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  • Review Article
  • Published:

Advanced imaging in valvular heart disease

Nature Reviews Cardiology volume 14, pages 209–223 (2017)Cite this article

Subjects

Key Points

  • Multimodality imaging has provided important insights in the pathophysiology of mitral regurgitation, aortic stenosis, and aortic regurgitation

  • Grading the severity of valve dysfunction is an important step in the management of patients with valvular heart disease and, at present, echocardiography, computed tomography, and cardiac magnetic resonance are important diagnostic tools

  • Strain imaging with echocardiography and tissue characterization with late gadolinium enhanced cardiac magnetic resonance have prognostic value in patients with valvular heart disease

  • Accumulating data show that the extent of fibrosis associated with severe VHD has important prognostic implications

Abstract

Although echocardiography remains the mainstay imaging technique for the evaluation of patients with valvular heart disease (VHD), innovations in noninvasive imaging in the past few years have provided new insights into the pathophysiology and quantification of VHD, early detection of left ventricular (LV) dysfunction, and advanced prognostic assessment. The severity grading of valve dysfunction has been refined with the use of Doppler echocardiography, cardiac magnetic resonance (CMR), and CT imaging. LV ejection fraction remains an important criterion when deciding whether patients should be referred for surgery. However, echocardiographic strain imaging can now detect impaired LV systolic function before LV ejection fraction reduces, thus provoking the debate on whether patients with severe VHD should be referred for surgery at an earlier stage (before symptom onset). Impaired LV strain correlates with the amount of myocardial fibrosis detected with CMR techniques. Furthermore, accumulating data show that the extent of fibrosis associated with severe VHD has important prognostic implications. The present Review focuses on using these novel imaging modalities to assess pathophysiology, early LV dysfunction, and prognosis of major VHDs, including aortic stenosis, mitral regurgitation, and aortic regurgitation.

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Figure 1: 3D transoesophageal echocardiography for the characterization of primary mitral regurgitation.
Figure 2: Mitral leaflet remodelling in functional mitral regurgitation (MR).
Figure 3: 2D speckle tracking longitudinal strain analysis in functional mitral regurgitation (MR).
Figure 4: Fused positron emission tomography (PET) and computed tomography (CT) images of the aortic valve in patients with increasing degree of aortic stenosis (AS).
Figure 5: Assessment of pressure recovery phenomenon with 4D magnetic resonance imaging turbulent kinetic energy (TKE) mapping.
Figure 6: Speckle tracking echocardiography to assess left ventricular (LV) mechanics in severe aortic stenosis.
Figure 7: Patterns of late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR) in aortic stenosis.
Figure 8: 4D magnetic resonance imaging patterns of aortic blood flow in patients with bicuspid aortic valve.
Figure 9: 3D modelling of the aortic valve from computed tomography data.
Figure 10: Assessment of myocardial fibrosis with late gadolinium-enhanced (LGE) cardiac magnetic resonance (CMR).
Figure 11: Association between left ventricular (LV) myocardial fibrosis on histopathology or late gadolinium-enhanced (LGE) cardiac magnetic resonance (CMR) and LV systolic function improvement and prognosis after aortic valve replacement.

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  1. Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Leiden, Albinusdreef 2, 2300 RC, Leiden, Netherlands

    Jeroen J. Bax & Victoria Delgado

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Both authors researched data for the article, discussed its content, and wrote, reviewed, and edited the manuscript before submission.

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The Department of Cardiology of the Leiden University Medical Center, Netherlands received research grants from Biotronik, Boston Scientific, Edwards Lifesciences, and Medtronic. V.D. received speaker fees from Abbott Vascular. J.J.B. declares no competing interests.

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Bax, J., Delgado, V. Advanced imaging in valvular heart disease. Nat Rev Cardiol 14, 209–223 (2017). https://doi.org/10.1038/nrcardio.2017.1

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  • DOI: https://doi.org/10.1038/nrcardio.2017.1

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