Question 1: 46 year old male with atypical chest pain. What’s the best diagnosis based on the image set?

Diagnosis: Bicuspid Valve and Aortic Stenosis

The 3D and 4D images were critical in planning surgery with AVR and aortic root replacement.

Normal Three Leafs of the Aortic Valve

Bicuspid Aortic Valve:Facts

• Incidence of 0.4-2.2%
• More common on Turner’s syndrome, coarctation of the aorta and VSD
• Leads to early valve calcification and aortic stenosis with dilated ascending aorta

What is the significance of a bicuspid valve?
Degenerative calcification occurs in all aortic valves over time and aortic leaflet thickening and aortic stenosis occur in 26% and 2% of the population by age 90. With bicuspid valves the same process occurs but 2-3 decades earlier.

Calcified Bicuspid Aortic Valve

Diseased Aortic Valve

"Multidetector CT enables accurate noninvasive assessment of the aortic valve area. It also correctly depicted all 14 bicuspid valves identified by TEE, eight of which were missed with TTE."

Aortic Valve Area Assessment: Multidetector CT Compared with Cine MR Imaging and Transthoracic and Transesophageal Echocardiography
Pouleur AC et al
Radiology 2007;244:745-754

"Aortic valve replacement is recommended when patients present with symptoms of chest pain, heart failure, or syncope and have severe aortic stenosis, which is typically defined as AVA reduced to less than 0.8 cm2."

Aortic Valve Area Assessment: Multidetector CT Compared with Cine MR Imaging and Transthoracic and Transesophageal Echocardiography
Pouleur AC et al
Radiology 2007;244:745-754

"Multidetector CT enables accurate noninvasive assessment of the aortic valve area."

Aortic Valve Area Assessment: Multidetector CT Compared with Cine MR Imaging and Transthoracic and Transesophageal Echocardiography
Pouleur AC et al.
Radiology 2007; 244:745-754

"The diagnostic accuracy of multidetector CT, as compared with TTE, in the identification of patients with moderate or severe aortic stenosis was excellent."

Aortic Valve Area Assessment: Multidetector CT Compared with Cine MR Imaging and Transthoracic and Transesophageal Echocardiography
Pouleur AC et al.
Radiology 2007; 244:745-754

"The diagnostic accuracy of multidetector CT, as compared with TTE, in the identification of patients with moderate (100% sensitivity,specificity, and accuracy) or severe aortic stenosis (91% sensitivity,97% specificity,96% accuracy) was excellent."

Aortic Valve Area Assessment: Multidetector CT Compared with Cine MR Imaging and Transthoracic and Transesophageal Echocardiography
Pouleur AC et al.
Radiology 2007; 244:745-754

"Aortic valve planimetry is best performed at phase starts of 50-100 milliseconds after the R peak because the area of the aortic opening is widest and image quality is best at that phase."

Feasibility and Optimization of Aortic Valve Planimetry with MDCT
Abbar S et al.
AJR 2007; 188:356-360

"Four dimensional cardiac CT will make a major contribution to harnessing the full morphologic and functional potential of high quality MDCT data acquired form a single cardiac cycle."

Four-Dimensional Imaging of the Heart Based on Near Isotrophic MDCT Datasets
Lawler LP, Ney DR, Pannu HK, Fishman EK
AJR 2005 Mar;184(3):774-776