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- “The preferred method for assessing valvular heart disease (VHD) is contrast-enhanced whole-heart retrospective ECG-gated acquisition. Semilunar valve planimetry is optimally achieved during mid-systole, while 0-5% of the RR interval proves most effective for measuring atrioventricular valve regurgitant orifice area. In contrast, semilunar regurgitant orifice area planimetry and atrioventricular anatomic valve opening area are best depicted during mid-diastole.”
Cardiac Computed Tomography of Native Cardiac Valves
Jordi Broncano, et al.
Radiol Clin N Am - (2024) in press - “In degenerative aortic stenosis (AS), calcification, commonly heavy, initiates at the annulus and progresses towards the cusp, resulting in asymmetric opening and closure. Conversely, rheumatic disease typically exhibits symmetric calcification, commissural fusion, and reduced aperture.”
Cardiac Computed Tomography of Native Cardiac Valves
Jordi Broncano, et al.
Radiol Clin N Am - (2024) in press - “Calcification not only correlates with AS severity but also serves as a subclinical surrogate marker for atherosclerotic burden and coronary artery calcification. Gender – specific thresholds for severe aortic calcification aid in predicting disease severity, mortality excess, and offer incremental prognostic value, particularly in patients with discordant echo cardiographic Doppler severity of AS or paradoxical low flow-low gradient with preserved LVEF.”
Cardiac Computed Tomography of Native Cardiac Valves
Jordi Broncano, et al.
Radiol Clin N Am - (2024) in press - “Bicuspid aortic valve (BAV) respresents the most frequent form of congenital aortic VHD, characterized by commissural fusion and two unequally – sized cusps. BAV may be associated with AS, AR, combined AS/AR or no relevant functional VHD. Each case should detail (1) the type, specific phenotype, and function; (2) the presence and characteristics of the raphe, as well as the cusp size, shape, and symmetry; and (3) the presence and phenotype of BAV-related aortopathy and/or aortic coarctation.”
Cardiac Computed Tomography of Native Cardiac Valves
Jordi Broncano, et al.
Radiol Clin N Am - (2024) in press - “Mitral regurgitation (MR) is the most common manifestation of VHD, classified as primary or secondary. Primary MR results from anatomic abnormalities or direct damage to the mitral valve or subvalvular apparatus, while secondary MR is associated with regional/global left ventricular dysfunction and/or dilatation. leading to tethering and restriction of the mitral leaflets. Computed tomography - derived MV tenting area has been linked to the severity of MR.”
Cardiac Computed Tomography of Native Cardiac Valves
Jordi Broncano, et al.
Radiol Clin N Am - (2024) in press
- Shone Complex
- Shone complex is a congenital heart defect consisting of four obstructive defects in the left heart: a mitral supravalvular ring, sub-aortic stenosis, parachute mitral valve, and coarctation of the aorta (CoA), which affects only a small minority of people. - Shone Complex
- Its complete form associates a supra-mitral valve ring, sub aortic stenosis, parachute mitral valve (PMV), and coarctation of the aorta. Otherwise, the incomplete form, which is the most common, consists of a left ventricle inlet defect (PMV, Mitral stenosis congenitally or supravalvular mitral ring) associated with at least one left ventricular escape lesion (bicuspid aortic valve, subvalvular aortic stenosis, coarctation of the aorta) - The complete Shone syndrome consists of four cardinal left-sided cardiac defects
- supravalvular mitral membrane
- subvalvular aortic stenosis (membranous or muscular)
- parachute mitral valve
- coarctation of the aorta
- Although four features were originally described, it is more common for patients to have incomplete Shone syndrome with only some of the obstructive lesions
- “Retrospectively EKG gated acquisition is advisable for Prosthetic Heart Valve (PHV) imaging because it enables dynamic leaflet evaluation and anatomic assessment in both systole and diastole.”
Multidetector CT Angiography in Evaluation of Prosthetic Heart Valve Dysfunction
Habets J et al.
