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Dynamic Cine Imaging of the Mitral Valve with 16-MDCT: A Feasibility Study

Hatem Alkadhi1, Dominique Bettex2, Simon Wildermuth1, Bernhard Baumert1, Andre Plass3, Jurg Grunenfelder3, Lotus Desbiolles1, Borut Marincek1 and Thomas Boehm1,4

1 Department of Medical Radiology, Institute of Diagnostic Radiology, University Hospital Zurich, Zurich 8091, Switzerland.
2 Division of Cardiovascular Anaesthesiology, Institute of Anaesthesiology, University Hospital Zurich, Zurich 8091, Switzerland.
3 Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich 8092, Switzerland.
4 Department of Radiology, Spitaeler Chur AG, Loestrasse 170, Chur 7000, Switzerland.



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  		Fig. 1A —Drawings show location and orientation of reconstruction planes. (Reprinted with permission from Shanewise et al. [4]). Schematic drawing shows location and orientation of parallel reconstruction planes, which were oriented parallel to short-axis of left ventricle, including small part of left atrium and covering valve leaflets, commissures, annulus, and subvalvular apparatus including tendinous cords and papillary muscles.

 


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  		Fig. 1B —Drawings show location and orientation of reconstruction planes. (Reprinted with permission from Shanewise et al. [4]). Schematic drawing shows location and orientation of perpendicular reconstruction planes, planned on parallel short-axis reconstructions and consisting of radial long-axis slices that were perpendicular to plane of mitral valve. Center of rotation for those reconstructions was placed in center of anterior bend of mitral valve.

 


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  		Fig. 1C —Drawings show location and orientation of reconstruction planes. (Reprinted with permission from Shanewise et al. [4]). Schematic drawing shows short-axis view of mitral valve and illustrates how it is transected by midesophageal transesophageal echocardiography views. Rotating probe from multiplane angle of 0° to 180° moves imaging plane axially through entire mitral valve.

 


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  		Fig. 2 —Images in 10% step reconstructions of R-R interval in parallel short-axis plane show dynamic morphology of mitral valve throughout one cardiac cycle. Because of space limitations, only every second image of 5% step reconstructions is shown. Image at 5% on level of commissures (large white arrows) demarcates zone of apposition, where anterior meets posterior leaflet during systole. Images at 15% and 25% show opening of leaflets with reversion of curvature (25%, black arrowhead), while edges stay approximated (large white arrows). During early diastole (35%), leaflets open rapidly (black arrows). After reaching maximal opening (45%, black arrows), leaflet opening is minimally reduced (55%, black arrows) until second opening impulse occurs (65%, black arrows). Some tendinous cords and anterolateral papillary muscle belly (small white arrows, 55% and 65%) can be depicted on these images. At 75% and 85%, rapid closure can be visualized with bulging of leaflets (black arrows) until reaching each other at late diastole (95%). Note good image quality of leaflets and zone of apposition during valve closure and maximal opening and inferior image quality of leaflets in transitional phases. Because of additional movements of valve plane toward atrium and ventricular apex, images chosen to visualize leaflets are located more cranially during diastole and more caudally during systole.

 


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  		Fig. 3 —Images in 10% step reconstructions of R-R interval in perpendicular long-axis plane show dynamic morphology of mitral valve throughout one cardiac cycle. Plane through middle of valve was chosen for visualization of valve motion. At 5%, valve is closed, and anterior (white arrowhead) and posterior (black arrowhead) leaflets are opposed to each other at apposition zone (black arrow). Note attachment of leaflets to mitral annulus (white arrows). At 15% and 25%, slight flattening of leaflets (white and black arrowheads) can be depicted, while edges are still opposed to each other (black arrow). In transitional phase (35% and 45%), both leaflets open toward ventricle (large white arrows). One head of posteromedial papillary muscle and tendinous cord attaches to free edge of posterior leaflet (45%, small white arrows). After maximal opening (55%), leaflets (white and black arrowheads) exhibit to-and-fro movement until another opening impulse occurs (65% and 75%). At 85%, rapid valve closure can be seen with bulging of leaflets (white and black arrowheads) until approximating each other at late diastole (95%). Note excellent image quality for showing leaflets during valve closure and maximal opening and slight reduction of image quality during rapid movements in transitional phases. Because of orientation of long-axis plane, up- and downward movements of whole valve apparatus together with intrinsic valve movements can be visualized on single reconstruction.

 


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  		Fig. 4 —Bar graph shows number of cases and corresponding percent reconstruction phases that showed best image quality for visualization of mitral valve leaflets in closed and open states in parallel plane (light gray bars) and perpendicular plane (dark gray bars). At 5% and 65%, closed and open leaflets were visualized with best image quality in most patients.

 


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  		Fig. 5 —Transesophageal echocardiography transgastric short-axis views show mitral valve in eight phases throughout cardiac cycle (0°, see Fig. 1C). Note assessment of leaflet contours and of apposition zone is difficult in this view.

 


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  		Fig. 6 —Transesophageal echocardiography midesophageal four-chamber views show mitral valve (0°, see Fig. 1C). Similar to assessment on MDCT, dynamic assessment of valve leaflets including apposition zone is visualized more easily in this long-axis view when compared with short-axis plane. In addition, note contour of leaflets (arrowheads) is blurred during their rapid movements in transition phases.

 

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