Impaction of regurgitation jet on anterior mitral leaflet is associated with diastolic dysfunction in patients with bicuspid aortic valve and mild insufficiency: a cardiovascular magnetic resonance study

Figures

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  Fig. 1. BAV phenotypes according to Sievers classification. BAV types percentages according to Sievers classification among “Posterior jet” (PJ) group, “Non-posterior jet” (nPJ) group and controls. Type 1 R–L resulted to be the more represented (66.7% in PJ; 40% in nPJ and 70% in controls). Type 1 R–N was the second most frequent phenotype (33.3% in PJ; 26.7% in nPJ and 10% in controls). PJ group was only composed by type 1 R–L and R–N; type 1 L–N and type 2 were only found in nPJ group (26.7 and 6.7%, respectively); type 0 was only present among controls (20%). BAV Bicuspid aortic valve; L–N left – non coronary cusps; R–L right-left coronary cusps; R–N right – non coronary cusps

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  Fig. 2. Histograms of diastolic strain parameters by feature tracking technique. Comparison between PJ, nPJ and control groups as regards peak diastolic strain rate (on the left) and peak diastolic velocity (on the right). The top of the histogram represents the mean value; the error bar represents the confidence interval (95%). PJ posterior jet; nPJ non-posterior jet

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  Fig. 3. BAV patient with aortic regurgitation and posterior jet. Set of three chamber cine-SSFP images acquired during A systolic, B mid-diastolic and C end-diastolic phase, shows aortic valve leaflets movement over the entire cardiac cycle, with the regurgitation jet impacting the anterior mitral valve leaflet. 4D Flow color encoded vector map (D) and streamlines (E) at the mid diastole demonstrate the abnormal intracavitary flow with generation of large organized mid-ventricular vortexes (asterisks) caused by the interference from an eccentric and angulated regurgitation jet (arrow) on the transmitral diastolic flow. Analysis of circumferential and longitudinal strain was respectively performed on cine-SSFP images acquired on short-axis (F) and horizontal long-axis (G) views. Systolic and diastolic strain values have been assessed as peak systolic strain (PSS, red arrowheads), peak systolic strain rate (PSSR, orange arrows), time-to-peak systolic strain (TTPSS, white brackets) and peak diastolic strain rate (PDSR, yellow arrows). SSFP Steady state free precession

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  Fig. 4. BAV patients with (non-posterior jet) and without aortic regurgitation. Three chamber cine-SSFP images acquired during mid diastolic phase in BAV patient with aortic valve regurgitation and jet non impacting the valve leaflet (A, arrow) and in BAV patient with no regurgitation (B). The corresponding 4D Flow color encoded streamlines images, matching the same three-chamber views, demonstrated similar organized laminar diastolic transvalvular flow, both in patient with (C) and without aortic regurgitation (D) with predominant streamline orientation along the LV longitudinal axis. The asterisk marks the regurgitant flow within LV outflow tract just under the aortic valve. BAV bicuspid aortic valve; LV left ventricle; SSFP steady state free precession