RadioGraphics 2012; 32:1893-1905 - “ PHV assessment with CT angiography is a promising cardiac CT application that is of complementary diagnostic value to the clinical routine imaging techniques-echocardiography and fluoroscopy-and can provide additional relevant anatomic information that can have an impact on patient care.”
Multidetector CT Angiography in Evaluation of Prosthetic Heart Valve Dysfunction
Habets J et al.
RadioGraphics 2012; 32:1893-1905 - Indications for Aortic Valve Replacement in Aortic Stenosis
- Severe aortic stenosis defined by either
- Aortic valve area < 1.0 CM2
- OR
- Maximum aortic velocity > 4m/sec
- AND EITHER
- Symptoms referable to aortic stenosis
- Or
- Evidence of left ventricular dysfunction (ejection fraction <50%) - “ Infectious vegetations or nodular excrescences that form on the valve cusps, most commonly on the ventricular surface of the cusps, sometimes lead to embolism in patients with bacterial endocarditis .”
CT and MR Imaging of the Aortic Valve: Radiologic –Pathologic Correlation
Bennett CJ et al.
RadioGraphics 2012;32:1399-1420 - “ Papillary Fibroelastomas are rare benign excrescences with a propensity to arise on the surface of cardiac valves. Aortic and mitral valve lesions may be somewhat more common than tricuspid valve and pulmonic valve lesions.”
CT and MR Imaging of the Aortic Valve: Radiologic –Pathologic Correlation
Bennett CJ et al.
RadioGraphics 2012;32:1399-1420 - Papillary Fibroelastomas : Facts
- Maximum diameter less than 1 cm
- Peak incidence is the 7-8th decade of life
- Usually asymptomatic and incidental finding but may be associated with embolic phenomena
- Surgical resection is curative
- Thrombi on the Aortic Valve Prosthesis: Facts
- Valve thrombosis, which can lead to valvular obstruction, occurs with an annual incidence ranging from 0.1 to 5.7 percent; higher rates are observed in patients with mitral prostheses and/or subtherapeutic anticoagulation
- Systemic embolization (predominantly cerebrovascular events) occurs at a frequency of approximately 0.7 to 1.0 percent per patient-year in patients with mechanical valves who are treated with warfarin
- “ Multidetector computed tomographic (CT) angiography is a promising complementary technique for evaluation of prosthetic heart valves (PHV), especially in patients with PHV obstruction and endocarditis.”
Multidetector CT Angiography in Evaluation of Prosthetic Heart Valve Dysfunction
Habets J et al
RadioGraphics 2012; 32:1893-1905 - “ Retrospectively electrocardiographically gated acquisition is advisable for PHV imaging because it enables dynamic leaflet evaluation and anatomic assessment in both systole and diastole.”
Multidetector CT Angiography in Evaluation of Prosthetic Heart Valve Dysfunction
Habets J et al
RadioGraphics 2012; 32:1893-1905 - Prosthetic Heart Valves: Facts
- Two main types are biologic and mechanical prosthetic heart valves
- Biologic prosthetic heart valves require no anticoagulation but are prone to wear and will degenerate within 10-20 years
- Mechanical prosthetic heart valves require anticoagulation for life but failure is rare and reported as 0.01%-6%
- CT especially of value in biologic prosthetic heart valves when associated abscess is suspected
- “ Radiologists should be aware of the clinical significance and the varied appearance of bicuspid valve at cardiac MDCT and cardiovascular MRI.”
Bicuspid Aortic Valve: Spectrum of Imaging Findings at Cardiac MDCT and Cardiovascular MRI
Ko SM et al.
AJR 2012; 198:89-97 - Bicuspid Aortic Valve: Complications
- Aortic stenosis
- Aortic regurgitation
- Infective endocarditis
- Dilated ascending aorta
- Aneurysm of the ascending aorta
- Dissection of the ascending aorta - Bicuspid Valve Classiciation
There are 3 key characteristics
- The number of raphes (type)
- The spatial position of the cusps and raphe
- The functional status of the valve
- Bicuspid valve: CT Features
- Two leaflets without a raphe are clearly visualized
- There are two unbalanced leaflets with an anomalously dilated sinus of Valsalva
- No indentation is seen at the edge of the anomalous leaflet
- Raphe is clearly identified
- There are two balanced leaflets about 180° for each leaflet
- Cardiac CT for the Differentiation of Bicuspid and Tricuspid Aortic Valves: Comparison With Echocardiography and Surgery
Alkadhi H et al.
