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Detection and Quantification of Valvular Heart Disease with Dynamic Cardiac MR Imaging¹

¹ From the Department of Radiology, Hôpital Cantonal Universitaire de Genève, 24 rue Micheli du Crest, 1211 Geneva 14, Switzerland (D.D., R.L., B.F.); and the Department of Radiology, University of California, Los Angeles (O.R.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 29, 1999; revision requested May 6 and received June 22; accepted June 22. Address correspondence to D.D. (e-mail: didier@dim.hcuge.ch).

View larger version (125K): [in a new window]   Figure 1a.   Mitral regurgitation. Horizontal long-axis cine gradient-echo MR images (four-chamber view) demonstrate mitral regurgitation (arrow). The parameters used to obtain the two images were identical except for TE. The flow void is more clearly depicted on the long-TE image (TE = 12 msec) (b) than on the short-TE image (TE = 7 msec) (a). LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (120K): [in a new window]   Figure 1b.   Mitral regurgitation. Horizontal long-axis cine gradient-echo MR images (four-chamber view) demonstrate mitral regurgitation (arrow). The parameters used to obtain the two images were identical except for TE. The flow void is more clearly depicted on the long-TE image (TE = 12 msec) (b) than on the short-TE image (TE = 7 msec) (a). LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (120K): [in a new window]   Figure 2a.   Measurement of the area of signal void on cine gradient-echo MR images in valvular regurgitation. Horizontal long-axis gradient-echo MR image (four-chamber view) (a) and coronal gradient-echo MR image (b) demonstrate mitral and aortic regurgitation, respectively. The region of interest has been outlined manually on both images. Ao = aorta, LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (147K): [in a new window]   Figure 2b.   Measurement of the area of signal void on cine gradient-echo MR images in valvular regurgitation. Horizontal long-axis gradient-echo MR image (four-chamber view) (a) and coronal gradient-echo MR image (b) demonstrate mitral and aortic regurgitation, respectively. The region of interest has been outlined manually on both images. Ao = aorta, LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

View larger version (127K): [in a new window]   Figure 3.   Calculation of regurgitant fraction with ventricular volumetric measurements. Horizontal long-axis (four-chamber view) (A, B) and short-axis (C, D) cine gradient-echo MR images of the ventricles at end-diastole (A, C) and end-systole (B, D) illustrate the measurements of ventricular volumes used to calculate regurgitant fraction. Double-headed arrows in B indicate the planes perpendicular to the long axis of the ventricles. The short-axis level 1 and level 2 images were obtained in these planes, which are numbered accordingly. Ar = area, L = length, LV = left ventricle, RV = right ventricle.

View larger version (145K): [in a new window]   Figure 4.   Quantification of regurgitant blood flow in a patient with aortic regurgitation. Sixteen transverse oblique magnitude VEC MR images were obtained perpendicular to blood flow direction in the ascending aorta (Asc Ao) at the level of the right pulmonary artery. On each frame of the series, cross-sectional area is measured by manually tracing a region of interest centered on the lumen (images 1 in systole and 7 in diastole).

View larger version (118K): [in a new window]   Figure 5.   Quantification of regurgitant blood flow in the same patient as in Figure 4. Sixteen corresponding transverse oblique phase VEC MR images demonstrate bright signal intensity in the ascending aorta (Asc Ao) in systole, a finding that indicates antegrade flow (image 1), and decreased signal intensity in diastole, which indicates retrograde flow (image 7). The signal intensity of the descending aorta (Des Ao) is opposite that of the ascending aorta. Gray areas represent stationary tissue. The regions of interest traced on the magnitude images (cf Fig 4) have been transferred to the corresponding phase image for each frame, allowing through-plane measurement of the average velocity.

View larger version (117K): [in a new window]   Figure 6.   Regurgitant blood flow in the same patient as in Figure 4. Magnified (top) and color-coded (bottom) views of the transverse oblique phase VEC MR images in systole (left) and diastole (right) shown in Figure 5 allow better differentiation of antegrade (red) and retrograde (blue) flow. Asc Ao = ascending aorta, Des Ao = descending aorta.

