‘How I do’ CMR in valvular heart

disease

Dr. Saul Myerson

Clinical Lecturer in Cardiovascular Medicine
For www.scmr.org 02/2007

This presentation posted for members of scmr as an educational guide – it represents the views and
practices of the author, and not necessarily those of SCMR.

University of Oxford Centre for Clinical Magnetic Resonance Research

(OCMR)
 Advantages of CMR
• All areas of the body accessible - free choice of
imaging planes with no ‘hidden’ sections
• Range of imaging techniques – anatomical, cine,
angiography, flow
• Quantification of flow and thus valve lesion severity
• 3D imaging with angiography
• No ionising radiation
• Other techniques (Echo) do have strengths, esp. in
the acute setting
© Saul Myerson 2007
 Standard imaging for all studies

• Long axis planes – HLA, VLA, LVOT,

LVOT coronal, (RVOT +/- RV inflow if
right-sided lesions)

• Need two perpendicular views of the

valve(s) in question

• LV & RV function

© Saul Myerson 2007

 LV and RV function
This is important for assessing the impact of the valve lesion on
the LV / RV and should be performed in all cases

See How I do a CMR volume

study by James Moon, here

 Gold standard accuracy for

volumes, mass & function
© Saul Myerson 2007
 Specific valve lesions - overview

• Aortic valve disease

• Mitral valve disease
• Pulmonary stenosis & regurgitation
• Tricuspid regurgitation
• Complex lesions
– Mixed stenosis/regurgitation
– Multiple valves
© Saul Myerson 2007
 Aortic stenosis (1)

SA pilot LVOT view Coronal LVOT view

• Plan initial LVOT view from short axis pilot scan, with the plane through the
aortic root/valve

• The second LVOT (coronal) plane is planned through this, aligned with the
stenotic jet. There is often a central core in the jet comprising laminar flow,
with turbulent flow (black/low intensity on gradient echo) surrounding this

• Align planes with AS jet rather than Ao root

© Saul Myerson 2007
 Aortic stenosis (2)

Choose the best LVOT view for in-plane flow assessment (the one with
the best view of the core jet)

© Saul Myerson 2007

 Aortic stenosis (3)
• Measure the peak velocity, either from the in-plane flow
itself, or using the in-plane flow to identify the point of
peak velocity and acquire a through-plane flow sequence
at this point:

Position for through-plane flow

acquisition
© Saul Myerson 2007
 Aortic stenosis (4)
• Measure the valve area by direct planimetry, by
acquiring a thin (5-6mm) slice through the tips of the
aortic valve in systole, piloted from the 2 LVOT views.
• It is important to ensure you are at the tips, as you may
overestimate the valve area otherwise

Need still image of valve in

systole here, including
planimetry

Valve tips in systole – area = 1.0cm2

© Saul Myerson 2007

 Aortic stenosis (5)

Advantages of CMR:

• Correct alignment with AS jet

– Accurate trans-valvular velocity (in-plane / through
plane) – avoids underestimation with angulated roots

• Valve orifice area (direct planimetry)

• LV mass & volumes to assess impact on LV

© Saul Myerson 2007

 Aortic regurgitation
• Through-plane flow measurement
• Allows quantification of regurgitation

© Saul Myerson 2007

 Aortic regurgitation (2)

+218 mls
- 52 mls (24% regurgitant fraction)
© Saul Myerson 2007
 Aortic regurgitation (3)

• Quantification allows more accurate

assessment of severity
(echo parameters less precise)

• More detail required on how quantification

fits into clinical practice

© Saul Myerson 2007

 Aortic disease
Don’t forget the aorta in your valve assessment !

Residual root dissection in a patient with a previous type A dissection repair

(inter-positional graft)
© Saul Myerson 2007
 Mitral regurgitation

Standard methods of quantification are indirect:

1) Regurgitant flow = LVSV - Ao systolic flow
(independent of other valve lesions)
2) Regurgitant flow = LVSV - RVSV
© Saul Myerson 2007
 Mitral stenosis
• Can assess mitral valve area by direct planimetry
• Important to ensure correct slice positioning at MV tips
(as for echo)
• Diastolic flow (volume and velocity) is feasible though
temporal resolution is lower than echo

© Saul Myerson 2007

 Mitral stenosis (2)

Planimetry of the MV tips:

© Saul Myerson 2007

 Pulmonary stenosis

Horizontal RVOT planned

RVOT planned from transverse slices from previous RVOT
• Good visualisation of pulmonary valve motion
• Accurate velocity assessment
• RVOT sizing for potential surgery / balloon
valvuloplasty / percutaneous valve replacement
© Saul Myerson 2007
 Pulmonary regurgitation

• Quantification of PR

• Size & shape of RVOT -

?percutaneous stent-
valve replacement

• Size & function of RV

Forward flow: 72mls

Regurgitant flow: 27mls
(38% regurgitant fraction)
© Saul Myerson 2007
 Pulmonary valve disease (3)
CMR is also important for:
• determining RV mass & volumes
• assessing RVOT morphology

Dilated RV secondary to chronic PR

© Saul Myerson 2007

 Complex pulmonary disease
• Supravalvular stenosis with previous surgical widening
• Now recurrent supravalvular stenosis & valvular
regurgitation
• Dilated post-stenotic pulmonary artery

© Saul Myerson 2007

 Tricuspid disease

Severe TR (note low velocity

causes minimal turbulence
from dephased spins).
Also has pericardial effusion

• Regurgitation can be quantified similarly to mitral

regurgitation (RVSV – pulmonary flow)
• Stenosis can be assessed with direct planimetry
of the tips
• RV volumes & function for all
© Saul Myerson 2007
 Multiple valve disease
Detailed assessment of severity of each lesion & LV function

Mixed aortic and mixed

mitral valve disease

Proceed sequentially through assessment of each lesion,

including LV/RV funciton assessment

© Saul Myerson 2007