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Prosthetic valve function

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  • mechanical valves can be quite difficult to assess with two-dimensional echocardiography. Although gross abnormalities can be detected, more subtle changes are often missed, especially with transthoracic imaging.
  • M-Mode image of a Bileaflet prosthetic valve -- leaflets form two parallel lines while open, disappearing when closed
  • measurementisoften difficult because of the reverberations andartefactscausedbytheprosthesisstentorsewingring
  • usually requires a position 0.5 to 1 cm below thesewing ring (toward the apex)
  • Schematic representation of the concept of the DVI.Velocity across the prosthesis is accelerated through the jetfrom the LVO tract. DVI is the ratio velocity in the LVO (Vlvo)tothat of the jet (Vjet)
  • DVI is always less than unity, because velocity will alwaysaccelerate through the prosthesis. A DVI < 0.25 is highly suggestive ofsignificant valve obstruction.Similar to EOA, DVI is not affectedby high flow conditions through the valve, including AR, whereas bloodvelocity and gradient across the valve are.
  • Localized high gradient in a mitralbileaflet valve. A, Visualization of lateral (narrow arrow) and central (large arrow) jets oncolor Doppler image. B, C, Two Doppler envelopes are superimposed. The highest one, which presumably reflects the velocity withinthe central orifice, yields a value of peak gradient of 21 mm Hg, whereas the smallest one (lateral orifices) provides a gradient of12 mm Hg.
  • Examples of bileaflet, single-leaflet, and caged-ball mechanical valves and their transesophagealechocardiographic char-acteristics taken in the mitral position in diastole(middle)and in systole(right). The arrows in diastole point to the occluder mechanismof the valve and in systole to the characteristic physiologic regurgitation observed with each valve. Videos 1 to 6 show the motion andcolor flow patterns seen with these valvesStarr-Edwards valve,there is a typical small closing volume and usually little or no truetransvalvular regurgitationsingle tilting disc valveshave both types of regurgitation, but the pattern may vary: theBjork-Shiley valve has small jets located just inside the sewing ring,where the closed disc meets the housing, while the Medtronic Hallvalve has these same jets plus a single large jet through a centralhole in the discThe bileaflet valves typically have multiplejets located just inside the sewing ring, where the closed leaflets meet the housing, and centrally, where the closed bileaflets meet eachother
  • The white or black arrows indicate the regurgitant jet(s). (A, B)Transoesophagealechocardiographic (TOE) views of normal physiological regurgitant jets (thin white arrows; A and B) and paravalvularregurgitant jets(thick white arrows; B) in mitralbileaflet mechanical valves
  • (G) TTE short axis view of a mild paravalvular regurgitation (one single jet occupying20% ofcircumference) in a transcatheterbioprosthetic aortic valve
  • Pannus formation on a St Jude Medical valve prosthesis in the aortic position as depicted by TEE. The mass is highly echogenicand corresponds to the pathology of the pannus at surgery
  • Prosthetic St Jude Medical valve thrombosis in the mitral position(arrow)obstructing and immobilizing one of the leaflets ofthe valve. After thrombolysis, leaflet mobility is restored, and the mean gradient (Gr) is significantly decreased.
  • De-gassing involves separation of the gas containedin the water (or blood). In the case of a tran-sient drop in pressure, the gas separates out be-fore redissolving in the water when normalpressure is re-established.
  • ie, the atrial side of a mitral pros-thesis or the ventricular side of an aortic pros-thesisStrands have been found to be morecommon in patients undergoing TEE for evalu-ation of the source of embolism than in patientsexamined for other reasons the thera-peutic implications of prosthetic valve-associat-ed strands remain unclear. Importantly, ifstrands consist of collagen, aggressive thera-peutic anticoagulation is not likely to com-pletely eliminate their embolic potential
  • Real-time three-dimensional transesophageal echocardiography of a normal mechanical mitral valve visualized from the left atrium with the leafletsinsystole (A) and in diastole (B).
