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Radiología. 2014;56(3):219---228

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RADIOLOGY THROUGH IMAGES

Valvular heart disease: Multidetector computed tomographyevaluation�

A. Francoa, G.C. Fernández-Pérezb,∗, M. Tomás-Mallebreraa, S. Badillo-Portugala,M. Orejasc

a Servicio de Radiodiagnóstico, Hospital Fundación Jiménez Díaz, Madrid, Spainb Servicio de Radiodiagnóstico, Complejo Asistencial de Ávila, Ávila, Spainc Servicio de Cardiología, Hospital Fundación Jiménez Díaz, Madrid, Spain

Received 27 October 2011; accepted 20 September 2012Available online 11 June 2014

KEYWORDSValvular heartdisease;Multidetectorcomputedtomography;Image reconstruction;Valvular stenosis;Valvular regurgitation

Abstract Heart valve disease is a clinical problem that has been studied with classical imag-ing techniques like echocardiography and MRI. Technological advances in CT make it possible toobtain static and dynamic images that enable not only a morphological but also a functional anal-ysis in many cases. Although it is currently indicated only in patients with inconclusive findingsat echocardiography and MRI or those in whom these techniques are contraindicated, multide-tector CT makes it possible to diagnose stenosis or regurgitation through planimetry, to evaluateand quantify valvular calcium, and to show the functional repercussions of these phenomena onthe rest of the structures of the heart. Given that multidetector CT is being increasingly usedin the diagnosis of ischemic heart disease, we think it is interesting for radiologists to know itspotential for the study of valvular disease.© 2011 SERAM. Published by Elsevier España, S.L. All rights reserved.

PALABRAS CLAVEEnfermedades de lasválvulas cardíacas;Tomografía

Enfermedad valvular cardíaca. Valoración con tomografía computarizadamultidetector

Resumen La enfermedad valvular cardíaca es un problema clínico que se ha estudiado

loaded from http://www.elsevier.es, day 12/05/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

computarizada con técnicas de imagen clásicas como la ecocardiografía o la RM. El avance tecnológico

multidetector;Reconstrucciónde imágenes;Estenosis valvular;Insuficiencia valvular

de la TC permite obtener imágenes estáticas y dinámicas con las que hacer un análisismorfológico y, en muchas ocasiones, funcional. A pesar de que actualmente está solo indi-cada en los pacientes en los que la ecocardiografía o la RM no son concluyentes o estáncontraindicadas, la TC multidetector permite diagnosticar la estenosis o insuficiencia porplanimetría, valorar y cuantificar el calcio valvular, y mostrar las repercusiones funcionales

� Please cite this article as: Franco A, Fernández-Pérez GC, Tomás-Mallebrera M, Badillo-Portugal S, Orejas M. Enfermedad valvularcardíaca. Valoración con tomografía computarizada multidetector. Radiología. 2014;56:219---228.

∗ Corresponding author.E-mail address: [email protected] (G.C. Fernández-Pérez).

2173-5107/$ – see front matter © 2011 SERAM. Published by Elsevier España, S.L. All rights reserved.

dx.doi.org/10.1016/j.rxeng.2014.05.006

http://www.elsevier.es/rx

mailto:[email protected]

220 A. Franco et al.

en el resto de estructuras cardíacas. Teniendo en cuenta que la TC multidetector es una técnicacada día más utilizada para el diagnóstico de la enfermedad isquémica, creemos interesanteque el radiólogo conozca la potencialidad que esta técnica tiene en el estudio de la afecciónvalvular.© 2011 SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados.

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Figure 1 Mitral valvular apparatus. (A) Basal short-axis sliceshowing the opening orifice with the typical ‘‘D’’-shape. Thevalvular apparatus is not only a 2-leaflet structure but rathera more complex structure made up of 6 segments: 3 forthe anterior leaflet (A1---A3), and 3 for the posterior one.(B) Three-camera projection showing the remaining compo-nents like tendon cords uniting from both leaflets towards thehighest portion of papillary muscles (black arrows). The antero-lateral muscle provides tendon cords for the posteriomedialleaflets while the posteromedial muscle provides tendon cordsfor both anterolateral leaflets (white arrows). (C) During sys-tole papillary muscles are contracted with tendon cord-traction(black arrows) to close the valve (white arrows). The coapta-

Document downloaded from http://www.elsevier.es, day 12/05/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

ntroduction

ardiac valve disease causes a great number of deaths inestern countries. In 2004 in the United States mortality

ate was around 20,260 patients.1 Physiologically the valvesnsure that blood flow from cardiac cavities is unidirectional

