Valvular heart disease

a) SCMR official document standardized acquisition guidelines – relevant extract

Patients with artificial valves can safely undergo CMR at 1.5 and 3 Tesla. The force exerted by the beating heart is many-fold higher than the force exerted by the magnetic field.

LV structure and function module.
a. Use horizontal long axis to look for valve anatomy and turbulence of the mitral and tricuspid valve.
b. Use LVOT view for mitral and aortic valve.
c. Use vertical long axis for mitral valve.
d. Coronal view for aortic valve
e. Additional views (RV long axis, RV-outflow tract as needed).
Specific
a. Valve morphology assessment with SSFP cine in the plane of the valve in question. Care must be taken to optimize the level and angle of imaging
b. Note – if planimetry of a stenotic valve is to be attempted, a contiguous or slightly overlapping stack of high resolution cines transecting the line of the jet and moving from orifice level to immediately downstream is recommended. Planimetry is most likely to be valid where the cross section of the orifice, or rather of the jet, is clearly delineated. This may not always be the case due to fragmented or oblique jet flow.
c. Gradient echo or hybrid gradient echo/echo planar imaging may visualize regurgitant jets with a higher sensitivity (for qualitative purposes only).
d. In mitral or tricuspid regurgitation, a contiguous stack of 5 mm cines is recommended aligned with the direction of inflow and transecting the principal line of coaptation, moving from the more superior commissure to the inferior. The orientation can be that of the LVOT plane for the mitral and transaxial for the tricuspid. Such a stack enables assessment of tethering, prolapse, or regurgitation through the scallops of both mitral leafletes.
Measure flow velocity and volume perpendicular to the vessel distal to valve leaflet tips.
a. Adapt velocity encoding to actual velocity (using lowest velocity without aliasing).
b. Use lowest TE possible for high velocity jet flows.
c. The CMR software should routinely correct for phase errors due to concomitant gradients. As long as this is the case, background phase errors due to eddy currents may be correctable by normalizing velocities to reference in static tissue.
Analysis:
a. Determine left and right ventricular stroke volume using volumetric analyses of SSFP cine sequences to measure single valve regurgitation.
b. Mitral regurgitation can be measured by subtracting aortic flow from the LV stroke volume.
c. Multiple valve lesions can be assessed from comparison of the aortic and pulmonary diastolic regurgitant flow and the LV and RV stroke volumes.
d. Measure aortic valve area by direct planimetry
e. Alternatively, measure aortic valve area by (Velocity time integral LVOT/Velocity time integral aorta) × Area LVOT
f. Calculate peak mitral valve gradient from peak mitral valve flow

b) SCMR official document reporting recommendations – relevant extract

The following lists of items should be reported for the cardiac valves.
Qualitative parameters:
• morphology of each component of the valve complex (e.g. leaflets, annulus, chordae)
• presence of any insufficiency or reduced valvular excursion
When quantitative flow measurements are acquired:
• the velocity encoding Venc setting;
• the peak velocity, a single value when recorded across semilunar valves or a vessel in cross-section, or both early (E) and late (A) peak velocities for atrioventricular valves;
• the forward stroke volume and peak and mean transvalvular gradients;
• the regurgitant volume and fraction;
• the heart rate during acquisition;
• the method and determination of valve area (by planimetry or the continuity equation);
• the measurement of ventricular dimensions and volumes as described in III-B.

c) Standardized web based images

no case yet

d) Case of the Week example(s)

Number 11-02: Another cause of mitral regurgitation
History: A 65 year old female patient with severe, symptomatic mitral regurgitation underwent mitral valve repair for posterior mitral valve leaflet restriction (type IIIb). At surgery, the left atrial wall appeared abnormal and a left atrial biopsy was performed. Surprisingly, histological examination of this biopsy showed chronic, non-caseating granulomatous changes suggestive of sarcoidosis. .

Number 10-03: Unicuspid aortic valve and associated anomalies
History: A 24-year-old male underwent a subclavian flap repair for aortic coarctation at the age of 1. A recent echocardiogram had been reported as showing mild aortic regurgitation and a dilated aortic root.

