10.8.21 ECHO Normal prosthetic valve - FLOREN.pptx
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10.8.21 ECHO Normal prosthetic valve - FLOREN.pptx
- 1. Normal Prosthetic Valve Franz Neil M. Floren, MD Adult Cardiology Fellow Level II Dr. Roland Delos Reyes, MD Moderator
- 2. Sources:
- 3. Introduction • The past six decades have witnessed significant advancements in patient survival and functional outcomes following heart valve replacement surgery. • The choice of valve prosthesis is inherently a trade-off between durability and risk of thromboembolism, with the associated hazards and lifestyle limitations of anticoagulation.
- 4. ECHOCARDIOGRAPHY PERSPECTIVE • The echocardiographic assessment of prosthetic valves is complex. • The echocardiographer must determine the specific type of prosthetic valve and whether the structural and functional parameters exceed the limits of normal for a given size and type. • PHV dysfunction is rare but potentially life-threatening. Although often challenging, establishing the exact cause of PHV dysfunction is essential to determine the appropriate treatment strategy
- 6. Outline I. Types of Prosthetic Valves II. Normal Prosthetic Valve Function III. Assessment of Specific Prosthetic Valves
- 7. Outline I. Types of Prosthetic Valves II. Normal Prosthetic Valve Function III. Assessment of Specific Prosthetic Valves
- 8. Types of prosthetic valve
- 10. Know the product Mechanical prosthetic valves The three basic types : 1. Bileaflet 2. Tilting disc 3. Caged ball
- 12. Basic parts of a prosthetic valve Know the product
- 16. Prosthetic valves do not look the same Know the look
- 17. Design Influences the 2D appearance Know the look
- 18. Design Influences the 2D appearance
- 19. Design Influences the 2D appearance
- 20. Outline I. Types of Prosthetic Valves II. Normal Prosthetic Valve Function III. Assessment of Specific Prosthetic Valves
- 21. Echocardiographic assessment • 2D and Doppler echocardiography are essential for initial and longitudinal assessment of patients with PHV. • At the time of echocardiography, it is essential to know and document (i) the reason for the echo study (ii) the patient’s symptoms (iii) the type and size of the PHV (iv) the date of surgery (v) the blood pressure and heart rate (vi) the patient’s height, weight, and body surface area
- 22. Check the valve bed and stability of the valve Normal Prosthetic Valve Function
- 23. Normal Prosthetic Valve Function
- 24. Normal Prosthetic Valve Function
- 25. Normal Prosthetic Valve Function
- 26. Normal Prosthetic Valve Function • Artificial Heart Valves are inherently stenotic. Flow velocity: Generally higher vs. normal native valve. • TAVR: detection and quantitation of paravalvar regurgitation. • Difference in shape and number of orifice for forward flow. -Bileaflet tilting-disk valve: 3 separate orifices (rectangular-shaped central orifice surrounded by two larger semicircular orifices)
- 28. Normal Prosthetic Valve Function Pressure Recovery • Occurs when a portion of the kinetic energy released as blood crosses the valve is recovered in the form of pressure downstream. • Net effect: development of a high, but very localized, gradient through the central orifice of the prosthesis immediately distal to the disks.
- 29. Normal Prosthetic Valve Function Normal/Physiologic Regurgitation Occurs with virtually all types of mechanical prostheses 2 Types: Closure backflow and Leakage
- 30. Normal Prosthetic Valve Function Doppler Imaging Measure both the maximal and mean pressure gradient across prostheses
- 31. Normal Prosthetic Valve Function Doppler Imaging
- 32. Normal Prosthetic Valve Function Effective Orifice Area (EOA) • The smallest cross-sectional area of the flow profile (the vena contracta) within the prosthesis. • Continuity Equation Mitral and Tricuspid valves – PHT • Pressure half-time generally overestimates the valve area in the presence of a mitral prosthesis.
