Evaluation of prosthetic heart valve

1. •Thanks …………
EVALUATION OF PROSTHETIC
HEART VALVES
PRESENTER – DR SIVANAND PATEL
PERCEPTOR – DR (PROF.) GIRISH MP

2. INTRODUCTION
Replacement of a diseased heart valve with a prosthetic heart valve
exchanges the native disease for prosthesis-related complications .

3. Complications of prosthetic valve
1.Structural valve deterioration(Changes intrinsic to valve) .
2.Non structural dysfunction (Extrinsic) .
3.Valve thrombosis and embolism .
4.Infective endocarditis .

4. OUTLINE
 History & Clinical Examination
 CXR
 2d Echo & Doppler
 TEE & 3D echo
 Cinefluoroscopy
 CT
 Cardiac catheterization
 MRI

5. MAJOR TYPES OF PROSTHETIC HEART VALVES

7. TTK - CHITRA VALVE

8. Clinical manifestations of prosthetic valve thrombosis
• Congestive heart failure (56%)1
• Change in valve closing sound(65%)
• New murmur(13%)1
• Shock (13%)1
• Thromboembolism (stroke or limb or organ ischemia) (23%)1
1. Nicolas Dürrleman, The Journal of Thoracic and Cardiovascular
Surgery,Volume 127, Issue 5,2004
2. Gupta D, Kothari SS, Bahl VK, et al. short- and long-term results. Am Heart
J. 2000

9. Physical examination
• Inaudible click ( normally , closing click heard except caged ball
valve ) .
• Any new murmur or change in pre existing murmur .

10. 3Dec
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11. Chest X ray
 Helps in identification valve type

14. Foot, C & Coucher, John & Stickley, M & Mundy, Julie & Venkatesh, B. (2006). The imaginary line method is not reliable for identification of prosthetic heart valves on
AP chest radiographs. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 8. 15-8.

15. Foot, C & Coucher, John & Stickley, M & Mundy, Julie & Venkatesh, B. (2006). The imaginary line method is not reliable for identification of prosthetic heart
valves on AP chest radiographs. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 8. 15-8.

16. Foot, C & Coucher, John & Stickley, M & Mundy, Julie & Venkatesh, B. (2006). The imaginary line method is not reliable for identification of
prosthetic heart valves on AP chest radiographs. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 8.
15-8.

18. Echo Imaging of Prosthetic Valves

19. CLINICAL INFORMATION
 Type & size of replacement valve .
 Date of surgery .
 Height, weight, and BSA -> assess prosthesis-patient mismatch
(PPM) .
 BP &HR -> as mean gradient depend on the diastolic filling
period .

20. Diagnosis and Follow-Up of Prosthetic Valves
Otto et al, 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease, Circulation. 2021;143:e00–e00

21. Management of embolic events and valve thrombosis.
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease

22. Diagnosis of Prosthetic Valve Stenosis
2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease

23. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease

24. 24
Management
of embolic
events and
valve
thrombosis.
Otto et al, 2020 ACC/AHA Guideline for the Management of Valvular Heart
Disease, Circulation. 2021;143:e00–e00

25. Key parameters in evaluation of PHV
Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler
Ultrasound, JASE 2009

26. Mechanical valve in mitral position

27. Starr-Edwards mitral prosthesis . A: During systole, the poppet is seated within the sewing
ring (arrows). B: During diastole, the poppet moves forward into the cage arrows), allowing
blood flow around the occluder.

28. St. Jude mitral prosthesis . A: During systole, the hemidisks are shown in the closed position
(arrows). B: During diastole, the two disks are recorded in the open position(arrows).
ST JUDE mitral bileaflet

29. St. Jude aortic prosthesis . The sewing ring is indicated by the arrows. The walls of the
aortic root (Ao) often obscure the motion of the disks
St Jude aortic valve

30. Bioprostheses leaflet degeneration can be recognized as
 Leaflet thickening (cusps >3 mm in thickness)- earliest sign
 Calcification (bright echoes of the cusps)
 Tear (flail cusp).

