Aortic stenosis MRI

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Mohammed A. Sbeih, M.D. [2]; Usama Talib, BSc, MD [3] Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]

Overview

Magnetic resonance imaging is rarely used in the diagnosis of aortic stenosis, except in rare cases where the echocardiographic findings are inconclusive. There is a signal void where the high velocity jet exits the aortic valve.

MRI

Cardiac MRI may be helpful in the diagnosis of aortic stenosis. Findings on MRI suggestive of/diagnostic of aortic stenosis include:

• Thickening of the aortic valve cusps
• Diminished aortic valve area
• Stenotic jets (low signal intensity)
• Poststenotic dilatation of the ascending aorta
• Myocardial thickening
• Delayed myocardial enhancement

Advantages of MRI

• Cardiac magnetic resonance (CMR) can be used in cases where echocardiographic results are inconclusive.
• CMR can assist in measuring heart volumes, blood flow and ventricular wall thickness.
• Magnetic Resonance Angiography (MRA) assists in visualizing the heart vasculature.
• Phase velocity mapping helps in measuring the ratio of pulmonary to systemic blood flow (Qp:Qs).
• CMR is a useful tool in the diagnosis and evaluation of a bicuspid aortic valve.
• Differentiation may be made between an anatomically bicuspid valve, and an anatomically trileaflet valve with fused comissures ("functionally-bicuspid valve").
• CMR is invaluable in defining anatomic aortic valve area, in quantitating aortic regurgitation, and in the diagnosis of concomitant cardiovascular abnormalities, such as thoracic aortic dilatation/aneurysm and mitral valve abnormalities.

Disadvantages of MRI

• The scan times are longer than most other imaging modalities.
• The MRI environment itself is often uncomfortable for the patient (loud noises, confined area, patients are required to remain motionless for long periods of time).
• The MRI environment can potentially be dangerous, if specific safety measures are not strigently followed. Patients should be screened for any surgically implanted device that may not be MRI compatiable before entering the MRI department. The MRI environment must be kept free of any ferro magnetic material, which may otherwise be drawn into the magnet with sufficent force to injure, or kill patients, family and or staff in the area. Small metallic objects such as paper clips or hairpins which may not have significant mass to cause serious injury to a person, may be drawn into the magnet, and distort the magnetic field until removed. The removal of these items is very costly, and may result in downtime of several days for the imaging system. In the event that a serious (potentally life threatening) accident occurs in the MRI scan room, an emergency quench of the magnets' cryogens is performed. In such an instance (very rare) the scan room may be suddenly filled with helium gas, there is the potential for suffocation, cryogen burns, ruptured eardrums. An emergency quench of the magnet is very expensive (the magnet may be ruined) and is considered to be a option of last resort. In the event of medical emergencies in the MRI environment, the general rule of thumb, is to remove the patient from the scan room prior to the arrival of emergency support personnel. Safety of patients, family members, and staff are always the first priority in any MRI facility.
• For a successful MRI procedure, breath holding is required, which is sometimes difficult to achieve with small kids. Due to this, the procedure is sometime performed under general anesthesia in children.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Recommendations for Diagnostic Testing: Initial Diagnosis of AS Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I

2.   In patients with suspected low-flow, low-gradient severe AS with normal LVEF (Stage D3), optimization of blood pressure control is recommended before measurement of AS severity by TTE, TEE, cardiac catheterization, or CMR(Level of Evidence: B-NR)

ACC/AHA Guidelines- ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance (DO NOT EDIT)

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CMR may be used for assessing individuals with valvular heart disease in which evaluation of valvular stenosis, regurgitation, para- or perivalvular masses, perivalvular complications of infectious processes, or prosthetic valve disease are needed. CMR may be useful in identifying serial changes in LV volumes or mass in patients with valvular dysfunction.

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