View larger version (64K): [in a new window]   Figure 7.   Severe aortic regurgitation in the same patient as in Figure 4. Graph of ascending aortic flow volume over time illustrates the stroke volume in systole (red) and the regurgitant volume in diastole (blue), which is calculated as the area bounded by the curve under the baseline in diastole. The regurgitant fraction, which is defined as regurgitant volume divided by stroke volume, is 48% (70.2 mL/147.6 mL), a finding that indicates severe aortic regurgitation.

View larger version (151K): [in a new window]   Figure 8a.   Aortic valvular stenosis. Coronal (a) and long-axis (b) cine gradient-echo MR images obtained at midsystole demonstrate a stenotic aortic valve. Qualitative evaluation of the degree of stenosis is based on the area and extent of the signal void caused by high-velocity flow and turbulence (arrow). Ao = aorta, LA = left atrium, LV = left ventricle.

View larger version (145K): [in a new window]   Figure 8b.   Aortic valvular stenosis. Coronal (a) and long-axis (b) cine gradient-echo MR images obtained at midsystole demonstrate a stenotic aortic valve. Qualitative evaluation of the degree of stenosis is based on the area and extent of the signal void caused by high-velocity flow and turbulence (arrow). Ao = aorta, LA = left atrium, LV = left ventricle.

View larger version (129K): [in a new window]   Figure 9.   Aortic valvular stenosis. Transverse axial cine gradient-echo magnitude MR image obtained parallel to the aortic annulus (Ao) with a short TE (magnitude image obtained with the VEC MR imaging sequence) demonstrates the abnormal motion of the stenotic valve and allows direct measurement of the valve area (in this case, 0.51 cm2 [inset]). PA = pulmonary artery.

View larger version (136K): [in a new window]   Figure 10a.   Calculation of maximum flow velocity within an aortic stenotic jet. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate the calculation of maximum velocity with placement of a region of interest (arrow in c and d) in a plane either perpendicular (through-plane velocity measurement) (a, c) or parallel (in-plane velocity measurement) (b, d) to the direction of flow. Ao = aorta, LV = left ventricle, PA = pulmonary artery.

View larger version (134K): [in a new window]   Figure 10b.   Calculation of maximum flow velocity within an aortic stenotic jet. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate the calculation of maximum velocity with placement of a region of interest (arrow in c and d) in a plane either perpendicular (through-plane velocity measurement) (a, c) or parallel (in-plane velocity measurement) (b, d) to the direction of flow. Ao = aorta, LV = left ventricle, PA = pulmonary artery.

View larger version (102K): [in a new window]   Figure 10c.   Calculation of maximum flow velocity within an aortic stenotic jet. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate the calculation of maximum velocity with placement of a region of interest (arrow in c and d) in a plane either perpendicular (through-plane velocity measurement) (a, c) or parallel (in-plane velocity measurement) (b, d) to the direction of flow. Ao = aorta, LV = left ventricle, PA = pulmonary artery.

View larger version (116K): [in a new window]   Figure 10d.   Calculation of maximum flow velocity within an aortic stenotic jet. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate the calculation of maximum velocity with placement of a region of interest (arrow in c and d) in a plane either perpendicular (through-plane velocity measurement) (a, c) or parallel (in-plane velocity measurement) (b, d) to the direction of flow. Ao = aorta, LV = left ventricle, PA = pulmonary artery.

View larger version (134K): [in a new window]   Figure 11.   Calculation of valve area. Long-axis cine gradient-echo MR image with superimposed corresponding color-coded phase image (blue areas) obtained in a patient with severe aortic stenosis allows the calculation of valve area (AAo) with Equation (4). DOT = diameter of the outflow tract (from which its area is calculated), LA = left atrium, LV = left ventricle, VAo = maximum velocity measured within the stenotic jet on the phase image, VOT = maximum velocity in the left ventricular outflow tract.