--failure to do has serious functional repercussions.2 To studyhem both the transthoracic and the transesophageal ultra-ounds are the selected image modalities. MRI is a secondine modality and the multidetector computed tomogra-hy (MDCT) is an exceptional indication modality used inatients in whom other modalities are inconclusive. Thisoes not mean that the MDCT does not have any pro-nostic values since it provides morphological functionalnformation from valvulopathies.3 This together with theact that the use of this modality is on the rise in studiesf ischemic cardiopathies makes it interesting to know whathe potentialities of this modality are in the study of valveffectation.

echnical issues

he modality used is no different from CT-coronarographyith retrospective acquisition and synchronization to theCG. To improve the quality of images it is important forhe heart rate to be <65 b.p.m. So the use beta-blockers isot recommended. One multiphase contrast injection proto-ol allows us to assess right cavities too. Static images needo include multi-planar orthogonal reconstructions on thealves and it is also possible to obtain dynamic images withotion-compensated image reconstructions (MCIR) using

ntervals every 10% of cardiac cycle.4

itral valve

t opens during diastole enabling ventricular filling. Thenterior leaflet is part of the left ventricular outflow tractnd is slightly thicker and longer than the posterior leaflet.n normal conditions it is <5 mm-thick4,5 (Fig. 1).

itral stenosis

t is defined as the incomplete opening of the valve. Its nor-al area is around 4---6 cm2.6 Functional repercussion occurshen the area is <2.5 cm2 while clinical signs occur when the
rea is <1 cm2. The most common cause is often rheumaticalvulopathy (Table 1) and less commonly the significantegenerative calcification of the valve (Fig. 2), congeni-al abnormalities, diseases of connective tissue or articular
tion of both leaflets does not occur in one particular point butin a segment with variable length of several millimeters called‘‘coapted area’’ (circle).

Valvular heart disease: Multidetector computed tomography evaluation 221

Table 1 Causes of mitral stenosis.

1. Rheumatic disease2. Acquired non-rheumatic mitral stenosis:

a. Significant calcification of mitral ringb. Ergotamine and methyergide-induced stenosesc. Appetite-suppresant and cabergolide-induced stenosesd. Obstructive mitral vegetations in endocarditise. Lupus erythematosus systemicf. Antiphospholipid antibody syndromeg. Carcinoidh. Rheumatoid arthritisi. Whipple’ diseasej. Pseudoxanthoma elasticumk. Tumors (left atrial myxoma and others)

3. Cor triatriatum4. Other congenital causes (supravalvular ring, parachute

Figure 2 Seventy seven year old-woman with calcificationof mitral ring. (A) Four-camera projection showing concentra-tion of valvular calcium (arrows). This calcification is associatedwith age and is present in 70% of patients between 80 and 90years old so virtually the rule works beyond this age. The func-tional repercussion it causes is variable. We can have smallinsignificant regurgitations and occasionally functional steno-sis. It has also been associated with the degree of high bloodpressure, atherosclerosis and even osteoporosis. (B) Short axisst

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1the dilation of the ascending aorta and hypertrophy of the

12


valve)

myxoma (Fig. 3). Symptoms include dyspnea, lung hyperten-sion, lung edema, atrial fibrillation, and systemic strokes.5

Messika-Zeitoun et al. compared ECG to MDCT in29 patients with different degrees of mitral stenosis and con-firmed excellent correlation (r = 0.88) when mitral stenosiswas analyzed through planimetry.6

Mitral failure

It is defined as the incomplete closure of leaflets during sys-tole with blood regurgitation from the ventricle to the leftatrium. Causes include the deposit of myxoid material in theleaflets, congenital abnormalities (mitral prolapse), tendoncord tears or papillary muscle tears due to trauma, infec-tion (Fig. 5) or MI, and ring dilation due to dilation of leftventricle.

