Adult Cardiac Valvular Disease for the General Radiologist - PowerPoint Presentation

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Adult Cardiac Valvular Disease for the General Radiologist - PPT Presentation

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 SB Cardiothoracic Radiology Section Mallinckrodt Institute of Radiology Washington University School of Medi ID: 909109

aortic left valve mitral left aortic mitral valve regurgitation stenosis disease pulmonary tricuspid valvular chest show cardiac endocarditis enlargement

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Slide1

Adult Cardiac Valvular Disease for the General Radiologist

Mark M. Hammer, MDKareem Mawad, MDFernando R. Gutierrez, MDSanjeev 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 63110 (e-mail:

bhallas@mir.wustl.edu

Slide2

Contents

Learning objectivesIntroductionOverview of cardiac valvular anatomyMitral disease: regurgitation, annular calcifications, stenosisAortic disease: stenosis, regurgitation, calcificationsTricuspid disease: regurgitation

Pulmonic disease: stenosis

Endocarditis and

vegetations

Slide3

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).

Slide4

Introduction

Valvular abnormalities underlie a large fraction of cardiac disease casesModerate to severe valvular disease is present in 8.5% of adults aged 65–74 years and 13.2% of adults 75 years or olderPresence of a valvular

abnormality may affect how other medical conditions (

, 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

Slide5

Normal Valvular

Anatomy

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

Slide6

Mitral Regurgitation

Has multiple causes, most commonly:Mitral valve prolapseInfarct involving a papillary muscleDilated 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

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.

IIII

Slide7

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

Slide8

Mitral Regurgitation

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 (

, top) and left ventricle (

, bottom). The right atrium (

RA,

bottom)

is also dilated from tricuspid regurgitation.

Slide9

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.

Slide10

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.

Slide11

Mitral Stenosis

Virtually always associated with a history of rheumatic heart diseaseRarely from endocarditis, congenital malformation, or mitral annular calcificationConsequent pulmonary venous hypertensionLeft 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

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.

LAA

Slide12

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

Slide13

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

Slide14

Aortic Stenosis

Common in aging populationsCaused by calcification of leaflets in a similar mechanism to aortic atherosclerosisA bicuspid aortic valve (1%–2% of population) is predisposed to early stenosisDense calcification of the aortic leaflets is closely associated with severe aortic stenosisIn 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).

Slide15

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.

Severe Aortic Stenosis

Click to view animations

Slide16

Aortic Stenosis

Outflow obstruction produces hypertrophy of the left ventricle Ventricular hypertrophy may be overestimated on non–cardiac-gated images obtained during systoleLeft 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).

Slide17

Aortic Regurgitation (Insufficiency)

Most commonly related to aortic root dilatationRoot dilatation may be idiopathic or may be related to atherosclerosis due to aging or to an aortopathic syndrome such as Marfan diseaseValvular 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

Slide18

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.

Slide19

Aortic Regurgitation

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

Slide20

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.

Slide21

Aortic Annular Calcifications

Pathogenesis is similar to that of atherosclerosis in arteriesSame risk factorsHave 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).

Slide22

Tricuspid Regurgitation

Mild or trace tricuspid regurgitation is normal A majority of cases of pathologic tricuspid regurgitation are related to chamber abnormalitiesHeart 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

Slide23

Moderate Tricuspid Regurgitation

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.

Slide24

MHV

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.

Severe Tricuspid Regurgitation

Click to view animations

Slide25

Pulmonic Stenosis

Results from a congenitally thickened or partially fused valveFrequently asymptomatic in children, commonly manifested in adulthoodA flow jet due to pulmonic stenosis is directed toward the main and left pulmonary artery and causes them to become enlargedObstruction also causes right ventricular hypertrophy

Patient with severe pulmonic stenosis and

conse-quent

main and left pulmonary artery enlargement (arrow).

Slide26

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).

Slide27

Endocarditis with Vegetations

Endocarditis manifests with both embolic phenomena and valvular regurgitationPredisposing conditions include intravenous drug use and underlying valvular diseaseSeptic 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

Slide28

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).

Endocarditis with

Vegetations

Click to view animation

Slide29

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).

Slide30

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

suggestive of tricuspid

valvular

dysfunction.

Slide31

Endocarditis with Septic Emboli

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.

Slide32

Summary

Valvular disease is common and can be identified on routine chest radiographs and CT imagesAortic valve diseaseCalcification of leaflets is associated with stenosisLeft 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 diseaseRegurgitation causes enlargement of both the left ventricle and

the left atrium Stenosis causes enlargement of the left atrium onlyPulmonary vascular redistribution may also be seenLeft atrial calcification is associated with rheumatic heart disease(continues)

Slide33

Summary

Tricuspid valve diseaseRegurgitation is associated with right ventricular and right atrial enlargementCan cause cardiac cirrhosis due to back-pressure on hepatic veinsPulmonic 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 enlargementPresence of emboli is the best clue to diagnosis(continues)

Slide34