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EDUCATION EXHIBIT 1393

CT Angiography of the
Cardiac Valves: Normal,
Diseased, and Postop-
erative Appearances1
Joseph J. Chen, MD • Maria A. Manning, MD • Aletta Ann Frazier, MD
ONLINE-ONLY
CME Jean Jeudy, MD • Charles S.White, MD
See www.rsna
.org/education
/rg_cme.html Although echocardiography remains the principal imaging technique
for assessment of the cardiac valves, contrast material–enhanced
electrocardiographically gated computed tomographic (CT) angiogra-
LEARNING
phy is proving to be an increasingly valuable complementary modality
OBJECTIVES
After reading this
in this setting. CT angiography allows excellent visualization of the
article and taking morphologic features and function of the normal valves, as well as of
the test, the reader a wide range of valve diseases, including congenital and acquired dis-
will be able to:
■ Discuss the causes eases, infectious endocarditis, and complications of valve replacement.
and pathologic The number, thickness, and opening and closing of the valve leaflets,
features of cardiac
valve disease. as well as the presence of valve calcification, can be directly observed.
■ Identify the imag- CT angiography also permits simultaneous assessment of the valves
ing findings of car- and coronary arteries, which may prove valuable in presurgical plan-
diac valve disease.
■ Describe the im-
ning. Unlike echocardiography and magnetic resonance imaging, how-
aging appearances ever, CT angiography requires ionizing radiation and does not pro-
of valvular vegeta-
tion, tumors, and
vide a direct measure of the valvular pressure gradient. Nevertheless,
prostheses and the with further development of related imaging techniques, CT angiog-
complications as-
sociated with these
raphy can be expected to play an increasingly important role in the
entities. evaluation of the cardiac valves. Supplemental material available at
http://radiographics.rsna.org/cgi/content/full/29/5/1393/DC1.
TEACHING
©
POINTS RSNA, 2009 • radiographics.rsna.org

See last page

Abbreviations: ECG = electrocardiographically, MIP = maximum intensity projection

RadioGraphics 2009; 29:1393–1412 • Published online 10.1148/rg.295095002 • Content Codes:

1
From the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD
21201 (J.J.C., M.A.M., A.A.F., J.J., C.S.W.) and the Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, DC
(A.A.F.). Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received January 7, 2009; revision
requested February 11 and received March 18; accepted March 30. C.S.W. is a research consultant with Riverain Medical; all other authors have no
financial relationships to disclose. Address correspondence to J.J.C. (e-mail: jchen1@umm.edu).
©
RSNA, 2009
1394 September-October 2009
Introduction
Cardiac valve disease causes significant mortality
and morbidity in the United States. An estimated
20,260 persons died from valvular heart disease
in 2004, with aortic and mitral valve disease ac-
counting for 12,665 and 2554 deaths, respectively
(1). Pulmonic and tricuspid valve diseases are less
common than diseases of the aortic and mitral
valves. In 2004, an estimated 99,000 valvulo-
plasties (valve replacement procedures) were per-
formed in the United States at an average cost of
$119,918 per procedure and an overall in-hospital
mortality rate of 5.1% (1,2), figures that are much
higher than those for many other cardiac proce-
dures, including coronary bypass graft surgery,
percutaneous coronary intervention, and place-
ment of an implantable defibrillator. The number
of cardiac valve surgeries performed annually is
increasing at a rate of 4%–7% per year, largely due
to aging of the population (1–3). Aortic stenosis,
a disease affecting patients of advanced age, is the
most common indication for cardiac valve surgery.
Echocardiography is the current imaging stan-
dard for assessment of the cardiac valves (4). Not
only is echocardiography cost effective, widely
accessible, and portable, but in most cases, it pro-
vides adequate information for therapy planning.
However, echocardiography has several limita-
tions, including operator dependence and poor
acoustic windows in patients with emphysema or
a large body habitus. Magnetic resonance (MR)
imaging has been investigated as an alternative
noninvasive imaging modality and, like echocar-
diography, does not expose the patient to ion-
izing radiation (5–8). MR imaging is evolving
into the reference standard in valve evaluation,
since it allows better visualization of the valvular
anatomy and quantification of ventricular volume,
mass, and function than does echocardiography
(9). In valves affected by stenosis or regurgita-
tion, MR imaging allows both qualitative and
quantitative assessment, which are not achievable
with echocardiography. MR imaging also allows
straightforward alignment of the imaging plane,
with the valve unobstructed by poor acoustic
windows. In addition, MR imaging has superior
radiographics.rsna.org
interstudy reproducibility compared with echocar-
diography (10). However, the limited availability
of MR imaging and the contraindications for its
use in certain patients (eg, those with implanted
pacemakers) constrain its widespread use.
Computed tomographic (CT) angiography
has already proved valuable in the morphologic
evaluation of congenital heart disease and can
help assess the coronary arteries noninvasively,
with a high sensitivity and specificity approaching
those for invasive coronary angiography (11–18).
Recent technologic advances in multidetector ret-
rospective electrocardiographically (ECG) gated
CT angiography permit improved visualization
and detailed anatomic evaluation of the cardiac
valves (19–21). Currently, CT angiography is not
the primary imaging modality for assessment of
the cardiac valves, but is used instead as a supple-
ment to echocardiography and MR imaging. An
important limitation of retrospective ECG-gated
CT angiography is the need for ionizing radiation
in the evaluation of valve morphologic features
and function. Instead of being performed prospec-
tively at a specific point in the cardiac cycle, as is
now often possible for coronary artery evaluation,
the imaging assessment of valve function must be
performed throughout the cardiac cycle, leading
to a substantial radiation dose penalty. Therefore,
CT angiography of the cardiac valves should
be performed only in selected patients, such as
those with contraindications for MR imaging. In
particular, patients who are undergoing a cardiac
valve procedure may benefit from preoperative CT
angiography of the valves, which allows simultane-
ous coronary artery evaluation for the purpose of
excluding significant arterial stenosis. Postopera-
tive patients with prosthetic valves may also benefit
from undergoing CT angiography if echocardiog-
raphy and MR imaging are suboptimal.
Multidetector retrospective ECG-gated CT
angiography and subsequent image manipula-
tion at an independent workstation facilitate
three-dimensional reformation along the short
and long axes of the heart to directly evaluate
the aortic valve cusps (short axis) and both out-
flow tracts with their associated atrioventricular
valves (long axis). Cine clips obtained through
each valve also allow the monitoring of valve
motion. In addition, CT angiography permits
RG ■ Volume 29 • Number 5 Chen et al 1395