  • Real-time three-dimensional transesophageal echocardiography of a bioprostheticmitral valve with vegetation on the atrial side of the leaflet asvisualized from the left atrium (A) and left ventricle (B). In image B, the struts of the bioprosthetic valve are clearly visible. Black arrow points to thevegetation
  • Long-axis view of left ventricular outflow tract (LVOT) perpendicular to prosthetic valve leaflets in systolic phase shows residual opening angle (dashed lines) is 19°, which is still within normal limit (≤ 20°)

Prosthetic valve function Prosthetic valve function Presentation Transcript

  • DR. DURGAPAVAN
  • OUTLINE Approch Clinical Examination CXR 2Decho Doppler TEE 3D echo CineFluoro CT Cardiac catheterisationEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Introduction The introduction of valve replacement surgery in theearly 1960s has dramatically improved the outcome ofpatients with valvular heart disease. Despite the improvements in prosthetic valve designand surgical procedures , valve replacement does notprovide a definitive cure. Instead, native valve diseaseis traded for “prosthetic valve disease”.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Introduction After a valve is replaced, the prognosis for the patientis highly correlated with the function of the prostheticvalve like- hemodynamics, durability, thrombogenicity. Thus, early diagnosis of a prosthetic valve disorder iscrucial for reducing morbidity and mortality.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Introduction Symptoms of prosthetic valve dysfunntion may benonspecific, making it difficult to differentiate the effectsof prosthetic valve dysfunction from ventricular dysfunction, pulmonar hypertension, the pathology of the remaining native valves, noncardiac conditions. Although physical examination can alert clinicians to thepresence of significant prosthetic valve dysfunction,diagnostic methods are often needed to assess the functionof the prosthesis.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Types of prosthetic valves Prosthetic Valves are classified as tissue or mechanical Tissue:• Made of biologic tissue from an animal (bioprosthesis orheterograft) or human (homograft or autograft) source Mechanical Made of non biologic material (pyroliticcarbon, polymeric silicone substances, or titanium) Blood flowcharacteristics, hemodynamics, durability, andthromboembolic tendency vary depending on the typeand size of the prosthesis and characteristics of thepatient EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Types of Prosthetic Heart Valves Mechanical Bileaflet (St Jude)(A) Single tilting disc (Medtronic Hall)(B) Caged-ball (Starr-Edwards) (C) Biologic Stented Porcine xenograft (MedtronicMosaic) (D) Pericardial xenograft (Carpentier-Edwards Magna) (E) Stentless Porcine xenograft (MedronicFreestyle) (F) Pericardial xenograft Homograft ( allograft) Percutaneous Expanded over a balloon(Edwards Sapien) (G) Self –expandable (CoreValve) (H)Circulation 2009, 119:1034-1048EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Mechanical Valves Extremely durable with overall survival rates of 94% at10 years Primary structural abnormalities are rare Most malfunctions are secondary to perivalvular leakand thrombosis Chronic anticoagulation required in all With adequate anticoagulation, rate of thrombosis is0.6% to 1.8% per patient-year for bileaflet valves.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Biological Valves Stented bioprostheses Primary mechanical failure at 10 years is 15-20% Preferred in patients over age 70 Subject to progressive calcific degeneration & failureafter 6-8 years Stentless bioprostheses Absence of stent & sewing cuff allow implantation oflarger valve for given annular size->greater EOA Uses the patient’s own aortic root as the stent, absorbingthe stress induced during the cardiac cycleEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Biologic Valves Continued Homografts Harvested from cadaveric human hearts Advantages: resistance to infection, lack of need foranticoagulation, excellent hemodynamic profile (insmaller aortic root sizes) More difficult surgical procedure limits its use Autograft Ross ProcedureEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Desired valves Mechanical valves - preferred in young patients who have a life expectancy of more than 10 to 15 years who require long-term anticoagulant therapy for otherreasons (e.g., atrial fibrillation). Bioprosthetic valves Preferred in patients who are elderly Have a life expectancy of less than 10 to 15 years who cannot take long-term anticoagulant therapy A bileaflet-tilting-disk or homograft prosthesis is mostsuitable for a patient with a small valvular annulus in whoma prosthesis with the largest possible effective orifice area isdesired.