Valvular Heart Disease Flashcards
Valvular heart disease — role of CMR ?
Cine Imaging: anatomy, coaptation, LV volumes/function
Phase Contrast Imaging: stroke volume (SV), regurgitant volume (RV), Vmax
Aortic valve stenosis — facts ?
Most common acquired valvular disease
Leads to left ventricular pressure overload
Leads to left ventricular hypertrophy
Aortic valve insufficiency — facts ?
Leads to left ventricular volume overload
Leads to left ventricular dilatation and secondary hypertrophy — concentric/symmetric, wall thickness <15mm
Mitral valve stenosis — facts ?
Leads to left atrial dilatation
Leads to pulmonary congestion / edema
Mitral valve insufficiency — facts ?
Leads to left ventricular volume overload
Leads to left atrial dilatation
Leads to pulmonary congestion / edema
Pulmonary valve stenosis — facts ?
Most frequent congenital valve disorder?
Leads to right ventricular pressure overload
Leads to right ventricular hypertrophy
Pulmonary valve insufficiency — facts ?
Common complication after repair of Tetralogy of Fallot (ToF) or pulmonary stenosis
Leads to right ventricular volume overload
Leads to secondary right ventricular hypertrophy
Tricuspid valve stenosis — facts ?
Rare valvular disorder
Leads to right atrial dilatation
Tricuspid valve insufficiency — facts ?
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.
aortic stenosis — aetiology ?
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
aortic stenosis — epidemiology ?
most frequent valvular heart disease in Europe and North America
prevalence 2-5% after 65y, increasing with age
m>f 4:1
aortic stenosis — clinical symptoms ?
late symptoms with high grade stenosis
syncope, dizziness, dyspnea, angina
aortic stenosis — therapy and prognosis ?
aortic valve replacement
mortality after surgical valve replacement ~ 4% (~7% with bypass)
10 year survival rate ~ 85%
aortic stenosis — imaging (TTE) ?
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
aortic stenosis — imaging (CT) ?
calcium score: >2100 (m) / >1200 (f)
AVA > 1.5cm2 — mild stenosis
AVA 1.0-1.5cm2 — moderate stenosis
AVA < 1.0cm2 — high-grade stenosis
aortic stenosis — imaging (MRI) ?
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
aortic insufficiency — aetiology ?
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
aortic insufficiency — Carpentier classification ?
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
aortic insufficiency — epidemiology ?
prevalence ~ 4.9%
increasing with age
m:f - 3:1
aortic insufficiency — clinical symptoms ?
acute left heart decompensation, pulmonary congestion
chronic left ventricular insufficiency, stress dyspnea
aortic insufficiency — therapy ?
medications — reducing afterload
surgery — valve reconstruction or replacement (Ross operation)
aortic insufficiency — prognosis ?
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%
aortic insufficiency — imaging (TTE) ?
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
aortic insufficiency — imaging (CT) ?
clarifying aetiology e.g. aneurysm, dissection, congenital
incomplete cusp coaptation, regurgitant orifice area (AROA)
< 25 mm2 — mild
25-75 mm2 — moderate
> 75 mm2 — severe
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
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
mitral stenosis — aetiology ?
rheumatic valve disease (95%)
obstruction e.g. myxoma, vegetations
mitral stenosis — epidemiology ?
prevalence ~1%
age peak 50-70y
f:m - 2:1
mitral stenosis — clinical symptoms ?
left atrial dilatation
pulmonary congestion
atrial fibrillation
mitral stenosis — therapy ?
mitral valve reconstruction, valvuloplasty, mitral valve replacement
antiarrhythmic medications, anticoagulation
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%
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
mitral stenosis — imaging (CT) ?
morphologic changes
quantification of the mitral valve orifice area < 1.5 cm2 (severe)
preoperative evaluation of coronary artery disease
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)
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)
mitral insufficiency — epidemiology ?
most common mitral dysfunction
increasing with age, predominantly > 65 years
mitral insufficiency — clinical symptoms and complications ?
acute: cardiogenic shock, reduced ejection fraction
chronic: left atrial then left ventricular dilatation, atrial fibrillation
mitral insufficiency — therapy ?
surgical intervention indicated in high-grade insufficiency
also dependant on aetiology and pathophysiology
controversial in secondary functional aetiology e.g. DCM
mitral insufficiency — prognosis ?
variable
higher mortality in moderate to high-grade insufficiency (EF<50%)
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
mitral insufficiency — imaging (CT) ?
clarification of the aetiology
visualisation of regurgitant orifice area (ROA) possible
surgical planning
characterisation of mitral annulus calcification
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
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
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
tricuspid stenosis — clinical symptoms and therapy ?
fatigue, edema
diuretics, salt restriction
balloon valvuloplasty — VOA < 1.7 cm2 or TVPG > 5 mmHg
tricuspid stenosis — imaging ?
TTE — method of choice:
assessment of transvalvular pressure gradient
MRI — diastolic jet, right atrial dilatation, thickened valve
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
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
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)
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
pulmonary stenosis — epidemiology ?
~8% of all congenital defects
~1:2000 of newborns
pulmonary stenosis — clinical symptoms ?
mild — asymptomatic
moderate and severe — systemic venous congestion
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
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
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
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
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)
pulmonary insufficiency — clinical symptoms ?
mild PI — asymptomatic
moderate to severe or long-standing — right sided heart failure with exertional dyspnea
pulmonary insufficiency — therapy and prognosis ?
pulmonary valve replacement with progressing right cardiac failure
prognosis depends on the underlying aetiology
pulmonary insufficiency — imaging (TTE) ?
method of choice
~75% with mild insufficiency are diagnosed
diastolic insufficiency jet for quantification
pulmonary insufficiency — imaging (CT) ?
possible aid to find the underlying aetiology
pulmonary insufficiency — imaging (MRI) ?
visualisation of the diastolic jet
assessment of regurgitant volume / fraction (PCI)
assessment of right ventricular function
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
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
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
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)
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
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
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
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
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