AJR 2010; 195:900-908 - Bicuspid Aortic Valve: facts
- 1-2 % of the general population
- Male predominance of 4-1
- Associated with aortic coarctation, patent ductus arteriosus, and coronary artery anomalies
- Develop valvular disease earlier so have increased incidence of aortic regurgitation and stenosis, infective endocarditis and aortic dilatation - Tricuspid valve: CT Features
- Three leaflets are clearly visualized in systolic phase
- Leaflets are balanced, about 120° for each leaflet
- Indentation between two leaflets is seen when the leaflets are in contact with each other
- There is continuity of the contacting edges of the leaflets, from the edge to the annulus- Location of calcification (calcification on the ventricular side) is suggestive of rheumatic aortic valve disease
- Cardiac CT for the Differentiation of Bicuspid and Tricuspid Aortic Valves: Comparison With Echocardiography and Surgery
Alkadhi H et al.
AJR 2010; 195:900-908 "Overall sensitivity and specificity of CT for the diagnosis of bicuspid aortic valve were 94% and 100%."
Cardiac CT for the Differentiation of Bicuspid and Tricuspid Aortic Valves: Comparison With Echocardiography and Surgery
Alkadhi H et al.
AJR 2010; 195:900-908"CT is highly accurate for differentiation between bicuspid and tricuspid aortic valves. For bicuspid valves without raphe, diastolic reconstruction are sufficient whule in those with a raphe, additional reconstructions in systole are required."
Cardiac CT for the Differentiation of Bicuspid and Tricuspid Aortic Valves: Comparison With Echocardiography and Surgery
Alkadhi H et al.
AJR 2010; 195:900-908"In conclusion we found that aortic valve assessment by cardiac CT with ECG gating is useful for accurately identifying bicuspid aortic stenosis in patients with severe aortic valve stenosis requiring surgical repair, especially those with extensively calcified aortic valves."
Diagnostic Value of Cardiac CT in the Evaluation of Bicuspid Aortic Stenosis: Comparison with Echocardiography and Operative Findings
Tanaka R et al.
AJR 2010;195:895-899"The CT findings were not significantly different from the intraoperative findings (p=0.99), but the echocardiographic findings were (p<0.05)."
Diagnostic Value of Cardiac CT in the Evaluation of Bicuspid Aortic Stenosis: Comparison with Echocardiography and Operative Findings
Tanaka R et al.
AJR 2010;195:895-899"The sensitivity, specificity, positive predictive value, and negative predictive value for the detection of bicuspid aortic valve were 76.5%, 60.6%, 68.4%, and 95.2%, respectively for echocardiography and 94.1%, 100%, 100%, and 97.1% respectively for CT."
Diagnostic Value of Cardiac CT in the Evaluation of Bicuspid Aortic Stenosis: Comparison with Echocardiography and Operative Findings
Tanaka R et al.
AJR 2010;195:895-899"ECG-gated cardiac CT is useful for the accurate morphologic assessment of bicuspid aortic stenosis, especially in patients with severe aortic valve disease."
Diagnostic Value of Cardiac CT in the Evaluation of Bicuspid Aortic Stenosis: Comparison with Echocardiography and Operative Findings
Tanaka R et al.
AJR 2010;195:895-899"Mitral valve prolapse (MVP) can be diagnosed at coronary CT angiography with a high accuracy (90-95%) as compared with the accuracy of echocardiography."
Cardiac CT Angiography for the Diagnosis of Mitral Valve Prolapse: Comparison with Echocardiography
Feuchter GM et al.