Table 1
Technical Parameters for Various Imaging Modalities in Cardiac Valve Evaluation

Modality

64-Section
Parameter CT Angiography MR Imaging Echocardiography
Temporal resolution (msec) 90–180 20–50 15–60
Spatial resolution (mm) 0.4–0.6 1.0–2.0 0.6–1.0
Acquisition time 8 sec 5–10 min Operator dependent
Radiation dose (mSv) 13–15 (males); None None
18–21 (females)
Intravenous contrast material Nonionic None None

Table 2
Technical Considerations
Protocol for 64-Section CT Angiographic Assessment of the cardiac valves requires high
Cardiac Valve Evaluation temporal resolution to reduce artifacts caused
by cardiac and respiratory motion. The temporal
Parameter Description resolution of 64-section CT angiography is ap-
Tube voltage (kVp) 120 proximately 90–180 msec, whereas the recently
Tube current (mAs) Up to 800 introduced dual-source CT allows a temporal
Field of view (mm) 220 resolution of 83 msec. However, even this tempo-
Scan thickness (mm) 0.67 ral resolution is inferior to that of two- and three-
Increment (mm) 0.33
dimensional echocardiography and MR imaging
Rotation time (sec) 0.4
Direction Cephalocaudal
(26,27). On the other hand, the acquisition time
Scanning time (sec) 9–10 and spatial resolution of CT angiography are
Conventional tripha- Rapid infusion of 100% superior to those of both echocardiography and
sic injection pro- contrast agent, followed cardiac MR imaging (Table 1) (26,27).
tocol by mixture of agent and Image acquisition in CT angiography for car-
saline solution, followed diac valve evaluation is based on protocol used
by saline flush for coronary artery evaluation. Rapid intravenous
Volume of solution 80, 50, 50 injection of nonionic contrast material with an
(mL) anatomic triggering mechanism that makes use
Injection rate 6, 5, 5
of either bolus tracking or a test bolus is required
(mL/sec)
Region of interest Ascending aorta (Table 2). A preacquisition scanning delay is calcu-
(bolus tracker) lated on the basis of the time to peak attenuation
by placing the region of interest in the ascending
aorta. Prior to image acquisition, oral or intrave-
nous β-blockers are administered to reduce the
concurrent evaluation of ventricular function heart rate to less than 65–70 bpm, thereby improv-
(global and regional) and of valve morphologic ing image quality by reducing the number of arti-
features, function, and disease (4,22–26). facts related to valve motion and cardiac motion.
In this article, we review the technical aspects In addition, this procedure permits simultaneous
of CT angiography of the cardiac valves, includ- evaluation of the coronary arteries. Sublingual
ing postprocessing methods for optimal delinea- nitroglycerin can also be used for maximum vessel
tion of valve morphologic features and function.
In addition, we discuss and illustrate the CT
angiographic appearances of normal, pathologic,
and postoperative cardiac valves.
1396 September-October 2009 radiographics.rsna.org

Figure 1. Normal versus pathologic aortic valve. A normal aortic valve (A) has left, right, and posterior cusps that
are thin, noncalcified, and well coapted. Degenerative (“senile”) aortic valve (B) is characterized by diffuse valve
thickening and nodular calcific deposits at the base of the cusps (sparing the closing edges). Bicuspid aortic valve (C)
is a congenital lesion with two cusps of unequal size. The conjoint cusp is smaller and contains a median raphe. Dys-
trophic calcification may produce severe aortic stenosis. A bioprosthetic or mechanical valve (D) may be used to
replace a severely diseased aortic valve.

