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DR. DURGAPAVAN
OUTLINE Approch Clinical Examination CXR 2Decho Doppler TEE 3D echo CineFluoro CT Cardiac catheterisationEVALUAT...
Introduction The introduction of valve replacement surgery in theearly 1960s has dramatically improved the outcome ofpati...
Introduction After a valve is replaced, the prognosis for the patientis highly correlated with the function of the prosth...
Introduction Symptoms of prosthetic valve dysfunntion may benonspecific, making it difficult to differentiate the effects...
Types of prosthetic valves Prosthetic Valves are classified as tissue or mechanical Tissue:• Made of biologic tissue fro...
Types of Prosthetic Heart Valves Mechanical Bileaflet (St Jude)(A) Single tilting disc (Medtronic Hall)(B) Caged-ball ...
Mechanical Valves Extremely durable with overall survival rates of 94% at10 years Primary structural abnormalities are r...
Biological Valves Stented bioprostheses Primary mechanical failure at 10 years is 15-20% Preferred in patients over age...
Biologic Valves Continued Homografts Harvested from cadaveric human hearts Advantages: resistance to infection, lack of...
Desired valves Mechanical valves - preferred in young patients who have a life expectancy of more than 10 to 15 years w...
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...
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 PR...
CLINICAL INFORMATION Clinical data including reason for the study and thepatient’s symptoms Type & size of replacement v...
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 identi...
 The location of the cardiacvalves is best determinedon the lateral radiograph. A line is drawn on thelateral radiograph...
EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
 For further localizationprosthetic valves involvesdrawing a second linewhich is perpendicular tothe patients uprightposi...
 On the frontal chestradiograph ( AP or PA ) -longitudinal line through themid sternal body. draw aperpendicular line div...
 Patients with cardiac valves often have chamberenlargement and cardiac rotation which can displacethe positions of the v...
 Some bioprosthetic valves have components thatdetermine the direction of flow which helps localizethe valve prosthesis....
EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
Radiologic IdentificationStarr-Edwards cagedball valveRadiopaque base ringRadiopaque cageSilastic ball impregnatedwith bar...
 Appearance ofCarboMedics prosthesison plain radiography.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTIL...
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 b...
 Bioprosthetic valves Annual echocardiography isrecommended after the first 5years, Mechanical valves, routine annual ec...
challenges in echocardiographyThe high reflectance leads to shadowing Reverberationsmultiple echocardiographic windows ...
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...
Primary goals of 2D echo (cont)Calculate valve gradientCalculate effective orifice areaConfirm normal blood flow patter...
Starr-Edwards mitral prosthesis is shown. A: During systole, the poppet is seatedwithin the sewing ring (arrows). B: Durin...
St. Jude mitral prosthesis is demonstrated. A: During systole, the hemidisks areshown in the closed position (arrows). B: ...
St. Jude aortic prosthesis is demonstrated. The sewing ring is indicatedby the arrows. The walls of the aortic root (Ao) o...
M-Mode M-Mode echocardiography enables better evaluationof valve movements and corresponding time intervalsand recognitio...
EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
 For bioprostheses, evidence of leaflet degeneration canbe recognized asleaflet thickening (cusps >3 mm in thickness)-ea...
Assessment of Flow Characteristicsof Prosthetic Valves Normal functioning mechanical prosthetic valvescause:some obstruc...
Valve type Flow CharacteristicsBall-in-cage prosthetic valve (Starr-Edwards, Edwards Lifescience)much obstruction and litt...
Dopplar interogationEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
 color flow imaging isoften helpful to definethe location anddirection of the variousflow patterns. pulsed and continuou...
Challenges in doppler interogation variability of flowthrough and around thedifferent prostheses Some prosthetic valvesh...
Challenges in doppler interogation Because the signal-to-noise ratio for Doppler imaging islower compared with two-dimens...
Primary goals of dopplarinterogation ASSESMENT OF OBSTRUCTION OFPROSTHETIC VALVE DETECTION AND QUANTIFICATION OFPROSTHET...