31. Echocardiographic signs of obstructive
prosthetic valve thrombosis
• Reduced valve mobility
 Presence of thrombus
 Abnormal transprosthetic flow
 Central prosthetic regurgitation
 Elevated transprosthetic gradients
 Reduced effective prosthetic area

32. Pannus vs Thrombus

33. Bioprosthetic Valve Thrombosis: Structural Valve Deterioration

34. Prosthetic valve dehiscence

35.  Annular Abscess
Echolucent irregularly shaped area adjacent to the sewing ring of the
prostheticvalve.

36. Dopplar interrogation

37.  Contour of jet velocity signal
 Peak velocity and gradient
 Mean pressure gradient
 VTI of the jet
 DVI
 Pressure half time in MV and TV
 EOA
 Presence, location and severity of regurgitation
Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler
Ultrasound update, JASE 2019
Doppler study of prosthetic valve

38. Assessment of Flow Characteristics of Prosthetic Valves
 Normal functioning mechanical prosthetic valves cause:
 some obstruction to blood flow
 closure backflow (necessary to close thevalve)
 leakage backflow (after valve closure)
 Extent of normal obstruction and leakage of prosthetic valves
depends on prosthetic valve design

39. Challenges in Doppler Interogation
 Variability of flow through
and around the different
prostheses
 Some prosthetic valves have
more than one orifice and,
consequently, a complex flow
profile

40. Obstructive prosthetic valve

41. PRESSURE RECOVERY
smaller central orifice give rise to a high-velocity jet -> pressure drop . CW Doppler -> overestimation of gradients and
underestimation of EOA . Differentiation of central from lateral orifice jets by Doppler is possible with TEE . situations in
which bileaflet valves are small (19 mm) , differentiation from normal may be difficult & requires evaluation of valve motion
& structure using TEE .

42. PRESSURE RECOVERY PHENOMENON
The Aortic Pressure measured by cath distal to the orifice Is higher
than at the orifice .
Therefore The AoV gradient measured by cath is LOWER then the
the gradient measured by Doppler .

43. Double envelope spectral doppler

44. Jet Contour

45. Prosthetic Aortic Valve Stenosis

46. Diagnosis
• Based on TTE
 Gradient elevation by >50 % compared with baseline (or >10 mm Hg
increase from baseline for an Aortic prosthesis ) s/o significant thrombosis 1
 In conditions of low cardiac output, gradients may be normal despite
prosthetic valve obstruction -> “Silent Doppler PVT” .
1. Barbetseas J, et al J Am Coll Cardiol. 2018

47. ACCELERATION TIME
Depends on HR
LV function
Independent of beam of angulation

48. ACCELERATION TIME /EJECTION TIME

49. Jet Velocity & Mean Gradient

50. GOA is not EOA .. EOA can not be measured by planimetry / from valve label size …determines
prognosis

51. Continuity equation : law of conservation of mass

52. LVOT DIAMETER MEASUREMENTS
Measure at the
annulus not below

53. LVOT –VTI –PW Doppler
Trace modal velocity

54. Effective Orifice Area

56. Doppler velocity index
 DVI -> ratio of velocity proximal to the
valve (PW) Doppler to velocity through
the valve CW Doppler
 Screen for valve dysfunction, when
the Cross sectional area of the LVO
tract not known.
 For aortic prosthesis
 DVI = VTI LVOT/ VTI PrAv
Prosthetic mitral valves
 DVI = VTI PrMv/ VTI LVOT

57. Patient Prosthetic mismatch
It occurs when the EOA of the prosthesis is too small in relation to the patient's body size,
resulting in abnormally high postoperative gradients.
PPM AORTIC MITRAL
Insignificant >0.85 cm2/m2. >1.20 cm²/m²
moderate 0.65 and
0.85cm2/m2.
0.9-1.20 cm²/m²
severe <0.65 cm2/m2. <0.90 cm²/m²
2017 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines
EOA indexed to the patient’ s body surface area

58. Zoghbi WA, Chambers JB, Dumesnil JG, et al.

59. Prosthetic mitral valve stenosis

60. Mitral valve continuity equation

61. Doppler echo criteria for detection and quantification of
prosthetic valve stenosis

62. DETECTION AND QUANTIFICATION OF
PROSTHETIC VALVE REGURGITATION

63. Homogeneous in color, with aliasing mostly confined to the base of the jet

65. Pathologic Prosthetic Regurgitation
Pathologic regurgitation iseither
• Central
• Paravalvular
 Most pathologic central valvular regurgitation -> Biologic valves
 Paravalvular regurgitation -> Either type

66. Diagnosis of Prosthetic Valve Regurgitation
Otto et al, 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease,
Circulation. 2021;143:e00–e00

67. Prosthetic Aortic Valve Regurgitation

68.  TTE can detect prosthetic aortic valve regurgitation, since the prosthesis position is anterior
and visualizes the ventricular aspect of the valve.
 Biologic valves have minor degrees of central regurgitation .
 When there is significant dehiscence of the valve , a rocking motion is detected, a/w severe
regurgitation.