- 33. Outline I. Types of Prosthetic Valves II. Normal Prosthetic Valve Function III. Assessment of Specific Prosthetic Valves
- 34. Prosthetic Aortic Valves • Gross abnormalities • Valve dehiscence, large thrombi, or vegetations. • Function • Regurgitation
- 35. Prosthetic Aortic Valves • Effective Orifice Area (EROA) • Continuity Equation
- 36. Prosthetic Aortic Valves • Doppler examination
- 37. Prosthetic Aortic Valves • Doppler Velocity Index (DVI) • Alternative way to evaluate stenosis • Dimensionless • Ratio between the outflow tract peak velocity (OT) and the maximal velocity through the prosthesis (PV)
- 38. Prosthetic Aortic Valves Assessing Regurgitation • Some degree of regurgitation is a normal finding for most prostheses. • Shadowing from the prosthesis can obscure significant regurgitant jets: use of multiple windows (and often TEE) to completely interrogate the left ventricular outflow tract.
- 39. Prosthetic Aortic Valves Assessing Regurgitation
- 40. Prosthetic Aortic Valves Assessing Regurgitation
- 41. Prosthetic Aortic Valves Transcatheter Aortic Valves • TEE: Guide position of device prior to deployment. • Post procedure TTE: Mean and peak gradients, EOA, presence and severity of central and paravalvar regurgitation.
- 42. Prosthetic Aortic Valves Determination of EOA • Proper placement of Doppler sample volume • Positioned just proximal to lower edge of stent Normally functioning TAVR valves • Mean gradient: 10-15 mmHg • EOA: 1.3-1.8 cm2
- 43. Prosthetic Aortic Valves Paravalvar regurgitation • May involve multiple eccentric jets: requires a comprehensive approach • Recommended approach: Measurement of the circumferential extent of the color flow disturbance, mapped from the basal short-axis view. • >30% annular circumference involvement – Severe Regurgitation
- 44. Prosthetic Aortic Valves Paravalvar regurgitation
- 46. Prosthetic Mitral Valves Visualizing mitral prostheses with transthoracic echocardiography is somewhat easier than visualizing aortic prostheses
- 48. Prosthetic Mitral Valves Role of Echocardiography: • Evaluating stability of mitral prosthesis, excluding dehiscence, visualizing motion of leaflets/occluding mechanism. • Determination of mean gradient • Determination of EOA: PHT, CE
- 49. Prosthetic Mitral Valves Pressure Half time: • The pressure half-time method can also be performed in the setting of prosthetic valves. • With native valves, it was empirically determined that mitral valve area was approximated by the equation: MV area = 220 ÷ P½t • Both mean gradient and pressure half-time should be assessed to determine whether prosthetic valve stenosis is present
- 50. Prosthetic Mitral Valves Continuity Equation • Alternatively, the continuity equation can be applied (in the absence of mitral regurgitation). • According to the following formula in which MV is the mitral valve, LVOT is the left ventricular outflow tract, and TVI is the time velocity integral:
- 51. Prosthetic Mitral Valves Factors to consider: • Type of valve Bileaflet disks: 1 central and 2 peripheral small jets • Characteristic of Regurgitation “Normal” prosthetic regurgitation – Jet area <2cm2 and jet length <2.5 cms
- 52. Valvular vs. Paravalvular regurgitation
- 53. Prosthetic Mitral Valves Doppler Velocity Index (DVI) • Alternative way to evaluate stenosis • Dimensionless
- 55. CASE HR: 100 bpm BP: 90/60 mmHg Weight: 51 kg Height: 159 cm BSA: 1.5 m^2 Hancock mitral valve #25 Medtronics Avalus Aortic Valve #19 • 23 years, female • No known comorbidities • Rheumatic Heart Disease with Severe AR and Severe MR • S/P dual valve replacement (MV, AV) (September 3, 2019)
- 57. PLAX
- 58. AP4C
- 59. SAX-GV
- 60. Doppler PLAX
- 61. AV Doppler
- 62. LVOT Diameter
- 65. Pressure Half Time Acquisition
- 67. QUIZ 1-2. Give the two types of prosthetic valve 3-5. 3 basic types of mechanical valve 6-8. 3 basic parts of a prosthetic valve 9. True or False? All prosthetic valves are inherently stenotic. 10-11. Give at least two methods to compute for the EOA of a prosthetic valve with complete formula?
