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Pulmonary Oligemia in Aortic Valve Disease

¹ Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, MCN R-1322, 21st Ave S, Nashville, TN 37232-2675 (M.A.B.)
² Department of Radiological Sciences, University of California–Irvine Medical Center, Orange (E.N.C.M.)
³ Department of Radiology, University of Iowa College of Medicine, Iowa City (W.S.)
⁴ Department of Radiology, Memorial Medical Center of Long Beach, Calif (C.W.S.).

View larger version (137K): [in a new window]   Figure 1. A "typical" case of AS. Posteroanterior radiograph shows that the pulmonary blood vessels are small for the patient's build (mild oligemia) and are also discrepant with the enlarged left ventricle. The vascular pedicle (arrows) is slightly narrow (4.8 cm) because of the patient's size.

View larger version (106K): [in a new window]   Figure 2a. Posteroanterior radiographs in a patient with burns. (a) At the time of admission, the patient was dehydrated and the lungs showed oligemia, with fluid out of physiologic control (ie, "third spacing"). The azygos vein (arrows) is reduced in size. (b) After hydration, the circulating BV is restored, and the pulmonary BV is normal (ie, normovolemic). The size of the azygos vein (arrows) is increased because of an increase in systemic BV. Pulmonary and systemic BV usually cannot be dissociated. (c) With overhydration, the pulmonary BV is too large (ie, hyperemia). The azygos vein (arrows) now is very large, which indicates the marked increase in total BV. This progressive increase in the size of the azygos vein is caused by an increase in the systemic BV.

View larger version (106K): [in a new window]   Figure 2b. Posteroanterior radiographs in a patient with burns. (a) At the time of admission, the patient was dehydrated and the lungs showed oligemia, with fluid out of physiologic control (ie, "third spacing"). The azygos vein (arrows) is reduced in size. (b) After hydration, the circulating BV is restored, and the pulmonary BV is normal (ie, normovolemic). The size of the azygos vein (arrows) is increased because of an increase in systemic BV. Pulmonary and systemic BV usually cannot be dissociated. (c) With overhydration, the pulmonary BV is too large (ie, hyperemia). The azygos vein (arrows) now is very large, which indicates the marked increase in total BV. This progressive increase in the size of the azygos vein is caused by an increase in the systemic BV.

View larger version (102K): [in a new window]   Figure 2c. Posteroanterior radiographs in a patient with burns. (a) At the time of admission, the patient was dehydrated and the lungs showed oligemia, with fluid out of physiologic control (ie, "third spacing"). The azygos vein (arrows) is reduced in size. (b) After hydration, the circulating BV is restored, and the pulmonary BV is normal (ie, normovolemic). The size of the azygos vein (arrows) is increased because of an increase in systemic BV. Pulmonary and systemic BV usually cannot be dissociated. (c) With overhydration, the pulmonary BV is too large (ie, hyperemia). The azygos vein (arrows) now is very large, which indicates the marked increase in total BV. This progressive increase in the size of the azygos vein is caused by an increase in the systemic BV.

View larger version (16K): [in a new window]   Figure 3. Example of the reading table (in this example, for reader 2) used for the assessment of vascularity and chamber size.

View larger version (12K): [in a new window]   Figure 4a. Scatterplots show correlations between radiographic severity grade and catheterization data. Group 1 (radiographic severity grade, 0–2) consisted of normovolemic cases () in which the mean stroke volume was 88 mL, and the mean cardiac output was 6.0 L/min. Group 2 (radiographic severity grade, 2–8) consisted of oligemic cases (•) in which the mean stroke volume was 40 mL, and the mean cardiac output was 4.6 L/min. The vertical line indicates the junction between groups. (a) Correlation between radiographic severity and wedge pressure (in millimeters of mercury). For group 1 (n = 4), there was no correlation between wedge pressure and radiographic severity. Significant correlations were found for groups 1 and 2 together (r = 0.81, P = .002; n = 12, with cases 10, 16, and 24 excluded, because no wedge pressure was recorded) and for group 2 alone (r = 0.93, P < .001; n = 8). (b) Correlation between radiographic severity and pulmonary arterial (P.A.) pressure (in millimeters of mercury). For group 1 (n = 4), there was no correlation between pulmonary arterial pressure and radiographic severity. Significant correlations were found for groups 1 and 2 together (r = 0.64, P = .044; n = 10, with cases 10, 16, 17, 20, and 24 excluded, because no pulmonary arterial pressure was recorded) and for group 2 alone (r = 0.93, P = .002; n = 6).