View larger version (126K): [in a new window]   Figure 12a.   Moderate to severe aortic regurgitation. Long-axis (a) and coronal (b) cine gradient-echo MR images clearly demonstrate a large signal void in diastole (arrow). Note the uniform, massive (65-mm-diameter) dilatation of the aortic annulus and proximal ascending aorta (Ao), a finding that is compatible with aortoannular ectasia.

View larger version (130K): [in a new window]   Figure 12b.   Moderate to severe aortic regurgitation. Long-axis (a) and coronal (b) cine gradient-echo MR images clearly demonstrate a large signal void in diastole (arrow). Note the uniform, massive (65-mm-diameter) dilatation of the aortic annulus and proximal ascending aorta (Ao), a finding that is compatible with aortoannular ectasia.

View larger version (132K): [in a new window]   Figure 13a.   Combined aortic stenosis and regurgitation due to long-standing bicuspid aortic valve. Long-axis cine gradient-echo MR images clearly demonstrate a large signal void related to valvular stenosis in systole (arrow in a) and a small signal void related to mild aortic regurgitation in diastole (arrow in b). Ao = aorta, LV = left ventricle.

View larger version (122K): [in a new window]   Figure 13b.   Combined aortic stenosis and regurgitation due to long-standing bicuspid aortic valve. Long-axis cine gradient-echo MR images clearly demonstrate a large signal void related to valvular stenosis in systole (arrow in a) and a small signal void related to mild aortic regurgitation in diastole (arrow in b). Ao = aorta, LV = left ventricle.

View larger version (126K): [in a new window]   Figure 14a.   Mitral stenosis. Horizontal long-axis cine gradient-echo MR image (four-chamber view) (a) and coronal oblique cine gradient-echo MR image encompassing the left atrium and left ventricle (b) show massive enlargement of the left atrium (LA) and an abnormal flow jet due to mitral stenosis in diastole (arrow). Note the size and extent of the jet, which reaches to the apex of the left ventricle. This finding is compatible with severe stenosis. RA = right atrium.

View larger version (119K): [in a new window]   Figure 14b.   Mitral stenosis. Horizontal long-axis cine gradient-echo MR image (four-chamber view) (a) and coronal oblique cine gradient-echo MR image encompassing the left atrium and left ventricle (b) show massive enlargement of the left atrium (LA) and an abnormal flow jet due to mitral stenosis in diastole (arrow). Note the size and extent of the jet, which reaches to the apex of the left ventricle. This finding is compatible with severe stenosis. RA = right atrium.

View larger version (121K): [in a new window]   Figure 15a.   Calculation of pressure gradient across a stenotic mitral valve in the same patient as in Figure 14. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate how calculation of maximum velocity can be made by placing a region of interest (arrow in c and d) in a plane either perpendicular to the direction of flow just below the mitral valve (through-plane velocity measurement) (d) or parallel to the direction of flow on a four-chamber image (in-plane velocity measurement) (c). In this case, maximum velocity was calculated as 2.3 meters per second, which corresponds to a pressure gradient across the mitral valve of 22 mm Hg. LA = left atrium, LV = left ventricle.

View larger version (112K): [in a new window]   Figure 15b.   Calculation of pressure gradient across a stenotic mitral valve in the same patient as in Figure 14. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate how calculation of maximum velocity can be made by placing a region of interest (arrow in c and d) in a plane either perpendicular to the direction of flow just below the mitral valve (through-plane velocity measurement) (d) or parallel to the direction of flow on a four-chamber image (in-plane velocity measurement) (c). In this case, maximum velocity was calculated as 2.3 meters per second, which corresponds to a pressure gradient across the mitral valve of 22 mm Hg. LA = left atrium, LV = left ventricle.

View larger version (87K): [in a new window]   Figure 15c.   Calculation of pressure gradient across a stenotic mitral valve in the same patient as in Figure 14. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate how calculation of maximum velocity can be made by placing a region of interest (arrow in c and d) in a plane either perpendicular to the direction of flow just below the mitral valve (through-plane velocity measurement) (d) or parallel to the direction of flow on a four-chamber image (in-plane velocity measurement) (c). In this case, maximum velocity was calculated as 2.3 meters per second, which corresponds to a pressure gradient across the mitral valve of 22 mm Hg. LA = left atrium, LV = left ventricle.

