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Pulmonary Parenchymal Manifestations of Mitral Valve Disease¹

¹ From the Department of Radiology, VA Palo Alto Health Care System and Stanford University School of Medicine, 3801 Miranda Ave, Palo Alto, CA 94304. Received May 26, 1998; revision requested July 20 and received September 1; accepted September 1. Address reprint requests to P.S.

View larger version (173K): [in a new window]   Figure 1.  Interstitial pulmonary edema in a 45-year-old man with paroxysmal nocturnal dyspnea. Frontal chest radiograph shows interstitial pulmonary edema with a normal-sized cardiac silhouette, double contour overlying the right atrial shadow (arrowhead), effacement of the cardiac waist, enlarged central pulmonary arteries, and distended upper lobe pulmonary vessels. Note the clearly visible thickened interlobar septa forming Kerley A lines (arrow).

View larger version (163K): [in a new window]   Figure 2.  Acute pulmonary edema in a 37-year-old woman with previously undiagnosed rheumatic mitral stenosis who experienced acute onset of dyspnea and pulmonary edema in the recovery room following a gynecologic procedure. Frontal chest radiograph shows multiple confluent acinar shadows due to hydrostatic pulmonary edema resulting from intraoperative volume overload. The cardiac silhouette shows an enlarged, convex main pulmonary artery segment and a convex left atrial appendage (arrow).

View larger version (127K): [in a new window]   Figure 3a.  Acute pulmonary edema in a 28-year-old woman with previously undiagnosed combined mitral stenosis and regurgitation who had just given birth to a full-term neonate. (a) Frontal chest radiograph shows massive pulmonary edema with a bias for the perihilar and lower lung regions. The cardiac silhouette is moderately enlarged. Dilation of the main and central pulmonary arteries and cephalization of pulmonary vascular flow are evident. Note the splaying of the angle of tracheal bifurcation, a finding that is indicative of marked left atrial enlargement (arrow). (b) Lateral radiograph helps confirm the enlarged left atrium, which is seen displacing the left main bronchus dorsally (arrow).

View larger version (143K): [in a new window]   Figure 3b.  Acute pulmonary edema in a 28-year-old woman with previously undiagnosed combined mitral stenosis and regurgitation who had just given birth to a full-term neonate. (a) Frontal chest radiograph shows massive pulmonary edema with a bias for the perihilar and lower lung regions. The cardiac silhouette is moderately enlarged. Dilation of the main and central pulmonary arteries and cephalization of pulmonary vascular flow are evident. Note the splaying of the angle of tracheal bifurcation, a finding that is indicative of marked left atrial enlargement (arrow). (b) Lateral radiograph helps confirm the enlarged left atrium, which is seen displacing the left main bronchus dorsally (arrow).

View larger version (149K): [in a new window]   Figure 4a.  Pulmonary hemorrhage in a 33-year-old man with rheumatic mitral and aortic stenosis who presented with hemoptysis. The patient had undergone replacement of both valves with Ionescu-Shiley bovine pericardial prostheses followed by temporary anticoagulation therapy with warfarin sodium (Coumadin; DuPont Merck, Wilmington, Del). Frontal (a) and lateral (b) chest radiographs demonstrate extensive bilateral diffuse pulmonary consolidation with sparing of the periphery of the lungs, creating the window frame effect that is suggestive of pulmonary hemorrhage.

View larger version (119K): [in a new window]   Figure 4b.  Pulmonary hemorrhage in a 33-year-old man with rheumatic mitral and aortic stenosis who presented with hemoptysis. The patient had undergone replacement of both valves with Ionescu-Shiley bovine pericardial prostheses followed by temporary anticoagulation therapy with warfarin sodium (Coumadin; DuPont Merck, Wilmington, Del). Frontal (a) and lateral (b) chest radiographs demonstrate extensive bilateral diffuse pulmonary consolidation with sparing of the periphery of the lungs, creating the window frame effect that is suggestive of pulmonary hemorrhage.

View larger version (148K): [in a new window]   Figures 5, 6.  (5) Pulmonary hemosiderosis due to long-standing mitral stenosis in a 35-year-old man. The patient had undergone mitral valve replacement with a Hancock porcine bioprosthesis. Frontal (a) and lateral (b) chest radiographs show diffuse small, rounded, "miliary" nodular areas of increased opacity bilaterally. A left lingular calcified granuloma is noted incidentally (arrows in a). (6) Pulmonary hemosiderosis in a 7-year-old child with congenital mitral valve stenosis and a concurrent atrial septal defect (Lutembacher syndrome). Frontal chest radiograph shows diffuse micronodules scattered throughout the lungs. The cardiac silhouette is moderately enlarged. Dilation of both atria, the right ventricle, the main pulmonary artery segment, and both central pulmonary arteries is evident.

