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Cardiac Valve Disease: Spectrum of Findings on Cardiac 64-MDCT

¹ Department of Radiology, Cardiac CT/MRI Program, St. Vincent's University Hospital, Elm Park, 24 Castledawson, Sion Hill, Blackrock, Dublin 4, Ireland.
² Cardiac MRI-PET-CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
³ Department of Cardiology, Cardiac CT/MRI Program, St. Vincent's University Hospital, Dublin, Ireland.

View larger version (22K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —ECG-rhythm strip in 52-year-old woman undergoing cardiac MDCT for suspected coronary artery disease. See Figure S1C in supplemental data. For coronary artery evaluation, data sets are usually reconstructed at 60–70% (arrow) of each R-R interval, which is portion of cardiac cycle with least amount of motion. Note pulse of 50–53 beats per minute after β-blocker administration, which improves image quality.

View larger version (30K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —ECG-rhythm strip in 52-year-old woman undergoing cardiac MDCT for suspected coronary artery disease. See Figure S1C in supplemental data. For cardiac valve evaluation, multiple data sets (gray bars) are reconstructed in 10% increments, commencing at 0% and ending at 90% of each R-R interval.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Cardiac MDCT in 48-year-old woman being evaluated for suspected coronary artery disease. See Figure S2C, cine CT, in supplemental data. Optimal image plane for normal mitral valve is three-chamber long-axis view. Image at 55% of R-R interval (diastolic phase) shows normal opening of anterior and posterior mitral leaflets (straight arrows) into left ventricle. Attachments to commissures are clearly depicted. Anterolateral and posteromedial papillary muscles (curved arrows) and chordae tendineae (arrowheads) can be clearly seen attached to leaflet tips. Aortic valve is closed as expected.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Cardiac MDCT in 48-year-old woman being evaluated for suspected coronary artery disease. See Figure S2C, cine CT, in supplemental data. Image at 5% of R-R interval (systolic phase) shows complete coaptation of leaflets (thin straight arrows). Chordae tendineae (arrowhead) and papillary muscles (curved arrows) remain well visualized in ventricular systole. Aortic valve (thick straight arrow) is open as expected.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —Cardiac MDCT in 68-year-old man being evaluated for suspected coronary artery disease. Three-chamber view shows severe mitral annular calcification involving posterior commissure (curved arrow) impeding normal movement of posterior mitral leaflet, resulting in restricted mitral valve orifice (straight arrow). Note calcification also of aortic cusps. See Figure S3, cine CT, in supplemental data.

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —Cardiac MDCT in 68-year-old man being evaluated for atypical chest pain and dyspnea. Multiplanar reformat four-chamber image during ventricular systole shows marked thickening of anterior leaflet of mitral valve (arrow) and severely restricted opening of mitral leaflets.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Cardiac MDCT in 53-year-old man being evaluated for coronary artery disease before tumor resection. See Figure S5C, cine CT, in supplemental data. Multiplanar reformat three-chamber long-axis image shows low-density, oval, well-circumscribed mass (straight arrow) in left atrium. Note characteristic attachment to interatrial septum. Mitral valve leaflets (curved arrow) are closed indicating ventricular systole.

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Cardiac MDCT in 53-year-old man being evaluated for coronary artery disease before tumor resection. See Figure S5C, cine CT, in supplemental data. Four-chamber view shows prolapse of mass (straight arrow) through mitral valve orifice into left ventricle. Widely open mitral valve leaflets (curved arrows) indicate ventricular diastole.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Cardiac MDCT in 36-year-old man with known mitral valve prolapse who developed sudden-onset severe dyspnea. See Figure S6C, cine CT, in supplemental data. Multiplanar reformat three-chamber long-axis image in ventricular systole shows prolapse of posterior leaflet of mitral valve (arrow) into left atrium.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Cardiac MDCT in 36-year-old man with known mitral valve prolapse who developed sudden-onset severe dyspnea. See Figure S6C, cine CT, in supplemental data. Multiplanar reformat three-chamber long-axis image shows no attachment of chordae tendineae (arrow) of posteromedial papillary muscle to posterior leaflet. Findings were confirmed on transesophageal echocardiography (not shown).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —Cardiac MDCT in 42-year-old woman being evaluated for coronary artery disease before mitral valve surgery for mitral regurgitation. Multiplanar reformat three-chamber long-axis image in ventricular systole shows thickened anterior and posterior leaflets (straight arrows). Posterior leaflet shows slight prolapse into left atrium. Tips of posterior leaflet (curved arrow) do not coapt fully, consistent with mitral regurgitation. See Figure S7, cine CT, in supplemental data.