View larger version (57K): [in a new window]   Figure 15d.   Calculation of pressure gradient across a stenotic mitral valve in the same patient as in Figure 14. Magnitude (a, b) and corresponding phase (c, d) VEC MR images demonstrate how calculation of maximum velocity can be made by placing a region of interest (arrow in c and d) in a plane either perpendicular to the direction of flow just below the mitral valve (through-plane velocity measurement) (d) or parallel to the direction of flow on a four-chamber image (in-plane velocity measurement) (c). In this case, maximum velocity was calculated as 2.3 meters per second, which corresponds to a pressure gradient across the mitral valve of 22 mm Hg. LA = left atrium, LV = left ventricle.

View larger version (138K): [in a new window]   Figure 16a.   Mitral regurgitation. Horizontal long-axis cine gradient-echo MR images (four-chamber view) (a, c) and coronal oblique cine gradient-echo MR images encompassing the left atrium (LA) and left ventricle (LV) (b, d) show enlargement of the left atrium and an abnormal flow jet due to mitral regurgitation in systole (arrow). The area of the signal void appears larger on the second frame of the cine loop (b). On the third frame (c), the signal void has changed shape and direction, which helps explain why it is difficult to choose the image to be used for measurement. In this case, the severity of mitral regurgitation was evaluated by measuring the ventricular volumes on one horizontal long-axis and two short-axis cine gradient-echo images of the ventricles (not shown) and applying Equation (2). The regurgitant fraction was calculated as 0.52. RV = right ventricle.

View larger version (161K): [in a new window]   Figure 16b.   Mitral regurgitation. Horizontal long-axis cine gradient-echo MR images (four-chamber view) (a, c) and coronal oblique cine gradient-echo MR images encompassing the left atrium (LA) and left ventricle (LV) (b, d) show enlargement of the left atrium and an abnormal flow jet due to mitral regurgitation in systole (arrow). The area of the signal void appears larger on the second frame of the cine loop (b). On the third frame (c), the signal void has changed shape and direction, which helps explain why it is difficult to choose the image to be used for measurement. In this case, the severity of mitral regurgitation was evaluated by measuring the ventricular volumes on one horizontal long-axis and two short-axis cine gradient-echo images of the ventricles (not shown) and applying Equation (2). The regurgitant fraction was calculated as 0.52. RV = right ventricle.

View larger version (143K): [in a new window]   Figure 16c.   Mitral regurgitation. Horizontal long-axis cine gradient-echo MR images (four-chamber view) (a, c) and coronal oblique cine gradient-echo MR images encompassing the left atrium (LA) and left ventricle (LV) (b, d) show enlargement of the left atrium and an abnormal flow jet due to mitral regurgitation in systole (arrow). The area of the signal void appears larger on the second frame of the cine loop (b). On the third frame (c), the signal void has changed shape and direction, which helps explain why it is difficult to choose the image to be used for measurement. In this case, the severity of mitral regurgitation was evaluated by measuring the ventricular volumes on one horizontal long-axis and two short-axis cine gradient-echo images of the ventricles (not shown) and applying Equation (2). The regurgitant fraction was calculated as 0.52. RV = right ventricle.

View larger version (158K): [in a new window]   Figure 16d.   Mitral regurgitation. Horizontal long-axis cine gradient-echo MR images (four-chamber view) (a, c) and coronal oblique cine gradient-echo MR images encompassing the left atrium (LA) and left ventricle (LV) (b, d) show enlargement of the left atrium and an abnormal flow jet due to mitral regurgitation in systole (arrow). The area of the signal void appears larger on the second frame of the cine loop (b). On the third frame (c), the signal void has changed shape and direction, which helps explain why it is difficult to choose the image to be used for measurement. In this case, the severity of mitral regurgitation was evaluated by measuring the ventricular volumes on one horizontal long-axis and two short-axis cine gradient-echo images of the ventricles (not shown) and applying Equation (2). The regurgitant fraction was calculated as 0.52. RV = right ventricle.

