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Cardiac Imaging > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

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1
Q

Valvular heart disease — role of CMR ?

A

Cine Imaging: anatomy, coaptation, LV volumes/function

Phase Contrast Imaging: stroke volume (SV), regurgitant volume (RV), Vmax

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2
Q

Aortic valve stenosis — facts ?

A

Most common acquired valvular disease
Leads to left ventricular pressure overload
Leads to left ventricular hypertrophy

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3
Q

Aortic valve insufficiency — facts ?

A

Leads to left ventricular volume overload

Leads to left ventricular dilatation and secondary hypertrophy — concentric/symmetric, wall thickness <15mm

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4
Q

Mitral valve stenosis — facts ?

A

Leads to left atrial dilatation

Leads to pulmonary congestion / edema

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5
Q

Mitral valve insufficiency — facts ?

A

Leads to left ventricular volume overload
Leads to left atrial dilatation
Leads to pulmonary congestion / edema

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6
Q

Pulmonary valve stenosis — facts ?

A

Most frequent congenital valve disorder?
Leads to right ventricular pressure overload
Leads to right ventricular hypertrophy

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7
Q

Pulmonary valve insufficiency — facts ?

A

Common complication after repair of Tetralogy of Fallot (ToF) or pulmonary stenosis
Leads to right ventricular volume overload
Leads to secondary right ventricular hypertrophy

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8
Q

Tricuspid valve stenosis — facts ?

A

Rare valvular disorder

Leads to right atrial dilatation

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9
Q

Tricuspid valve insufficiency — facts ?

A

mild to moderate regurgitation is common
leads to right atrial dilatation
signs and symptoms are those of right sided heart failure, meaning ascites and peripheral edema etc.

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10
Q

aortic stenosis — aetiology ?

A

most common cause of valvular stenosis:
age > 70y degenerative
age < 70y congenital bicuspid
most common cause of subvalvular stenosis:
congenital postpartum characterised by a fibromuscular membrane within the outflow tract

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11
Q

aortic stenosis — epidemiology ?

A

most frequent valvular heart disease in Europe and North America
prevalence 2-5% after 65y, increasing with age
m>f 4:1

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12
Q

aortic stenosis — clinical symptoms ?

A

late symptoms with high grade stenosis

syncope, dizziness, dyspnea, angina

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13
Q

aortic stenosis — therapy and prognosis ?

A

aortic valve replacement
mortality after surgical valve replacement ~ 4% (~7% with bypass)
10 year survival rate ~ 85%

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14
Q

aortic stenosis — imaging (TTE) ?

A

AVA > 1.5cm2 / mpg < 25mmHg — mild stenosis
AVA 1.0-1.5cm2 / mpg 25-40mmHg — moderate stenosis
AVA < 1.0cm2 / mpg > 40mmHg — high grade stenosis
critical stenosis: < 0.7cm2 / mpg > 70mmHg
low-flow-low-gradient stenosis with AVA < 1.0cm2 -> bad prognosis
requires stress echo

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15
Q

aortic stenosis — imaging (CT) ?

A

calcium score: >2100 (m) / >1200 (f)
AVA > 1.5cm2 — mild stenosis
AVA 1.0-1.5cm2 — moderate stenosis
AVA < 1.0cm2 — high-grade stenosis

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16
Q

aortic stenosis — imaging (MRI) ?

A

AVA > 1.5 cm2 / Vmax <2.5m/s — mild stenosis
AVA 1.0-1.5 cm2 / Vmax 2.5-4m/s — moderate stenosis
AVA < 1.0cm2 / Vmax > 4m/s — high-grade stenosis
critical stenosis: < 0.7cm2 / mpg > 70mmHg
low-flow-low-gradient stenosis with AVA < 1.0cm2 -> bad prognosis
requires stress echo

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17
Q

aortic insufficiency — aetiology ?

A

acute: infectious endocarditis, vegetations, aortic dissection
-> rapid increase of left ventricular pressure
chronic: degenerative, rheumatic, bicuspid valves, collagenosis
-> slow elevation of left ventricular pressure and dilatation
surgical Carpentier classification

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18
Q

aortic insufficiency — Carpentier classification ?

