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Chapter 4. Anatomy of Cardiac Valves for the Interventionalist

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The most accurate estimate of the annular size for transcatheter aortic valve implantation is obtained from which imaging modality?

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A. Two-dimensional (2D) transthoracic echocardiography (TTE)

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B. 2D transesophageal echocardiography (TEE)

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C. Three-dimensional (3D) TEE

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D. Multidetector computed tomography (MDCT)

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The correct answer is D.

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Accurate measurement of the oval-shaped aortic annulus is crucial for precise valve sizing in patients undergoing transcatheter aortic valve implantation (TAVI). The “annulus” is not circular but elliptical, and therefore, different modalities that measure different planes of the annulus do not necessarily yield same results. The annular size obtained by MDCT is typically larger than when measured by 2D TTE/TEE. Aortic annulus measurement by 3D TEE, although better than with 2D TTE/TEE, is smaller than that obtained on MDCT. 3D TEE should be used for transcatheter aortic valve replacement (TAVR) sizing only when MDCT is not available or contraindicated. MDCT provides the most accurate measurement of the aortic annulus.

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Which imaging modality is preferred for mitral valve disease?

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A. MDCT

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B. Fluoroscopy

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C. Cardiac magnetic resonance (CMR)

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D. Echocardiography

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The correct answer is D.

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Echocardiography is the preferred imaging modality for mitral valve disease. The proximity of the mitral valve to the posteriorly positioned TEE probe in the esophagus strikingly improves anatomic assessment of the mitral valve. This has been successfully exploited to improve patient selection and safety of percutaneous mitral valve therapies. The poor temporal resolution of MDCT limits its role in the anatomic assessment of the mitral valve. The anatomic information from CMR is not equivalent to that from echocardiography due to relatively thick imaging size.

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The anterior mitral leaflet is closely related to which of the following structures?

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A. Left and right coronary cusps of the aortic valve

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B. Left and noncoronary cusps of the aortic valve

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C. Right and noncoronary cusps of the aortic valve

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The correct answer is B

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The aortic/anterior leaflet of the mitral valve is dome shaped with attachment to the anterior two-fifths of the annular circumference. This leaflet lies in close relation to the left and noncoronary cusps of the aortic valve in combination with which it forms the aorto-mitral curtain.

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