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Assessment of Mitral Valve Disease: A Review of Imaging Modalities

  • Imaging (J Hung, Section Editor)
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Opinion statement

Mitral valve disease (MVD) related to mitral valve prolapse (MVP), coronary artery disease (CAD), and calcific mitral stenosis, is increasing in prevalence across the USA and Europe in the context of a longer life expectancy and aging population. In developing countries, rheumatic heart disease remains a major cause of MVD. Echocardiography represents the primary diagnostic modality for assessment of the mitral valve (MV). With the implementation of three-dimensional imaging, echocardiography has become an indispensable tool to evaluate the morphology, geometry, and function of the MV apparatus in the pre-operative setting. However, recognition of its limitations and advances in newer technologies have led to a growing interest in other imaging modalities such as cardiac magnetic resonance (CMR). Although still not widely available, CMR is an essential complement to echocardiography, especially when poor image quality, significant variability in flow diameter measurements, and geometric assumptions of flow orifice preclude accurate quantification of mitral regurgitation on echocardiographic images. In addition, CMR can reliably provide quantitative determination of ventricular volumes and function, hence facilitating surgical decision-making when serial linear echocardiographic measurements are discrepant. Finally, CMR assessment of fibrosis using late gadolinium enhancement allows better understanding of the interactions between MVD and the myocardium in both MVP and MVD related to CAD or other myopathy. In this review, we summarize the role of the available imaging modalities in understanding valvular pathology and determining severity of regurgitation or stenosis. Recently published valvular guidelines highlight the importance of monitoring MVD progression and the shift to intervention earlier in the course of disease. In this context, we also discuss the potential role of echocardiography and CMR in identifying early stages of MVD and/or pre-clinical markers of myocardial dysfunction.

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Acknowledgments

We thank Dr. Feroze Mahmood for the intra-operative 3D TEE images.

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Conflict of Interest

Francesca N. Delling is funded by National Heart, Lung and Blood Institute K23HL116652.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Rd, Baker 4, Boston, MA, 02215, USA

    Shweta R. Motiwala MD

  2. Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, E/SH-458, Boston, MA, 02215, USA

    Francesca N. Delling MD

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  1. Shweta R. Motiwala MD
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Correspondence to Francesca N. Delling MD.

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Video 1

Example of rheumatic mitral stenosis shown in a 2D TTE parasternal long-axis view. Both mitral leaflets are thickened and deformed, with a characteristic “hockey stick” appearance of the anterior leaflet as a result of diastolic leaflet doming, and poor excursion of the posterior leaflet. The narrowest orifice occurs at the leaflet tips, while the mitral valve annulus is not affected. 2D = 2-dimensional; TTE = transthoracic echocardiogram. (AVI 8,492 kb)

Video 2

A 3D TEE en face view of the mitral valve from the left atrial perspective, demonstrating prominent fusion of the lateral commissure and preserved A3 and P3 mobility. 3D = 3-dimensional; TEE = transesophageal echocardiogram. (MOV 329 kb)

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Motiwala, S.R., Delling, F.N. Assessment of Mitral Valve Disease: A Review of Imaging Modalities. Curr Treat Options Cardio Med 17, 30 (2015). https://doi.org/10.1007/s11936-015-0390-1

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