Symptoms depend on whether mitral valve is acute orchronic. If acute the fast overload of left atrium causesacute lung edema and heart failure due to a reduced ante-grade flow. If chronic it can be well-tolerated for decades.The left atrium and ventricles dilate and act as a reservoirwithout a greater lung pressure. In time the left ventricledecompensates reducing the heart beat volume and leadingto heart failure.5

MDCT cannot only confirm the regurgitant orifice area butalso the abnormalities of valve ring, the dilation of the leftatrium and the signs of lung hypertension. When it comesto estimating the regurgitant orifice area through panimetrythe MDCT shows high correlation to transthoracic ultrasoundand ventriculography (r = 0.8 and 0.9 respectively).7,8

Aortic valve

It is a 3 leaflet-valve though some congenital disorders havebeen described where it can be a 2 leaflet-valve (bicuspid)
and in rare occasions a 4 leaflet-valve. Its normal area rangesbetween 2.5 and 4 cm2 (Fig. 7).9 The phase of the cardiaccycle that best shows its opening is often a 20% RR interval.10
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howing semicircular shaped-calcifications-often located in pos-erior segments of the ring.

ortic stenosis

e talk about stenosis when the area is <2 cm2 and aboutritical stenosis <0.8 cm2. In young people the most com-on cause is the bicuspid valve (Fig. 8).11,12 Other causes

re rheumatic disease and less common subvalvular steno-is (caused by a fixed membrane or fibromuscular tunnel)nd the dynamic subvalvular obstruction of hypertrophicardiomyopathy.9,10 Degenerative calcification is common inhe elderly.13

Patients remain asymptomatic until the area is below cm2. The increase of transvalvular pressure will cause

eft ventricle. Dyspnea, syncope and chest pain with nor-al coronaries are all symptoms that often manifest with

xercise.13


Figure 3 Atrial myxoma. Three-camera projection showinghypodense nodular images attached to the inter-atrial septumand inside the left atrium (arrow). They usually occur in isola-tion though other multiple manifestations in clusters have alsobeen described as part of the Carney complex. They can oftenbe found in the oval fossa, in the posterior wall or in the ante-rior leaflet. When in the leaflet they are often located in theanterior leaflet and though a pedicle they move with it allowingthe prolapse of myxoma during diastole.

With MDCT we must remember that: the valve appa-ratus is thickened and some times calcified being theorifice small (Fig. 4). Physiological repercussions likethe dilation of left atrium or intra-articular thrombiare other radiological findings associated. In the mostserious cases there are signs of lung hypertension andhypertrophy of right ventricle. Motion-compensatedimage reconstructions (MCIR) can show restriction inthe movement of the leaflets. The phase of 65% of car-diac cycle is the one that better shows the opening of

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Figure 4 Fifty-eight year old-woman with mitral stenosis ofrheumatic origin. (A) Four-camera projection showing narrow-ing and thickening of mitral valve with affectation of the distalarea of leaflets. This disorder causes a typical ‘‘doming’’-shapeas it is known in echocardiographical studies (arrows). Due tothe stenosis the left atrium gets bigger. (B) Orthogonal valveprojection obtained during diastole showing reduced opening(1.4 cm2-planimetry) and thickening of tendon cords in thea

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the valve.1---4

ortic failure

ts causes can be found in the valvular apparatus on in dis-rders of the aortic root. Some of the former causes areyoxide degeneration, bicuspid valve, rheumatic disease

nd endocarditis. Disorders of the aortic root can be seenn anulectasis (Marfan’ syndrome), high blood pressure andneurysms (Fig. 10). Aortic dissection can produce acuteailure when it spreads proximally, protrudes through thealvular ring and causes symptoms associated to acute heartailure (Fig. 11). In chronic failure the patient can remainsymptomatic for years until the disease becomes worsend signs of heart failure become evident-including suddeneath. It is because of these features that it has been named‘silent killer’’.5,13

MDTC confirms loss of coaptation (Fig. 12) and the regur-itant orifice area can be estimated through planimetry. It
an also inform us on criterion of severity like dilation ofhe left ventricle and increase of the myocardial mass.15
ome times in motion-compensated image reconstructionsMCIR) a more vigorous contraction of the interventricular

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nterolateral and posteromedial rims of leaflets (arrow).

eptum compared to the posterior wall can be seen. Com-ared to the transesophagic ultrasound, Fleutchner confirms

95% sensibility and a 96---100% specificity in the detectionf moderate-serious aortic failures analyzing not only therifice but also the regurgitant fraction.15,16

ricuspid valve

ricuspid valve is a 3-leaflet valve consisting of one anterior
eaflet, one septal leaflet and one posterior leaflet whoseize and shape are variable-commonly the anterior leaflet issually longer. The normal leaflet area is often 3---5 cm2.5,17


Figure 5 Sixty-two year old-woman with fever after toothextraction, recent onset-click and multiple brain infarcts.(A) Three-camera projection showing wart attached to the atrialzone of posterior leaflet. (B) Basal short-axis slice showingboth the wart’ oval shape and anchor zone to posterior leaflet(arrow).