dilatation to improve visualization of the vascula-
ture. The images should be acquired during breath
holding in midinspiration to prevent contrast ma-
terial from flowing into the right atrium. Such flow
may result in heterogeneous enhancement of the
heart, which is of particular concern in the evalua-
tion of the right side of the heart.
Visualization of the right side of the heart can
be limited if a conventional coronary CT angiog-
raphy triphasic injection protocol (ie, rapid infu-
sion of contrast material followed by a mixture of
contrast material and saline solution and a saline
flush) is used. A modified triphasic protocol (ie,
rapid infusion of contrast material followed by
slower infusion of 100% contrast material and a
saline flush) allows better delineation of the tri-
cuspid and pulmonic valves.
Retrospective ECG-gated CT angiography
is essential for obtaining both static and cine
images. The reformatted images are usually ob-
tained in a limited field of view through the entire
heart. The cardiac cycle is typically reformatted
into 10 evenly spaced cardiac phases for valve as-
sessment. Although reduction of radiation dose is
desirable, ECG-triggered radiation dose modula-
tion may be disadvantageous for valve assessment
because valve morphologic features are often
difficult to evaluate during the reduced-dose car-
diac phases. Thus, depending on whether optimal
visualization of all phases of the cardiac cycle is
needed, dose modulation can be used to lower
the radiation dose for a portion of the cardiac
cycle, leading to somewhat grainy but reasonably
good-quality images for that part of the cycle. If
valve assessment is particularly important during
systole, dose modulation could be used during
diastole, with a dose reduction of 30%–40%.
Postprocessing of the acquired CT data set in-
cludes both static and cine images in various car-
diac orientations. Static images are created with
minimum intensity projection, maximum inten-
sity projection (MIP), multiplanar reformation,
and thick-slab volume rendering. Reformatted
images are also obtained to reflect the standard
echocardiographic views, namely, four-chamber
long-axis, two-chamber long-axis, and two-cham-
ber short-axis views. Cine images are acquired by
combining the 10 cardiac phases for qualitative
assessment of valve motion and function.
Cardiac Valves
Normal Morphologic
Features and Function
The cardiac valves regulate the blood flow through
the four chambers of the heart: the right and left
atria and the right and left ventricles. There are
two semilunar (pulmonic and aortic) valves, each
separating the ventricle from a great vessel, and
two atrioventricular (tricuspid and mitral) valves.
The semilunar valves have three cusps that coapt
when pressure in the main pulmonary artery and
aortic root exceeds ventricular pressure (Fig 1).
 RG ■ Volume 29 • Number 5 Chen et al 1397

Figure 2. Normal versus pathologic mitral valve. In A, a normal mitral

valve has been opened to show the anterior (Ant) and smaller posterior
(Pos) leaflets connected by commissures. Delicate chordae tendinae from
each leaflet insert into anterolateral and posteromedial papillary muscles
on the ventricular surface. Mitral valve endocarditis (B) is characterized by
multiple small vegetations (inflammatory Aschoff nodules) on both leaflets,
often along the line of closure. Rheumatic mitral stenosis (C) is produced
by fibrotic leaflet thickening, commissural fusion, and chordal fusion with
shortening. Myxomatous degeneration (D) is one of many conditions that
produces mitral regurgitation, which is characterized by leaflet thickening
and “hooding” as well as chordal elongation or rupture. These features are
associated with valve prolapse toward the left atrium.

The leaflets of the atrioventricular valves are con-
nected to the ventricular papillary muscles by the
chordae tendinae, thin cords of connective tissue
that prevent valve prolapse (Fig 2). The main func-
tion of the cardiac valves is to allow unidirectional
blood flow through the cardiac chambers, which
occurs normally when the valves are open.
Pathologic Condi-
tions and Dysfunction
In developed countries, cardiac valve disease
Teaching is due primarily to degenerative and inherited
Point causes, whereas postrheumatic heart disease is the
primary cause worldwide (28–30). Postrheumatic
heart disease is a sequela of acute rheumatic fe-
ver, a systemic inflammatory reaction that results
from infection by group A streptococcus. The
streptococcal infection mainly involves the heart,
joints, skin, and subcutaneous tissues. Within the
heart, acute rheumatic fever is a pancarditis char-
acterized by vegetations that form predominantly
within the mitral and aortic valves. Subsequent
scarring from chronic inflammation results in val-
vular deformity. Chronic rheumatic valve disease
manifests clinically after a latency period of 20–25
years (31). Although rheumatic heart disease can
involve any of the cardiac valves, the mitral and
aortic valves are the most severely affected, with
the mitral valve almost always being involved.
Many other diseases may also involve the car-
diac valves. Endocarditis, either infectious or non-
infectious, commonly affects the valves and other
cardiac structures (Fig 2). Although extremely
 1398 September-October 2009 radiographics.rsna.org

Figure 3. Normal aortic valve. (a, b) Coronal (a) and axial (b) multiplanar reformatted images through the aortic
valve show the normal valvular anatomy, with thin, noncalcified cusps (arrows). (c) Axial CT angiogram illustrates
planimetric measurement of the aortic valve area (outlined). In this case, the area is 372.3 mm2, with an average at-
tenuation of 330.0 HU and a standard deviation of the attenuation of 23.7 HU.