Number 09-13: Severe AI in a bicuspid AV assessed with CMR
History: A nice example of how CMR can be used to evaluate the severity of AI using cine and phase contrast CMR imaging.

Number 09-11: Gerbode Ventricular Septal Defect after Ross Procedure
History: A 26-year-old male patient with past medical history of aortic coarctation repair...

Number 09-10: An unusual complication of the Ross procedure and the role of CMR in its assessment
History: A 26 year old male had previously undergone a Ross procedure for a stenosed bicuspid aortic valve when aged 17yrs.

Number 07-02. Coarctation, MS and bicuspid AoV
History: A 17-yr-old female, referred with hypertension.

Number 07-11: Valvular disease by CMR
History: A 74 year old female with increasing breathlessness. Known rheumatic heart disease and LVH.

e) Expert opinion – ‘How we do’

"How I do CMR of valvular heart disease" (Saul Myerson, Oxford CMR unit)

Siemens assessment of valve disease.

f) Relevant Online Talks

Free talks

CMR for valves
By Saul Myerson
Recorded at LondonCMR

Percutaneous valve replacement
By Alain Cribier
Recorded at Advanced Cardiac Imaging Course for the Interventional Cardiologist, 2008, London

Members only talks - general
MR velocity mapping in clinical work up of valvular heart disease
By Steven Wolff - Advanced Cardiovascular Imaging
Recorded at SCMR 2010
CMR Flow measurement: applications errors and optimization
By Mark B.M. Hofman - VU University Medical Center
Recorded at SCMR 2010
Aortic Valve disease (eg bicuspid, AS, AR)
By Kevin Whitehead - Childrens' Hospital of Philadelphia
Recorded at SCMR 2010
Flow and valves - (this talk has had 2 slides with unpublished data edited out)
By Philip Kilner
Recorded at EuroCMR 2008

Members only talks - cutting edge
Should All ASD/VSDs Undergo CMR Assessment for Percutaneous Valve Closure?
By Karen Ordovas - University of California
Recorded at SCMR 2009 Clinical Valvular/Haemodynamics
Does CT have a role in Valve Imaging?
By Ricardo Curry instead of Gudrun Feuchtner - Medical University, Innsbruck
Recorded at SCMR 2009 Clinical Valvular/Haemodynamics
How accurate is Velocity Coding?
By Jos Westenberg, - Leiden University Medical Centre
Recorded at SCMR 2009 Clinical Valvular/Haemodynamics
The role of CMR in Valvular Heart Diease
By Saul Myerson - Oxford University
Recorded at SCMR 2009 Clinical Valvular/Haemodynamics

g) Relevant papers (starting point):

John AS, Dill T, Brandt RR, Rau M, Ricken W, Bachmann G, Hamm CW. Magnetic resonance to assess the aortic valve area in aortic stenosis: how does it compare to current diagnostic standards? J Am Coll Cardiol. 2003;42:519-26.
Cawley PJ, Maki JH, Otto CM. Cardiovascular magnetic resonance imaging for valvular heart disease: technique and validation. Circulation. 2009;119:468-78.
Westenberg JJ, Roes SD, Ajmone Marsan N, Binnendijk NM, Doornbos J, Bax JJ, Reiber JH, de Roos A, van der Geest RJ. Mitral valve and tricuspid valve blood flow: accurate quantification with 3D velocity-encoded MR imaging with retrospective valve tracking. Radiology. 2008;249:792-800
Assessment of mitral bioprostheses using cardiovascular magnetic resonance
von Knobelsdorff-Brenkenhoff F, Rudolph A, Wassmuth R, Schulz-Menger J
Journal of Cardiovascular Magnetic Resonance 2010, 12:36 (23 June 2010)
Towards comprehensive assessment of mitral regurgitation using cardiovascular magnetic resonance
Chan KMJ, Wage R, Symmonds K, Rahman-Haley S, Mohiaddin RH, Firmin DN, Pepper JR, Pennell DJ, Kilner PJ
Journal of Cardiovascular Magnetic Resonance 2008, 10:61 (22 December 2008)