- 68. Thank You.
Editor's Notes
- Continued refinements in prosthetic valve design and performance, operative techniques, myocardial preservation, systemic perfusion, cerebral protection, and anesthetic management have enabled the application of surgical and transcatheter valve therapy to an increasingly wider spectrum of patients. The ideal heart valve substitute remains an elusive goal.
- Flow dynamics are different through prosthetic valves compared with native valves. Both the size and type of the prosthesis influence the range of expected flow velocities and thus the definition of normal versus abnormal function. Despite these challenges, the combination of echocardiography and Doppler imaging techniques is ideally suited to assessing prosthetic valves.
- Continued refinements in prosthetic valve design and performance, operative techniques, myocardial preservation, systemic perfusion, cerebral protection, and anesthetic management have enabled the application of surgical and transcatheter valve therapy to an increasingly wider spectrum of patients. The ideal heart valve substitute remains an elusive goal.
- Continued refinements in prosthetic valve design and performance, operative techniques, myocardial preservation, systemic perfusion, cerebral protection, and anesthetic management have enabled the application of surgical and transcatheter valve therapy to an increasingly wider spectrum of patients. The ideal heart valve substitute remains an elusive goal.
- Continued refinements in prosthetic valve design and performance, operative techniques, myocardial preservation, systemic perfusion, cerebral protection, and anesthetic management have enabled the application of surgical and transcatheter valve therapy to an increasingly wider spectrum of patients. The ideal heart valve substitute remains an elusive goal.
- A comprehensive echocardiographic study is indicated in case of new murmur or any symptoms possibly related to PHV. When obtained early after hospital discharge, it can serve to define baseline PHV characteristics (‘fingerprint’).
- In evaluating prosthetic valves, echocardiography is essential in the assessment of prosthetic valve structure and function. Among the factors assessed in the 2DED study are the stability of the sewing ring, checking for rocking or independent motion of the prosthesis. A 27mm St. Jude Mechanical Mitral Valve was anchored to the annuls using Ticron 2-0 sutures
- an example of a normally functioning porcine aortic prosthesis. Leaflet opening during systole resembles that of a normal native valve. The overall appearance is so similar, in fact, that when examined with transthoracic echocardiography (Fig. 14.6A,B), normally functioning aortic bioprostheses are occasionally mistaken for “normal” native valves. When examined carefully, however, the sewing ring and struts are more echogenic than normal and tend to shadow the leaflets, a clue to the presence of prosthetic material. Transesophageal echocardiography, however, permits clear visualization of sewing ring and supporting struts, as well as the cusps (see Fig. 14.6C,D). FIGURE 14.6. An example of normally functioning bioprosthetic aortic valve is shown. Transthoracic long-axis (A, B) and transesophageal short-axis (C, D) images of the valve are provided.
- Starr–Edwards valve in the mitral position. The protruding, high-profile cage in the left ventricle is diagnostic. When examined in real time, the poppet can be seen moving forward and backward in the cage. These valves are highly echogenic, and small thrombi or vegetations can be easily hidden or overlooked. two hemidisks open and close in synchrony, although it is often difficult to distinguish both on transthoracic imaging. Significant shadowing occurs, and the left atrium is not well seen in most cases. In Figure 14.10, threedimensional echocardiography is used to more completely visualize the hemidisks. This approach also provides a thorough circumferential recording of the sewing ring.
