitation may develop. Annuloaortic ectasia also may occur in other hereditary aortopathies, such as a bicuspid aortic valve.

21. Aortic Annular Calcifications
Pathogenesis is similar to that of atherosclerosis in arteries
Same risk factors
Have no effect on valvular function
Lateral chest radiograph (left) and axial CT image (above) in an 81-year-old pa-tient show aortic annular calcifications (arrows).

22. Tricuspid Regurgitation
Mild or trace tricuspid regurgitation is normal
A majority of cases of pathologic tricuspid regurgitation are related to chamber abnormalities
Heart failure or pulmonary hypertension with dilatation of the right ventricle
Less common causes are endocarditis and carcinoid syndrome
Recirculation within the right-sided chambers causes dilatation and hypertrophy of both the right atrium and the right ventricle; the effect is similar to that of mitral regurgitation on the left-sided cardiac chambers
Increased hepatic venous pressure can lead to cardiac cirrhosis

23. Moderate Tricuspid RegurgitationRV RA RA
Chest CT image (above) and PA radiograph (right) in a 62-year-old woman with mod-erate tricuspid regurgitation show right a-trial (RA) enlargement. RV = right ventricle.

24. Severe Tricuspid RegurgitationRV RA LV
Axial CT images obtained in a 55-year-old man with shortness of breath and abdominal distention show a dilated right atrium (RA) and right ventricle (RV) with a tricuspid annuloplasty ring (above left); nodular liver with ascites (above right); and a di-lated left ventricle (LV) due to nonischemic cardio-myopathy. Biphasic hepatic vein waveform (right) from Doppler ultrasonography is consistent with severe tricuspid regurgitation and cardiac cirrhosis.
MHV
Click to view animations

25. Pulmonic Stenosis
Results from a congenitally thickened or partially fused valve
Frequently asymptomatic in children, commonly manifested in adulthood
A flow jet due to pulmonic stenosis is directed toward the main and left pulmonary artery and causes them to become enlarged
Obstruction also causes right ventricular hypertrophy
Patient with severe pulmonic stenosis and conse-quent main and left pulmonary artery enlargement (arrow).

26. Pulmonic Stenosis
Axial chest CT images show a thickened pulmonic valve (above left) in a patient with pulmonic stenosis. Note also the enlargement of the main and left pulmonary artery (above right).

27. Endocarditis with Vegetations
Endocarditis manifests with both embolic phenomena and valvular regurgitation
Predisposing conditions include intravenous drug use and underlying valvular disease
Septic emboli within the lungs may provide clues to the presence of endocarditis
Actual vegetations are infrequently seen; rarely, a perivalvular abscess or pseudoaneurysm can develop, with potentially catastrophic consequences
Right-sided vegetations produce pulmonary emboli; left-sided vegetations produce systemic emboli

28. Endocarditis with Vegetations
Axial chest CT images obtained in a 57-year-old man with shortness of breath show aortic valve vegeta-tion (above left) and peripheral cavitary pulmonary nodules (above right). These findings are indicative of infective endocarditis and septic pulmonary emboli. Tricuspid and mitral valve vegetations were seen at echocardiography (not shown).
Click to view animation

29. Endocarditis with Vegetation
Axial chest CT images obtained in a patient with a fever after undergoing tricuspid and mitral annuloplasties show an ill-defined nodular region of consolidation consistent with septic emboli (above left) and a vegetation on the tricuspid valve (above right).

30. Endocarditis with Septic Emboli
Bilateral, patchy, nodular areas of consolidation, some of which are cavitary, are suggestive of septic emboli.
Cardiomegaly with right atrial enlargement is suggestive of tricuspid valvular dysfunction.

31. Endocarditis with Septic EmboliRA
Axial pulmonary CT image shows bilateral, peri-pheral, ill-defined nodular areas of consolidation (arrows, above), some of which are cavitary. These findings are characteristic of septic emboli. Top right: Axial CT image shows thickening of the tricuspid valve leaflets, a finding that represents a vegetation, with right atrial (RA) enlargement due to tricuspid valve insufficiency. Bottom right: Axial CT image shows splenic and renal embolic infarcts.

32. Summary
Valvular disease is common and can be identified on routine chest radiographs and CT images
Aortic valve disease
Calcification of leaflets is associated with stenosis
Left ventricular hypertrophy may also be seen
Calcification of the aortic annulus is usually not associated with valvular disease
Aortic regurgitation is associated with a dilated aortic root
Left ventricular enlargement and left ventricular hypertrophy may also be seen
Mitral valve disease
Calcification of the mitral annulus is usually not associated with valvular disease
Regurgitation causes enlargement of both the left ventricle and the left atrium
Stenosis causes enlargement of the left atrium only
Pulmonary vascular redistribution may also be seen
Left atrial calcification is associated with rheumatic heart disease
(continues)

33. Summary Tricuspid valve disease Pulmonic valve disease Endocarditis
Regurgitation is associated with right ventricular and right atrial enlargement
Can cause cardiac cirrhosis due to back-pressure on hepatic veins
Pulmonic valve disease
Stenosis from congenital defect; direction of jet causes enlargement of the left pulmonary artery
Endocarditis
Manifests as embolic phenomena and valvular dysfunction
Septic emboli are peripheral, ill-defined, nodular opacities that may show cavitation
May also see cerebral infarcts, renal infarcts, splenic infarcts, or peripheral emboli
Right-sided endocarditis: pulmonary emboli
Left-sided endocarditis: systemic emboli
Vegetations are uncommonly seen at non–cardiac-gated chest CT
Vegetations cause valvular insufficiency and may manifest with chamber enlargement
Presence of emboli is the best clue to diagnosis
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34. Summary Valve Dysfunction Imaging Findings Left Atrium Left Ventricle
Right
Atrium
Right Ventricle
Aortic
Stenosis
Calcified leaflets …
Hypertrophy
Regurgitation
Dilated aorta
Enlargement
Mitral
None
Thickened or calcified leaflets
Tricuspid
Enlarged IVC, cardiac cirrhosis (late-stage)
Pulmonic
Enlarged main and left pulmonary artery
Note.―IVC = inferior vena cava.

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