Doppler Assessment of Obstructionof Prosthetic Valves Quantitative parameters of prosthetic valve functionTrans prosthet...
Effective orifice area(EOA) Continuity equation EOA PrAV = (CSA LVO x VTI LVO) / VTI PrAVEVALUATION OF PROSTHERIC VALVEF...
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 lengthenin...
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 h...
Transprosthetic jet contour andacceleration timeEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITYAT and ...
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 aort...
EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITYDVI had a sensitivity, specificity, positive and negati...
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 ...
Transprosthetic velocity and gradient• The flow is eccentric - monoleaflet valves three separate jets - bileaflet valves...
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 patie...
Algorithm for interpreting abnormally high transprosthetic pressure gradientsEVALUATION OF PROSTHERIC VALVEFUNCTION-METHOD...
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 c...
Homogeneous in color, with aliasing mostly confined to the base of thejet EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS A...
Pathologic Prosthetic Regurgitation Pathologic regurgitation is either centralparavalvular. Most pathologic central va...
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 ...
Distinction between thrombus andpannusThrombus Large,mobile,less echo-dense,associated with spontaneous contrast,INR<2.5Pa...
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),...
 Spontaneous echo contrast (SEC)is defined as smoke-like echoes. SEC is caused by increased red cell aggregation thatocc...
 Microbubbles are characterized by a discontinuousstream of rounded, strongly echogenic, fast movingtransient echoes Mic...
Kaymaz et al 75% of the normal bileaflet valves compared with 39%of the tilting-disk valves. In prosthetic valves with t...
 Strands are thin, mildly echogenic, filamentousstructures that are several mm long and moveindependently from the prosth...
 Sutures are defined as linear, thick, bright, multiple,evenly spaced, usually immobile echoes seen at theperiphery of th...
TEE Careful alignment of the transducer is essential to fullydisplay leaflet motion as comprehensively as possible. Mult...
TEE evaluation immediately after valve replacement1. Verify that all leaflets or occluders move normally.2. Verify the abs...
Importance of TEE Higher-resolution image than TTE Proximity of the esophagus to the heart . Size of vegetation defined...
 limitation -inability to detect aortic prosthetic-valveobstruction or regurgitation, especially when a mitralprosthesis ...
CONSIDERATIONS IN TAVI The echocardiographic evaluation of TAVI is , inmost ways same as that for surgically implanted va...
CONSIDERATIONS IN TAVI LVOT diameter and velocity should be measuredimmediately proximal to the apical border of the sten...
CONSIDERATIONS IN TAVI Paravalvular regurgitation is more common followingtranscatheter aortic valve implantation versuss...
CONSIDERATIONS IN TAVI Delayed migration and embolisation of the prosthesishave been reported following transcatheter val...
Considerations for IntraoperativePatients TEE and epicardial and epiaortic ultrasound TEE remains the most widely usedA...
Considerations for IntraoperativePatients Multiple echocardiographic views are obtained todetermine Appropriate movement...
Stress Echocardiography in EvaluatingProsthetic Valve Function Stress echocardiography should be considered inpatients wi...
Stress Echocardiography(cont)Prosthetic Aortic Valves Guide to significant obstruction would be similar tothat for native...
RT-3D TEE Excellent spacial imaging Ease of use Enables enface viewing(surgical view) adds to the available informatio...
Limitations of 3D echo poor visualization of anterior cardiac structures, poor temporal resolution, poor image quality ...
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 - partial...
Fluoroscopy of a normally functioning CarboMedicsbileaflet prosthesis in mitral positionA=opening angle B=closing angleEVA...
 St. Jude medical bileafletvalve Mildly radiopaqueleaflets are best seenwhen viewed on end Seen as radiopaquelines when...
MULTISLICE CT Because of its high temporal and spatial resolution,MDCT has recently shown good potential in assessingpros...
 The residualopeningangle, the anglebetween two leaflets whenfully opened, is measuredusing the planeperpendicular to the...