rare, valvular neoplasms may also develop. In ad- Aortic Valve

dition, metastatic carcinoid tumor to the liver may
injure the valves through the secretion of vasoac-
tive products, resulting in thickening of the tricus-
pid valve leaflets or pulmonic valve cusps (32).
Cardiac valves typically malfunction as a result
of either valvular stenosis or valvular insufficiency.
Teaching Valvular stenosis is due to valve thickening or
Point calcification, fusion of the cusps or leaflets, or con-
genital malformations, which narrow the orifice
and hinder antegrade blood flow. In hemodynamic
terms, to maintain adequate forward flow, the
pressure within the proximal cardiac chamber in-
creases to maintain cardiac output until the cham-
ber proximal to the stenosis fails. In valvular insuf-
Teaching ficiency, also known as regurgitation, inadequate
Point coaptation of valve cusps permits retrograde blood
flow across the diseased valve. The hemodynamic
consequence is volume overload of the proximal
cardiac chamber, irrespective of the particular
valve affected, leading to irreversible ventricular
damage and remodeling. Both valvular stenosis
and valvular insufficiency may occur in isolation or
concurrently in one or more cardiac valves (8).
The aortic valve is a semilunar valve—usually
with three thin cusps (right, left, and posterior) of
equal size—that is located between the left ventri-
cle and the aorta (Fig 1). Occasionally, instead of
being a tricuspid valve, the aortic valve has one,
two, or even four cusps. The right and left cusps
are inferior to the right and left coronary sinuses,
respectively, from which arise the right and left
coronary arteries. The third cusp is the noncoro-
nary cusp and is posterior to the other two cusps.
The area of the normal aortic valve varies from
2.5 to 4.0 cm2 (4,33).
The aortic valve is well visualized at cardiac
CT angiography (Fig 3), allowing evaluation that
includes assessment of cusp excursion and esti-
mation of aortic valve area. Optimal image qual-
Teaching
ity for aortic valve planimetry is best achieved
Point
during midsystole (approximately 20% of the
R-R interval or 50–100 msec from the R-wave
peak depending on heart rate) (34). Through the
acquisition of images during midsystole, pitfalls
such as “double leaflet” artifact (one valve cusp
with two contours) and “incomplete contour” ar-
tifact (<80% of the cusp circumference is visual-
ized) are minimized (34).
RG ■ Volume 29 • Number 5 Chen et al 1399

Figure 4. Bicuspid aortic valve. (a) Axial MIP reformatted image obtained during systole
shows thin, noncalcified bicuspid aortic valve cusps (arrows). (b) Oblique sagittal steady-state
free precession MR image shows a normal bicuspid aortic valve (arrows).

Figure 5. Bicuspid aortic valve with

calcification. Axial MIP reformatted
image obtained during diastole shows
coarse calcification of the posterior
cusp of the aortic valve.

one of the most common congenital anomalies

Aortic Stenosis
The causes of aortic stenosis are classified as
congenital or acquired, with acquired causes be-
ing either degenerative or rheumatic. Both con-
genital and rheumatic acquired causes of aortic
stenosis occur in younger patients, whereas
age-related degeneration occurs in older patients
(35,36). Age-related degeneration is usually as-
sociated with diffuse atherosclerotic disease in
the aorta and coronary arteries. Bicuspid valve,
of the aortic valve, is characterized by a single
fused commissure at birth with two separate
cusps of unequal size (Figs 1, 4; see also Movie
1 at http://radiographics.rsna.org/cgi/content/full/29
/5/1393/DC1) (33). Age-related and bicuspid
valve degeneration result in cusp fibrosis and
calcification (Figs 1, 5, 6). Rheumatic valve dis-
ease results from postinflammatory fusion of the
cusp commissures with superimposed fibrosis of
the free borders of the cusps.
The natural history of aortic stenosis consists
of a gradual decrease in valve area. Patients are
usually asymptomatic until the stenosis reduces
the aortic valve area to approximately 1 cm2. The
result is elevation of the transvalvular pressure gra-
dient, often with associated dilatation of the aortic
root (33). As stenosis progresses, left ventricular
afterload increases, resulting in compensatory con-
centric left ventricular hypertrophy (37).
1400 September-October 2009 radiographics.rsna.org

Figure 6. Age-related degenerative aortic stenosis. (a, b) Oblique (a) and axial (b) MIP reformatted images show
thickening and coarse calcification of the cusps of the aortic valve. Secondary findings include marked left ven-
tricular hypertrophy (*). (c) Axial CT angiogram illustrates planimetric measurement of the aortic valve area (Ar)
(outlined), which is significantly reduced (147.2 mm2) owing to the degenerative changes in a and b. Av = average
attenuation (305.9 HU), SD = standard deviation of attenuation (98.5 HU).

