0:04

So again, we're gonna load this

0:07

and we wanna get into the habit

0:09

of like loading all these phases,

0:12

looking at the valves themselves,

0:14

and then trying to determine what,

0:17

what the issue ends up being here, right?

0:20

So again,

0:25

we're gonna line up things in this particular case.

0:29

Uh, I want you to kind of see the anatomy.

0:33

This particular case is also important

0:34

because you can see that there's a cardiac device

0:37

that's going to create some beam hardening artifact

0:39

could affect your ability to assess the ejection fraction

0:43

and function as it does with MRI,

0:45

but you really can see how this really doesn't affect our

0:48

ability to assess the right ventricular wall motion,

0:51

ejection fraction regional wall motion abnormality.

0:54

So that's one of the advantages of cardiac CT when it comes

0:57

to these particular assessments of questions

1:00

of the right ventricular size, function,

1:02

and dimensions in patients with established

1:04

and known intracardiac device.

1:07

You can also see the benefits

1:09

of having a dual source scanner

1:11

and the temporal resolution

1:12

as you see very minimal motion in the opening

1:15

and closure of the mitral valve as well as the myocardium

1:18

during systole and dle.

1:20

So this temporal resolution is pretty difficult to to,

1:24

to challenge in this particular case.

1:28

Uh, what we're going to do is we're also going

1:31

to now align ourselves to the, um, to the valve.

1:34

Now what I wanna emphasize here is how we're going

1:38

to look at this valve and it's morphology, right?

1:41

We wanna assess it, you wanna see it,

1:44

but you're also interested in

1:45

how the valve itself is moving.

1:48

So what this person has a bicuspid aortic valve

1:52

and is being evaluated for aortic valve stenosis.

1:55

I want you to see this and you can

1:56

see why it's so important.

1:58

I don't think this was mentioned that all in any

2:01

Of the cases, and that's in their reports.

2:03

And this is one of the things that I wanted

2:05

to ensure we reviewed together

2:06

because you can see the leaflet in here.

2:10

The valve itself does not look that restricted.

2:13

In fact, it seems to open quite well.

2:15

So for a valve that's quote unquote stenotic,

2:17

that's a pretty good motion of the valve quite opening.

2:22

But You see that there's definitely poor co-optation

2:24

of the valve and you can see there's a notable gap

2:28

as a result of this that's likely contributing

2:31

to a significant degree of aortic valve regurgitation.

2:35

When you get into this plane

2:38

and you're trying to orient in this direction to kind

2:42

of see the size of the gap, right?

2:44

You, you, you're seeing this here, this is

2:47

where you're going to be able to really assess the degree

2:50

of regurgitation in here.

2:52

And you can see how that poor coaptation

2:54

and that prolapsing of the valve leaflet into the left

2:58

and field outflow tract is what's likely contributing

3:01

to this patient's symptoms.

3:02

So in this case where there was concern about like they have

3:05

severe aortic valve stenosis

3:07

and evaluation, you see that there is actually not

3:12

so much severe stenosis,

3:13

but more so, uh, a valve leaflet that has some regurgitation

3:19

that is contributing to a lot of these, uh, findings.

3:23

So that's an important thing to remember, an important thing

3:28

to kind of not forget to assess

3:30

and mention on on your case report.

Wk 10, Case 2 - Review

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0:04

So again, we're gonna load this

0:07

and we wanna get into the habit

0:09

of like loading all these phases,

0:12

looking at the valves themselves,

0:14

and then trying to determine what,

0:17

what the issue ends up being here, right?

0:20

So again,

0:25

we're gonna line up things in this particular case.

0:29

Uh, I want you to kind of see the anatomy.

0:33

This particular case is also important

0:34

because you can see that there's a cardiac device

0:37

that's going to create some beam hardening artifact

0:39

could affect your ability to assess the ejection fraction

0:43

and function as it does with MRI,

0:45

but you really can see how this really doesn't affect our

0:48

ability to assess the right ventricular wall motion,

0:51

ejection fraction regional wall motion abnormality.

0:54

So that's one of the advantages of cardiac CT when it comes

0:57

to these particular assessments of questions

1:00

of the right ventricular size, function,

1:02

and dimensions in patients with established

1:04

and known intracardiac device.

1:07

You can also see the benefits

1:09

of having a dual source scanner

1:11

and the temporal resolution

1:12

as you see very minimal motion in the opening

1:15

and closure of the mitral valve as well as the myocardium

1:18

during systole and dle.

1:20

So this temporal resolution is pretty difficult to to,

1:24

to challenge in this particular case.

1:28

Uh, what we're going to do is we're also going

1:31

to now align ourselves to the, um, to the valve.

1:34

Now what I wanna emphasize here is how we're going

1:38

to look at this valve and it's morphology, right?

1:41

We wanna assess it, you wanna see it,

1:44

but you're also interested in

1:45

how the valve itself is moving.

1:48

So what this person has a bicuspid aortic valve

1:52

and is being evaluated for aortic valve stenosis.

1:55

I want you to see this and you can

1:56

see why it's so important.

1:58

I don't think this was mentioned that all in any

2:01

Of the cases, and that's in their reports.

2:03

And this is one of the things that I wanted

2:05

to ensure we reviewed together

2:06

because you can see the leaflet in here.

2:10

The valve itself does not look that restricted.

2:13

In fact, it seems to open quite well.

2:15

So for a valve that's quote unquote stenotic,

2:17

that's a pretty good motion of the valve quite opening.