- Figure 14.15 is an example of a recently deployed TAVR device. The stent is seen within the aortic root, extending just below the annulus. The leaflets are barely discernable within the lower portion of the scaffold. The normally functioning leaflets are thin mobile structures partially obscured by the aortic wall, the native (often calcified) aortic valve material, and the alloy frame. Two models of currently available transcatheter aortic valves are shown. Edwards SAPIEN valve on the left and a Medtronic CoreValve on the right.
- There is a variety of explanations for this consistent observation. The sewing ring of the valve may be too small relative to the flow. In young patients, what passes for an adequately sized valve in childhood may become functionally stenotic as the patient grows. More importantly, the effective orifice area (EOA) is significantly smaller than the area of the sewing ring because the valve assembly (i.e., the occluder mechanism) occupies some of the central space. Leaflets of bioprostheses, by virtue of the preservation process, are stiffer, and therefore, these valves have a higher resistance to forward flow compared with equivalently sized native valves. Thus, flow velocity through a normally functioning artificial valve is generally higher than would occur through a normal native valve. Since paravalvular regurgitation is a more common complication of transcatheter compared to surgical valves it must be analyzed from multiple windows. Multiple parameters, including the circumferential extent of the paravalvular flow, should be assessed and reported.
- An example of moderate paravalvular aortic regurgitation from a patient with a recent TAVR procedure. The regurgitation (arrows) is visualized from multiple views including the long-axis (A), short-axis (B) and four-chamber (C). In the short-axis, the circumferential extent of the regurgitant flow is indicated by the arrows.
- The concept of pressure recovery. A: Flow through a tapered stenosis results in significant pressure recovery downstream from the obstruction. In this case, sampling within the obstruction (SV1) yields a higher velocity compared with a sample site downstream (SV2) where pressure recovery has occurred. At this site, the recovery of pressure is associated with a lower velocity. B: In the absence of pressure recovery, different locations for sample volume (SV) measurement yield fairly similar velocities.
- Closure backflow occurs because of the flow reversal required to close the occluding mechanism. This results in a small amount of regurgitation that ends once the occluder mechanism is seated in the sewing rin Leakage backflow occurs after the prosthesis has closed and is the result of a small amount of retrograde flow between and around the occluding mechanism. It is often part of the design of the prosthesis to provide a washing mechanism and prevent thrombus formation on its upstream side.
- Despite these differences in flow characteristics, the basic Doppler principles applied to native valves are also relevant to the study of prosthetic valves. For example, Doppler imaging can be used to measure both the maximal and mean pressure gradient across prostheses (Fig. 14.24). The assumptions that are critical to the modified Bernoulli equation apply to prosthetic valves as well. the correlation between pressure gradients obtained by the Doppler technique compared with cardiac catheterization is generally very good. However, because flow velocity through normally functioning prosthetic valves is typically low (<2.5 m/sec), the simplified Bernoulli equation, DP = 4(v2)2, may lead to overestimation of the true gradient. This is due to the fact that v1 and v2 are similar enough that v1 cannot be ignored, so the more complete formula, DP = 4(v22 - v12), should be used. For practical purposes, it is sufficient to remember that flow velocity through “normal” prostheses is typically higher than native valves and a modest gradient does not necessarily imply clinically significant stenosis.
- Despite these differences in flow characteristics, the basic Doppler principles applied to native valves are also relevant to the study of prosthetic valves. For example, Doppler imaging can be used to measure both the maximal and mean pressure gradient across prostheses (Fig. 14.24). The assumptions that are critical to the modified Bernoulli equation apply to prosthetic valves as well. the correlation between pressure gradients obtained by the Doppler technique compared with cardiac catheterization is generally very good. However, because flow velocity through normally functioning prosthetic valves is typically low (<2.5 m/sec), the simplified Bernoulli equation, DP = 4(v2)2, may lead to overestimation of the true gradient. This is due to the fact that v1 and v2 are similar enough that v1 cannot be ignored, so the more complete formula, DP = 4(v22 - v12), should be used. For practical purposes, it is sufficient to remember that flow velocity through “normal” prostheses is typically higher than native valves and a modest gradient does not necessarily imply clinically significant stenosis.
