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Heavy calcification of aortic and mitral valves secondary to radiotherapy

EACVI Valvular Imaging Box

Authors: Dr. Julia Grapsa, Dr. Grigorios Karamasis, Dr. Andreas Kalogeropoulos, Prof. Petros Nihoyannopoulos

Hammersmith Hospital
Imperial College NHS Trust

Contact : Julia Grapsa,
EACVI club 35 ambassador for Greece

On behalf of the EACVI club 35 for Greece



MW 71 years old
Admitted with shortness of breath over the last 8 weeks. On admission was found to be clinically in cardiogenic shock (BP 83/50 mmHg, 90 bpm in sinus rhythm, raised jugular venous pressure, cold skin). She previously needed PCI to LAD 3 years ago (recent angiogram demonstrated patent stent and coronaries) and was treated 8 years ago with extensive radiotherapy and chemotherapy, due to breast carcinoma.

Clinical case information




Parasternal long axis view: the left ventricle has normal size while right ventricle is dilated. There is severe biventricular systolic impairment. There is also severe calcification of both the mitral and the aortic valves


Parasternal long axis view with the zoom mode on the mitral and aortic valves: severe calcification of both valves with restriction of leaflet movement


Parasternal long axis view with colour Doppler: the sector width is adapted for the imaging of the two valves. There is no posterior annular calcification but there is restriction of leaflets mobility.


Parasternal short axis view with colour Doppler with turbulence over the aortic valve suggesting stenosis.


Parasternal right ventricular inflow view: the tricuspid valve has normal anatomy with no evidence of calcification. However, due to the dilatation of the right ventricle and the right atrium, there is misapposition of the leaflets.


Parasternal right ventricular inflow view: tricuspid valve colour flow. Misappositon of the tricuspid leaflets causes tricuspid regurgitation.


Parasternal short axis view at the level above the mitral papillary muscles for assessment of left ventricular systolic function. There is global impairment of contractility and severe dysfunction


Parasternal short axis view at the level of the aortic valve: there is significant calcification and fusion between the aortic cusps with critical aortic stenosis.


Parasternal short axis view at the level of the mitral valve. Severe left ventricular systolic impairment. Severe calcification and fusion of both mitral leaflets leading to severe restriction of leaflet mobility.


Apical 4 chamber view: Global severe impairment of left ventricular systolic function. The left atrium – when the volume was measured and indexed to the body surface area - was significantly enlarged (volume 136 ml).


Apical 4 chamber view: The right ventricle is dilated and right ventricular systolic function is severely impaired. Right atrium is dilated (volume 98 ml).



Apical 4 chamber view – colour Doppler: Useful to identify eccentric diastolic mitral jets that may be encountered in cases of severe valve deformity of valvular. Doppler beam can be guided by the highest flow velocity zone identified by colour Doppler


Mitral valve Doppler assessment: Mean gradient varies according to the length of diastole

Mitral valve Doppler assessment: Mitral regurgitation jet

Continuous wave Doppler on aortic valve (low flow, low gradient).

Pulsed wave Doppler of the left ventricular outflow tract: the velocity of the flow is very low due to the poor cardiac output of the left ventricle. When continuity equation is applied, the aortic stenosis is determined as being critical (AVA 0.4 cm2)


  • Severe aortic and mitral valve calcification secondary to previous radiotherapy.
  • Severe biventricular disfunction
  • Severe aortic stenosis (low flow-low gradient). AVA 0.4 cm2
  • Moderate mitral stenosis and regurgitation

After recovery of shock the patient underwent successful double valve replacement