Multimodality imaging in heart valve disease

John B Chambers, Saul G Myerson, Ronak Rajani, Gareth J Morgan-Hughes, Marc R Dweck, John B Chambers, Saul G Myerson, Ronak Rajani, Gareth J Morgan-Hughes, Marc R Dweck

Abstract

In patients with heart valve disease, echocardiography is the mainstay for diagnosis, assessment and serial surveillance. However, other modalities, notably cardiac MRI and CT, are used if echocardiographic imaging is suboptimal but can also give complementary information to improve assessment of the valve lesion and cardiac compensation to aid the timing of surgery and determine risk. This statement discusses the way these imaging techniques are currently integrated to improve care beyond what is possible with echocardiography alone.

Keywords: VALVULAR DISEASE.

Figures

Figure 1
Figure 1
Multimodality imaging of aortic stenosis. (A) Contrast CT imaging of the aortic valve can provide detail regarding valve morphology and the distribution of calcification. (B) CT calcium scoring allows reproducible quantification of the calcific burden, which acts as a marker of disease severity. (C) Fused positron emission tomography and CT imaging with 18F-fluoride provides an indication of ongoing calcification activity in the valve. CT has an important clinical role in the workup of patients prior to transcatheter aortic valve implantation, providing accurate dimensions of the annulus for valve sizing (D) while cardiac MRI can be used to planimeter the aortic valve area (E) and to detect replacement myocardial fibrosis, red arrow (F).
Figure 2
Figure 2
Comparison of CMR and echocardiography in aortic regurgitation. In 109 asymptomatic patients with moderate or severe aortic regurgitation on echocardiography, prognosis was better related to the regurgitant fraction on CMR with a cut-point of 33%.The graph shows CMR regurgitant fraction ≤ 33% in blue and >33% in red. The regurgitation was either moderate or severe by echocardiography in both of these two CMR groups.
Figure 3
Figure 3
Imaging the aorta using CT and cardiac MRI (CMR). On the left is a reconstructed three-dimensional-rendered CT scan of the heart with a dilated ascending aorta and on the right is a steady-state free precession (SSFP) image on CMR of a moderately dilated ascending aorta.
Figure 4
Figure 4
The aorta using cardiac MRI (CMR). (A) A contrast MR angiogram showing critical coarctation and very dilated thoracic collateral vessels. (B) A four-dimensional CMR flow image showing very helical flow in the ascending aorta in a patient with a bicuspid aortic valve.
Figure 5
Figure 5
A three-dimensional (3D) echocardiogram showing planimetry of a stenotic mitral valve. The 3D image allows alignment of the plane to ensure that planimetry is performed at the minimum orifice (courtesy Dr Stam Kapetanakis).
Figure 6
Figure 6
Three-dimensional (3D) in mitral prolapse. (A) A 3D image of the valve showing prolapse of the middle scallop, P2 using the Carpentier classification. (B) A colour-contoured map with prolapsing areas in red and restricted areas in blue. The main lesion is prolapse of the middle portion of the anterior leaflet. (C) A colour-contoured map in a patient with functional mitral regurgitation showing restriction of both mitral leaflets (courtesy Dr Stam Kapetanakis). A, anterior; AL, anterolateral; Ao, aorta; P, posterior; PM, posteromedial.
Figure 7
Figure 7
Severe congenital pulmonic stenosis. This is a cardiac MRI image (steady-state free precession, SSFP) in a sagittal view through the right ventricular outflow tract, demonstrating mobile leaflets but fused tips of the pulmonic valve (arrow).
Figure 8
Figure 8
Pannus related to a stented biological valve. (A) CT and (B) surgical finding in the same patient.

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