Radio-opaque tricuspid aortic valve seen in X-Ray chest as mercedes-benz sign.

We are presenting a very interesting X-ray image of the calcific aortic valve in a septuagenarian male patient who underwent successful aortic valve replacement.

A 76-year-old male patient presented with the history of recurrent syncopal attack. He was investigated and found to have severe calcific aortic stenosis with the peak gradient of 180 mmHg and mean gradient of 110 mmHg across aortic valve at rest. His X-ray chest lateral view showed classical calcified tricuspid aortic valve with annular as well as cuspal calcification depicting Mercedes-Benz sign[12] which is usually seen in echocardiography of aortic valve [Figure 1]. In literature, roentographic “Mercedes-Benz sign” is described for triradiate radiolucency seen in gallstones due to the presence of gas (Nitrogen) in gallstone fissures.[3] In this case, a classical triradiate radio-opaque shadow mimicking “Mercedes-Benz sign” is seen in lateral X-ray chest due to extensive calcification of aortic valve leaflets. Roentographic evidence of Mercedes-Benz sign of aortic valve is not reported in English literature.

Figure 1

X-ray chest lateral view showing extensive aortic valve calcification giving the impression of Mercedes-Benz sign

The X-ray chest posterioranterior view is most commonly ordered radiological imaging during clinical rounds which may not pick up such extensive calcification [Figure 2]. Echocardiography though being a gold standard, can miss on anatomical completeness of evaluation of such valve due to the phenomenon of echo dropouts because of calcium present all around the valve. Here, a simple X-ray lateral view scores over others by revealing marked calcium present in the aortic valve. This finding is clinically very important as further investigation with computerized tomography becomes mandatory to rule out porcelain aorta, presence of significant coronary, coronary osteal and carotid calcium. These investigations may lead to clinically important findings and may alter the course of comprehensive perioperative management and outcome. Aortic valve replacement with bioprosthesis was done successfully, and the patient recovered well.

Figure 2

X-ray chest posterioranterior view compared with lateral view. X-ray chest posterioranterior view could not pick up much calcification in this elderly patient

Advanced calcific aortic valve disease is a common ailment in the elderly, and transthoracic echocardiography usually confirms the diagnosis, but we would like to recommend that for long-standing aortic valve disease in advanced age patients lateral X-ray is a must, it should not be ignored.

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Conflicts of interest

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