Heart valve disease module 4: diagnosis

The pulmonary valve

Minimum echocardiographic dataset

The minimum echocardiographic dataset for the pulmonary valve consists of:²⁴

• appearance of the valve
• colour map – in severe regurgitation reversed flow fills the whole pulmonary artery lumen to the branches and beyond and the jet within the RV is broad
• spectral Doppler for systolic V max and regurgitant pressure half (typically <100 ms in severe pulmonary regurgitation [PR])
• effect on right ventricle
• pulmonary artery size
• pulmonary artery pressure which may drive the regurgitation.

Grading pulmonary valve disease

This is summarised in table 8.

Cardiac computed tomography in pulmonary disease

Since pulmonary stenosis is usually congenital in origin, cardiac CT may be useful in defining complex congenital heart anatomy. In patients with pulmonary stenosis, the leaflets are often thin and difficult to visualise directly and so surrogate markers of pulmonary stenosis are usually required. These include dilatation of the main pulmonary artery and left pulmonary artery, right ventricular hypertrophy, right atrial enlargement and bowing of the interatrial septum to the left in keeping with elevated right atrial pressures.

Cardiac CT is of limited use in evaluating PR and is confined to the detection of secondary effects such as dilatation of the pulmonary valve annulus, pulmonary artery dilatation and right ventricular dilatation.

Cardiac magnetic resonance imaging

Turbulent flow in pulmonary stenosis can be visualised with SSFP cine imaging. Although planimetry of the pulmonary valve is of limited use, as with the aortic valve, CMR is able to provide accurate peak velocity data across the aortic valve.

CMR is the gold standard for the assessment of PR.⁴⁶ With visualisation of PR using cine SSFP imaging and the ability to accurately measure regurgitant volumes and regurgitant fractions with flow imaging, it has now become the technique of choice for the serial evaluation of patients with congenital heart disease, where progressive RV dilatation and RV dysfunction are important for the timing of pulmonary valve intervention.

Key learning messages

• Echocardiography is the mainstay of investigation
• CT and CMR are useful for the assessment of the aorta e.g. bicuspid aortic valve disease
• CT is useful in the work-up towards TAVI
• An ideal evaluation of a valvular lesion should include a description as to the aetiology of the valvular lesion, a qualitative and quantitative assessment of severity, an assessment of the haemodynamic effects on chamber size and function, and also an evaluation of concomitant valvular disease.

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Recommended reading

Aronow WS, Schwartz KS, Koenigsberg M. Correlation of serum lipids, calcium and phosphorus, diabetes mellitus, aortic valve stenosis and history of systemic hypertension with presence or absence of mitral anular calcium in persons older than 62 years in a long-term health care facility. Am J Cardiol 1987;59:381–2. http://dx.doi.org/10.1016/0002-9149(87)90827-7

Antonini-Canterin F, Huang G, Cervesato E, et al. Symptomatic aortic stenosis: does systemic hypertension play an additional role? Hypertension 2003;41:1268–72. http://dx.doi.org/10.1161/01.HYP.0000070029.30058.59

Kadem L, Dumesnil JG, Rieu R, Durand LG, Garcia D, Pibarot P. Impact of systemic hypertension on the assessment of aortic stenosis. Heart 2005;91:354–61. http://dx.doi.org/10.1136/hrt.2003.030601

Garcia D, Pibarot P, Dumesnil JG, Sakr F, Durand LG. Assessment of aortic valve stenosis severity: A new index based on the energy loss concept. Circulation 2000;101:765–71. http://dx.doi.org/10.1161/01.CIR.101.7.765

Briand M, Dumesnil JG, Kadem L, et al. Reduced systemic arterial compliance impacts significantly on left ventricular afterload and function in aortic stenosis: implications for diagnosis and treatment. J Am Coll Cardiol 2005;46:291–8. http://dx.doi.org/10.1016/j.jacc.2004.10.081

Lancellotti P, Donal E, Magne J, et al. Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay. Heart 2010;96:1364–71. http://dx.doi.org/10.1136/hrt.2009.190942

Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 2007;115:2856–64. http://dx.doi.org/10.1161/CIRCULATIONAHA.106.668681

Konen E, Goitein O, Feinberg MS, et al. The role of ECG-gated MDCT in the evaluation of aortic and mitral mechanical valves: initial experience. Am J Roentgenol 2008;191:26–31. http://dx.doi.org/10.2214/AJR.07.2951

Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988;60:299–308. http://dx.doi.org/10.1136/hrt.60.4.299

Kon MW, Myerson SG, Moat NE, Pennell DJ. Quantification of regurgitant fraction in mitral regurgitation by cardiovascular magnetic resonance: comparison of techniques. J Heart Valve Dis 2004;13:600–7.

Kizilbash AM, Hundley WG, Willett DL, Franco F, Peshock RM, Grayburn PA. Comparison of quantitative Doppler with magnetic resonance imaging for assessment of the severity of mitral regurgitation. Am J Cardiol 1998;81:792–5. http://dx.doi.org/10.1016/S0002-9149(97)01024-2

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