View larger version (118K): [in a new window]   Figure 17a.   Pulmonary stenosis. Cine gradient-echo MR image (a) and corresponding phase VEC MR image (b) obtained in the sagittal plane centered on the pulmonary trunk show bulging of the pulmonary leaflets (P valve) and an abnormal flow jet emanating from the stenotic valve in systole (arrow). This flow jet is responsible for poststenotic dilatation at the pulmonary bifurcation (arrowhead in a). Velocity was encoded vertically (in-plane velocity measurement). Maximum velocity was calculated by placing a region of interest within the stenotic jet on the phase image. LV = left ventricle, RV = right ventricle.

View larger version (87K): [in a new window]   Figure 17b.   Pulmonary stenosis. Cine gradient-echo MR image (a) and corresponding phase VEC MR image (b) obtained in the sagittal plane centered on the pulmonary trunk show bulging of the pulmonary leaflets (P valve) and an abnormal flow jet emanating from the stenotic valve in systole (arrow). This flow jet is responsible for poststenotic dilatation at the pulmonary bifurcation (arrowhead in a). Velocity was encoded vertically (in-plane velocity measurement). Maximum velocity was calculated by placing a region of interest within the stenotic jet on the phase image. LV = left ventricle, RV = right ventricle.

View larger version (94K): [in a new window]   Figure 18.   Pulmonary stenosis in the same patient as in Figure 17. Magnitude (A, C) and corresponding phase (B, D) VEC MR images obtained in a plane perpendicular to the pulmonary trunk (through-plane velocity measurement) before and after valvuloplasty demonstrate significant opening of the valve (arrow) on the postvalvuloplasty magnitude images. Graphs illustrate the concomitant decrease in pressure gradient, which was calculated on the phase images with excellent correlation with the catheterization data obtained during valvuloplasty. Ao = aorta, PA = pulmonary artery.

View larger version (117K): [in a new window]   Figure 19a.   Pulmonary regurgitation in a patient who had undergone surgery for tetralogy of Fallot several years earlier. Cine gradient-echo MR images obtained in the sagittal plane centered on the pulmonary artery (PA) and outflow tract of the right ventricle (RV) demonstrate pulmonary regurgitation. Note the large signal void in diastole (arrow in b), a finding that is suggestive of severe pulmonary regurgitation as well as right ventricular enlargement and hypertrophy. Black double-headed arrow in a indicates the plane perpendicular to the pulmonary trunk used for through-plane calculation of pulmonary flow.

View larger version (109K): [in a new window]   Figure 19b.   Pulmonary regurgitation in a patient who had undergone surgery for tetralogy of Fallot several years earlier. Cine gradient-echo MR images obtained in the sagittal plane centered on the pulmonary artery (PA) and outflow tract of the right ventricle (RV) demonstrate pulmonary regurgitation. Note the large signal void in diastole (arrow in b), a finding that is suggestive of severe pulmonary regurgitation as well as right ventricular enlargement and hypertrophy. Black double-headed arrow in a indicates the plane perpendicular to the pulmonary trunk used for through-plane calculation of pulmonary flow.

View larger version (84K): [in a new window]   Figure 20.   Pulmonary regurgitation in the same patient as in Figure 19. (A-D) Phase VEC MR images obtained in a plane perpendicular to the pulmonary trunk. In systole (A), bright signal intensity is demonstrated in the pulmonary artery (PA), a finding that indicates forward flow. In diastole (C), decreased signal intensity indicates retrograde flow (ie, pulmonary regurgitation). The color coding on B and D enhances the visualization of opposite flows. (E) Graph of flow volume in the pulmonary artery over time demonstrates stroke volume in systole (red) and retrograde flow in diastole (blue). Regurgitant volume is calculated as the area bounded by the curve under the baseline in diastole. The regurgitant fraction has been calculated as 50%, which indicates severe pulmonary regurgitation.

