CMR in Valvular Heart DiseaseMale elite athlete with chronic aortic regurgitation
Alexios Antonopoulos MD PhDCardiologist, Hippokration GHA, University of Athens
EACVI Fellow in Advanced Imaging CT/CMRAcademic Fellow, University of Oxford, UK
4/5/2019
Case presentation
25y male athlete (triathlon, >20h/week)
Cause of referral: Evaluation of aortic regurgitation; incidental finding during screening for sports participation
Medical Hx: het. beta thalassaemiareports previous hx of weight lifting (>120kg)
Family Hx: mother SLE
Medication: none
Functional status: NYHA I, no exercise limitation, symptoms of syncope, SOBOE, palpitations or chest pain
Case presentation
Physical exam. : Height 184cm, BMI: 23.1kg/m2, mild diastolic rumble, base of the heart 2/6none of the hallmark signs of severe AR , BP=142/70mmHg
ECG: SR, early repolarization, LVH (+)
CPET: VO2max 53ml/kg/min(115% predicted)
HM24h: rare supraventricular beats
TTE
LVEDD 60mm (30mm/m2)LVESD 44mm (22mm/m2)IVSd 8mmPWTd 8mmLA 38mm
LVEF 56%
Eccentric AR jet AR Jet/LVOT > 65%VCW unreliable
TTE
PHT (487msec) or PISA radius (<0.3cm) Unreliable for eccentric AR jets
TTE
Normal systolic and diastolic function
E 67 cm/sA 42 cm/s
E/AE’lat 20 cm/sE’sep 12 cm/sE/e’ <5
SRV 12 cm/s
TTE
Normal size ascending aorta& aortic arch
No holodiastolic flow reversal in descending aorta
From continuity equationVTI AV 18.3cmLVOT 29mmLVSV 121mL
VTI PV 18.1cmRVOT 23mmRVSV 75mL
RVol = 46mL (AR grade III)RF = 38%(+ mild MR/PR???)
AR severity ?
Severity of AR ? probably not severe; but need for accurate assessment.
a) Baseline data for comparative assessment during prospective follow-upb) Decision for timely intervention
CHALLENGES
LV dilation ?
Mechanism of AR ?
Patient management ?
CMR for LV volumetrics and AR severity assessment
LVEDV 237mLLVEDVi 118ml/m2
LVESV 110mLLVESVi 55ml/m2
LVSV 127mLLVEF 53%LV mass 226 g
RVEDV 184mLRVEDVi 92mL/m2
RVSV 97mLRVEF 53%
LV chamber reference values in athletes
D’ Ascenzi et al. J Am Coll Cardiol. 2018Peliccia et al. J Am Coll Cardiol. 2010;55:1619–1625
Peliccia et al. JAMA. 1996;276:211–215
LVEDD 60mm LVEDV 237mL
LVEDVi 118ml/m2
Quantitative measurements of AR severity by CMR
Phase-velocity encoding for aortic flow measurements
Aortic RVol
Aortic SV
Aortic SVAortic RVol
RF =
Phase-contrast CMR for aortic flow measurements
By volumes differences
LVSV 127mLRVSV 97mL
LVSV-RVSV 30mLMR 10mL
By flow measurements
Total flow 117mLForward flow 92mL
AV Rvol 25mL - RF 27%
AR severity by CMR Mild RF<20% Moderate RF 20-35%Severe RF>35-40%
Is LV dilated ?
Mechanism of AR ?
Severity of AR ?
Patient management ?
CHALLENGES
TOE
Primarily to assess the mechanism of AR
NCC
TOE
VCW 4mm3D VCA 0.2cm2
3DVCA not well validated yet (cut-off of 0.34cm2 for severe AR classification)
Is LV dilated ? - borderline LV size (normal for level of PA)
Mechanism of AR ? - tricuspid AV, dysplastic NCC
Severity of AR ? - moderate AR
Management ● no restrictions on level of aerobic physical activity● poor evidence but current consensus is to avoid isometric exercises (weight lifting)● close monitoring for the need of timely intervention
FINAL PATIENT REPORT
Bonow et al. Circulation 1983
Intervention in asymptomatic patients with chronic AR
most of the studies that laid thefoundation of guideline recommendations were published
more than a decade ago and included patientsmanaged more than 20 years ago.
2017 ESC/EACTS Guidelines for themanagement of valvular heart disease
Yang et al. JACC 2019
748 patients with moderate-severe chronic AR
Risk stratification in chronic AR
Mortality risk
Need for better risk stratification of patients with chronic AR!
Value of CMR in the assessment of AR severity
CMR for AV diseaseAccurate for AR quantitationExcellent reproducibility
Consider CMR particularly in poor acoustic windowseccentric AR jetsfor prognostic information
Discrepancies in Grading of AR Between Echo and CMR
Kammerlander et al. JACC CVI 2018
Value of CMR for prognosis of patients with chronic AR
Myerson et al. Circulation. 2012;126:1452-1460
113 patients with moderate-severe chronic AR
RF>33% identifies patients that will progress to surgery overtime (AUC 93%)
RF<26% 100% NPV for AVR surgery
Diffuse interstitial fibrosis in chronic AR detected by CMR
LGE : replacement fibrosisiECV: diffuse interstitial fibrosis(ECV% x LV mass / BSA)
Chronic AR leads to volume and pressure overload of LV leading to myocardial fibrosis
Debs et al. JACC 2019;73(9 Supp 1):1463
CMR strengths• Unlimited windows• Excellent image quality
- valve and aortic anatomy- SSFP/angio- Jet visualization (SSFP/GRE)
• Flow quantitation- good observer variability
• Excellent for RV/LV assessment (volumes/function)
• Multiparametric assessment (if needed)- LGE / ischaemia / T1 mapping
CMR weaknesses• Regurgitant jet visualization not as good as
echo• Through-plane spatial resolution low
- use thin slices (4-6mm)- perpendicular to valve
• Lower temporal resolution vs echo• Average of multiple RR• Peak velocities underestimated• Flow quantitation errors
CMR in valvular heart disease
EuroCMR 2019
• In cases of diagnostic uncertainty multimodality imaging can help
• CMR particularly useful in eccentric AR jets
complex patients
need for multiple answers
Conclusions
CMR - very good diagnostic tool for the quantitative assessment of valvular regurgitation (AR/ PR)