CT angiographic findings of aortic stenosis

include thickening and calcification of the
aortic valve cusps, resulting in reduction of the
aortic valve area (Figs 1, 6; see also Movie 2 at
http://radiographics.rsna.org/cgi/content/full/29/5
/1393/DC1). Although the presence of calcifica-
tion on the aortic valve can cause artifacts, these
artifacts are minor and do not hinder the planim-
etric measurement of the valve area (38). Studies
have shown that planimetric CT angiographic
measurements of the aortic valve area correlate
significantly with transthoracic echocardiographic
and transesophageal echocardiographic measure-
ments (38–41). They also correlate significantly Figure 7. Age-related degenerative aortic
with mean transvalvular pressure gradients as stenosis. Coronal MIP reformatted image ob-
determined at echocardiography (r > −0.74, P < tained during systole shows restriction of the
.01) (39). Aortic valve calcification can be quanti- aortic valve orifice, with poststenotic dilatation
fied and is associated with the severity of aortic of the ascending aorta (double arrow) and hy-
stenosis (42,43). Compensatory changes such as pertrophy of the left ventricle (*). Note that the
left ventricular hypertrophy and dilatation of the cusps are calcified, irregular, and thickened.
ascending aorta can also be visualized at CT an-
giography (Fig 7). In addition, cine images may
show decreased excursion of the valve cusps. Aortic Insufficiency
Aortic insufficiency can result from intrin-
sic valve disease, aortic root disease, or both.
Causes of intrinsic aortic insufficiency include
RG ■ Volume 29 • Number 5
myxomatous degeneration, congenital bicuspid
valve, rheumatic disease, and bacterial endo-
carditis (22). Primary aortic root disease with
secondary insufficiency may be due to idiopathic
dilatation of the aortic annulus, systemic hyper-
tension, Marfan syndrome (annuloaortic ecta-
sia), syphilitic aortitis, aortic aneurysm, aortic
dissection, or trauma (8). Idiopathic degenera-
tion of the normal aortic valve is the most com-
mon cause of aortic insufficiency, whereas aortic
root dilatation secondary to Marfan syndrome
is the most common cause in patients under 40
years of age (7).
Rheumatic disease produces diffuse fibrosis of
the valve cusps, with contracture and shortening
without calcification. In contrast, dilatation of the
aortic root causes tension and bowing of the valve
cusps with thickening and retraction. Both patho-
logic processes result in poor cusp coaptation,
which allows leakage of blood from the aorta into
the ventricle during diastole. There is a resultant
increase in left ventricular volume and pressure,
which in turn increases ascending aortic dilata-
tion in a reinforcing cycle (4).
Aortic insufficiency can be either acute or
chronic. In acute aortic insufficiency, pulmonary
edema develops due to the inability of the left
ventricle to adjust to the sudden increase in left
Chen et al 1401
Figure 8. Aortic insufficiency
due to intrinsic valve disease.
Axial (a) and sagittal (b) MIP
reformatted images obtained
during middiastole show thick-
ening (straight arrows) and
malcoaptation (arrowhead)
of the aortic cusps. A normal
open mitral valve (curved ar-
row in b) is incidentally seen.
atrial and ventricular filling pressure. In contrast,
in chronic aortic insufficiency, the gradual in-
crease in pressure and volume causes concentric
or eccentric left ventricular hypertrophy, followed
by dilatation and remodeling and, ultimately, left
ventricular failure (44).
Malcoaptation of the cusps that is visualized
during mid- to end diastole can be used to quali-
tatively and quantitatively assess aortic insuffi-
ciency. In two studies by Feuchtner et al (45,46),
CT angiography had a sensitivity of 95% and a
specificity of 96%–100% for detecting moder-
ate to severe aortic insufficiency when compared
with transesophageal echocardiography. In addi-
tion, the size of the central valvular leakage area
seen at CT angiography correlated significantly
with the severity of aortic regurgitation seen at
transesophageal echocardiography (46). Other
imaging findings of aortic insufficiency depend
on the cause of the insufficiency. In intrinsic valve
disease, the aortic cusps are visibly shortened and
thickened (Fig 8). In aortic root disease, dilata-
tion of the aortic root and findings related to the
underlying cause (eg, aortic aneurysm or dissec-
tion) may be seen (Fig 9). Nonspecific left ven-
tricular enlargement is often observed.
 1402 September-October 2009 radiographics.rsna.org

Figure 9. Aortic insufficiency due to aortic root disease. (a) Ax-

ial CT angiogram shows marked dilatation of the ascending aorta
(double arrow) relative to the adjacent pulmonary artery and
descending aorta. (b, c) Sagittal (b) and coronal (c) MIP refor-
matted images obtained during middiastole show dilatation of the
aortic root (double arrow) with malcoaptation of the aortic valve
(arrowhead). Note the secondary sign of left ventricular dilatation
(* in b). Curved arrow in c indicates a normal open mitral valve (cf
Fig 8). (d) Coronal steady-state free precession MR image of the
left ventricular outflow tract obtained during diastole shows a de-
phasing jet arising from the aortic root (white arrow), along with
dilatation of the ascending aorta (double arrow).

Mitral Valve
The mitral valve is a bicuspid valve that is com-
posed of a semicircular anterior leaflet and a
crescentic posterior leaflet and is anchored on the
mitral valve annulus (Figs 2, 10; see also Movie 3
at http://radiographics.rsna.org/cgi/content/full/29/5
/1393/DC1). The posterior leaflet typically has
three subunits known as scallops along its length
(47). Both leaflets are connected to the left ven-
tricular papillary muscles by the chordae tendinae.
In healthy adults, the thickness of the chordae
tendinae in the mitral valve ranges from 0.4 to 1.2
mm, the circumference of the mitral valve annulus
measures 10 cm, and the mitral valve area mea-
sures 4–6 cm2 (48).
CT angiography allows excellent visualization
of mitral valve morphologic features, thicken-
ing, and calcification. To best evaluate the valve
Teaching
Point components, reformatted images are obtained in
the two-chamber long-axis plane perpendicular
to the mitral valve during middiastole (49). For
most patients, 65% of the R-R interval is the best
phase for multiplanar reformatted imaging of the
open mitral valve, and 5% of the R-R interval is
the best phase for multiplanar reformatted imag-
ing of the closed mitral valve.
Mitral Stenosis
Chronic inflammatory change due to rheumatic
fever is by far the most common cause of mitral
stenosis (50). Less common causes include con-
genital mitral stenosis with parachute deformity
and connective tissue disorders.
Mitral stenosis is characterized by fusion of
the edges of the anterior and posterior leaflets
along the commissure (Fig 2). The chordae ten-
dinae may also become thickened and shortened,
thereby tethering the valve leaflets and restrict-
ing leaflet movement. Fibrosis and thickening of
the mitral valve leaflets and chordal apparatus,
combined with superimposed calcific changes,
produce increased resistance to antegrade flow
with an increasing transvalvular pressure gradient
as the mitral valve area falls below 2.5 cm2 (51).
The consequent elevation in left atrial pressure
and volume produces remodeling, dilatation, and
RG ■ Volume 29 • Number 5 Chen et al 1403

Figure 10. (a) Four-chamber long-axis MIP reformatted image obtained during
diastole shows an open mitral valve (arrowhead). (b) Two-chamber long-axis MIP
reformatted image obtained during systole shows thin, noncalcified mitral valve
leaflets (straight arrows). Note that the tricuspid valve leaflets (curved arrow) are
also thin and noncalcified.