A

Type 1: dilatation of the aortic root, normal valve
Type 2a: prolapse of one or more cusps (partial, complete, flail)
Type 2b: fenestration with eccentric jet
Type 3: destruction, irregular thickening, calcification of the cusps

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19
Q

aortic insufficiency — epidemiology ?

A

prevalence ~ 4.9%
increasing with age
m:f - 3:1

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20
Q

aortic insufficiency — clinical symptoms ?

A

acute left heart decompensation, pulmonary congestion

chronic left ventricular insufficiency, stress dyspnea

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21
Q

aortic insufficiency — therapy ?

A

medications — reducing afterload

surgery — valve reconstruction or replacement (Ross operation)

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22
Q

aortic insufficiency — prognosis ?

A

10 year survival ~90% (grade 1/2) ~50 (grade 3)
left ventricular function is indicating surgery
5 year survival after surgery (EF>45%) ~85%, (EF<45%) ~50%

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23
Q

aortic insufficiency — imaging (TTE) ?

A

pressure half time assessment
mild AI: proximal jet width < 3 mm — PHT > 500 ms
moderate AI: proximal jet width 3-6 mm — PHT 200-500 ms
severe AI: proximal jet width > 6 mm — PHT < 200 ms
differentiation central (tricuspid) or eccentric jet

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24
Q

aortic insufficiency — imaging (CT) ?

A

clarifying aetiology e.g. aneurysm, dissection, congenital
incomplete cusp coaptation, regurgitant orifice area (AROA)
< 25 mm2 — mild
25-75 mm2 — moderate
> 75 mm2 — severe