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Algorithm for choice of prostheticheart valveEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Approach to prosthetic valvefunction assesment CLINICAL INFORMATION &CLINICAL EXAMINATION IMAGING OF THE VALVES CXR 2D echocardiography TEE 3D echo CineFluoro CT Cardiac catheterisationEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • HISTORY Subtle symptoms of cardiac failure or neurologicevents can be clues to serious valve dysfunction.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • CLINICAL INFORMATION Clinical data including reason for the study and thepatient’s symptoms Type & size of replacement valve, date of surgery Patient’s height, weight, and BSA should be recordedto assess whether prosthesis-patient mismatch (PPM)is present BP & HR HR particularly important in mitral and tricuspidevaluations because the mean gradient is dependent onthe diastolic filling periodEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  • CXR chest x-ray are not performed on a routine basis in theabsence of a specific indication. It can be helpful in identification of valve type ifinformation about valve is not available.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  The location of the cardiacvalves is best determinedon the lateral radiograph. A line is drawn on thelateral radiograph from thecarina to the cardiac apex. The pulmonic and aorticvalves generally sit abovethis line and the tricuspidand mitral valves sit belowthis line.Sometimes the aortic rootcan be inferiorly displacedwhich will shift the aorticvalve below this line.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  For further localizationprosthetic valves involvesdrawing a second linewhich is perpendicular tothe patients uprightposition which bisects thecardiac silouette. The aortic valve projects inthe upper quadrant, themitral valve in the lowerquadrant ,the tricuspidvalve in the anteriorquadrant and pulmonaryvalve in the superiorportion of the posteriorquadrantEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  On the frontal chestradiograph ( AP or PA ) -longitudinal line through themid sternal body. draw aperpendicular line dividingthe heart horizontally. The aortic valve -intersection of these twolines. The mitral valve - lower leftquadrant (patient’s left). The tricuspid valve - lowerright corner (the patientsright) The pulmonic valve- upperleft corner (the patients left). This method is less reproducibleEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Patients with cardiac valves often have chamberenlargement and cardiac rotation which can displacethe positions of the valves as well as create difficultywhen drawing lines through the cardiac silouette. These rules are meant as a guideline to better localizecardiac valves although they do not always work.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Some bioprosthetic valves have components thatdetermine the direction of flow which helps localizethe valve prosthesis. If the direction of flow is frominferior to superior – likely aortic valve.superior to inferior- likely a mitral valve.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Radiologic IdentificationStarr-Edwards cagedball valveRadiopaque base ringRadiopaque cageSilastic ball impregnatedwith barium that ismildly radiopaque (butnot in all models)EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Appearance ofCarboMedics prosthesison plain radiography.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Echo Imaging of Prosthetic ValvesEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • TIMING OF ECHO CARDIOGRAPHICFOLLOW-UP Ideally, a baseline postoperative transthoracicechocardiography(TTE) study should be performed3-12weeks after surgery, when thechest wound has healed,ventricular function has improved, andanaemia with its associated hyperdynamic state hasresolved.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Bioprosthetic valves Annual echocardiography isrecommended after the first 5years, Mechanical valves, routine annual echocardiography isnot indicated in the absence of a change in clinicalstatus.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • challenges in echocardiographyThe high reflectance leads to shadowing Reverberationsmultiple echocardiographic windows must be used tofully interrogate the areas around prosthetic valves. transesophageal echocardiography is necessary toprovide a thorough examination.For stented valves-ultrasound beam aligned parallelto flow to avoid the shadowing effects of the stentsand sewing ring.