Figure 11. Mitral stenosis. Axial CT angiogram (a) and coronal multiplanar reformat-
ted image (b) show a dilated left atrium (*) and a funnel-shaped mitral valve (arrow) with
irregularly thickened leaflets. Arrowheads in b indicate calcification of the annulus and of a
leaflet of the mitral valve.

enlargement of the left atrium, which predisposes
to atrial fibrillation and thrombus formation.
Sustained elevation of left atrial pressure from
long-standing mitral stenosis can lead to pulmo-
nary hypertension and right ventricular failure
with tricuspid and, sometimes, pulmonary insuf-
ficiency. A well-recognized complication of mitral
stenosis is atrial fibrillation, which may adversely
impact the quality of ECG-gated CT scans due
to motion artifacts (52,53).
The mitral valve area can be directly measured
with CT angiography during early diastole (75%
of the R-R interval), with good reproducibility and
good correlation with transesophageal echocar-
diographic findings (r = 0.88, P < .0001) (54).
Typically, stenotic mitral valves appear funnel
shaped with thickened and calcified leaflets (Fig 11;
1404 September-October 2009 radiographics.rsna.org

Figure 12. Mitral insufficiency. (a) Sagittal MIP reformatted image obtained during di-
astole shows thickening (straight arrow) and calcification (arrowhead) of the mitral valve
leaflets. Curved arrow indicates a closed pulmonic valve. (b) Coronal MIP reformatted
image obtained during diastole shows left atrial and ventricular dilatation (*) secondary to
mitral insufficiency.

see also Movie 4 at http://radiographics.rsna.org Figure 13.

/cgi/content/full/29/5/1393/DC1). Other findings, Sagittal MIP
including left atrial enlargement, thrombus for- reformatted
mation, pulmonary edema, and right ventricular image obtained
during diastole
hypertrophy, are also seen. Cine images show the
shows a nor-
movement of the leaflets to be restricted. mal, thin, pli-
able pulmonic
Mitral Insufficiency valve without
Mitral insufficiency results when there is dysfunc- calcification.
tion of any of the components of the mitral valve MPA = main
apparatus, including annular dilatation, leaflet pulmonary
retraction resulting from fibrosis and calcification, artery, RV =
abnormalities of the chordae tendinae, and papil- right ventricle.
lary muscle dysfunction. Mitral valve prolapse due
to myxomatous degeneration is the most com-
mon cause of mitral insufficiency, followed by
postinflammatory (postrheumatic) degeneration
(55–58). Myxomatous degeneration is a congenital
defect in which abnormal fibroelastic connective
tissue in the leaflets, chordae tendinae, and annu- (“functional” mitral insufficiency), and collagen
lus causes elongation of the leaflets (which billow vascular diseases such as Marfan syndrome and
toward the left atrium), chordal elongation and systemic lupus erythematosus (62–64). Ischemic
thinning, and annular thickening and dilatation heart disease and dilated cardiomyopathy are con-
(Fig 2) (59–61). Postinflammatory degeneration sidered causes of functional mitral insufficiency in
causes diffuse fibrosis and thickening of the leaflets that they cause the insufficiency despite structur-
without calcifications or commissural fusion. The ally normal valves by bringing about altered func-
chordae tendinae are shortened, and there can be tion and symmetry of the papillary muscles and
asymmetric annular dilatation (60,62). annular dilatation, respectively (65).
Alternative causes include infectious endocardi- Like aortic insufficiency, mitral insufficiency
tis, ischemic heart disease, dilated cardiomyopathy can be either acute or chronic (66). In the acute
setting, left ventricular insufficiency of blood flow
into the left atrium during systole results in sud-
RG ■ Volume 29 • Number 5 Chen et al 1405

Figure 14. Pulmonary stenosis. (a) Axial CT angiogram of the chest shows
poststenotic dilatation of the main pulmonary artery (MPA) and left pulmonary
artery (LPA), with sparing of the right pulmonary artery. (b) Sagittal steady-state
free precession MR image of the right ventricular outflow tract shows poststenotic
dilatation of the main pulmonary artery with incomplete opening of the pulmonic
valve. There is dephasing of signal beyond the valve orifice (arrow), a finding that
is consistent with a turbulent flow jet.