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25
aortic insufficiency — role of MRI ?
visualisation of the diastolic regurgitant jet clarification of the underlying aetiology through-plane-phase-contrast measurement — regurgitant volume calculation of the regurgitant volume (LVSV-RVSV) — requires competence of the other valves planimetry of the effective regurgitant orifice area
26
aortic insufficiency — grading ?
RV < 30 ml/beat, RF < 30%, ROA < 0.1 cm2 — mild RV 30-60 ml/beat, RF 30-50%, ROA 0.1-0.3 cm2 — moderate RV > 60 ml/beat, RF > 50%, ROA > 0.3 cm2 — severe
27
mitral stenosis — aetiology ?
rheumatic valve disease (95%) | obstruction e.g. myxoma, vegetations
28
mitral stenosis — epidemiology ?
prevalence ~1% age peak 50-70y f:m - 2:1
29
mitral stenosis — clinical symptoms ?
left atrial dilatation pulmonary congestion atrial fibrillation
30
mitral stenosis — therapy ?
mitral valve reconstruction, valvuloplasty, mitral valve replacement antiarrhythmic medications, anticoagulation
31
mitral stenosis — prognosis ?
10 year survival in high-grade stenosis 50-60% in asymptomatic, ~15% symptomatic valvulotomy/mitral valve replacement mortality rate 1-3%/ 3-8% 5 year survival ~ 90%
32
mitral stenosis — imaging (TTE) ?
increased transvalvular pressure gradient reduced mitral valve orifice area < 1.5 cm2 (high grade) assessment of morphological changes e.g. doming, diffuse, irregular
33
mitral stenosis — imaging (CT) ?
morphologic changes quantification of the mitral valve orifice area < 1.5 cm2 (severe) preoperative evaluation of coronary artery disease
34
mitral stenosis — imaging (MRI) ?
visualisation of the diastolic jet characterisation of tumors / vegetations phase-contrast-imaging: Vmax calculation of transvalvular pressure gradient: 5-10 mmHg (severe) planimetry to assess the mitral valve orifice — 1.5 cm2 (severe)
35
mitral insufficiency — aetiology ?
acute: papillary tendon rupture rheumatic / inflammatory / traumatic / infarction (rare) chronic: primary / secondary primary: rheumatic-degenerative, mitral prolapse secondary: dilatation of the mitral annulus (DCM, ischaemic CM)
36
mitral insufficiency — epidemiology ?
most common mitral dysfunction | increasing with age, predominantly > 65 years
37
mitral insufficiency — clinical symptoms and complications ?
acute: cardiogenic shock, reduced ejection fraction chronic: left atrial then left ventricular dilatation, atrial fibrillation
38
mitral insufficiency — therapy ?
surgical intervention indicated in high-grade insufficiency also dependant on aetiology and pathophysiology controversial in secondary functional aetiology e.g. DCM
39
mitral insufficiency — prognosis ?
variable | higher mortality in moderate to high-grade insufficiency (EF<50%)
40
mitral insufficiency — imaging (TTE) ?
VC: 1-3 mm, RV: < 30 ml, ROA < 0.2 cm2 — mild VC: 4-6 mm, RV: 30-60 ml, ROA 0.2-0.4 cm2 — moderate VC: > 7 mm, RV: > 60 ml, ROA > 0.4 cm2 — severe also pressure half time calculation
41
mitral insufficiency — imaging (CT) ?
clarification of the aetiology visualisation of regurgitant orifice area (ROA) possible surgical planning characterisation of mitral annulus calcification
42
mitral insufficiency — role of MRI ?
systolic regurgitant jet visualisation clarification of aetiology: DCM, papillary infarct, HOCM, prolapse calculation regurgitant volume (RV): RV = LVSV-AoSV (PCI), RV = LVSV-RVSV (competence of other valves) planimetry of the effective regurgitant orifice
43
mitral insufficiency — MRI grading ?
RV < 30 ml/beat, RF < 30%, ROA < 0.2 cm2 — mild RV 30-60 ml/beat, RF 30-50%, ROA 0.2-0.4 cm2 — moderate RV > 60 ml/beat, RF > 50%, ROA > 0.4 cm2 — severe
44
tricuspid stenosis — aetiology and epidemiology ?
post-inflammatory or congenital rare disorder often not diagnosed because of concomitant mitral stenosis hemodynamically relevant: < 2.5cm2, severe: < 1cm2
45
tricuspid stenosis — clinical symptoms and therapy ?
fatigue, edema diuretics, salt restriction balloon valvuloplasty — VOA < 1.7 cm2 or TVPG > 5 mmHg
46
tricuspid stenosis — imaging ?
TTE — method of choice: assessment of transvalvular pressure gradient MRI — diastolic jet, right atrial dilatation, thickened valve
47
tricuspid insufficiency — aetiology and epidemiology ?
valvular tricuspid insufficiency — rare post-rheumatic, drug abuse, endocarditis, pacemaker wire functional tricuspid insufficiency — fairly frequent due to dilatation of the tricuspid annulus
48
tricuspid insufficiency — clinical symptoms and therapy ?
fatigue and right heart insufficiency with edema Natrium and fluid restriction surgical therapy only with severe insufficiency valve retaining techniques favoured
49
tricuspid insufficiency — imaging ?
TTE — method of choice MRI — right atrial and right ventricular enlargement systolic jet into right atrium quantification of regurgitant volume (RV) RV = RVSV-PaSV (PCI)