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • The concept of pressure recoveryEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • The primary goals of 2D echo Valves should be imaged from multiple views, withattention todetermine the specific type of prosthesis,confirm the opening and closing motion of theoccluding mechanism,confirm stability of the sewing ring(abnormal rockingmotion ) Presence of leaflet calcification or abnormal echo densityattached to the sewing ring, occluder, leaflets, stents, orcage such as vegetations and thrombiEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Primary goals of 2D echo (cont)Calculate valve gradientCalculate effective orifice areaConfirm normal blood flow patternsDetection of pathologic transvalvular andparavalvular regurgitation.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Starr-Edwards mitral prosthesis is shown. A: During systole, the poppet is seatedwithin the sewing ring (arrows). B: During diastole, the poppet moves forwardinto the cage (arrows), allowing blood flow around the occluder.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • St. Jude mitral prosthesis is demonstrated. A: During systole, the hemidisks areshown in the closed position (arrows). B: During diastole, the two disks arerecorded in the open position (arrows).EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • St. Jude aortic prosthesis is demonstrated. The sewing ring is indicatedby the arrows. The walls of the aortic root (Ao) often obscure the motionof the disks. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • M-Mode M-Mode echocardiography enables better evaluationof valve movements and corresponding time intervalsand recognition of quick movements and fibrillations.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  For bioprostheses, evidence of leaflet degeneration canbe recognized asleaflet thickening (cusps >3 mm in thickness)-earliest signcalcification (bright echoes of the cusps), tear (flail cusp). Prosthetic valve dehiscence is characterized by arocking motion of the entire prosthesis. An annular abscess may be recognized as anecholucent, irregularly shaped area adjacent to thesewing ring of the prosthetic valve.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Assessment of Flow Characteristicsof Prosthetic Valves Normal functioning mechanical prosthetic valvescause:some obstruction to blood flowclosure backflow (necessary to close the valve)leakage backflow (after valve closure)The extent of normal obstruction and leakage ofprosthetic valves depends on prosthetic valve designEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Valve type Flow CharacteristicsBall-in-cage prosthetic valve (Starr-Edwards, Edwards Lifescience)much obstruction and little leakage.Tilting disc prosthetic valve (Björk-Shiley; Omniscience; Medtronic Hall)less obstruction and more leakage.Bileaflet prosthetic valves (St. JudeMedical; Sorin Bicarbon; Carbomedics)Less obstruction and more leakage.Bioprostheses. little or no leakageHomografts, pulmonary autografts, andunstented bioprosthetic valves(Medtronic Freestyle,Toronto, Ontario, Canada)almost unobstructive to blood flow.Stented bioprostheses (leafletssuspended within a frame)obstructive to flow.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Dopplar interogationEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  color flow imaging isoften helpful to definethe location anddirection of the variousflow patterns. pulsed and continuouswave Doppler imagingcan be oriented toquantify flow velocity.Whenever velocity is higher thanexpected, consider the possibility ofpressure recovery. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Challenges in doppler interogation variability of flowthrough and around thedifferent prostheses Some prosthetic valveshave more than oneorificeand, consequently, acomplex flow profileEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Challenges in doppler interogation Because the signal-to-noise ratio for Doppler imaging islower compared with two-dimensionalechocardiographic imaging, the shadowing effect iseven more pronounced and the ability to record aDoppler signal behind a prosthetic valve is very limitedMultiple views must be used to fully interrogate the regurgitantsignal.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Primary goals of dopplarinterogation ASSESMENT OF OBSTRUCTION OFPROSTHETIC VALVE DETECTION AND QUANTIFICATION OFPROSTHETIC VALVE REGURGITATIONEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Doppler Assessment of Obstructionof Prosthetic Valves Quantitative parameters of prosthetic valve functionTrans prosthetic flow velocity & pressure gradients, valve EOA, Doppler velocity index(DVI).EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Effective orifice area(EOA) Continuity equation EOA PrAV = (CSA LVO x VTI LVO) / VTI PrAVEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  •  EOA of mitral prostheses:Pressure half time may be useful if it is significantlydelayed or shows significant lengthening from onefollow-up visit to the other despite similar heart rates.continuity equation using the stroke volumemeasured in the LVOT. However, this method cannotbe applied when there is more than mild concomitantmitral or aortic regurgitation.o better for bioprosthetic valves and single tilting discmechanical valves.o underestimation of EOA in case bileaflet valves.