AORTIC VALVE CASES. Richard L. Hallett, MD
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1 AORTIC VALVE CASES Richard L. Hallett, MD Section Chief, Cardiovascular Imaging Northwest Radiology Network Indianapolis, IN Adjunct Assistant Professor of Radiology Stanford University Hospital and Clinics Stanford, CA NASCI 2015 San Diego, CA September 26, 2015
2 DISCLOSURES None HANDOUT: Choose folder: NASCI 2015
3 CASE ONE
4 CASE ONE 32 yr old male Atypical CP, equivocal stress echo Cath: No vessel coming off R sinus, concern for anomalous coronary artery
5 CASE ONE
6 QUADRACUSPID AORTIC VALVE
7 QUESTION The most common complication of Quadricuspid Aortic Valve (QAV) is: A. Valvular aortic stenosis B. Aortic regurgitation C. Atrial fibrillation D. Left ventricular hypertrophy Douglas, H., Moore, M., & Purvis, J. (2012). Comprehensive assessment of a quadricuspid aortic valve and coronary arteries by multidetector cardiac CT. Heart, 98(24),
8 QUESTION: ANSWER The most common complication of Quadricuspid Aortic Valve (QAV) is: A. Valvular aortic stenosis B. Aortic regurgitation C. Atrial fibrillation D. Left ventricular hypertrophy Douglas, H., Moore, M., & Purvis, J. Heart, 2012: 98(24),
9 QUADRICUSPID AORTIC VALVE (QAV) Rare, 1/6000 aortic valve surgery patients 1 M = F, avg. age at Dx ~ 50 Classification by size of cusps 2 Most common: 3 same size + 1 smaller cusp (type B) Echo: X -shaped SAX view CT/MR: confirmatory; perform planimetry and/or flow measurement 3 1. Douglas, H., Moore, M., & Purvis, J. (2012) Heart 2012; 98(24), Hurwitz L, et al. Am J Cardiol 1973; 31(5) Khan SK, Tamin SS, Araoz PA. J Comput Assist Tomogr. 35 (5):
10 CLASSIFICATION OF QAV 1 A B C D E F G 4 equal sized cusps 3 equal + 1 smaller (most common) 2 equal + 2 equal smaller 1 large + 2 intermediate + 1 smaller 3 equal + 1 larger 2 equal large + 2 smaller unequal sizes 4 unequal sized cusps 1. Hurwitz L, et al. Am J Cardiol 1973; 31(5)
11 QUADRICUSPID AORTIC VALVE (QAV) Usually isolated, but can be associated with: Single or Anomalous Coronary Arteries Displacement of coronary ostia (from addl cusp) HCM / Subaortic Stenosis PDA, VSD Endocarditis 1. Jagganath AD, et al. Echocardiography 2011; 28(9), Zhu J, et al. J Cardiothor Surg 2013; 8(1) Tutarel O. J. Heart Valve Dis. 2004;13 (4):
12 QUADRICUSPID AORTIC VALVE (QAV) Complications: Aortic Insufficiency (#1) Up to 75% at time of Dx LVH Conduction problems (BBB) TX: Reconstruction and/or Surgical valve replacement 1. Jagganath AD, et al. Echocardiography 2011; 28(9), Zhu J, et al. J Cardiothor Surg 2013; 8(1) Tutarel O. J. Heart Valve Dis. 2004;13 (4):
13 CASE TWO
14 CASE TWO 68 yo Male, embolic lesions in kidneys on CT Technically difficult echo exam,? AoV lesion
15
16
17 CASE TWO: DDX Vegetation Thrombus Tumor Degenerated valve tissue
18 CASE TWO: PAPILLARY FIBROELASTOMA
19 QUESTION: Papillary Fibroelastoma is: A. the most common cardiac tumor B. potentially malignant C. more common in females D. responsible for 75% of valvular tumors
20 QUESTION: ANSWER Papillary Fibroelastoma is: A. the most common cardiac tumor B. potentially malignant C. more common in females D. responsible for 75% of valvular tumors Grebenc ML, Rosado de Christenson ML, Burke AP, Green CE, Galvin JR. Radiographics. 2000;20(4):
21 PAPILLARY FIBROELASTOMA Avg age 60 M=F #1 neoplasm of cardiac valves (prevalence only ~ 0.02%) #2 or 3 cardiac neoplasm overall (myxoma, lipoma) Often Asx but can present w/ embolic disease (tumor or bland), TIA/stroke, dyspnea, sudden cardiac death Imaging Diagnosis! Grebenc ML, Rosado de Christenson Ml et al. Radiographics. 2000;20(4): Kumbala, D, Sharp, T, Kamalesh M. Angiology, 2008; 59(5),