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —Cardiac MDCT in 68-year-old woman being evaluated for coronary artery disease. Multiplanar reformat three-chamber long-axis image in ventricular systole shows incomplete coaptation of mitral leaflets (straight arrow), consistent with mitral regurgitation. Left ventricle is dilated, and apex (curved arrow) is thin and partly calcified, consistent with chronic myocardial infarction in left anterior descending vascular territory. Appearances are consistent with ischemia-induced mitral annular dilatation.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —Cardiac MDCT in 52-year-old woman being evaluated for coronary artery disease before surgery for mitral valve prolapse. Multiplanar reformat three-chamber long-axis image in ventricular systole shows severe prolapse of posterior mitral leaflet (straight arrow) into left atrium. There is incomplete coaptation of mitral leaflets (curved arrow), consistent with mitral regurgitation. See Figure S9, cine CT, in supplemental data.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —Cardiac MDCT in 65-year-old woman being evaluated for coronary artery disease. See Figure S10C, cine CT, in supplemental data. N = noncoronary cusp, R = right coronary cusp, L = left coronary cusp. Multiplanar reformat cross-section image across aortic cusps in ventricular diastole shows normal tricuspid aortic valve apparatus that forms characteristic "Mercedes-Benz" appearance. Cusps show normal complete coaptation in center of valve orifice (arrow).

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —Cardiac MDCT in 65-year-old woman being evaluated for coronary artery disease. See Figure S10C, cine CT, in supplemental data. N = noncoronary cusp, R = right coronary cusp, L = left coronary cusp. Image in ventricular systole shows wide and symmetric opening of all three cusps (arrows).

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —Cardiac MDCT in 44-year-old man being evaluated for atypical chest pain. See Figure S11C, cine CT, in supplemental data. Multiplanar reformat three-chamber long-axis image in ventricular diastole shows asymmetric hypertrophy of left ventricular septal myocardium (arrows).

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —Cardiac MDCT in 44-year-old man being evaluated for atypical chest pain. See Figure S11C, cine CT, in supplemental data. During ventricular systole, there is systolic anterior motion of anterior mitral valve leaflet (curved arrow) with obstruction of left ventricular outflow tract (straight arrow).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12 —Cardiac MDCT in 82-year-old man being evaluated for chest pain. Multiplanar reformat cross-section image across aortic cusps in peak ventricular systole shows degenerative aortic valve disease with thickened calcified cusps (arrows) and restricted opening. See Figure S12, cine CT, in supplemental data.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —Cardiac MDCT in 42-year-old man being evaluated for atypical chest pain. See Figure S13C, cine CT, in supplemental data. Multiplanar reformat cross-section image across aortic cusps in ventricular systole shows two cusps (arrows) that do not open; this finding is fully consistent with congenital bicuspid valve and aortic stenosis.

View larger version (194K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —Cardiac MDCT in 42-year-old man being evaluated for atypical chest pain. See Figure S13C, cine CT, in supplemental data. Endoluminal view provides higher definition than A of congenital bicuspid valve cusps (arrows).

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14 —Cardiac MDCT in 41-year-old man with sepsis after ascending aortic graft repair for ascending aortic aneurysm. Multiplanar reformat cross-section image across aortic cusps in ventricular systole shows two cusps (thin straight arrows), consistent with bicuspid aortic valve. Large vegetation (curved arrow) is noted on anterolateral commissure. Infection had eroded through aortic graft resulting in extravasation and perigraft hematoma (thick straight arrows). See Figure S14, cine CT, in supplemental data.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15 —Cardiac MDCT in 38-year-old woman being evaluated for coronary artery disease before surgery. Multiplanar reformat three-chamber long-axis image in ventricular diastole shows flail aortic cusp (curved arrow) with complete loss of coaptation. Note small vegetations (thin straight arrows) on two aortic cusps. Small outpouching (thick straight arrow) on aortic wall distal to valve represents surgically proven mycotic aneurysm secondary to infected embolus that impacted in wall. See Figure S15, cine CT, in supplemental data.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16 —Cardiac MDCT of 53-year-old man with Ebstein's anomaly. Axial image shows atrialization of right ventricle (asterisk). Note apical displacement of septal leaflet (straight arrow) relative to anterior mitral leaflet hinge point. Anterior leaflet is tethered to trabeculae of right ventricular free wall (curved arrow). Note also bowing of interventricular septum into left ventricular cavity secondary to increased right heart pressure. See Figure S16, cine CT, in supplemental data.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17 —Cardiac MDCT in 42-year-old woman with shortness of breath. Axial 0.75-mm image shows large mass (arrow) in right atrium encroaching onto tricuspid valve orifice and causing obstructive tricuspid stenosis. Mass was surgically confirmed to be atrial myxoma. Note characteristic interatrial septal attachment.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18A — 53-year-old man with known carcinoid syndrome secondary to liver metastases from ileal primary tumor. See Figure S18C, cine CT, in supplemental data. Axial 1-mm image shows thickening of tricuspid leaflets (straight arrow) and chordae tendineae (curved arrow) within right ventricle. Note enlarged right atrium (asterisk).

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18B — 53-year-old man with known carcinoid syndrome secondary to liver metastases from ileal primary tumor. See Figure S18C, cine CT, in supplemental data. Axial 1-mm image through liver shows multiple hypervascular enhancing lesions (arrowheads), consistent with extensive carcinoid liver metastases.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19A — Cardiac MDCT in 33-year-old man with congenital pulmonary stenosis. Axial 0.75-mm image across pulmonary valve during ventricular diastole shows normal coaptation of valve leaflets (arrow).

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19B — Cardiac MDCT in 33-year-old man with congenital pulmonary stenosis. During ventricular systole, valve leaflets (arrow) do not open widely and are thickened. Echocardiogram (not shown) confirmed pulmonary stenosis.

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