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • PPM PPM occurs when the EOA of the prosthesis is toosmall in relation to the patient’sbody size, resulting inabnormally high postoperative gradients.EOA indexed to the patient’s body surface area. PPM AORTIC MITRALInsignificant >0.85 cm2/m2. >1.20 cm²/m²moderate 0.65and0.85cm2/m2. 0.9-1.20 cm²/m²severe <0.65 cm2/m2. <0.90 cm²/m²EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Transprosthetic jet contour andacceleration timeEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITYAT and AT/ET, angle-independent parameters.AT/ET > 0.4
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Doppler velocity index Dimensionless ratio of the proximal flow velocity inthe LVOT to the flow velocity through the aorticprosthesisDVI=VLVOT/VPrAv• Time velocity time integrals may also be used in Placeof peak velocitiesDVI= TVILVOT /TVIPrAv• Prosthetic mitral valves, the DVI is calculated byDVI=TVIPrMv/TVILVOTEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITYDVI had a sensitivity, specificity, positive and negative predictive values, andaccuracy of 59%, 100%, 100%, 88%, and 90%, respectively.
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  IMPORTENCEDVI can be helpful to screen for valvedysfunction, particularly when theCrosssectional area of the LVO tract cannot beobtainedValve size is not known.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Transprosthetic velocity and gradient• The flow is eccentric - monoleaflet valves three separate jets - bileaflet valvesmulti-windows examinationLocalised high velocity may be recorded bycontinuous wave(CW) DopplerInterrogation through the smaller centralorifice of the bileaflet mechanical prosthesesoverestimation of gradientEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Highvelocity or gradient alone is not proof of intrinsicprosthetic obstruction and may be secondary to prosthesis patient mismatch (PPM), high flow conditions, prosthetic valve regurgitation, or localised high central jet velocity in bileafletmechanical valves. Increased heart rate.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Algorithm for interpreting abnormally high transprosthetic pressure gradientsEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • DETECTION AND QUANTIFICATION OFPROSTHETIC VALVE REGURGITATION• Physiologic Regurgitation.closure backflow (necessary to close the valve)leakage backflow (after valve closure)- washing jetso short in durationo narrowo symmetricalo homogenous Pathologic Prosthetic Regurgitation.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Homogeneous in color, with aliasing mostly confined to the base of thejet EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Pathologic Prosthetic Regurgitation Pathologic regurgitation is either centralparavalvular. Most pathologic central valvular regurgitation is seenwith biologic valves, whereas paravalvular regurgita-tion is seen with either valve type and is frequently thesite of regurgitation in mechanical valves. Pathologic jets tend to be highvelocity, intense, broad, and highly aliased.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Thrombus and Pannus In one surgical study of 112 obstructed mechanicalvalves, pannus formation was the underlying cause in11 percent of valves, pannus formation in combination with thrombus waspresent in 12 percent, thrombus alone was the etiology in the remainingcases.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Distinction between thrombus andpannusThrombus Large,mobile,less echo-dense,associated with spontaneous contrast,INR<2.5Pannus Smallfirmly fixed (minimal mobility) to the valve apparatushighly echogenic, (fibrous composition)common in aortic positionPara valve jet suggests pannusEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Abnormal echoes Abnormal echoes that may be found in patients withprosthetic valves arespontaneous echo contrast (SEC),microbubbles or cavitations, strands,sutures,vegetations, thrombus.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Spontaneous echo contrast (SEC)is defined as smoke-like echoes. SEC is caused by increased red cell aggregation thatoccurs in slow flow, for example, because of alow cardiac output,severe left atrial dilatation,atrial fibrillation, or pathologic obstruction of a mitral prosthesis. The prevalence of SEC is 7% to 53%.