22 PAPILLARY FIBROELASTOMA Path: gelatinous, avascular papilloma covered by single layer epithelium sea anemone surface: but can be obscured by surface thrombus Mobile, pedunculated lesions w/ connection to endothelium by stalk Grebenc ML, Rosado de Christenson Ml et al. Radiographics. 2000;20(4): Kumbala, D, Sharp, T, Kamalesh M. Angiology, 2008; 59(5),
23 PAPILLARY FIBROELASTOMA Aortic >> mitral > tricuspid > pulmonic Can also occur on endocardial surfaces of atria / ventricles Mobility is independent predictor of non-fatal and fatal events (surgical treatment) Grebenc ML, Rosado de Christenson Ml et al. Radiographics. 2000;20(4): Kumbala, D, Sharp, T, Kamalesh M. Angiology, 2008; 59(5),
24 PULMONIC VALVE FIBROELASTOMA
25 CASE THREE
26 CASE THREE 45 yr old female 330 lb, 5 2 Previous pacer (vent rate 75) Previous aortic valve replacement
27 CASE THREE New onset CHF Abnormal echo possible lesion on prosthetic aortic valve CTA requested to assess valve. And.CCTA requested for pre-op coronary clearance
28 TECHNICAL ISSUES How to scan with low enough noise to fully assess valve and coronaries Impact of paced HR Pacer wire artifacts?
29
30 VEGETATION ON ST. JUDE PROSTHETIC AORTIC VALVE (330 LB PATIENT) 5mm MPR 3mm MINIP
31 QUESTION In order to improve image quality in larger patients, one should: A. Use filtered back projection reconstruction B. Utilize ECG pulsing C. Utilize weight-based contrast medium dosing D. Scan at 100 kv to save dose
32 QUESTION: ANSWER In order to improve image quality in larger patients, one should: A. Use filtered back projection reconstruction B. Utilize ECG pulsing C. Utilize weight-based contrast medium dosing D. Scan at 100 kv to save dose 1. Fleischmann D. How to design injection protocols for multiple detector-row CT angiography (MDCTA). Eur Radiol Dec 1;15 Suppl 5:E60 5.
33 PROSTHETIC VALVE DYSFUNCTION SX: Heart Murmur Heart Failure Fever Stroke DOE Angina Habets, J., Mali, WPTM, & Budde, RPJ (2012). Radiographics, 32(7):
34 PROSTHETIC VALVE DYSFUNCTION Echo primary imaging tool Fluoroscopy can visualize stuck leaflets CT useful if echo limited (obese, COPD) Leaflet excursion Perivalvular abscess Mycotic aneurysms
35 PROSTHETIC VALVE DYSFUNCTION: CT IMAGING Retrospective ECG gating useful for motion No ECG pulsing Ni / Ti alloys : GOOD (St. Jude: Nickel alloy) Cobalt Chrome: BAD (Bjork Shiley) Most Bioprosthetic valves are well assessed Habets, J., Mali, WPTM, & Budde, RPJ (2012). Radiographics, 32(7):
36 TECHNICAL TIPS FOR IMAGING LARGE PATIENTS - 1 Consider 140 kv voltage (trade-offs) Less blooming artifact from metal Less image noise More dose Scan at thicker initial collimation Slow gantry rotation time (~ 0.5 sec)
37 TECHNICAL TIPS FOR IMAGING LARGE PATIENTS -2 Use iterative reconstruction techniques WEIGHT-BASED Contrast medium flow-rates and volume Radiation dose: HIGH but re-do valve surgery for dysfunction has mortality up to 15%!!
38 CONCLUSIONS Quadricuspid aortic valve is visualized as an X on echo and CT/MR, and is associated with AI Aortic valve fibroelastoma is the most common valvular tumor Vegetations and lesions of prosthetic valves can be well assessed on ECG-synchronized CTA Adaptations / tradeoffs necessary for imaging valves in larger patients
39 THANKS FOR YOUR ATTENTION! Special Thanks to: Albert Hsiao, MD, PhD Dominik Fleischmann, MD HANDOUT: Choose folder: NASCI 2015
Richard L. Hallett, MD
Richard L. Hallett, MD Chief, Cardiovascular Imaging Northwest Radiology Network Indianapolis, IN Adjunct Assistant Professor of Radiology Stanford University Hospital and Clinics Stanford, CA NASCI 2016
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