Radiology 2010; 254:374-383"The combined use of three and two chamber views allows an accurate diagnosis of mitral valve prolapse at coronary CT angiography."
Cardiac CT Angiography for the Diagnosis of Mitral Valve Prolapse: Comparison with Echocardiography
Feuchter GM et al.
Radiology 2010; 254:374-383"ECG-gated cardiac 64-MDCT angiography can be used reliably to detect mitral valve prolapse."
Mitral Valve Prolapse: Evaluation With ECG-Gated Cardiac CT Angiography
Shah RG et al.
AJR 2010; 194:579-584- Aortic Valve: Facts
- 3 cusps normally but can be 1-4
- Area of normal aortic valve is 2.5-4 cm2
- Symptoms of aortic stenosis usually begin at at area of less than 1 cm2
- With aortic stenosis LV hypertrophy and dilated ascending aorta are common - Cardiac Valve Disease: Etiologies
- Degenerative and inherited causes (number one cause in US)
- Post-rheumatic heart disease ((number one cause worldwide)
- Endocarditis
- Metastatic carcinoid tumor to liver "CT angiography allows excellent visualization of the morphologic features and function of the normal valves, as well as of a wide range of valve disease, including congenital and acquired diseases, infectious endocarditis, and complications of valve replacement."
CT Angiography of the Cardiac Valves: Normal, Diseased, and Postoperative Appearances
Chen JJ et al.
RadioGraphics 2009; 29:1393-1412"CT can measure the size and function of mechanical valves with high interobservor agreement and results similar to specifications. The opening angle with CT strongly correlates with cinefluoroscopy. CT is promising for the assessment of mechanical valves."
Evaluation of Mechanical Heart Valve Size and Function with ECG-Gated 64 MDCT
LaBounty TM et al.
AJR 193 Nov 2009"Minor aortic valve calcification is a common finding on multi-detector row CT scans and is usually hemodynamically unimportant.”
Prevalence and Clinical Importance of Aortic Valve Calcification Detected Incidentally on CT Scans: Comparison with Echocardiography
Koos R et al.
Radiology 2006; 241:76-82"Aortic valve calcification was an incidental finding in 18% of multi-detector row CT scans. The grade of aortic valve calcification is correlated with the hemodynamic severity of aortic valve disease as determined with echocardiography."
Prevalence and Clinical Importance of Aortic Valve Calcification Detected Incidentally on CT Scans: Comparison with Echocardiography
Koos R et al.
Radiology 2006; 241:76-82- Coarctation of the Aorta:Facts
Associated with cardiac anomalies
- Bicuspid valve (50%)
- VSD (33%)
- PDA (66%)
- Subaortic and mitral stenosis
- Bicuspid Aortic Valve:Facts
- Incidence of 0.4-2.2%
- More common on Turner’s syndrome, coarctation of the aorta and VSD
- Leads to early valve calcification and aortic stenosis with dilated ascending aorta
- "Aortic valve planimetry is best performed at phase starts of 50-100 milliseconds after the R peak because the area of the aortic opening is widest and image quality is best at that phase."
Feasibility and Optimization of Aortic Valve Planimetry with MDCT
Abbar S et al.
AJR 2007; 188:356-360
- "We show in this study that MDCT can potentially be used to evaluate stenotic aortic valves, which often coexist with coronary artery disease. Additional studies need to be performed to further clarify the accuracy of the technique and its role in the clinicaldecision making process."
Feasibility and Optimization of Aortic Valve Planimetry with MDCT
Abbar S et al.
AJR 2007; 188:356-360
- "Our preliminary results suggest that MDCT is a promising technique for functional evaluation of bileaflet mechanical valves, allowing reliable measurements of opening and closing leaflet angles."
The Role of ECG-Gated MDCT in the Evaluation of Aortic and Mitral Mechanical Valves: Initial Experience
Konen E et al.
AJR 2008; 191:26-31
- "Our preliminary results suggest that MDCT is a promising technique for functional evaluation of bileaflet mechanical valves, allowing reliable measurements of opening and closing leaflet angles. However, the role of MDCT in the evaluation of single leaflet valves may be limited."
