Protocol

Anatomy / LV function / RV function module (A/B/C) Optimized cine views: (B) Slice thickness 5mm Two orthogonal cine stacks through the valve One cine stack parallel to the annulus Phase contrast velocity encoded module (F)

Report

Dimensions, mass (corrected for BSA) and function LV: EDV, ESV , SV, EF, mass RV: EDV, ESV, SV, EF Valve morphology: leaflets, annulus, chordae Valve stenosis Mean / peak valvular gradients Minimum valve area Valve regurgitation Regurgitation volume and fraction Estimated orifice area

Key Points

CMR is a reasonable alternative if poor echocardiographic image quality (lower spatial and temporal resolution) Comprehensive valve assessment: LV / RV dimensions, mass, fibrosis, and function Forward and regurgitant flow / fraction Mean / peak velocity Jet detection, direction and origin Valve area by direct planimetry VENC settings (see “Flow velocity encoding” section)

Pulse Sequence	Indication
SSFP cine	Anatomy and motion LV / RV volumes and function
Gradient echo cine	Valve leaflet motion Turbulent flow
Flow velocity encoding	Forward / regurgitant volume

Calculation of regurgitant volume in SINGLE valve disease

Aortic regurgitation	Regurgitation volume/fraction from phase contrast VENC above aortic valve Alternatively LV SV – RV SV
Mitral regurgitation	SV from phase contrast VENC above aortic valve – LV SV Alternatively LV SV – RV SV
Pulmonary regurgitation	Regurgitation volume/fraction from phase contrast VENC above pulmonary valve RVSV–LVSV
Tricuspid regurgitation	SV from phase contrast VENC above pulmonary valve – LV SV Alternatively RV SV – LV SV

Limitations

Degree of stenosis or regurgitation – cines imaging Visual assessment from cine images alone is NOT recommended due to a signal void in turbulent flow Valve area – planimety Correct imaging planes at the tip of the leaflets are fundamental Note that a perfect 2D image plane of a 3D structure is impossible Flow velocity encoding– forward flow / peak velocity VENC tends to underestimate velocities due to Partial volume averaging Slice orientation NOT perpendicular to the flow Flow velocity encoding– regurgitation volume / fraction Consider volume shift through moving aorta or PA during cardiac cycle Consider regular back-flow into the coronary arteries

Tips and Tricks

Reduce slice thickness to <6mm Consider overlapping of slices Patchy mid-wall fibrosis in conjunction with LV hypertrophy is a prognostic sign in aortic stenosis Aortic regurgitation fraction of >33% predicts symptom development and the need for valve replacement A pulmonary regurgitation fraction of >40% predicts symptom development and the need for valve replacement