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Advanced Imaging and Functional Tools for Aortic Valve Assessment
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is a measure of left ventricular decompensation and a powerful independent predictor of
mortality [52].
Stress perfusion CMR depicts contrast medium wash-in into the myocardium during a
hyperemic state (induced by adenosine, dipyridamole or regadenoson): in territories supplied
by significantly stenosed coronary arteries, the contrast wash-in is delayed and this results in
hypointense areas within the myocardium in specific T1-weighted perfusion sequences [53].
Combined with LGE, stress CMR allows visualization of viable, ischaemic myocardium, thus
providing diagnostic and prognostic information [54]. An important alternative to
vasodilators is dobutamine stress CMR, which detects ischemia by monitoring regional wall
motion during infusion of increasing doses of dobutamine. This technique is similar to stress
echocardiography, but image quality is higher [55].
In the last few years, different CT techniques for detecting myocardial ischemia have
emerged, such as CT-derived fractional flow reserve (FFR-CT), transluminal attenuation
gradient (TAG), and myocardial CT perfusion (CTP) imaging. Myocardial CTP imaging can
be performed with a single static scan during first pass of the contrast agent, with
monoenergetic or dual-energy acquisition, or as a dynamic, time-resolved scan during stress
by using coronary vasodilator agents (adenosine, dipyridamole, or regadenoson) [56]. CTP
can obtain quantitative data of myocardial blood flow and coronary flow reserve to identify
ischemia-associated lesions [57, 58].
Current guidelines recommend valvular replacement mainly for patient with symptomatic
severe valvular disease, or LV function impairment. In the future, tissue characterization
offered by CMR could be helpful in patient stratification by identifying those asymptomatic
patients with subclinical interstitial myocardial fibrosis or with ovearload-induced myocardial
ischaemia, that would benefit from an early treatment to prevent progression to symptomatc
stages, heart failure and irreversible damages.
AORTIC REMODELLING AND DILATION
Considering the valve defect and its related ascending aortopathy as a single “aortic
disease complex,” CCTA holds superior ability to anatomically evaluate the aortic root and
thoracic aorta morphology over time, while CMR has the potential to merge morphological
and functional valve features with the aortic anatomy and flow hemodynamics. In particular,
4D flow imaging identifies the regions of ascending aorta with increased wall shear stress, as
shown in BAV patients [10, 11]. Indeed, in BAV patients without AS, the different cusp
fusion phenotypes result in distinct wall shear stress patterns: right-left BAV patients exhibit
increased wall shear stress by 9% to 34% (P < 0.001) at the aortic root and along the entire
outer curvature of the ascending aorta, whereas right-noncoronary BAV patients show 30%
wall shear stress increase (P < 0.001) at the distal portion of the ascending aorta. Viceversa, in
patients with tricuspid aortic valve and no AS, aortic dilatation is associated with an aortic
wall shear stress reduction by 21% to 33% (P < 0.01).
Aortic stenosis has been demonstrated to alter hemodynamics and wall shear stress in the
ascending aorta, independently from aortic valve phenotype, overriding the previously
described flow patterns associated with BAV [11]. In all patient groups, mild, moderate, and
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severe AS resulted in a marked increase in regional wall shear stress, while differences
between valve phenotypes were no longer apparent.
PLANNING SURGICAL INTERVENTIONS
Surgical aortic valve replacement (SAVR) is indicated in case of severe AS or AR,
depending on symptoms and on ventricular function/remodelling[2]. The role of CMR in
SAVR planning is growing since it allows to precisely assess the size of the aortic root, valve
morphology, the associated aortic abnormalities, surgical access and relationships of aortic
root with the surrounding structures. Moreover, the LV evaluation offered by CMR allows a
more accurate estimate of the degree of hypertrophy, function and myocardial viability, which
is particularly useful for potential candidates of a SAVR and coronary bypass combined
procedure. However, the use of CMR in pre-surgical planning is still marginal in many
centers, a secondary choice compared to echocardiogram and CT, generally limited to
selected cases (young patients or those with renal failure).
Emerging applications of CMR include the investigation of the relationship between
specific surgical techniques and resulting aortic hemodynamics, which could help to
customize the intervention to the individual anatomy [59].