View larger version (116K): [in a new window]   Figure 21a.   Tricuspid pulmonary regurgitation. Horizontal long-axis cine gradient-echo MR image (four-chamber view) (a) and coronal oblique cine gradient-echo MR image encompassing the right atrium (RA) and the right ventricle (RV) obtained in a different patient (b) show massive enlargement of the right atrium and an abnormal flow jet due to tricuspid regurgitation in systole (arrow). The large signal void, particularly in a, is suggestive of severe tricuspid regurgitation. Note also the associated pericardial effusion in a.

View larger version (120K): [in a new window]   Figure 21b.   Tricuspid pulmonary regurgitation. Horizontal long-axis cine gradient-echo MR image (four-chamber view) (a) and coronal oblique cine gradient-echo MR image encompassing the right atrium (RA) and the right ventricle (RV) obtained in a different patient (b) show massive enlargement of the right atrium and an abnormal flow jet due to tricuspid regurgitation in systole (arrow). The large signal void, particularly in a, is suggestive of severe tricuspid regurgitation. Note also the associated pericardial effusion in a.

View larger version (111K): [in a new window]   Figure 22a.   Paravalvular abscess with regurgitation in a patient with rheumatic disease who presented with fever. The patient had previously undergone placement of a St Jude prosthetic valve. Spin-echo (a, b) and cine gradient-echo (c, d) MR images clearly depict a paravalvular abscess (Ab) situated behind the aortic annulus (Ao) and prolapsing into the left atrium. c and d demonstrate a prosthesis-related artifact (arrowhead) as well as a small signal void extending from the prosthetic valve into the left ventricle (LV) in diastole, a finding that suggests mild aortic regurgitation (Reg). VEC MR images obtained in a plane perpendicular to the aortic flow (not shown) helped confirm mild aortic regurgitation (regurgitation fraction = 20%).

View larger version (99K): [in a new window]   Figure 22b.   Paravalvular abscess with regurgitation in a patient with rheumatic disease who presented with fever. The patient had previously undergone placement of a St Jude prosthetic valve. Spin-echo (a, b) and cine gradient-echo (c, d) MR images clearly depict a paravalvular abscess (Ab) situated behind the aortic annulus (Ao) and prolapsing into the left atrium. c and d demonstrate a prosthesis-related artifact (arrowhead) as well as a small signal void extending from the prosthetic valve into the left ventricle (LV) in diastole, a finding that suggests mild aortic regurgitation (Reg). VEC MR images obtained in a plane perpendicular to the aortic flow (not shown) helped confirm mild aortic regurgitation (regurgitation fraction = 20%).

View larger version (122K): [in a new window]   Figure 22c.   Paravalvular abscess with regurgitation in a patient with rheumatic disease who presented with fever. The patient had previously undergone placement of a St Jude prosthetic valve. Spin-echo (a, b) and cine gradient-echo (c, d) MR images clearly depict a paravalvular abscess (Ab) situated behind the aortic annulus (Ao) and prolapsing into the left atrium. c and d demonstrate a prosthesis-related artifact (arrowhead) as well as a small signal void extending from the prosthetic valve into the left ventricle (LV) in diastole, a finding that suggests mild aortic regurgitation (Reg). VEC MR images obtained in a plane perpendicular to the aortic flow (not shown) helped confirm mild aortic regurgitation (regurgitation fraction = 20%).

View larger version (123K): [in a new window]   Figure 22d.   Paravalvular abscess with regurgitation in a patient with rheumatic disease who presented with fever. The patient had previously undergone placement of a St Jude prosthetic valve. Spin-echo (a, b) and cine gradient-echo (c, d) MR images clearly depict a paravalvular abscess (Ab) situated behind the aortic annulus (Ao) and prolapsing into the left atrium. c and d demonstrate a prosthesis-related artifact (arrowhead) as well as a small signal void extending from the prosthetic valve into the left ventricle (LV) in diastole, a finding that suggests mild aortic regurgitation (Reg). VEC MR images obtained in a plane perpendicular to the aortic flow (not shown) helped confirm mild aortic regurgitation (regurgitation fraction = 20%).