70. Prosthetic mitral Valve Regurgitation

71. • Increased rocking of the prosthesis a/w dehiscence of the sewing ring.
• Peak transmitral E wave velocity is increased as is the mean gradient, although the
pressure half-time remains within normal range.
• significant MR -> decrease in the LVOT VTI.
• Suspicion of prosthetic mitral regurgitation should prompt a TEE, which is
diagnostic.

73. Prosthetic pulmonary valves
dysfunction

74. • Normal Peak velocity -> homograft <2.5 m/sec and heterograft <3.2 m/sec.
• Unexplained increase in transvalvular velocity on serial studies -> most reliable
method of detecting stenosis .
• Increase in the RVSP -> indirectly indicate prosthetic PS .
• Prosthetic PR is usually detected by a low velocity PR jet on color flow Doppler
in the parasternal short axis view on TTE.
Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with
echocardiography J Am Soc Echocardiogr 2017; 22:975

75. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic
valves with echocardiography J Am Soc Echocardiogr 2017; 22:975

76. Prosthetic tricuspid valve dysfunction

77. • Because of the respirophasic variation in transtricuspid velocities, at least five beats should
be measured.
• Peak e wave velocity should be less than 2.1 m/sec, the mean gradient <9 mmhg, and the
pressure half-time <200 msec .
• Normal mechanical tricuspid valve prosthesis : (more than this s/o stenosis)
– Peak E velocity <1.7 m/sec,
– Mean gradient <6 mmhg
– Pressure half-time <130 msec .
• When the peak E wave velocity and mean gradient are increased with a low pressure half-
time, regurgitation is suggested.

78. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with echocardiography
J Am Soc Echocardiogr 2017; 22:975

79. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic
valves with echocardiography J Am Soc Echocardiogr 2017; 22:975

80. CONSIDERATIONS IN TAVI
• TAVI - TTE before discharge and at 1 month & 1 year .
• If the border of the stent sits low in LVOT ( self expandable prostheses eg
CoreValve), measure LVOT diameter & velocity within the proximal portion
of the stent at approx. 5-10 mm below the bioprosthetic valve leaflets.

83. Recommendations for Initial Management of Prosthetic Heart Valves in Pregnant Women
Otto et al, 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease, Circulation. 2021;143:e00–e00

84. TEE VS MDCT
Favours TEE
Mechanical mitral and tricuspid valves.
Bjork-Shiley or Sorin monoleaflet valves ( MDCT
suboptimal due to artifact)
If TTE assessment of prosthetic valve gradients is
suboptimal
Other causes of emboli such as atrial thrombi or
vegetations are suspected.
Risk for contrast nephropathy.
Favor MDCT
Contraindication to TEE
MDCT is preferred for mechanical aortic
or pulmonic valves (except Bjork-Shiley
or Sorin monoleaflet valves)
Multimodality Imaging Assessment of Prosthetic Heart Valves. SucháD, Symersky P, Tanis W, Mali WP, Leiner T, van Herwerden LA,
Budde RP Circ Cardiovasc Imaging. 2015 Sep;8(9):e003703.

85. Considerations for Intraoperative Patients
 TEE as a class I indication for patients undergoing valve
replacement with stentless xenograft, homograft, or autograft
valves.
Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves
with echocardiography J Am Soc Echocardiogr 2017; 22:975

86. Is TEE really necessary?
• PRO-TEE suggested that TEE may be required for making treatment decisions based on
thrombus size.1
• In PRO-TEE registry, there was correlation between NYHA class and the thrombus area,
suggesting that higher NYHA class at presentation can be substituted for higher thrombus
area 1
• Roudaut et al reported in their analysis that the routine use of TEE did not change the efficacy
or safety of FT 2
1.Tong AT, et al. PRO-TEE registry. J Am Coll Cardiol 2004
2. Roudaut R et al Arch Cardiovasc Dis 2000

87. BPVT on TEE . long-axis views
• Visible thickening of the body of the prosthetic cusp, with an echo intensity similar to cusp or soft tissues.
• Reduced mobility of the leaflets at the affected sites.

88. MULTISLICE CT
 To evaluate leaflet motion and on the residual opening angle
between leaflets .
 Less artifact for aortic valve .

89.  Residual opening angle, the
angle between two leafletswhen
fully opened, is measured using
the plane perpendicular to the
two leaflets
 Normal limit (≤ 20°)
For a single-leaflet prosthetic
valve, the maximal opening angle
is recorded.