- The continuity equation can also be used to measure the EOA of prosthetic valves. The EOA is defined as the smallest cross-sectional area of the flow profile (the vena contracta) within the prosthesis. As is the case with native valves, calculation of EOA for prosthetic valves offers advantages over pressure gradient alone but also has a greater potential for measurement error. For prosthetic mitral and tricuspid valves, the pressure half-time technique has also been used to quantify the severity of stenosis. However, pressure half-time generally overestimates the valve area in the presence of a mitral prosthesis and may be more appropriate for serial evaluation. Again, having a baseline study and using the patient as his or her own control is essential for future management.
- Continued refinements in prosthetic valve design and performance, operative techniques, myocardial preservation, systemic perfusion, cerebral protection, and anesthetic management have enabled the application of surgical and transcatheter valve therapy to an increasingly wider spectrum of patients. The ideal heart valve substitute remains an elusive goal.
- Transthoracic M-mode and two-dimensional echocardiography have relatively low sensitivity for detecting dysfunction of aortic prostheses. Gross abnormalities, such as valve dehiscence or large thrombi or vegetations, can be identified using two-dimensional echocardiography. Thickened and fibrocalcific leaflets of bioprostheses can also be visualized, but assessing the functional significance of such changes is difficult. Thus, most of the diagnostic information related to aortic prostheses depends on a thorough and quantitative Doppler study.
- When the continuity equation is used to estimate the EOA of a prosthetic valve, it should be remembered that this area corresponds to the vena contracta of flow rather than the actual orifice. The equation itself is identical to the one used in the setting of native valve stenosis (Fig. 14.34). If the outflow tract dimension cannot be accurately measured, some investigators suggest substituting the sewing ring outer diameter for this value. Again, the most important point is that the Doppler recording and the diameter measurement be obtained at the same level. The continuity equation can be used to calculate the effective valve area across prostheses. A: The diameter of the left ventricular outflow tract is measured. B: Time velocity integral (TVI) of the outflow tract is calculated using planimetry. C: Using continuous wave Doppler imaging, flow through the prosthetic valve is recorded. Because of a hyperdynamic left ventricle, the TVIOT and the maximal pressure gradient are quite high. Despite the maximal gradient of 65 mm Hg, the aortic valve area is approximately 1.9 cm2. The calculations used to measure valve area are provided. AVA, aortic valve area; CSA, crosssectional area; Dlvot, left ventricular outflow tract diameter.
- Figure 14.35 is an example of a stenotic bioprosthetic aortic valve. FIGURE 14.35. The leaflets of a stenotic bioprosthetic aortic valve appear thick, immobile, and echogenic as seen from the long-axis view in this example (A). Doppler is essential to quantify the degree of obstruction and to follow changes over time (B).
- In the absence of any gradient, the two velocities would be the same, yielding a ratio of 1. Because all prostheses are somewhat stenotic, a DVI of less than 1 is consistently obtained. The expected range for normally functioning aortic prostheses is 0.3 to 0.5. Although this dimensionless number has limited utility in isolation, it can be obtained reproducibly and provides a useful parameter to detect changes over time. In addition, it avoids the challenges of measuring the outflow tract diameter
- Assessing regurgitation is similar in prosthetic and native aortic valves with two exceptions. First, it must be remembered that some degree of regurgitation is a normal finding for most prostheses. Distinguishing physiologic from pathologic regurgitation is generally a matter of degree. Second, shadowing from the prosthesis can obscure significant regurgitant jets, mandating the use of multiple windows (and often transesophageal echocardiography) to completely interrogate the left ventricular outflow tract. However, this is far less a problem for aortic prostheses (compared to mitral) and in most cases, transthoracic imaging is adequate to characterize prosthetic aortic regurgitation.