den volume overload. Without compensatory left Pulmonic Valve

ventricular hypertrophy, the abrupt increase in
left ventricular stroke volume also reduces cardiac
output. These rapid changes produce left atrial
hypertension and pulmonary edema. Acute mi-
tral insufficiency is most commonly due to (a) an
acute myocardial event causing papillary muscle
dysfunction or rupture; or (b) infectious endo-
carditis, which results in chordae tendinae rupture
or leaflet perforation. In the chronic setting, a prior
insult eventually leads to left ventricular dilatation
and eccentric hypertrophy, with compensatory left
atrial dilatation. Cardiac output is maintained for
a period of time but ultimately decreases. Patients
usually experience a gradual onset of symptoms,
including dyspnea and fatigue.
Similar to mitral stenosis, mitral insufficiency
can be assessed quantitatively with planimetric
measurements of the regurgitant orifice area.
The mean regurgitant orifice area as seen at CT
angiography correlates well with that seen at
transesophageal echocardiography (67). In addi-
tion, CT angiography allows direct evaluation of
the mitral leaflets, chordae tendinae, and papil-
lary muscles (ie, morphologic features, thicken-
ing, and calcification) (Fig 12). Other findings,
including compensatory left atrial dilatation, left
ventricular dilatation, and pulmonary congestion,
may also be visualized. Cine images may demon-
strate valve prolapse into the left atrium.
The pulmonic valve is a semilunar valve composed
of three cusps (anterior, right, and left). Unlike the
aortic valve, which is also a semilunar valve, the
pulmonic valve lacks coronary ostia and is separate
from the atrioventricular valves. The pulmonic
valve is more delicate than the aortic valve because
of lower right-sided pressures (Fig 13). The area
of the normal pulmonic valve is approximately 2.0
cm2 per square meter of body surface area.
Pulmonary Stenosis
Pulmonary stenosis is a congenital disorder in
95% of cases (68). It is most often an isolated
abnormality but can be a component of com-
plex congenital heart disease such as tetralogy of
Fallot (33). Acquired pulmonary stenosis is ex-
ceedingly rare and may be due to rheumatic fever
or metastatic carcinoid syndrome (4). Pulmonary
stenosis may produce elevated right ventricular
pressure and volume, with resultant right ventric-
ular hypertrophy, dilatation, and dysfunction.
Findings of pulmonary stenosis at CT an-
giography include poststenotic enlargement of
the main and left pulmonary arteries and right
ventricular hypertrophy (Fig 14). The right pul-
monary artery is not dilated because the turbu-
lent jet arising from pulmonary stenosis extends
1406 September-October 2009 radiographics.rsna.org

Figure 15. Tricuspid insufficiency caused by Ebstein anomaly. Screen shot from a cine loop
obtained along the four-chamber long axis (a) and axial CT angiogram (b) show dilatation of
the right atrium (*) with apical displacement of the posterior and septal leaflets of the tricus-
pid valve (arrow). Arrowhead in a indicates a normal mitral valve.

posteriorly into the main and left pulmonary
arteries, which dilate, whereas the right pulmo-
nary artery originates at a 90° angle from the
main pulmonary artery and thus is not exposed
to this jet. The valve leaflets are usually pliable
and thin. The elevated right ventricular pressure
and volume result in bowing of the interventricu-
lar septum to the left. Cine images may show the
mobility of valve leaflets to be decreased.
Pulmonary Insufficiency
Pulmonary insufficiency commonly occurs sec-
ondary to disorders that dilate the valve, such as
pulmonary hypertension and Marfan syndrome
(4). Rarely, pulmonary insufficiency can also
develop from direct damage to the cusps due to
rheumatic heart disease, infectious endocarditis,
or carcinoid disease.
At CT angiography, there is inadequate ap-
position of the cusps at end diastole, dilatation
of the pulmonic ring and pulmonary artery, and
compensatory changes of right ventricular dilata-
tion and hypertrophy.
Tricuspid Valve
The right atrioventricular valve is usually made
up of papillary muscles, chordae tendinae, the an-
nulus, and three leaflets (septal, anterior, and pos-
terior). Occasionally, instead of three leaflets, the
right atrioventricular valve can have two or four
leaflets. The tricuspid valve is usually thinner than
the mitral valve due to lower right-sided pressures
(Fig 10; see also Movie 3 at http://radiographics
.rsna.org/cgi/content/full/29/5/1393/DC1).
Tricuspid Stenosis
Tricuspid stenosis is nearly always caused by
rheumatic heart disease (4). Other causes include
infectious endocarditis (most commonly in intra-
venous drug users), congenital tricuspid atresia,
and metastatic carcinoid syndrome. In rheumatic
disease, tricuspid stenosis often accompanies mi-
tral and aortic valve disease. As in the mitral and
aortic valves, postinflammatory changes within
the tricuspid valve leaflets include fibrosis, thick-
ening, and commissural fusion. Symptomatic
patients demonstrate signs of right-sided heart
failure with elevated jugular venous pressure,
hepatomegaly, and ascites.
Findings at CT angiography include a nar-
rowed valve annulus with fused and shortened
chordae tendinae and leaflet edges, right atrial
dilatation, enlargement of the superior and infe-
rior vena cavae, and hepatic venous congestion.
Tricuspid Insufficiency
Most commonly, tricuspid insufficiency is sec-
ondary to dilatation of the right ventricle and
RG ■ Volume 29 • Number 5 Chen et al 1407

Figure 16. Tricuspid insufficiency. (a, b) Axial CT an-

giograms show marked dilatation of the right atrium and
ventricle (*) causing deviation of the interventricular septum
toward the left ventricle (arrow). There is also marked dila-
tation of the inferior vena cava (IVC). (c) Axial CT angio-
gram shows marked dilatation of the hepatic veins (HV).

tricuspid annulus, with stretching of the leaflets,
typically in response to elevated pulmonary arte-
rial pressures (69). Causes of elevated pulmo-
nary arterial pressure include severe left-sided
heart disease, pulmonary vascular disease, and
chronic lung disease. Primary causes of tricuspid
insufficiency, although less common, include
rheumatic heart disease, infectious endocarditis,
myocardial infarction, metastatic carcinoid syn-
drome, trauma, Marfan syndrome, and Ebstein
anomaly (Fig 15). Postrheumatic involvement of
the tricuspid valve causes stenosis, usually with
concomitant insufficiency secondary to leaflet
fibrosis and retraction (68).
CT angiographic findings of tricuspid insuf-
ficiency reflect the morphologic changes in the
tricuspid leaflets and right side of the heart
(cor pulmonale). The tricuspid leaflets are not
apposed during end diastole. The right atrium
and ventricle are dilated, the right ventricle is
displaced to the left, and the interventricular
septum is bowed to the left (Fig 16). Additional
findings include distention of the superior and
inferior vena cavae and hepatic venous conges-
tion, as well as evidence of the underlying cause
(eg, emphysema, pulmonary hypertension, left-
sided heart disease).
Valvular Vegetations and Tumors
Endocarditis has an incidence of 1.7–6.2 per
100,000 persons per year in developed coun-
tries, with high morbidity and mortality rates
1408 September-October 2009 radiographics.rsna.org