PLANNING PERCUTANEOUS INTERVENTIONS
Transcatheter aortic valve implantation (TAVI, sometimes referred to as replacement,
TAVR) is a minimally invasive alternative to conventional SAVR based on the transaortic,
transfemoral, transsubclavian or transapical deployment of specific bioprosthetic valves. The
procedure has shown to improve quality of life and survival not only in high risk individuals
(non-eligible for SAVR), but also in intermediate and low risk subjects. A recent metaanalysis of all the currently available randomized controlled trials suggests that TAVI may
even reduce 30-day and 1‑year all-cause mortality compared with SAVR, independently from
the surgical risk [60]. For these reasons, a steep increase in the number of TAVI procedures
may soon be expected, accompanied by a rising demand of pre- and post-TAVI imaging
examinations.
Pre-TAVI imaging is routinely performed for planning the preferred anatomic access and
selecting the type and the size of implanted prosthesis [61] (Table 2).
CCTA is considered the gold-standard because of its wide availability, ease of use and
comprehensiveness, covering the whole spectrum of required anatomical information, from
the evaluation of the annular and aortic root to imaging of the coronary arteries and peripheral
vascular vessels (Figure 9).
The systo-diastolic CCTA assessment of the aortic Virtual Basal Ring (VBT) allows to
evaluate the stiffness of the fibro-muscular structures and their deformation related to the
variation of the endocavitary pressures. The diameters and cross-sectional area on multiplanar
reformatted CCTA images perpendicular to the median centerline of the aortic root are
needful in identifying the correct device size to be released. The determination of the shape of
Advanced Imaging and Functional Tools for Aortic Valve Assessment
69
TTE/TOE
CCTA
CMR
AS severity
+++
++*
++
LV function
+++
++*
++
LV septal thickness
++
++*
+ ++
Concomitant valvular disease
+++ + +++
AV annulus diameter
+++
+++
+++
AV anatomy
++
+++
++
AV calcification
++
+++
-
Aortic root measurements
++
+++
+++
AV annulus - coronary arteries distance
±
+++
+++
Coronary artery disease
-
+++
++
Coronary stenosis
-
+++
-
Peripheral arteries anatomy
-
+++
++
Peripheral arteries calcification
-
+++
-
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the VBR allows to plan which type of interventional approach to adopt in case of replacement
[62, 63] (Figure 10).
Table 2. Imaging methods for the evaluation of patients’ anatomical suitability
for TAVI according to current practice
AS, aortic stenosis; LV, left ventricular; AV, aortic annulus; TTE, transthoracic echocardiography; TOE,
transoesophageal echocardiography; CCTA, Cardiac Computed Tomography Angiography; CMR, cardiac
magnetic resonance. + + + Most frequentl used, + + less frequently used, + least used, - unsuitable. * related to
the retrospective multiphasic acquisition.
In addition, CCTA in the same acquisition permits the evaluation of the thoracic aorta,
the abdominal aorta and iliofemoral arteries in relation to the endovascular planning. The
presence of kinking, luminal obstructions, intraluminal aortic thrombi, calcifications are
always evaluable with the same CT scan as one-stop-shop option in planning percutaneous
aortic valve replacement[64–66].
Figure 9. TAVI planning with CCTA scan. Coronal (A) and corresponding axial reconstructions (B) of
the ECG-gated left ventricle and aortic root to be operated on. 3D-whole body vascular representation
of the same scan (C), particularly useful to plan the percutaneous approach.
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Figure 10. Three-dimensional CCTA reconstruction of the aortic root (A) and axial images at the level
of the virtual basal ring (VBR) during diastole (B) and systole (C).
