imaging of the mitral valve - jficv · imaging of the mitral valve role of ct and mri pr. alban...
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Imaging of the Mitral ValveRole of CT and MRI
Pr. Alban REDHEUIL
Département d’Imagerie Cardiovasculaire
Institut de Cardiologie, La Pitié Salpêtrière, Paris
Laboratoire d’Imagerie Biomédicale INSERM-CNRS
ICAN Imaging Core Lab
SFICVImagerie des valvesDeauville, juin 2017
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Valvular Heart DiseasePrevalence and Outcome
Nkomo VT et al. Burden of valvular heart diseases: a population-based study. Lancet 2006
PREVALENCE SURVIVAL
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Iung et al. EHJ 2003
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Carabello BA et Paulus WJ. Aortic stenosis. Lancet 2009;373: 956-66
Valvular heart diseaseClinical presentation and role of imaging: example of AS
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Valvular Heart DiseaseRole of imaging
• Primary diagnosis: lesion, etiology, severity
• Associated valvular disease
• Differential diagnosis: MR vs. DCM
• Cardiac remodeling: LV, LA, RV and PA
• Coronary arteries (preoperative workup)
• Timing of valvular intervention
• Post operative assessment/follow-up
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Transthoracic echocardiography
• First line modality for initial assessment and longitudinal evaluation
• cost-effective, widely available
• great temporal resolution (≈2 ms)
• absence of partial volume effects
• Pulmonary pressures (SPAP)
• Exercise
• Limitations– Incomplete acoustic windows
(pulmonary valve)
– operator dependent
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Transesophageal echocardiography
& 3D
• if TTE is of suboptimal
quality
• if thrombosis, prosthetic
dysfunction or
endocarditis is suspected
• optimal investigation for
mitral leaflet assessment
• superior leaflet detail
• 3D images
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Guidelines ESC
IRM• Exploration échographique
insuffisante ou résultats conflictuels
• Quantifications des insuffisances/sténoses valvulaires
– Insuffisance>sténose
– Valve pulmonaire
• Examen de référence
– Volumes, fonction bi ventriculaire
– Fibrose myocardique
Scanner
Vahanian et al. EHJ 2012
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8%8%
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Intérêt de l’IRM
FORCES•Imagerie CV exhaustive et non invasive (ETO)
•Multiparamétrique: anatomie (angio 3D), cinétique (ciné), flux (contraste de phase)
•Référence pour Fonction VG et VD
•Anomalies associées: aorte, OG, veine cave, HTAP, fibrose ventriculaire
•Préopératoire– IRM de stress (détection ischémie)
– Viabilité
FAIBLESSES•Résolution temporelle et spatiale (0,8-1mm, 10-30ms)
•Visualisation des jets très dépendante de la séquence (GRE/SSFP)
•Sous estimation relative des Vmax mais robustesse des Vmoy
•Plusieurs R-R
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Protocole Acquisition IRM - CINE
• Séquences dynamiques ciné
– Multiplan
• Long axe: 2cavités VD et VG, 3, 4
cavités VG
• Petit axe: volumes
biventriculaires et masse VG
– Haute résolution
• Spatiale: 0,8-1mm, FOV ajusté,
épaisseur: 5mm
• Temporelle: ajuster #vps pour
obtenir 10-30ms, accélération=2
– SSFP ou GRE (3T)
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Fonction biventriculaire
• Mesures de référence des
volumes ventriculaires et de la
masse VG (indexer à la SC)
– Fonction systolique VG globale
– Retentissement droit d’une
valvulopathie gauche
– Quantification volumique d’une
régurgitation mono valvulaire
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Conséquences ventriculaires des valvulopathies
Normal Surcharge pressionnelle Surcharge volumique
Hypertrophie
concentrique
Hypertrophie
excentrique
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Quantification des volumes VD et VG en
scanner
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Protocole Acquisition IRM – Contraste de phase
• Séquences dynamiques PC
– Multiplan
• Long axe: repérage du jet avec encodage V dans le plan
• Transversales: encodage des V àtravers le plan
– Haute résolution
• Spatiale: FOV ajusté
• Temporelle: ajuster vps pour obtenir 10-30ms, accélération=2
– Difficultés
• Segmentation: contourage automatisé
• VENC maximale: aliasing
• Décalage des phases (courants de Foucault)
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EHJ 2012
AND
LVESD<55mm
LA dilation
>60ml/m2
and sinus
rhythm
SPAP exertion
>60mmHg
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Mitral valve segmentation – Analogy with TEE
A1A1A2A2
A3A3
P1P1
P2P2
P3P3
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Mitral valve assessment in CT
N=29
Age: 26-81 yrs
Gender: 13m/16w
Degenerative MR
Taldir G, …Redheuil A. 2012
CT RF vs. Echo gradeCT RF vs. Echo grade
CT vs. Echo : mitral valve motionCT vs. Echo : mitral valve motion
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Mitral Valve Regurgitation
• direct flow measurement cannot be optimally performed
• more extensive movement of the valve annulus during ventricular systole
• non-planar geometry of the regurgitant orifice
• eccentric jet directions
Gatehouse…Kilner et al. JCMR 2010
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Insuffisance mitrale
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Quantification IM en IRM
• Vélocimétrie directe souvent difficile– Jets multiples
– Jets excentrés
• Conservation des débits– FR=VES VG – Débit antérograde
aortique
– FR=VES VG – VES VD ou VES VG/VES VD > 1.4
– Hypothèse atteinte mono valvulaire et absence de shunt
• Jet très important
• Dilatation OG, VG, VD
• Attention à une FEVG à 50% en présence IM sévère
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MRI gradation of MR and AR
Gelfand EV et al. Severity of mitral and aortic regurgitation as assessed by CMR: optimizing correlation with Doppler echocardiography.