- Distinguishing valvular from paravalvular regurgitation is also important. Using either the transthoracic or the transesophageal approach, a short-axis view at and immediately below the Level of the sewing ring often allows this distinction to be made (Fig. 14.37). FIGURE 14.37. An example of an aortic root abscess. A: In the short-axis view, an echo-free space is seen posterior to the aortic root (arrows). B: Color Doppler imaging demonstrates flow within the abscess cavity (arrows) and associated paravalvular regurgitation
- A bioprosthetic aortic valve and a mitral annuloplasty ring are demonstrated in this study from a patient with a dilated cardiomyopathy. Both aortic valve prosthesis and the mitral ring are apparent in the long-axis view (A). Color Doppler (B) reveals mild aortic regurgitation from the four-chamber view (B, arrow).
- During the procedure, transesophageal echocardiography may be used to guide position of the device prior to deployment (Fig. 14.39). Echocardiography, along with fluoroscopy, assures that the device is neither too low, where it can result in paravalvular regurgitation, mitral valve interference, or conduction abnormalities, nor too high, where regurgitation, coronary ostia obstruction, or device embolization can occur. Once deployed, echocardiography is used to assure proper seating of the valve, normal motion of the leaflets, and to assess for both valvular and paravalvular regurgitation
- When determining EOA, proper placement of the Doppler sample volume for outflow tract velocity is critical. It should be positioned just below (i.e., proximal to) the lower edge of the stent. If the sample volume is within the stent, some degree of flow acceleration may be present, leading to overestimation of EOA (potentially underestimating any degree of prosthesis dysfunction). Normally functioning TAVR valves will usually have a mean gradient of 10 to 15 mm Hg and a calculated EOA of 1.3 to 1.8 cm2. Aortic regurgitation, especially paravalvular, should be carefully and thoroughly evaluated. Paravalvular aortic regurgitation may involve multiple eccentric jets and requires a comprehensive approach, including color and continuous wave Doppler, descending aortic flow, pressure half-time determination, and, if possible, determination of regurgitant volume.
- A recommended approach to paravalvular regurgitation involves the measurement of the circumferential extent of the color flow disturbance, mapped from the basal short-axis view. If more than 30% of the annular circumference is involved, severe regurgitation is present. Clinical trials have demonstrated the important impact aortic regurgitation severity has on patients who have undergone TAVR. Precise assessment, however, remains challenging and an area of active study. Other complications may occur post procedure. Figure 14.42 depicts a perforated anterior mitral valve leaflet due to erosion from a malpositioned transcatheter valve. This resulted in severe mitral regurgitation.
- An example of paravalvular aortic regurgitation (arrows) following TAVR implantation is shown from the long-axis (A) and short-axis (B) views.
- Visualizing mitral prostheses with transthoracic echocardiography is somewhat easier than visualizing aortic prostheses. This is because the prosthetic mitral valve is seated within the mitral annulus and can be easily visualized from both the parasternal and apical windows. In contrast, aortic prostheses may be partially obscured by the walls of the aorta (from the parasternal view) and by the prostheses itself from the apical view. Evaluating the stability of the mitral prosthesis, excluding dehiscence, and visualizing the motion of leaflets or the occluding mechanism are generally possible with transthoracic imaging. FIGURE 14.43. Examples of normally functioning (A, B) and stenotic (C, D) bioprosthetic mitral valves. In A, transesophageal echocardiography demonstrates mild thickening but normal motion of the leaflets. Absence of any significant gradient is confirmed using pulsed Doppler (B). The second patient demonstrates severe thickening, calcification, and reduced leaflet mobility (C). With spectral Doppler, severe stenosis is demonstrated with a 31 mm Hg mean mitral gradient.