50
pulmonary stenosis — aetiology ?
congenital (80%) mobile pulmonary valve with 2-4 raphes / commissures and incomplete separation dysplastic pulmonary valve subvalvular or infundibular as part of the ToF (tetralogy of Fallot) supravalvular stenosis
51
pulmonary stenosis — epidemiology ?
~8% of all congenital defects | ~1:2000 of newborns
52
pulmonary stenosis — clinical symptoms ?
mild — asymptomatic | moderate and severe — systemic venous congestion
53
pulmonary stenosis — therapy and prognosis ?
therapy: watchful waiting, balloon-valvuloplasty, valvulotomy prognosis: mild to moderate stenosis are well tolerated, high-grade stenosis lead to reduced ejection fraction, right heart hypertrophy, pulmonary congestion and cyanosis
54
pulmonary stenosis — imaging (TTE) ?
method of choice in detection and grading reduced mobility, reduced valve area doming of the valve pathological increased flow velocity in the main pulmonary artery
55
pulmonary stenosis — imaging (CT) ?
anatomy of the right ventricular outflow tract dilatation of the main and left pulmonary artery thickened, immobile cusps reduced size of the pulmonary annulus
56
pulmonary stenosis — imaging (MRI) ?
morphology and anatomy of the right ventricular outflow tract thickened, fused cusps, systolic doming increased peak velocity (Vmax) and transvalvular pressure gradient right heart hypertrophy
57
pulmonary insufficiency — aetiology & epidemiology ?
valvular pulmonary insufficiency — rare due to rheumatic fever, endocarditis relative pulmonary insufficiency — more frequent due to pulmonary hypertension of different aetiology e.g. fibrosis, mitral stenosis, left heart insufficiency or congenital defects or postoperative (surgical corrected ToF)
58
pulmonary insufficiency — clinical symptoms ?
mild PI — asymptomatic | moderate to severe or long-standing — right sided heart failure with exertional dyspnea
59
pulmonary insufficiency — therapy and prognosis ?
pulmonary valve replacement with progressing right cardiac failure prognosis depends on the underlying aetiology
60
pulmonary insufficiency — imaging (TTE) ?
method of choice ~75% with mild insufficiency are diagnosed diastolic insufficiency jet for quantification
61
pulmonary insufficiency — imaging (CT) ?
possible aid to find the underlying aetiology
62
pulmonary insufficiency — imaging (MRI) ?
visualisation of the diastolic jet assessment of regurgitant volume / fraction (PCI) assessment of right ventricular function
63
mitral prolapse — aetiology ?
degenerative: diffuse myxomatous degeneration (Barlow disease) thickened leaflets with abundant myxomatous fibrous tissue fibroelastic deficiency: decreased amount of fibrous tissue with thin walled leaflets and dilated annulus
64
mitral prolapse — definition and forms ?
systolic protrusion of one or two mitral leaflets into the left atrium exceeding the mitral annulus more than 2mm billowing form: due to myxomatous degeneration flail form: protrusion of a free leaflet margin due to tendon rupture
65
mitral prolapse — clinical symptoms, complications and therapy ?
~60% asymptomatic, otherwise diverse symptoms e.g. fatigue, angina, loss of autonomic function: panic attacks, depression Complications: increased risk of endocarditis, mitral insufficiency Therapy: only with progressing mitral insufficiency
66
mitral prolapse — role of MRI ?
visualisation of the mitral valve 3ch to visualise A2/P2 prolapse additionally parallel views to depict A1/P1 and A3/P3 portions of the mitral valve assessment of mitral insufficiency RV = LVSV-AoSV (PCI)
67
calcification of the mitral annulus — facts ?
increasing with age, f:m — 4:1 risk factors: hypertension, diabetes, hyperlipidemia, metabolic syndrome increased risk of CAD increased risk of arrhythmia
68
bicuspid aortic valve — definition and pathophysiology ?
2 functional cusps congenital: conotruncal anomaly, developmental disturbance acquired: fusion of a tricuspid valve e.g. after rheumatic fever fusion most often occurs between the right and left coronary cusp (85%) true valves with 2 cusps, 2 commissures, 2 sinus are less frequent
69
bicuspid aortic valve — epidemiology ?
one of the most common congenital malformations prevalence ~ 2% associated with aortic coarctation and other congenital malformations dilatation of the aortic root in ~ 80% with bicuspid valve
70
bicuspid aortic valve — therapy ?
dependant on symptoms e. g. valve replacement with severe valve or LV dysfunction e. g. aortic replacement with severe dilatation of the aortic root
71
bicuspid aortic valve — role of MRI ?
diagnosis assessment of cusp mobility detection and quantification of valve stenosis and insufficiency evaluation of the aortic root / ascending aorta and LV function

Cardiac Imaging (9 decks)

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