This document discusses the use of cardiovascular magnetic resonance (CMR) to assess aortic regurgitation in a 43-year-old male patient. CMR showed a dilated left ventricle with impaired function, a bicuspid aortic valve, and severe aortic regurgitation based on quantified regurgitant volume and fraction as well as halodiastolic flow reversal in the descending aorta. Guidelines support using CMR when echocardiography is inconclusive or has poor image quality. CMR provides accurate assessment of ventricular volumes, valve structure, aortic dimensions, and regurgitation severity to guide management, in this case recommending the patient for surgery.

1. Assessment of Aortic
Regurgitation with
Cardiovascular Magnetic
Resonance
Dr Cemil Izgi
Department of Cardiology
Royal Brompton Hospital
London, UK

2. Case presentation
• 43 years-old, Male
• Presented with shortness of breath present for the last 12 months
• 2-3/6 diastolic murmur at left sternal border
collapsing pulse
• Transthoracic Echo:
o Not diagnostic; significantly limited (poor echogenicity, obese patient)
o suggestive of poor LV systolic function with some eccentric aortic regurgitation but
severity and cause could not be assessed; a bicuspid aortic valve was suspected
o Patient was unwilling to have a transesophageal echo study.
 Patient was referred for a cardiovascular magnetic resonance (CMR) study
to assess LV systolic function and aortic regurgitation severity

3. Is CMR an appropriate test for assessment of
valvular heart disease?
ESC/EACTS Guidelines on management of VHD-2012
3.1 Patient evaluation
3.1.3.2 Cardiac magnetic resonance
“In patients with inadequate echocardiographic quality or discrepant
results, cardiac magnetic resonance (CMR) should be used to
assess the severity of valvular lesions—particularly regurgitant
lesions—and to assess ventricular volumes and systolic function,
as CMR assesses these parameters with higher reproducibility
than echocardiography.”

4. Is CMR an appropriate test for assessment of
valvular heart disease?
Clinical indications for cardiovascular magnetic resonance (CMR):
Consensus panel report.
European Heart Journal.2004;25:1940-1965

5. CMR examination:
-Ventricles
Watch video
Watch video
Dilated LV with impaired systolic function. An eccentric aortic regurgitation jet is also seen.

6. CMR examination:
-Ventricular Volumes and EF
EDV (ml)
ESV (ml)
Stroke V (ml)
EF (%)
LV
354
198
156
44
RV
144
64
80
55
- Dilated LV with decreased EF
- Normal RV size and EF
- LV/RV stroke volume difference of 76ml

7. CMR examination:
-aortic valve and aortic root
Watch video
Watch video
Bicuspid aortic valve
Normal aortic root and ascending aorta

8. CMR examination:
-aortic regurgitation severity -1
Watch video
LVOT- magnitude image
Watch video
LVOT- phase contrast image
In plane flow mapping images showed an eccentric jet of aortic regurgitation.

9. CMR examination:
-aortic regurgitation severity -2
Watch video
Through plane phase contrast
cine just above aortic valve tips
Flow-time curve of flow through aortic valve showing
forward and regurgitant flows which can be quantified
Forward flow 147 ml/beat, regurgitant volume 72 ml/beat, regurgitant fraction 49%
(in accordance with LV-RV stroke volume difference )
•
•
Regurgitant volume >60 ml as quantified by Doppler echo indicates severe AR 1,
Regurgitant fraction >30-33% derived from phase contrast CMR indicates severe AR 2,3
Lancellotti P, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary
from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging (2013) 14, 611–644
2
Gabriel RS, et al. Comparison of severity of aortic regurgitation by cardiovascular magnetic resonance versus transthoracic
echocardiography. Am J Cardiol. 2011 Oct 1;108(7):1014-20.
3
Myerson SG, et al. Aortic regurgitation quantification using cardiovascular magnetic resonance: association with clinical outcome.
Circulation. 2012 Sep 18;126(12):1452-60
1

10. CMR examination:
-aortic regurgitation severity -3
Watch video
Thoracic aorta cine
•
•
Watch video
Descending aorta through
plane phase contrast
Descending aorta flow curve:
Halodiastolic flow reversal
Doppler evidence of halodiastolic flow reversal in descending aorta is a strong
indicator for severe aortic regurgitation1,
also validated with CMR2
Lancellotti P, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive
summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging (2013) 14, 611–644
2
Bolen MA, et al. Cardiac MR assessment of aortic regurgitation: holodiastolic flow reversal in the descending aorta helps
stratify severity. Radiology. 2011 Jul;260(1):98-104
1

11. Diagnosis
• -Bicuspid aortic valve with severe aortic regurgitation
-LV dilatation and systolic dysfunction
-Normal aortic root and ascending aorta size
• Symptomatic

12. ESC/EACTS Guidelines on management of VHD-2012
Management of severe AR
Patient referred for surgery

13. Conclusion
• CMR can provide important information for the assessment of
regurgitant valvular lesions. It can be used as an adjunct to echo or when
echo findings are inconclusive.
• For aortic regurgitation it can reliably assess:
 LV ventricular volumes and systolic function
 structure of the aortic valve
 size of the aortic root and ascending aorta
 severity of aortic regurgitation
• visual assessment by cine images (qualitative only and not recommended)
• quantification of regurgitation volume and regurgitant fraction
-difference between left and right ventricular stroke volumes
-velocity mapping of aortic flow
• demonstration of halodiastolic flow reversal in the descending aorta

14. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!