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Microbubbles are characterized by a discontinuousstream of rounded, strongly echogenic, fast movingtransient echoes Microbubbles occur at the inflow zone of the valvewhen flow velocity and pressure suddenly drop at thetime of prosthetic valve closing, but may also be seenduring valve opening. Microbubbles are probably due to carbon dioxidedegassing.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Kaymaz et al 75% of the normal bileaflet valves compared with 39%of the tilting-disk valves. In prosthetic valves with thrombotic obstruction,microbubbles were found in only 6% , whereas theyreappeared after successful thrombolytic treatmentwith relief of valvular obstruction in 69% Microbubbles are not found in bioprosthetic valves.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Strands are thin, mildly echogenic, filamentousstructures that are several mm long and moveindependently from the prosthesis. They are often visible intermittently during the car-diac cycle but recur at the same site. They are usually located at the inflow side of theprosthetic valve Strands are found in 6% to 45% of patients. Have a fibrinous or a collagenous composition.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Sutures are defined as linear, thick, bright, multiple,evenly spaced, usually immobile echoes seen at theperiphery of the sewing ring of a prosthetic valve; They may be mobile when loose or unusually long.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • TEE Careful alignment of the transducer is essential to fullydisplay leaflet motion as comprehensively as possible. Multiplane imaging should be done at a minimum ofevery 30˚from 0–180˚.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • TEE evaluation immediately after valve replacement1. Verify that all leaflets or occluders move normally.2. Verify the absence of paravalvular regurgitation.3. Verify that there is no left ventricular outflow tractobstruction by struts or subvalvular apparatus.TEE diagnosis of prosthetic valve dysfunction1. Identification of prosthetic valve type.2. Detection and quantification of transvalvular orparavalvular regurgitation.3. Detection of annular dehiscence.4. Detection of vegetations consistent with endocarditis.5. Detection of thrombosis or pannus formation on thevalve.6. Detection and quantification of valve stenosis.7. Detection of tissue degeneration or calcification.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Importance of TEE Higher-resolution image than TTE Proximity of the esophagus to the heart . Size of vegetation defined more precisely Absence of interference with lungs and ribs, a verydetailed image can be obtained of the atrial sideof the mitral valve prosthesis and especially theposterior part of the aortic prosthesis. Peri annular complications indicating a locallyuncontrolled infection (abscesses, dehiscence,fistulas) detected earlier.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  limitation -inability to detect aortic prosthetic-valveobstruction or regurgitation, especially when a mitralprosthesis is present.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVI The echocardiographic evaluation of TAVI is , inmost ways same as that for surgically implanted valves But 2 areas of chalenges are Caluculation of EOA Quantification of post TAVI AREVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVI LVOT diameter and velocity should be measuredimmediately proximal to the apical border of the stent. However, if the border of the stent sits low in theLVOT, which may occur more frequently with self-expandable prostheses (such as the CoreValve), it maybe preferable to measure the LVOT diameter andvelocity within the proximal portion of the stent atapproximately 5-10 mm below the bioprosthetic valveleaflets.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVI Paravalvular regurgitation is more common followingtranscatheter aortic valve implantation versusstandard valve replacement– 30-80% with 5-14%beingmoderate or severe.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • CONSIDERATIONS IN TAVI Delayed migration and embolisation of the prosthesishave been reported following transcatheter valveimplantation. The distance between the ventricular end of theprosthesis stent and the hinge point of the mitral valvemeasured in the parasternal long axis view can be usedto monitor the position of the prosthesis duringfollow-up.