However, TAVI candidates, may be ineligible to CT in up to 20% of cases due to
coexisting borderline renal function. In such cases, CMR may be a valid alternative to CT
using non-contrast enhanced techniques, like the 3D-SSFP ECG-gated navigator-echo (socalled “whole heart”) for thoracic aorta and the various MR-angiography sequences for the
evaluation of the aorto-iliac arteries [67, 68]. CMR has shown an excellent correlation with
CT for all the relevant pre-procedural parameters, including annulus size, aortic leaflet length,
and coronary artery ostia height. It systemically underestimates the amount of leaflet
calcifications, which have been demonstrated to be a negative predictor of post-procedural
paravalvular leak, particularly when located in the so-called “landing zone.” An additional
strength of CMR is its higher temporal resolution than CT, which allows to obtain high
quality motion-free images of the aortic root even in patients with higher heart rate. Precise
measurements of aortic dimensions is crucial for procedural success, hence high-quality
images are essential in order to provide reliable measurements.
Finally, still favouring CMR utilization in pre-TAVI planning, is the incremental
prognostic value of assessing systo/diastolic LV function and tissue characterization,
particularly for postoperative outcome prediction. In a study with tagging CMR, TAVI and
SAVR procedures were associated with comparable declines in rotational LV mechanics at 6
months, with largely unchanged circumferential strain and strain rates. A reduced preoperative mid LV circumferential strain was associated with post-operative mortality [38].
POST-PROCEDURAL IMAGING
Aortic Valve Complications
Sternal wire and valve prostheses are generally MR compatible, but they may degrade
image quality: after mechanical valve implantation CMR is not recommended for the postprocedural assessment of valvular and paravalvular complications, while for most biological
valves CMR allows to measure the effective orifice area (EOA) recognizing prosthesispatient mismatch, to visualize the possible incomplete opening or closing of prosthetic cusps,
sometimes to identify the underlying cause (e.g., pannus ingrowth or thrombosis) [69]
(Figure 11).
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Figure 11. CMR Three-chamber cine view of a patient with mechanical aortic and mitral valves. In
systole (left panel), please note the transaortic flow turbulence (arrow); in diastole (right panel), please
note the transmitrali flow turbulence (arrow).
Figure 12. Sutureless aortic valve thrombosis formation evaluated with CCTA. Axial aortic valvular
reconstruction (A) and tree-chambers view (B) showing the predominant involvement of the
noncoronary (NC) and right coronary (RC) cusps with thrombus formation.
The implanted valve can be obstructed by thrombosis and pannus formation. The
differential diagnosis cannot be easily performed by echocardiographic imaging modalities
(TOE and TTE); only a few CMR studies have addressed this issue, while CT attenuation is
the reference imaging modality to differentiate a thrombus (hypodense structure adhering to
the prosthesis) from a pannus (its attenuation should be similar to the myocardium) [70]
(Figures 12, 13).
Figure 13. CCTA prosthetic aortic valve pannus formation identified as a small black circumferential
low-attenuation (noncalcific) material with radial thickness >= 2 mm and encroachment on the valve
cusps just below the suture ring extending into the housing (A-C).
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Figure 14. Sutureless valve after deployment (Perceval S, Livanova, London, UK). The double oblique
axial multiplanar reconstraction image shows a tipical example of major valve stent deformation with
minor thrombosis/pannus overgrowth at the basis of the prosthetic cusps, with aortic regurgitation
attributed to the presence of a paravalvular leakage due to the invagination of the inflow stent (A, B)
that is clearly visible at 1 o’clock (A).
When image quality is preserved, PC-CMR is also able to measure transprosthetic blood
flow velocities and to estimate peak transprosthetic velocity, tranvalvular gradient and
residual transvalvular regurgitation, as for native valves. Paravalvular leak refers to
regurgitation between the prosthetic sewing ring and the surrounding anchoring tissue and
represents a serious complication potentially related to valve dehiscence or malposition. In
cine CMR images, a paravalvular leak appears as a signal-void artefact in the 3 chamber view
and can be quantified using PC sequences, provided that the acquisition plane is positioned
just below the valve, perpendicular to the jet direction; CMR grading of paravalvular leaks is
more accurate than TTE, based on the regurgitation fraction (none/trivial, mild, moderate and
severe AR defined as ≤8%, 9-20%, 21-39%, >40% regurgitant fractions respectively) [71]. At
CCTA the paravalvular leak can be related to the stent deformation and underexpanded or
incorrect size prosthesis (Figure 14).