Figure 17. Endocarditis. (a) Coronal MIP reformatted image shows a small, pedunculated
vegetation (arrow) attached to a cusp of the aortic valve. (b) Two-dimensional ultrasono-
graphic image obtained at the aortic root shows an echodense polypoid structure (arrow-
head) attached to the cusp.

Figure 18. Septic emboli in a patient with known tri- Figure 19. Papillary fibroelastoma. MIP
cuspid endocarditis. Axial CT scan of the chest shows reformatted image shows a 9-mm hypoat-
multiple bilateral, thin-walled cavitary lesions and nod- tenuating mass (arrow) attached to the right
ules, findings that are compatible with septic emboli. cusp of the aortic valve.

(Fig 2) (70). Predisposing factors include intra-
venous drug use, poor dental hygiene, long-term
hemodialysis, diabetes mellitus, mitral valve
prolapse syndrome, and prosthetic valves.
Findings of valvular vegetation at echocar-
diography typically help establish the diagnosis of
infectious endocarditis. In a retrospective study of
10 patients by Reiner et al (71), CT angiography
routinely depicted vegetations over 1 cm in diame-
ter (Fig 17; see also Movie 5 at http://radiographics
.rsna.org/cgi/content/full/29/5/1393/DC1). The veg-
etation size correlated well with that at echocar-
diography. One advantage of CT angiography over
echocardiography is its capacity to help evaluate
perivalvular abscess and to simultaneously help
assess extracardiac disease, such as septic and pe-
ripheral emboli (Fig 18) (72).
Primary valvular tumors are very rare. Papil-
lary fibroelastoma, an atypical nonneoplastic mass
RG ■ Volume 29 • Number 5 Chen et al 1409

Figure 20. Mechanical mitral valve. LA = left atrium, LV = left ventricle. (a) Four-chamber
MIP reformatted image shows an open mechanical mitral valve (arrow). (b) On an axial oblique
MIP reformatted image, the valve is closed (arrow).

Figure 21. Bioprosthetic aortic valve with

pseudoaneurysm. Coronal MIP reformatted
image shows a small pseudoaneurysm (arrow)
anteroinferior to a bioprosthetic aortic valve
(arrowhead). Ao = Aorta, LV = left ventricle.

are two types of artificial valves: tissue (biologic)

that frequently occurs on aortic valve cusps, is the
most common primary valvular tumor (73). Other
less common tumors include myxoma and ham-
artoma (73). Depending on their location, these
tumors can develop fibrin clots, which can subse-
quently embolize into the systemic or pulmonary
circulation. CT angiography can often help detect
these small tumors and help assess their motion
throughout the cardiac cycle (Fig 19).
Valve Prostheses
Artificial valve replacement is most commonly
performed for the aortic and mitral valves. There
valves and mechanical valves (Fig 1). Tissue
valves have limited durability compared with me-
chanical valves, but the latter require long-term
anticoagulation therapy (26). In patients with mi-
tral and tricuspid insufficiency, annuloplasty with
use of a ring device can also be performed.
Fluoroscopy is traditionally used to assess the
function of artificial valves. CT angiography with
appropriate window width and level settings and
cine images can be used to evaluate mechanical
leaflet motion and to determine the opening an-
gle (Fig 20) (22,74). In certain studies dedicated
to the assessment of mechanical valve function,
CT scans may be acquired without contrast ma-
terial, thereby reducing the dose dramatically.
CT angiography can also be used to assess
prosthetic complications, such as “frozen” leaf-
lets from thrombus or pannus, valve dehiscence,
pseudoaneurysm, infectious endocarditis, or
paravalvular abscess (Fig 21). Although CT an-
giograms obtained for the evaluation of artificial
valves, especially bioprostheses, can have streak
1410 September-October 2009
artifacts from surgical clips and wires, these ar-
tifacts do not usually limit the ability to identify
thrombus or vegetation on the prosthetic leaflets.
In contrast, one of the limitations of echocardiog-
raphy in evaluating prosthetic valves is the acous-
tic shadowing caused by the prosthesis itself or by
surgical clips and wires.
Conclusions
Contrast material–enhanced ECG-gated CT an-
giography allows excellent visualization of normal
valve morphologic features and function, as well
as of congenital or acquired structural valvular ab-
normalities. The number, thickness, and opening
and closing of the leaflets, as well as the presence
of valve calcification, can be directly observed. CT
angiography also permits simultaneous assess-
ment of the valves and coronary arteries, which
may prove valuable in presurgical planning. Nev-
ertheless, CT angiography remains a secondary
technique in valve assessment. CT angiography
makes use of ionizing radiation, whereas echocar-
diography and MR imaging do not. Moreover,
unlike alternative techniques, it does not provide
a direct measure of the valvular pressure gradient.
However, with further development of CT angio-
graphic techniques, including the use of dose low-
ering methods and novel approaches to improving
the measurement of valve function, this modality
can be expected to play a larger role in evaluating
cardiac valves in the future.
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