Assessment of Aortic Regurgitation with Cardiovascular Magnetic Resonance

Assessment of Aortic Regurgitation with Cardiovascular Magnetic Resonance

Dr Cemil Izgi

Department of CardiologyRoyal Brompton HospitalLondon, UK

Case presentation

• 43 years-old, Male

• Presented with shortness of breath present for the last 12 months

• 2-3/6 diastolic murmur at left sternal border collapsing pulse

• Transthoracic Echo: o Not diagnostic; significantly limited (poor echogenicity, obese patient) o suggestive of poor LV systolic function with some eccentric aortic regurgitation but

severity and cause could not be assessed; a bicuspid aortic valve was suspectedo Patient was unwilling to have a transesophageal echo study.

Patient was referred for a cardiovascular magnetic resonance (CMR) study to assess LV systolic function and aortic regurgitation severity

“In patients with inadequate echocardiographic quality or discrepantresults, cardiac magnetic resonance (CMR) should be used toassess the severity of valvular lesions—particularly regurgitantlesions—and to assess ventricular volumes and systolic function,as CMR assesses these parameters with higher reproducibilitythan echocardiography.”

ESC/EACTS Guidelines on management of VHD-2012

3.1 Patient evaluation3.1.3.2 Cardiac magnetic resonance

Is CMR an appropriate test for assessment of valvular heart disease?

Clinical indications for cardiovascular magnetic resonance (CMR): Consensus panel report. European Heart Journal.2004;25:1940-1965

Is CMR an appropriate test for assessment of valvular heart disease?

CMR examination:-Ventricles

Dilated LV with impaired systolic function. An eccentric aortic regurgitation jet is also seen.

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CMR examination:-Ventricular Volumes and EF

- Dilated LV with decreased EF- Normal RV size and EF- LV/RV stroke volume difference of 76ml

EDV (ml) ESV (ml) Stroke V (ml) EF (%)

LV 354 198 156 44

RV 144 64 80 55

CMR examination:-aortic valve and aortic root

Bicuspid aortic valve Normal aortic root and ascending aorta

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CMR examination:-aortic regurgitation severity -1

In plane flow mapping images showed an eccentric jet of aortic regurgitation.

LVOT- magnitude image LVOT- phase contrast image

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CMR examination:-aortic regurgitation severity -2

• Regurgitant volume >60 ml as quantified by Doppler echo indicates severe AR1, • Regurgitant fraction >30-33% derived from phase contrast CMR indicates severe AR2,3

1Lancellotti P, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging (2013) 14, 611–644 2Gabriel RS, et al. Comparison of severity of aortic regurgitation by cardiovascular magnetic resonance versus transthoracic echocardiography. Am J Cardiol. 2011 Oct 1;108(7):1014-20. 3Myerson SG, et al. Aortic regurgitation quantification using cardiovascular magnetic resonance: association with clinical outcome. Circulation. 2012 Sep 18;126(12):1452-60

Through plane phase contrast cine just above aortic valve tips Flow-time curve of flow through aortic valve showing

forward and regurgitant flows which can be quantified

Forward flow 147 ml/beat, regurgitant volume 72 ml/beat, regurgitant fraction 49%(in accordance with LV-RV stroke volume difference )

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• Doppler evidence of halodiastolic flow reversal in descending aorta is a strong indicator for severe aortic regurgitation1,

• also validated with CMR2

1Lancellotti P, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging (2013) 14, 611–644 2Bolen MA, et al. Cardiac MR assessment of aortic regurgitation: holodiastolic flow reversal in the descending aorta helps stratify severity. Radiology. 2011 Jul;260(1):98-104

CMR examination:-aortic regurgitation severity -3

Thoracic aorta cine Descending aorta through plane phase contrast

Descending aorta flow curve:

Halodiastolic flow reversal

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• -Bicuspid aortic valve with severe aortic regurgitation -LV dilatation and systolic dysfunction -Normal aortic root and ascending aorta size

• Symptomatic

Diagnosis

ESC/EACTS Guidelines on management of VHD-2012

Management of severe AR

Patient referred for surgery

Conclusion

• CMR can provide important information for the assessment of regurgitant valvular lesions. It can be used as an adjunct to echo or when echo findings are inconclusive.

• For aortic regurgitation it can reliably assess: LV ventricular volumes and systolic function structure of the aortic valve size of the aortic root and ascending aorta severity of aortic regurgitation

• visual assessment by cine images (qualitative only and not recommended)• quantification of regurgitation volume and regurgitant fraction -difference between left and right ventricular stroke volumes -velocity mapping of aortic flow• demonstration of halodiastolic flow reversal in the descending aorta

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