2:22

But You see that there's definitely poor co-optation

2:24

of the valve and you can see there's a notable gap

2:28

as a result of this that's likely contributing

2:31

to a significant degree of aortic valve regurgitation.

2:35

When you get into this plane

2:38

and you're trying to orient in this direction to kind

2:42

of see the size of the gap, right?

2:44

You, you, you're seeing this here, this is

2:47

where you're going to be able to really assess the degree

2:50

of regurgitation in here.

2:52

And you can see how that poor coaptation

2:54

and that prolapsing of the valve leaflet into the left

2:58

and field outflow tract is what's likely contributing

3:01

to this patient's symptoms.

3:02

So in this case where there was concern about like they have

3:05

severe aortic valve stenosis

3:07

and evaluation, you see that there is actually not

3:12

so much severe stenosis,

3:13

but more so, uh, a valve leaflet that has some regurgitation

3:19

that is contributing to a lot of these, uh, findings.

3:23

So that's an important thing to remember, an important thing

3:28

to kind of not forget to assess

3:30

and mention on on your case report.

Report

Patient History
A 65-year-old male presents with severe aortic valve stenosis. Request for Cardiac CT and CT angiogram chest, abdomen and pelvis for pre-procedural evaluation.

Report
Procedure: Computed tomographic angiography, heart, coronary arteries, and thoracic, abdominal, and proximal peripheral arteries, with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) (CPT code: 75574).

Technique: TAVR CT cardiac and CT angiogram chest, abdomen and pelvis.
Gating: Retrospective, ECG-gated helical cardiac volume transitioning to non-gated helical aorta and distal run-off acquisition
Cardiac cycle timing: 0-95%
Contrast type and volume: 60mL at 5ml/sec then 40mL at 2.50mL/sec, followed by 40mL saline at 2.5mL/sec at 4ml/sec
Complications: None
QC: Good signal noise
Artifacts: None

Findings:
Morphology: bicuspid aortic valve Sievers type 1 with fusion of the right and non-coronary cusp leaflet. Calcium distribution in the leaflets is asymmetric involving the raphe and the non-coronary cusp leaflet. The estimated AVA is 118 mm2 by 3D planimetry.

LVOT calcification: Severe with a single nodule of calcification protruding into the annular lumen and extending into the posterior LVOT.

Aortic Annulus measurements:

Cardiac phase used quantification: 20%

Maximum diameter: 31.8 mm

Minimum diameter: 24.7 mm

Mean diameter: 27.8 mm

Area: 608 mm2

Perimeter: 89.6 mm

Coronary ostia height:

Right: 28 mm (to annular plane)

Left: 18.9 mm (to annular plane)

Optimum gantry angles:

3 cusp view: LAO 20, CAU 17

Anterior view: RAO 0, CAU 43

No CRA- CAU view: LAO 29 CAU 0

Cardiac Findings:
Coronary Arteries: Normal coronary origins with a medium amount of calcified and non calcified plaque in a multivessel distribution. This study was not optimized for the assessment of the coronary arteries.

Chambers: Left atrial size is normal in size with no left atrial appendage filling defect. The left and right ventricular cavity sizes are within normal limits. There are no abnormal filling defects. Normal left ventricular systolic function with an estimated EF of 65% with no regional wall motion abnormalities.

Myocardium: Increased wall thickness in concentric hypertrophy pattern. No outpouching or masses.

Pericardium: Normal thickness with no significant effusion or calcium present.

Pulmonary arteries: Normal in size without proximal filling defect. Not fully opacified.

Pulmonary veins: Normal pulmonary venous drainage. There were four noted pulmonary veins, two on the right and two on the left.

Aortoiliac Evaluation: Cardiac phase used for evaluation 75%

Thoracic Aorta:
The aortic root is dilated measuring 45.3 mm (sinus to sinus measurement).

The ascending aorta has a minimum diameter of 38.4 mm

There is a three-vessel arch with minimum diameter of 36.2 mm.

The descending aorta has a minimum diameter of at 21.5 mm.

The left subclavian has a minimum diameter of 8.65 mm.

There is diffuse calcific atherosclerotic disease throughout the thoracic aorta and its branches. No significant tortuosity.

Abdominal Aorta:
The abdominal aorta has a minimum diameter of 15.5 mm

There is no evidence of significant tortuosity. There is no intraluminal obstruction or thrombi. The celiac axis, SMA, and IMA are patent. There are single renal arteries bilaterally that are patent. There is diffuse calcific atherosclerotic disease throughout the abdominal aorta.

Iliofemoral arteries:

The right common iliac has a minimum diameter of 10.6 mm.

The right external iliac has a minimum diameter of 8.55 mm.

The right common femoral has a minimum diameter of 8.65 mm.

There is posterior calcification in the RCFA. The femoral head is located at the center of the vessel.

The left common iliac has a minimum diameter of of 10.7 mm.

The left external iliac has a minimum diameter of 8.49 mm.

The left common femoral has a minimum diameter of 8.38 mm.

There is posterior calcification in the LCFA. The femoral head is located at the center of the vessel.

Impressions
1. Aortic annular, root and valve measurements as above.
2. Overall, there is a medium amount of plaque in the coronary arteries.
3. Aortoiliac measurements as above.

Case Discussion

Faculty

Giovanni E. Lorenz, DO

Cardiothoracic Radiologist

San Antonio Military Health System (SAMHS)

Emilio Fentanes, MD

Director of Cardiac Imaging, Department of Cardiology

Brooke Army Medical Center