View larger version (12K): [in a new window]   Figure 4b. Scatterplots show correlations between radiographic severity grade and catheterization data. Group 1 (radiographic severity grade, 0–2) consisted of normovolemic cases () in which the mean stroke volume was 88 mL, and the mean cardiac output was 6.0 L/min. Group 2 (radiographic severity grade, 2–8) consisted of oligemic cases (•) in which the mean stroke volume was 40 mL, and the mean cardiac output was 4.6 L/min. The vertical line indicates the junction between groups. (a) Correlation between radiographic severity and wedge pressure (in millimeters of mercury). For group 1 (n = 4), there was no correlation between wedge pressure and radiographic severity. Significant correlations were found for groups 1 and 2 together (r = 0.81, P = .002; n = 12, with cases 10, 16, and 24 excluded, because no wedge pressure was recorded) and for group 2 alone (r = 0.93, P < .001; n = 8). (b) Correlation between radiographic severity and pulmonary arterial (P.A.) pressure (in millimeters of mercury). For group 1 (n = 4), there was no correlation between pulmonary arterial pressure and radiographic severity. Significant correlations were found for groups 1 and 2 together (r = 0.64, P = .044; n = 10, with cases 10, 16, 17, 20, and 24 excluded, because no pulmonary arterial pressure was recorded) and for group 2 alone (r = 0.93, P = .002; n = 6).

View larger version (19K): [in a new window]   Figure 5. Diagrams show the hemodynamics in a normal heart and in a heart with mitral valve stenosis. LV = left ventricle. 1, During atrial diastole in the normal heart, the left atrium (LA) fills with blood from the pulmonary veins. 2, During atrial systole in the normal heart, the mitral valve opens wide, and most of the atrial contents is discharged into the left ventricle (large arrow), with only a small amount refluxing into the pulmonary veins (small arrows). 3, During atrial diastole in the case of mitral valve stenosis with no venospasm, the venous size is normal. 4, During atrial systole with no venospasm, however, much of the atrial content refluxes back into the compliant veins (short arrows) because of the high resistance to outflow through the stenosed mitral valve (long arrow). 5, During atrial systole with protective venospasm, the veins contract, and only minimal venous reflux (short arrows) can occur. Most of the atrial content will be discharged into the left ventricle (long arrow); that is, venospasm protects left atrial function. (Reprinted and adapted, with permission, from reference 7.)

View larger version (162K): [in a new window]   Figure 6a. Posteroanterior chest radiographs show subtle but physiologically important differences between normovolemic and oligemic cases, especially with regard to pulmonary BV, which can most easily be seen through the cardiac shadow. (a) Case 7. A patient with mixed AS and AI. The radiographic severity index is 1, the lungs are normovolemic, mild left ventricular enlargement is present, and the vascular pedicle is narrow (4.8 cm). Catheterization data include stroke volume of 90 mL, wedge pressure of 14 mm Hg, pulmonary arterial pressure of 19 mm Hg, and cardiac output of 5.5 L/min. (b) Case 1. A patient with AS. The radiographic severity grade is 5, the lungs are oligemic, mild biventricular enlargement is present, the vascular pedicle is narrow (4.6 cm), and the azygos vein is very small. Note also the convex main pulmonary artery (arrow). Catheterization data include stroke volume of 31 mL, wedge pressure of 27 mm Hg, pulmonary arterial pressure of 35 mm Hg, and cardiac output of 3.3 L/min.

View larger version (157K): [in a new window]   Figure 6b. Posteroanterior chest radiographs show subtle but physiologically important differences between normovolemic and oligemic cases, especially with regard to pulmonary BV, which can most easily be seen through the cardiac shadow. (a) Case 7. A patient with mixed AS and AI. The radiographic severity index is 1, the lungs are normovolemic, mild left ventricular enlargement is present, and the vascular pedicle is narrow (4.8 cm). Catheterization data include stroke volume of 90 mL, wedge pressure of 14 mm Hg, pulmonary arterial pressure of 19 mm Hg, and cardiac output of 5.5 L/min. (b) Case 1. A patient with AS. The radiographic severity grade is 5, the lungs are oligemic, mild biventricular enlargement is present, the vascular pedicle is narrow (4.6 cm), and the azygos vein is very small. Note also the convex main pulmonary artery (arrow). Catheterization data include stroke volume of 31 mL, wedge pressure of 27 mm Hg, pulmonary arterial pressure of 35 mm Hg, and cardiac output of 3.3 L/min.