90. MDCT -Pannus vs thrombus
• More precise for differentiating between
pannus and thrombus 1
• A high (HU<90) attenuation suggests
thrombus and responds to FT 2 .
2.Sabahattin Gündüz et al. Circ Cardiovasc Imaging. 2015;8:e003246
1. Symersky P,Am J Cardiol. 2009;104(8):1128–1134.

91. Infective Endocarditis
•Risk approximately 0.5%/year
•Mechanical valves
–Usually involves the sewing ring
–Rare to visualize vegetation on discs
•Tissue valves
–Vegetations seen both at sewing ring and leaflets

92. Diagnosis of IE
Otto et al, 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease,
Circulation. 2021;143:e00–e00

93. Transesophageal echocardiogram (TEE) showing a prosthetic mitral valve vegetation in patient
with endocarditis

94. Transesophageal echocardiogram (TEE) of a mechanical mitral valve prosthesis with
vegetations

95. Left atrial thrombus and thrombus adjacent to a prosthetic mitral valve seen on TEE

96. CardiacCatheterization
 Measure the transvalvular pressure gradient, from which the EOA
can be calculated –Gorlin formula.
 Can visualize and quantify valvular or paravalvular regurgitation
by Contrast injection.
 Crossing a prosthetic valve with a catheter should not be attempted in
mechanical valves because of limitations and possible complications.
 Tissue valves can be crossed with a catheter easily, but a
degenerative, calcified bioprosthesis is friable, and leaflet rupture
with acute severe regurgitation is possible.

97. Cinefluoroscopy
 Structural
integrity .
 Motion of the
disc .
 Excessive tilt of
thebase ring ->
partial
dehiscence .

98. MD NABi pneumopericardium , suture ring dehiscence

99. SATISH

100. SATISH

101. Bioprosthesis
and tilting disc
lonescu-Shiley pericardial tissue valve stent

103. Cinefluoroscopy
• Obstructive vs non obstructive PVT 1
• Provides visualization of valve leaflet motion
• Sensitivity 87% specificity 78% PPV 80%
2
• The concomitant use of Fluoroscopy and TTE has a PPV in 85% of
patients
2
1. Cianciulli TE, L et al. J Heart Valve Dis. 2005;14:664–73
2 .Montorsi P, et al Am J Cardiol. 2000; 85: 58–64

104. Normal opening and closing angles

105. Normally functioning bileaflet valve

107. Magnetic Resonance Imaging
• Used only when prosthetic-valve regurgitation or para valvular
leakage is suspected but not adequately visualized by
echocardiography .
• Quantification of severity of regurgitation .
• Location of origin of regurgitant jet .
• Multimodality Imaging Assessment of Prosthetic Heart Valves. SucháD, Symersky P, Tanis W, Mali WP, Leiner T, van Herwerden LA, Budde
RP Circ Cardiovasc Imaging. 2015 Sep;8(9):e003703.

108. CASE 1
• GULAB
• POST DVR (9/1/20)
• MITRAL TTK CHITRA #29
• AORTIC TTK CHITRA #23

110. MITRAL TILTING DISC LEAFLET MOVEMENT SEEMS NORMAL

111. Normally moving mitral prosthetic leaflet

112. Mitral PHV OC/CC+/+

113. MITRAL PROSTHETIC VALVE OC/CC+/+

114. OC/CC/ +/+ PG/MG7/5mm Hg , AV VTI =20cm

115. LVOT DIAM =2.2CM

116. PW LVOT VTI =8.4 cm

117. • AORTIC EOA=CSA LVOT * VTI LVOT / VTI Av =
3.14*1.1*1.1*8.4/20.1=1.6CM2

118. MV PG/MG =12/3, MV VTI=16.4,

119. • Vti prmv/ vti lvot= 16.4/8.4 =1.95
• Mean gradient =3 mm Hg
• EOA= CsAlvot* vti lvot /vti prmv
= 3.14*1.1*1.1*8.4/16.4= 1.95CM2

120. Recommendations for Evaluation of Prosthetic Valves With
Echocardiography and Doppler Ultrasound, JASE 2009

121. Aortic transprosthetic jet triangular and early peaking , AT=56ms

122. Aortic AT/ET=56/180=0.32MS

123. Doppler echo criteria for detection and quantification of
prosthetic valve stenosis

124. TAKE HOME
 Doppler-echo is the first line .
 Multiple-views and multiple planes imaging by various modality is key .
 Assess of the valve ( morphology, mobility, and orifices ); assessment of the
sewing ring; evaluation of valvular and paravalvular complications; and
assessment of other cardiac and vascular structures .

125. Thank you