Non-ischaemic acquired heart disease
ACQUIRED MITRAL VALVE DISEASE
MITRAL REGURGITATION
DEFINITION
• An incompetent mitral valve allowing regurgitant flow from the left ventricle (LV) into the left atrium (LA) during systole
pulmonary oedema (flow dynamics localizes this to the right upper zone)
it can assess any regurgitant jet direction (with Doppler assessment)PEARLS
• A very large left atrium is more commonly seen with long-standing mitral regurgitation than with mitral stenosis
• Mitral annulus calcification: this rarely occurs before 70 years of age (F>M) 
it is seen with hypercalcaemic states (e.g. end-stage renal disease) 
it may lead to mild mitral regurgitation (but rarely stenosis) 
there is an increased risk of infective endocarditis 
it is also associated with transient ischaemic attacks (due to emboli or a carotid stenosis) and atrioventricular conduction disturbances
• Dystrophic calcification of the mitral valve: unlike mitral annulus calcification, this is very suggestive of a rheumatic aetiology
MITRAL STENOSIS
DEFINITION
• This is usually due to chronic rheumatic fever resulting in a mixture of stenosis and regurgitation (but both cannot be severe at the same time)
• The resultant increased left atrial pressure leads first to interstitial and then alveolar pulmonary oedema 
secondary pulmonary arterial hypertension may develop, leading to pulmonary valve regurgitation, right ventricular dilatation and functional tricuspid regurgitation (there may also be tricuspid valve rheumatic involvement with additional stenosis or regurgitation)
RADIOLOGICAL FEATURES
CXR
• Left atrial enlargement: the left atrial appendage is particularly affected 
appearances can vary from a simple straightening of the left heart border to a large bulge at the site of the appendage 
a grossly dilated left atrium can enlarge to the right and also posteriorly (causing oesophageal displacement and dysphagia)
A ‘double density’ behind the heart
Widening of the subcarinal angle
Left ventricular enlargement is not a feature (cf. mitral regurgitation)
• Parenchymal lung changes of haemosiderosis and intrapulmonary ossification: these may appear after several years of pulmonary venous congestion
• Curvilinear calcification: this may occur within the left atrial wall or within the clot lining the wall
phase contrast CMR can be used as a substitute for Doppler in assessing valve areaPEARLS
• Congenital mitral stenosis is rare
• Long-standing mitral stenosis can result in atrial fibrillation (complicated by left atrial thrombus)
Causes of mitral regurgitation
| Valve abnormalities | Supporting structure abnormalities |
| Acute rheumatic mitral valve disease | Chordal rupture (e.g. post MI) |
| Mitral valve prolapse | Papillary muscle rupture dysfunction |
| Bacterial endocarditis | Functional mitral regurgitation |
| Prosthetic valve leaks | Mitral annular calcification |
| Connective tissue diseases (e.g. SLE/RA) | Atrial myxoma |
ACQUIRED AORTIC VALVE DISEASE
AORTIC REGURGITATION
Definition
• Acute aortic regurgitation: causes include bacterial endocarditis or (rarely) occurring after trauma or aortic dissection 
it develops rapidly with increasing left ventricular end-diastolic pressure and acute heart failure
• Chronic aortic regurgitation: congenital deformities (e.g. bicuspid aortic valve or Marfan’s syndrome) 
rheumatic heart disease 
syphilitic aortitis 
ankylosing spondylitis 
a descending aortic aneurysm
pulmonary oedema with left heart failure (an important cause of pulmonary oedema with a normal-sized heart) 
a normal aorta (unless there is associated aortic disease causing dilatation – e.g. Marfan’s syndrome)Chronic
moderate thoracic aortic enlargement (severe enlargement with aortitis or chronic dissection) 
infrequent valve calcification 
left atrial enlargement may dominate (if mitral valve disease is present)
it also allows assessment of LV functionPearls
• Acute disease: ventricular compliance cannot compensate 
it is associated with a very large rise in ventricular end-diastolic pressures (limiting regurgitant flow)
• Chronic disease: ventricular compliance compensates 
end-diastolic pressures remain low and the patient remains asymptomatic until heart failure develops (with a worsening prognosis)
AORTIC STENOSIS
Definition
• Calcific aortic stenosis: most commonly due to degenerative calcium deposition on normal aortic cusps (cf. mitral stenosis with calcium is deposition on a stenosed valve)
• Previously commonly due to calcification of a congenitally deformed bicuspid valve
• Rheumatic aortic stenosis: inflammatory fusion of aortic valve cusp commissures 
often associated with aortic regurgitation + mitral valve involvement 
associated mitral valve disease can cause severe dyspnoea
chest pain 
left ventricular hypertrophy (LVH)Radiological features
ultrafast CT can assess the severity of aortic stenosis by imaging the valve openingCalcified valves appear as a signal void
• It can demonstrate impaired aortic valve opening (and degree of stenosis), valve morphology and left ventricular function (± hypertrophy)
• Systolic flow dephasing within the aortic root has a loose relationship to the severity of the stenosis
• Diastolic flow dephasing within the left ventricular outflow tract can assess any associated aortic regurgitation
Rheumatic aortic stenosis
CXR
The appearances are commonly dominated by any associated mitral valve disease 
post-stenotic dilatation is rare 
gross valvular calcification is rare
TRICUSPID AND PULMONARY VALVE DISEASE
TRICUSPID VALVE DISEASE
TRICUSPID REGURGITATION
endocarditis (often as a complication of IV drug abuse) 
pulmonary hypertension (caused by the associated dilated right ventricle) 
previous mitral valve replacement 
Ebstein’s anomaly 
endomyocardial fibrosis
a low pressure drop across the valve is seen with severe diseaseTRICUSPID STENOSIS
carcinoid syndrome 
tumours (especially right atrial myxoma) 
endocarditisCXR
• Non-specific cardiac enlargement 
there may be dilatation of the superior and inferior vena cava
• In rheumatic heart disease the features of mitral stenosis predominate (left atrial enlargement and pulmonary arterial enlargement)
• Tricuspid valve calcification may be seen (dystrophic degeneration from ageing as well as chronic severe right ventricular hypertension)
PULMONARY VALVE DISEASE
PULMONARY STENOSIS
rheumatic heart disease (very rare)
tumour
rubella 
tumour 
thrombus 
surgical banding 
Takayasu’s aortoarteritis 
Behcet’s disease
right ventricular hypertrophyPULMONARY REGURGITATION
Definition
This is usually acquired due to pulmonary arterial hypertension 
pre- and post-stenotic dilatation occurs with dilatation of the right ventricle and central pulmonary arteries
• A congenital cause is the absence of the pulmonary valve in tetralogy of Fallot – characterized by large pulmonary arteries and a narrow pulmonary annulus resulting in stenosis
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