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Considerations for IntraoperativePatients TEE and epicardial and epiaortic ultrasound TEE remains the most widely usedAmerican Society of Anesthesiologists has recommendedintraoperative TEE as a category II indication in patientsundergoing valve surgeryCurrent ACC & AHApractice guidelines recommendTEE as a class 1 indication for patients undergoing valvereplacement with stentless xenograft, homograft, orautograft valves.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Considerations for IntraoperativePatients Multiple echocardiographic views are obtained todetermine Appropriate movement of valve leaflets,Color flow Doppler should exclude the presence ofparavalvular leaks• Immediate surgical attentionAny regurgitation that is graded moderate or severe,‘Stuck’’ mechanical valve leaflets,Valve dehiscence, Dysfunction of adjacent valvesEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Stress Echocardiography in EvaluatingProsthetic Valve Function Stress echocardiography should be considered inpatients with exertional symptoms for which thediagnosis is not clear. Dobutamine and supine bicycle exercise are mostcommonly used. Treadmill exercise provides additional informationabout exercise capacity but is less frequently usedbecause the recording of the valve hemodynamics isafter completion of exercise, when the hemodynamicsmay rapidly return to baseline.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Stress Echocardiography(cont)Prosthetic Aortic Valves Guide to significant obstruction would be similar tothat for native valves, such as a rise in mean gradient>15 mm Hg with stress.Prosthetic Mitral Valves Obstruction or PPM is likely if the mean gradientrises > 18 mm Hg after exercise, even when the restingmean gradient is normal.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • RT-3D TEE Excellent spacial imaging Ease of use Enables enface viewing(surgical view) adds to the available information provided bytraditional imaging modalities.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Limitations of 3D echo poor visualization of anterior cardiac structures, poor temporal resolution, poor image quality in patients with arrhythmias tissue dropoutEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Cinefluoroscopy Structural integrity Motion of the disc or poppet Excessive tilt ("rocking") of the base ring - partialdehiscence of the valve Aortic valve prosthesis - RAO caudal- LAO cranialMitral valve prosthesis - RAO cranial .EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Fluoroscopy of a normally functioning CarboMedicsbileaflet prosthesis in mitral positionA=opening angle B=closing angleEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  •  St. Jude medical bileafletvalve Mildly radiopaqueleaflets are best seenwhen viewed on end Seen as radiopaquelines when the leafletsare fully open Base ring is notvisualized on mostmodelsEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • MULTISLICE CT Because of its high temporal and spatial resolution,MDCT has recently shown good potential in assessingprosthetic valve disorders. to evaluate the prosthetic valve motion in variousplanes, with a focus on leaflet motion and on theresidual opening angle between leaflets.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  The residualopeningangle, the anglebetween two leaflets whenfully opened, is measuredusing the planeperpendicular to the twoleaflets• For a single-leafletprosthetic valve, themaximal opening angle isrecorded.Normal limit (≤ 20°)EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  Special attention is also paidto the relationship betweenthe suture ring and thesurrounding valve annulusfor detectingthrombosis,paravalvular leak (sutureloosening), pannus,pseudoaneurysm formation.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  •  In IE MDCT clarify the extent of the damage to thevalve and paravalvular region to provide the surgeonthe information required for débridement and a redoof the valve replacement.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Cardiac Catheterization measure the transvalvular pressure gradient, fromwhich the EOA can be calculated –Gorlin formula. can visualize and quantify valvular or paravalvularregurgitation by Contrast injection.In clinical practice, it is not commonly performed.Crossing a prosthetic valve with a catheter should notbe attempted in mechanical valves because oflimitations and possible complications.Tissue valves can be crossed with a catheter easily, buta degenerative, calcified bioprosthesis is friable, andleaflet rupture with acute severe regurgitation ispossible.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  • Take homeMany of the prosthesis-related complications can beprevented or their impact minimized through optimalprosthesis selection in the individual patient andcareful medical management and follow-up afterimplantation.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY