J Cardiovasc Imaging.  2019 Oct;27(4):235-246. 10.4250/jcvi.2019.27.e48.

Multimodality Imaging for the Assessment of Severe Aortic Stenosis

• Park SJ
• Dweck MR

• KMID: 2468349
• DOI: http://doi.org/10.4250/jcvi.2019.27.e48

Abstract

Aortic stenosis is the most common type of valvular heart disease. Aortic stenosis is characterized both by progressive valve narrowing and the left ventricular remodeling response that ensues. In aortic stenosis, therapeutic decision essentially depends on symptomatic status, stenosis severity, and status of left ventricular systolic function. Imaging is fundamental for the initial diagnostic work-up, follow-up, and selection of the optimal timing and type of intervention. Noninvasive imaging has played a pivotal role in enhancing our understanding of the complex pathophysiology underlying aortic stenosis, as well as disease progression in both the valve and myocardium. The present review provides the application of multimodality imaging in aortic stenosis.

Keyword

Aortic stenosis; Echocardiography; Dyspnea; Syncope; Angina; Diastolic dysfunction

MeSH Terms

Aortic Valve Stenosis*
Constriction, Pathologic
Disease Progression
Dyspnea
Echocardiography
Follow-Up Studies
Heart Valve Diseases
Myocardium
Syncope
Ventricular Remodeling

Figure

• 

  Figure 1 Continuous-wave Doppler recordings of aortic velocity in an elderly symptomatic patient with aortic stenosis. Peak velocities from the apex (Apex) (A) and right parasternal window (RPS) (B) are shown. Peak aortic valve velocity is higher (5.1 m/s) from the RPS position than from the apex (3.5 m/s). If continuous-wave Doppler had not been performed from the RPS position, the severity of aortic stenosis would have been underestimated.

• 

  Figure 2 CT calcium scoring in the aortic valve. An example of mild AVC of Patient A (A, B) and severe calcification by CT of Patient B in axial (C) and short-axis (D) views of the valve. Reproduced with permission from Dweck et al.50) AU: arbitrary unit(s), AVC: aortic valve calcification, CT: computed tomography.

• 

  Figure 3 Representative images from adenosine-stress CMR in the angina and asymptomatic groups. (A) Representative adenosine stress perfusion image from the angina group: perfusion defect seen during adenosine infusion (low signal intensity area). (B) Representative adenosine stress perfusion image from the asymptomatic group: no evidence of inducible perfusion defect. AS: aortic stenosis, CMR: cardiovascular magnetic resonance, LV: left ventricle, RV: right ventricle.

• 

  Figure 4 CMR myocardial tissue tracking analysis. (A) CMR tissue tracking analyses were performed using commercially available software (cvi42 version 5, Circle Cardiovascular Imaging Inc., Calgary, Alberta, Canada). (B) Two-, three-, and four-chamber, and short axis images were uploaded into the software, which reconstructs a 3D model that is used for analyses of 2D- and 3D radial, circumferential and longitudinal LV strain. CMR: cardiovascular magnetic resonance, LV: left ventricle, RV: right ventricle.

• 

  Figure 5 Measurement of T1 mapping in CMR and GLS in STE. Pre T1 (A) and post T1 (B) mapping images, the ROI was drawn manually at the basal septum (dark line) and LV cavity (white line) for native T1 value and ECV. (C) GLS in STE. GLS was acquired by average regional strain curves (16-segment model for 2D STE). Correlation between MF and ECV (D), native T1 value (E), and GLS (F). The ECV (r = 0.465, p < 0.0001), GLS (r = 0.421, p = 0.0003), and native T1 value (r = 0.429, p = 0.0002) were significantly correlated with the degree of MF. CMR: cardiovascular magnetic resonance, ECV: extracellular volume fraction, GLS: global longitudinal strain, MF: myocardial fibrosis, ROI: region of interest, STE: speckle tracking echocardiography.

• 

  Figure 6 18F-NaF PET-CT predicts disease progression in AS. Baseline CT calcium score scans (left) for patients 1 (A) and 2 (B). Fused 18F-NaF PET-CT scans (middle) show fluoride uptake in red and yellow. Follow-up CT at 1 year (right) suggests that the baseline PET signal predicts where new macroscopic calcium, visible on the CT, is going to develop. Reproduced with permission from Dweck et al.50) 18F-NaF: radiolabeled sodium fluoride, CT: computed tomography, PET: positron emission tomography.

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