View larger version (141K): [in a new window]   Figures 5, 6.  (5) Pulmonary hemosiderosis due to long-standing mitral stenosis in a 35-year-old man. The patient had undergone mitral valve replacement with a Hancock porcine bioprosthesis. Frontal (a) and lateral (b) chest radiographs show diffuse small, rounded, "miliary" nodular areas of increased opacity bilaterally. A left lingular calcified granuloma is noted incidentally (arrows in a). (6) Pulmonary hemosiderosis in a 7-year-old child with congenital mitral valve stenosis and a concurrent atrial septal defect (Lutembacher syndrome). Frontal chest radiograph shows diffuse micronodules scattered throughout the lungs. The cardiac silhouette is moderately enlarged. Dilation of both atria, the right ventricle, the main pulmonary artery segment, and both central pulmonary arteries is evident.

View larger version (145K): [in a new window]   Figures 5, 6.  (5) Pulmonary hemosiderosis due to long-standing mitral stenosis in a 35-year-old man. The patient had undergone mitral valve replacement with a Hancock porcine bioprosthesis. Frontal (a) and lateral (b) chest radiographs show diffuse small, rounded, "miliary" nodular areas of increased opacity bilaterally. A left lingular calcified granuloma is noted incidentally (arrows in a). (6) Pulmonary hemosiderosis in a 7-year-old child with congenital mitral valve stenosis and a concurrent atrial septal defect (Lutembacher syndrome). Frontal chest radiograph shows diffuse micronodules scattered throughout the lungs. The cardiac silhouette is moderately enlarged. Dilation of both atria, the right ventricle, the main pulmonary artery segment, and both central pulmonary arteries is evident.

View larger version (172K): [in a new window]   Figure 7a.  Pulmonary ossification in a 63-year-old woman with long-standing mitral stenosis. The patient had undergone valve replacement with a St Jude mechanical prosthesis. (a) Frontal chest radiograph shows bibasilar confluent calcific areas of increased opacity, which are most conspicuous at the right lung base. (b, c) Computed tomographic (CT) scans obtained with soft-tissue window (b) and lung window (c) settings help confirm the presence of ossified acinar clusters, which are more extensive in the right lower lung than in the left lung.

View larger version (128K): [in a new window]   Figure 7b.  Pulmonary ossification in a 63-year-old woman with long-standing mitral stenosis. The patient had undergone valve replacement with a St Jude mechanical prosthesis. (a) Frontal chest radiograph shows bibasilar confluent calcific areas of increased opacity, which are most conspicuous at the right lung base. (b, c) Computed tomographic (CT) scans obtained with soft-tissue window (b) and lung window (c) settings help confirm the presence of ossified acinar clusters, which are more extensive in the right lower lung than in the left lung.

View larger version (122K): [in a new window]   Figure 7c.  Pulmonary ossification in a 63-year-old woman with long-standing mitral stenosis. The patient had undergone valve replacement with a St Jude mechanical prosthesis. (a) Frontal chest radiograph shows bibasilar confluent calcific areas of increased opacity, which are most conspicuous at the right lung base. (b, c) Computed tomographic (CT) scans obtained with soft-tissue window (b) and lung window (c) settings help confirm the presence of ossified acinar clusters, which are more extensive in the right lower lung than in the left lung.

View larger version (142K): [in a new window]   Figure 8.  Asymmetric pulmonary edema in a 77-year-old man in cardiogenic shock with acute mitral regurgitation due to a flail posterior mitral leaflet that resulted from ischemic papillary muscle dysfunction and subsequent rupture of the chordae tendineae. Supine bedside chest radiograph shows asymmetric pulmonary edema that is more extensive on the right side with slight volume loss in the right upper lobe. The right apical cap is due to pleural effusion (arrow). The cardiac silhouette is enlarged, and the rounded sweep of the Swan-Ganz catheter suggests right ventricular dilation. An intraaortic counterpulsation balloon is also seen.

View larger version (147K): [in a new window]   Figure 9.  Asymmetric pulmonary edema in a 78-year-old woman with rupture of a papillary muscle and hyperacute mitral regurgitation due to a coronary artery bypass graft. Frontal bedside chest radiograph demonstrates asymmetric pulmonary edema with a bias for the right upper lobe. (Courtesy of Steven Weinberger, MD, Harvard Medical School, Boston, Mass.)