X-ray chest PA view in severe calcific mitral stenosis
- Aortic knuckle with intimal calcification (first mogul)
- Prominent main pulmonary artery segment (second mogul)
- Prominent left atrial appendage (third mogul)
- Calcification in mitral valve
- Elevated left bronchus – feature of left atrial enlargement
- Double atrial countour – border of enlarged left atrium (shadow within shadow)
- 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.
Aortic intimal calcification is useful in suspected cases of aortic dissection, in which cases, the calicification can be seen to be widely separated from the border of the aortic knuckle (calcium sign).