JCMR 2006
Regurgitant fraction
(%)
Regurgitant volume
(mL)
Mild <15%
Moderate 15-25% <30
Moderate
-severe26-48% 30-60
Severe >48% >60
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Rhumatismal Valve Disease
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Mitral Stenosis in cardiac CT
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Mitral Stenosis in cardiac CT
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EHJ 2012
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Mitral Paravalvular leaks in CTvs. TTE/TEE and surgical findings
• Retrospective blinded study
• N=78 redo surgery out of 208 pts
• CT>TTE and equivalent to TEE
• New strategy: TTE followed by
TEE or CT ?
Suh YJ et al. Circulation CVI 2016
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Periprosthetic Mitral Valvular Leak
Systole Diastole
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4D-Flow follow-up after 2 paravalvular Amplatzer
Regurgitant Fraction=9%
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Mitral Annulus Calcification
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Male 49yr, 6Follow-up post MVR
Courtesy A. Azarine
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SPECIFIC MITRAL VALVE DISEASEENDOCARDITIS
ISCHEMIC MR
HCM
ANNULAR CALCIFICATION
Mitral Valve Imaging
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Scanner et endocardite valvulaire
Performances Dg
• Reproducitibilité du Dg
positif EI
inter κ=0.96, intra: κ=1
• Abcès et faux anévrisme
Se=Sp=100% vs. 89% pour
l’ETO
• Végétations
Scanner=89% vs. 96% pour
l’ETO
• Valeur spécifique du
scanner pour le CALCIUM
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Ischemic MR
Morris MF, Radiographics 2010
• MR mechanism: related MI in LGE
• MR Quantification
• LV dilatation, systolic dysfunction + viability and
residual ischemia
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Mid LV obstruction in HCM
Maron BJ Circulation 2008
No SAM
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Caseous necrosis of the mitral annulus
• focal degeneration with central softening of the
annular calcification
• adjacent to the posterior mitral leaflet
• hyposignal in all pulse sequences
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ADDITIONAL DATA
NEW STRATEGIES
Mitral Valve Imaging
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Safety of preoperative coronary CT for non
coronary CV surgery
Catalàn et al. Radiology 2011
Significant predictor on non diagnostic CT:
Agatston>600
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Measuring LA dimensions with CMR
Simpson’s method
Reference methodContours: tediousShort or long axis views
Bi/triplane method
Diameters & area: 2 or 3 planes
Biplane volume calculation:
best of non volumetric methods
Nacif et al. Diag Interv Radiol 2013; Hudsmith et al. , Maceira et al. ; Sievers et
al.
3D modeling method
• d
volume=0.85×4c-area x
2c-area /
perpendicular
axis
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Normal values for LA size in CMR
LA dilatation
• Diameters: high variability
• Area / BSA
>16 cm2/m2 in 2ch and 4ch
• Volume / BSA
>52 ml/m2
Kawel-Boehm et al. JCMR 2015
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CT for LA thrombus
• Meta-analysis
19 studies n=2955 patients
(Av. age 61 yrs)– Romero et al. Circ cvi 2014
• Prevalence of LA
thrombus 8.9+/-7%
• Accuracy vs. TEE >92%
with delayed imaging
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A B
Left Atrial Flow in CMR
Evin M. et al.
2D velocity map(control)
ControlSevere MR and HF
3D vorticity maps
3D streamlinescontrol
(Res phase)
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Huber A…Kachenoura…Redheuil A. Radiology 2017 in press
LA strain by CMR-FT vs. histology
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Scanner post TAVIdysfonction et thrombose silencieuse de prothèse
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TAVM
• Initial experience
• HIGHLIFE Study: patient n°1 PSL in may 2017
Altisent et al. JACC 2015
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