Mitral stenosis with pulmonary hypertension: Double atrial contour seen on the right cardiac border as ‘shadow in shadow’ indicating left atrial enlargement. Right border is shifted to right suggesting right atrial enlargement. Bulge along the left upper border is due to enlarged pulmonary artery at the top and enlarged left atrial appendage just below that. Prominent upper lobe veins are due to pulmonary venous hypertension. Right pulmonary artery prominence and main pulmonary artery prominence are due to pulmonary arterial hypertension.
RPA: right pulmonary artery; LA: left atrium (shadow in shadow; double atrial contour) RA: right atrium; MPA: main pulmonary artery; LAA: left atrial appendage. Left atrial appendage prominence will not be seen in mitral restenosis after closed mitral valvotomy as the left atrial appendage is amputated during the procedure to prevent thromboembolic events.