- Normal values for the various types and sizes of mitral prosthetic valves are provide
- Normal values for the various types and sizes of mitral prosthetic valves are provide
- When the same approach is applied to prosthetic valves, the formula tends to overestimate the EOA. Despite this limitation, prolongation of the pressure half-time, especially when a baseline has been established, is a reliable marker of obstruction and is less flow-dependent than gradient alone. In most patients, both mean gradient and pressure half-time should be assessed to determine whether prosthetic valve stenosis is present.
- Detecting regurgitation through or around a mitral prosthesis using transthoracic echocardiography is limited by the shadowing effect of the prosthetic material. Whether imaging is performed from the parasternal or the apical view, the prosthetic valve will always obscure a portion of the left atrium so that the sensitivity of this method is reduced. In contrast, the transesophageal approach offers an excellent opportunity to assess the entire left atrium in the presence of prosthetic valves Using the transesophageal approach, some degree of regurgitation is detected in as many as 90% of normally functioning mitral prostheses. Characteristics of “normal” prosthetic regurgitation include a jet area less than 2 cm2 and a jet length less than 2.5 cm. In addition, the patterns of regurgitant flow are typical for each individual prosthesis. For example, a St. Jude mitral prosthesis often displays one central and two peripheral small jets, whereas a Medtronic-Hall valve typically has a single central regurgitant jet.
- Transesophageal echocardiography is also well suited for distinguishing valvular from paravalvular regurgitation. An example of how transesophageal threedimensional imaging can be used for this purpose is provided in Figure 14.48. In this example, the twodimensional echocardiogram demonstrated mitral regurgitation in the vicinity of the sewing ring of a St. Jude prosthesis (A). B: Using transesophageal threedimensional color Doppler imaging, the location of the regurgitant jet outside of the sewing ring (small arrows) is clearly demonstrated. The asterisk identifies the center of the disk structure. In this case, two-dimensional color flow imaging demonstrates regurgitant flow originating in the area of the sewing ring. In threedimensional views, the spatial orientation provided by this approach permits the origin of the regurgitant jet to be precisely located outside of the ring, confirming the presence of paravalvular regurgitation.
- (i) the reason for the echo study (ii) the patient’s symptoms (iii) the type and size of the PHV (iv) the date of surgery (v) the blood pressure and heart rate (vi) the patient’s height, weight, and body surface area
- This is the Parasternal Long Axis View showing LVMI of 108.5 g/m2 and RWT of 0.48 consistent with normal LV geometry. Bioprosthetic valves are seen in the aortic and mitral positions. There is no note of rocking motion or independent valve movement. Note that the echogenicity of the valves resemble that of the surrounding normal tissue. This is one differentiating factor favoring bioprosthetic valves since metallic usually valves usually appear as hyperechoic with significant shadowing.
- This is the A4c view showing the bioprosthetic valve in the mitral position. Again, there is no note of rocking motion or indepent valve movement.
- The short axis view at the level of the great vessels shows us the sewing ring that is noted to be hyperechoic compared to surrounding normal tissue...
- doppler interrogation of the aortic valve shows no significant regurgitation nor paravalvular leak...
- focused dopper interrogation of the AV shows no evidence of paravalvar leak...
- To deternime effective orifice area of the bioprosthetic AV, we compute for the continuity equation. LVOT diameter in this case was determined to be 1.6 cms
- To determine effective orifice area of the bioprosthetic AV, we compute for the continuity equation. LVOT diameter in this case was determined to be 1.6 cms
- EOA by CE= 1.1 cm2
- Atrioventricular PHT was determined to compute for the bioprosthetic MV EOA. Computed EOA was 3.95 cm2. Mean gradient was recorded at 0.68 mmHg with peak gradient of 0.99 mmHg.
- Atrioventricular PHT was determined to compute for the bioprosthetic MV EOA. Computed EOA was 3.95 cm2. Mean gradient was recorded at 0.68 mmHg with peak gradient of 0.99 mmHg.