 Special attention is also paidto the relationship betweenthe suture ring and thesurrounding valve annulusfor detectingt...
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 re...
Cardiac Catheterization measure the transvalvular pressure gradient, fromwhich the EOA can be calculated –Gorlin formula....
Take homeMany of the prosthesis-related complications can beprevented or their impact minimized through optimalprosthesis ...
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Prosthetic valve function

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Prosthetic valve function

  1. 1. DR. DURGAPAVAN
  2. 2. OUTLINE Approch Clinical Examination CXR 2Decho Doppler TEE 3D echo CineFluoro CT Cardiac catheterisationEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Algorithm for choice of prostheticheart valveEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  13. 13. 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
  14. 14. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  15. 15. HISTORY Subtle symptoms of cardiac failure or neurologicevents can be clues to serious valve dysfunction.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  16. 16. 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
  17. 17. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  18. 18. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  19. 19. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  20. 20. 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
  21. 21.  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
  22. 22. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  23. 23.  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
  24. 24.  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
  25. 25.  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
  26. 26.  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
  27. 27. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  28. 28. 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
  29. 29.  Appearance ofCarboMedics prosthesison plain radiography.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  30. 30. Echo Imaging of Prosthetic ValvesEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  31. 31. 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
  32. 32.  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
  33. 33. 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
  34. 34. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  35. 35. The concept of pressure recoveryEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  43. 43.  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
  44. 44. 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
  45. 45. 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
  46. 46. Dopplar interogationEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  47. 47.  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
  48. 48. 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
  49. 49. 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
  50. 50. Primary goals of dopplarinterogation ASSESMENT OF OBSTRUCTION OFPROSTHETIC VALVE DETECTION AND QUANTIFICATION OFPROSTHETIC VALVE REGURGITATIONEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  51. 51. 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
  52. 52. Effective orifice area(EOA) Continuity equation EOA PrAV = (CSA LVO x VTI LVO) / VTI PrAVEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  53. 53. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  54. 54. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  55. 55.  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
  56. 56. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  57. 57. 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
  58. 58. Transprosthetic jet contour andacceleration timeEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITYAT and AT/ET, angle-independent parameters.AT/ET > 0.4
  59. 59. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  60. 60. 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
  61. 61. 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.
  62. 62. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  63. 63.  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
  64. 64. 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
  65. 65. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  66. 66. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  67. 67.  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
  68. 68. Algorithm for interpreting abnormally high transprosthetic pressure gradientsEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  69. 69. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  70. 70. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  71. 71. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  72. 72. 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
  73. 73. Homogeneous in color, with aliasing mostly confined to the base of thejet EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  74. 74. 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
  75. 75. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  76. 76. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  77. 77. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  78. 78. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  79. 79. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  80. 80. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  81. 81. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  82. 82. 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
  83. 83. 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
  84. 84. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  85. 85. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  86. 86. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  87. 87. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  88. 88. 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
  89. 89.  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
  90. 90.  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
  91. 91. 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
  92. 92.  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
  93. 93.  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
  94. 94. 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
  95. 95. 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
  96. 96. 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
  97. 97.  limitation -inability to detect aortic prosthetic-valveobstruction or regurgitation, especially when a mitralprosthesis is present.EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  98. 98. 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
  99. 99. 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
  100. 100. 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
  101. 101. 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
  102. 102. 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
  103. 103. 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
  104. 104. 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
  105. 105. 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
  106. 106. 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
  107. 107. 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
  108. 108. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  109. 109. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  110. 110. 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
  111. 111. Fluoroscopy of a normally functioning CarboMedicsbileaflet prosthesis in mitral positionA=opening angle B=closing angleEVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICALUTILITY
  112. 112.  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
  113. 113. 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
  114. 114.  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
  115. 115.  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
  116. 116. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  117. 117. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  118. 118. EVALUATION OF PROSTHERIC VALVEFUNCTION-METHODS AND CLINICAL UTILITY
  119. 119.  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
  120. 120. 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
  121. 121. 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

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