Dehiscence is the spontaneous breakdown of the surgical sutures sewed between the
prosthetic valve and the annulus and, besides the presence of a paravalvular leak, at CMR can
be detected as a gap between the prosthetic valve and the annulus, using a stack of cine
sequences parallel to the annular plane[70].
Aortic Complications
Stanford type A aortic dissection occurs in approximately 0.6% of post-SAVR patients
but it appears to be more related to the intrinsic aortic wall abnormalities (aortic wall fragility,
aortic regurgitation, and aortic wall thinning) rather than to the surgical procedure itself [70].
In case of clinical suspicion, a prompt TTE evaluation is mandatory, but only CMR and CT
present a nearly 100% sensitivity and specificity to detect post-procedural aortic dissection.
Pseudoaneurysm formation is more common in composite graft (7-25% of the patients),
where the aortic root is replaced by a mechanical or biological valve pre-mounted on an tube
graft, rather than in isolated aortic valve replacement. Both CCTA and CMR are helpful in
the differential diagnosis between pseudoaneurysm and other pathological diverticular lesions
and for assessing the patency of coronary ostia.
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Ventricular Remodelling
Besides TTE, wich represents the cornerstone technique to track valvular and ventricular
changes after aortic valve surgery, CMR may be needed in case of poor acoustic windows or
for finer evaluations. In particular, CMR is able to accurately assess the LV reverse
remodelling and the mass regression occuring immediately after SAVR, whici is related to
good long-term prognosis. Following aortic valve replacement, native myocardial T1 has
been demostrated to decrease towards normal values, associated with left ventricular mass
regression and systolic function improvement; patients with persistent elevated native T1
after aortic valve replacement presented a worse outcome than those with T1 decrease [72].
Other studies have show on that, while LGE is not affected by SAVR, total extracellular
volume decreases together with peak aortic-jet velocity and LV mass, confirming that diffuse
interstitial fibrosis is indeed reversible; however, the accompanying rise (or unchange) in
percentage ECV suggests that regression in cellular hypertrophy occurs faster and to a greater
degree than the reduction of the extracellular component [51].
TECHNICAL LIMITATIONS
Nowadays advanced imaging is essential for a correct evaluation of the patient presenting
a disease involving the aortic valve; however, both CCTA and CMR require a dedicated
cardiac scanner and precise local skills, with higher costs compared with echocardiography.
Technical limitations including tachyarrhythmias or breathing artefacts can be considered
limited and relative contraindications together with claustrophobia. Selected patients may
undergo a CMR scan under general anesthesia. Several metallic devices (including
pacemakers and defibrillators) represent a limitation for CMR, but patients with newer CMRconditional devices may safely undergo a CMR scan after device reprogramming; metallic
devices can generate CT beam hardening artifacts and adequate sequences and parameters
must be applied to avoid unsuitable diagnosis. Gadolinium-based and iodinated contrast
agents are generally contraindicated in individuals with a glomerular filtration rate <30
mL/min/1.73 m2, even if the risk of nephrogenic systemic fibrosis is extremely low with
newer cyclic gadolinium-based contrast agents (Woolen et al., 2020) and risk of iodinated
contrast-induced nephropathy (CIN) is limited by the reduction in the amount of contrast
media to be used [73].
CONCLUSION
Aortic valve disease is a complex group of different pathological entities requiring a
multidisciplinary approach. From an imaging point of view, cardiac CT is the routinely used
all-in-one method in the planning and follow-up of the surgical or interventional procedure
from the sizing of the device to be implanted, passing through the study of the coronary artery
disease to the anatomical relationship between the mediastinal structures and the whole chest
anatomy, and studying the abdominal aorta and peripheral vascular accesses in a singlebreath-hold with high accuracy. The advanced imaging parterre includes also CMR, which is
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able to investigate all the different aspects of the disease, ranging from early diagnosis to
prognostic evaluation and pre- and post-treatment assessment. Although CMR is generally
considered a second line tool by current guidelines, it is more reproducible than
echocardiography concerning valve morphology, valve flow and ventricular function
evaluation; furthermore, its unique ability to provide histologically in vivo information has a
pivotal role in the detection of ventricular fibrosis and, therefore, in the prognostic patient
stratification.
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