REVIEW ARTICLE Cardiac magnetic resonance imaging in valvular heart disease Juha W. Koskenvuo 1 , Vesa Ja ¨rvinen 2 ,JussiP.Pa¨rkka¨ 1 , Tuomas O. Kiviniemi 1 and Jaakko J. Hartiala 1 1 Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, and 2 Department of Clinical Physiology, Hyvinka ¨a ¨ Hospital, Hyvinka ¨a ¨, Finland Correspondence Dr Juha W. Koskenvuo, MD, PhD, Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Kiinamyllynkatu 4-8, FIN 20520 Turku, Finland E-mail: juhkos@utu.fi Accepted for publication Received 14 October 2008; accepted 15 February 2009 Key words cardiac magnetic resonance imaging; congenital heart disease; coronary artery disease; regurgitation; stenosis; valvular heart disease Summary Cardiac magnetic resonance imaging (CMR) has rapidly gained acceptance as an accurate, reproducible and non-invasive imaging method for assessment of a wide range of cardiovascular diseases. However, CMR has not been used widely for diagnostic purposes in valvular heart disease (VHD). Unlike echocardiography it has no body habitus-related limitations and can thus be used to complement echocardiography. It is an especially good alternative for clinical follow-up in patients with VHD, as it allows accurate measurement of valvular dysfunction and related ventricular burden. Additionally, CMR is an ideal method for evaluating complex congenital heart disease and determining the significance of its components. It can also be used to study the physiological course of valvular dysfunction and response to therapeutic interventions. In this review, we present a basic introduction to CMR methodology, including its advantages and potential problems, and the physiology and quantification in VHD. We also discuss clinical applications of CMR in VHD. Furthermore, we describe how a CMR study statement should be structured in order to increase clinical use of this valuable methodology in cardiology. Introduction Echocardiography is a practical tool for evaluating valvular heart disease (VHD) and will probably maintain its prominent status in this field for years. Cost-effectiveness combined with quick screening make this method very useful in clinical work. Although valvular stenoses are evaluated adequately by echo- cardiography, the method does not provide consistently reliable and accurate quantification of valvular regurgitation. Thus, therapeutic decisions are mainly based on symptoms and indirect, echocardiographically derived measurements of valvu- lar regurgitation. Cardiac magnetic resonance imaging (CMR) is helpful whenever discrepancies exist between clinical status and the findings from echocardiography. The quantification of valvular function is important for the clinical management of VHD, and CMR allows precise quantification of valvular regurgitation. Moreover, it is highly accurate and reproducible in the measurement of ventricular and atrial function and volumes. Its capacity for assessing pulmonary valve regurgita- tion as well as right ventricular volumes and function have been found to be especially useful in paediatric patients. Clinical status is often misleading in VHD, as symptoms appear only in the advanced stages, when irreversible ventricular damage may have already occurred. Predicting when to operate on an incompetent valve is one of the most difficult decisions in cardiology. Cardiac magnetic resonance imaging quantification of valvular function and determination of concomitant ventric- ular burden are critical steps for guiding this decision. In this article, we review the utility of CMR techniques in the assessment of valvular regurgitation and stenosis. Furthermore, we discuss the advantages and potential problems of the methodology, quantification procedures in VHD and clinically useful tips for evaluating individual valve abnormalities includ- ing plane selection (Fig. 1). We also describe how a CMR study statement should be structured to increase clinical use of this valuable methodology in cardiology. CMR techniques Valvular function can be measured using electrocardiogram (ECG) gated breath-hold and free breathing sequences. In general, both prospective and retrospective ECG gating methods have found useful in CMR but a change of gating method should be avoided when performing follow-up studies (Ley et al., 2007b). Breath-holding requires co-operation, which is not possible for all young children. Therefore, children and patients with claustrophobia may need sedation or anaesthesia during a CMR study. Recently, a navigator-gated technique was Clin Physiol Funct Imaging (2009) 29, pp229–240 doi: 10.1111/j.1475-097X.2009.00865.x Ó 2009 The Authors Journal compilation Ó 2009 Scandinavian Society of Clinical Physiology and Nuclear Medicine 29, 4, 229–240 229