We must remember that: a common cause of mitral

Figure 6 Mitral prolapse. Two-camera projection during sys-tole showing typical ballooning of the anterior leaflet over themt

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failure is mitral prolapse defined as systolic ballooningof the leaflet >2 mm over the ring plane (Fig. 6).

Tricuspid stenosis

They are not usually isolated. Both the congenital steno-sis and the stenosis secondary to rheumatic disease are themost common causes. The carcinoid syndrome and the lupuserythematosus systemic are other causes too. There are alsorare cases like tumors in the right atrium prolapsed due tothe valve and causing functional obstruction. Symptoms cor-respond to right failure with an increased yugular pressure,
hepatomegalia and ascitis.5,12
On the MDTC we can see a narrowing of the ring withshortened tendon cords, dilation of the right atrium and anincreased caliber of the superior and inferior cava veins.17

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itral ring (arrow). There is also dilation of left atrium sugges-ive that this prolapse conditions mitral failure.

ricuspid failure

t occurs when the leaflet coaptation is incomplete andlood reflows towards the right atrium. The most commonause is dilation of the left ventricle due to pulmonaryypertension. Ebstein’ anomaly is the most common geneticisorder. In it the dysplastic valve has a more distal loca-ion than usual. The most common acquired causes arendocarditis, diseases of connective tissue, myocardialnfarction or rheumatic disease. Symptoms are right heartailure.18

We can also see dilation of the right atrium and ventricleith ballooning of the septum towards the left ventri-le --- particularly in the presence of serious pulmonaryypertension.5 In Ebstein’ anomaly we can see the rotationf the heart towards the right with larger right cavities andpical displacement of tricuspid valve.5

ulmonary valve

he pulmonary valve is a 3-leaflet valve and is often affectedy congenital disorders. Acquired disorders are rare. Its nor-al area = 2 cm2.

ulmonary stenosis

ulmonary stenosis is moderate when its area is <1 cm2

nd serious when it is <0.5 cm2. It can be subvalvular,alvular (90% of cases) or supravalvular.5 It is usu-lly an isolated congenital anomaly in 90% of caseshough it can also be part of other more complex casesike Fallot’ tetralogy. Acquired causes are less common
nd include rheumatic affectation, carcinoid syndrome andndocarditis. Pulmonary stenosis increases pressure on theight ventricle with hypertrophy, dilation and ventricularysfunction.5,12


Figure 7 Tricuspid shape of a normal aortic valve. (A) Per-pendicular projection towards the aortic valve. The typicaltricuspid appearance in ‘‘Mercedes-Benz’’-star like shape canbe seen here. There is complete coaptation of leaflets duringvalvular closure. (B) Images of the valve during systole wherewc

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Figure 8 Bicuspid valve. (A) Morphology of bicuspid aorticvalve during diastole with coaptation of leaflets. (B) During sys-tole is has a ‘‘fish mouth’’-shape with a reduced opening area.Even though it can be an isolated disorder it is commonly asso-ciated with other disorders particularly aortic coarctation anddilation of the aortic root.

Of MDTC we must remember that: it assesses thethickness, calcification, and reduction of the valvu-lar area. Calcification can be measure and it isclosely related to how serious the stenosis really is(Fig. 9). Other abnormalities such as ventricular hyper-trophy and dilation of the ascending aorta are easilyrecognizable.10---14

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e can see the complete opening where the sinuses of Valsalvaan be identified: R: right; L: left; NC: non-coronary.

On the MDTC the findings are a reduced valvular orificeFig. 14), the post-stenotic dilation of the main pulmonaryrtery (Fig. 14B), the hypertrophy of the right ventricle andhe ballooning of the interventricular septum towards theeft ventricles. The left pulmonary artery is dilated dueo ‘‘jet’’ crash on the posterior wall. It can be useful tossess the motion-compensated image reconstructions givenhe valve adopts a ‘‘funnel’’-like morphology due to fusedeaflets1,7 (Fig. 14B).

ulmonary failure

t is a blood reflow from pulmonary artery towards the rightentricle due to poor coaptation. It is often due to dilation

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f the valvular ring caused by pulmonary hypertension andt is not usually due to direct damage on the leaflets.1,7

On the MDTC we can see an inadequate closure ofeaflets, dilation of both the valvular ring and pulmonary
rtery and hypertrophy of the right ventricle.1,5,7


Figure 9 Association between aortic calcification and aor-tic stenosis. Three-camera projection during systole. Significantcalcification and reduced valvular opening is evident (arrow).