The Role of ECG-Gated MDCT in the Evaluation of Aortic and Mitral Mechanical Valves: Initial Experience
Konen E et al.
AJR 2008; 191:26-31
- Cardiac Tumors:Facts
- Most common primary cardiac tumor is myxoma
- Myxomas are most common in the left atrium in or near the foramen ovale
- Benign tumors make up 77% of primary cardiac tumors
- Pericardial tumors are more common than intracardiac tumors
- Bicuspid Aortic Valve:Facts
- Incidence of 0.4-2.2%
- More common on Turner’s syndrome, coarctation of the aorta and VSD
- Leads to early valve calcification and aortic stenosis with dilated ascending aorta
- "Four dimensional cardiac CT will make a major contribution to harnessing the full morphologic and functional potential of high quality MDCT data acquired form a single cardiac cycle."
Four-Dimensional Imaging of the Heart Based on Near Isotrophic MDCT Datasets
Lawler LP, Ney DR, Pannu HK, Fishman EK
AJR 2005 Mar;184(3):774-776
- "Four dimensional cardiac CT in its current form provides an overview of global and regional myocardial or valvular motion and volume changes during the cardiac cycle."
Four-Dimensional Imaging of the Heart Based on Near Isotrophic MDCT Datasets
Lawler LP, Ney DR, Pannu HK, Fishman EK
AJR 2005 Mar;184(3):774-776
- "Virtually all patients with aortic valve calcification had coronary calcification, potentially explaining the coronary risk associated with aortic valve calcification. There is substantially parallel development between rates of progression of EBT-assessed aortic valve calcification and coronary calcification."
Association Between Progression of Aortic Valve Calcification and Coronary Calcification
Takasu J et al.
Acad Radiol 2005; 12:298-304
- "Noninvasive cine-mode imaging of the mitral valve using retrospective ECG-gated MDCT is feasible and allows accurate visualization of the moving valve. Perpendicular long axis reconstructions yield images of superior quality when compared with the short axis reconstructions and enable a determination of its functional morphology."
Dynamic Cine Imaging of the Mitral Valve with 16-MDCT: A Feasibility Study Alkadhi H et al.
AJR 2005; 185 636-646
- What is the significance of a bicuspid valve?
- Degenerative calcification occurs in all aortic valves over time and aortic leaflet thickening and aortic stenosis occur in 26% and 2% of the population by age 90. With bicuspid valves the same process occurs but 2-3 decades earlier
- Bicuspid Aortic Valve: Facts
- 0.5-1% of population has a bicuspid valve
- Key finding is earlier and increased frequency of aortic valve calcification
- Sinus of Valsalva Aneurysm: Facts
- Due to trauma, infective endocarditis, or congenital causes
- Involvement of the non-coronary cusp is most common
- Patients present with chest pain, conduction abnormalities and aortic insufficiency
- "Once thought to be the domain of echocardiography and MRI, aortic valvular disease can often be assessed with current CT technology (16 MDCT)."
MDCT Evaluation of Aortic Valvular Disease
Gilkeson RC et al.
AJR 2006;186:350-360.
- "The severity of aortic valve calcifications on chest CT, as assessed either subjectively or objectively, correlated with increased pressure gradients across the aortic valve, particularly for calcification of the peripheral left posterior commissure and the central left-right commissure."
Aortic Valve Calcification as an Incidental Finding at CT of the Elderly:Severity and Location as predictors of Aortic Stenosis
Liu F et al.
AJR 2006; 186:342-349.
- "Visualization of the aortic valve and valvular motion during the cardiac cycle is feasible on CT studies performed for coronary angiography. CT has a potential role in the assessment of aortic valvular pathology."
Gated cardiac imaging of the aortic valve on 64-slice multidetector row computed tomography: preliminary observations
Pannu HK, Jacobs JE, Lai S, Fishman EK
J Comput Assist Tomogr 2006 May-Jun; 30(3):443-446.