Mitral valve calcification

Mitral valve calcification


X-ray chest PA view showing mitral valve calcification in severe rheumatic calcific mitral stenosis

  1. Aortic knuckle with intimal calcification (first mogul)
  2. Prominent main pulmonary artery segment (second mogul)
  3. Prominent left atrial appendage (third mogul)
  4. Calcification in mitral valve
  5. Elevated left bronchus – feature of left atrial enlargement
  6. Double atrial contour – border of enlarged left atrium (shadow within shadow)
  7. Right atrial border shifted to right, suggestive of right atrial enlargement

In addition left pulmonary artery can be seen descending from the main pulmonary artery within the cardiac shadow. Medial to that the descending aorta can be seen to the left of the spine. Right pulmonary artery is also seen as a prominent structure descending from the right hilum. Upper lobe vessels are also a little prominent.

Calcification of the mitral valve is seen only rarely these days as most persons with mitral stenosis get operated before the valves become calcified. Only long standing cases unfit for surgery due to other reasons can be noted to have such dense calcification on chest X-ray. Calcification on fluoroscopy and echocardiography can be seen more often.

Mitral valve is located below and to the left of the line joining main pulmonary artery segment (‘pulmonary bay’ on a normal chest X-ray) to the right cardiophrenic angle. Aortic valve is located above and to the right of this line. So calcifications and prosthetic valves in these locations can be identified with this reference to this line in mind.

Generally, calcification of mitral valve was part of rheumatic heart disease with long standing mitral stenosis. But rheumatic mitral stenosis is gradually becoming a rarity with lower prevalence of rheumatic fever and its sequelae. Mitral annular calcification can extend to the base of mitral valve leaflets, especially the posterior mitral leaflet and cause a gradient across the mitral valve. This form of mitral stenosis is distinct from rheumatic mitral stenosis. It has been called calcific or degenerative mitral stenosis [1]. Risk factors for mitral annular calcification are advanced age, female gender and end stage renal disease [1]. In rheumatic mitral stenosis, maximum narrowing is at the leaflet tips, associated with commissural fusion. In mitral annular calcification with mitral stenosis, the predominant narrowing is at the base of the mitral valve leaflets.

Aortic intimal calcification seen in the chest X-ray is useful in suspected cases of aortic dissection, in which cases, the calcification can be seen to be widely separated from the border of the aortic knuckle (calcium sign).

Reference

  1. Payvandi LA, Rigolin VH. Calcific mitral stenosis. Cardiol Clin. 2013 May;31(2):193-202.