Figure 10 Patient with Marfan syndrome. We can see aneurys-matic dilation of the aortic root (arrows) selectively affectingsinus and sinotubular regions. However the aortic arch and thedescending aorta are normal.

Figure 11 Acute aortic failure in a patient with type A-dissection. (A) Coronal-oblique view showing a Stanford aorticdissection type A with complex intimal tear while adoptinga spiroid shape and prolapsing through the valve (arrows).(B) Orthogonal reconstruction on the aortic valve showing thedetached intima (arrow) and calcification in 2 of its leaflets.

Figure 12 Aortic valvular failure. Orthogonal reconstructionon the acquired valve during diastole showing leaflet coaptation(arrow).



With MDTC we must remember that: there is incom-plete coaptation (Fig. 13). It is not uncommon to seecontrast reflow towards the inferior cava vein andsupra-hepatic vein during phase of the 1st step of con-trast. Despite before this sign was considered a highlysensible sign today cardiac protocols are implementedwith faster flow velocities that in turn make this findingless trustworthy.19

Figure 13 Tricuspid failure. (A) Basal short-axis slice showingthe tricuspid valve obtained during systole. Nodular calcifica-tion and lack of leaflet coaptation can be identified here (*).(B) Planimetry calculated during systole and in a perpendicularpsr

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Figure 14 Pulmonary valve stenosis. (A) It is a congenitaldisease causing commissural fusion (arrows) that gives rise tounicuspid shapes (in same cases bicuspid shapes). (B) Obliquesagittal slice showing the pulmonary valve with the typicaldome-or-tunnel-shape (arrows) and the hemodynamic conse-quences associated like hypertrophy of right ventricle (whiteaa

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rojection towards tricuspid valve. (C) Four-camera projectionhowing hemodynamic consequences of tricuspid failure likeight atrium dilation.

alvular prostheses

he aortic and mitral valves are the most commonlyurgically replaced valves of all. There are two (2)

sterisk) and dilation of the pulmonary artery trunk (blacksterisk).

ypes of valvular prostheses usually available: biologi-al and mechanical. The duration of biological valves ishorter than the duration of mechanical valves yet theatter need anticoagulation. Echocardiography replacedodalities like fluoroscopy though it is not free from lim-

tations due to prosthetic metallic artifacts or surgicallips.20

Thanks to the MDTC we can evaluate the accuracyof the opening angle of prosthetic discs (Fig. 15).21

We must remember that: in metallic valves the studycan be done without contrast and low doses and yetthe infusion of contrast is necessary to find thrombi,
pannus, surgical breakdown, pseudoaneurysms, orabscesses.


Figure 15 Aortic and mitral prostheses. 3D projection obtained during systole and diastole. (A) During diastole the mitral prosthesisopens partially due to the opening of 1 valvular disc only (arrow). However during systole (B) there is a proper closure of such discs.

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The aortic prosthesis shows normal opening and closure (arrow)

Conclusion

Heart valvular disease is a common clinical problem wherethe MDTC can be useful in showing relevant findings despitethe fact that it is not a selected diagnostic modality. Itsadvantage lies in the fact that it is a fast modality of greatspatial resolution that allows us to do reconstructions in dif-ferent planes for the assessment of valvular apparatus. Alsoits temporal resolution allows us to see motion-like Images-an added value to morphological analysis too.

Ethical responsibilities

Protection of humans and animals. Authors confirm that noexperiments have been done with humans or animals duringthis research.

Confidentiality of data. Authors confirm that in this reportthere are no personal data from patients.

Right to privacy and informed consent. Authors confirmthat in this report there are no personal data from patients.

Authors

1 Manager of the integrity of the study: AF and GCFP.2 Original Idea of the Study: AF, GCFP and MTM.3 Study Design: MTM, SBRP, MO and GCFP.4 Data Mining: AF, MTM, SBRP, MO and GCFP.5 Data Analysis and Interpretation: GCFP, MTM, MO and

SBRP.6 Statistical Analysis: NA.7 Reference Search: SBRP and GCFP.8 Writing: GCFP, SBRP and MTM.9 Manuscript critical review with intellectually relevant

contributions: GCFP, AF and MO.10 Final version approval: AF, GCFP, MTM, SBRP and MO.

Conflict of interests

Authors reported no conflicts of interests.

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