This document discusses a case of a 76-year-old female patient who underwent bioprosthetic aortic valve replacement in 2007 and is now experiencing fatigue, chest pain, dizziness, and dyspnea. Transthoracic echocardiography showed thickened aortic valve cusps, increased transvalvular gradients, and reduced effective orifice area compared to her post-op echocardiogram, indicating potential bioprosthetic valve degeneration. Transesophageal echocardiography confirmed degeneration of the bioprosthetic valve with fixed cusps and reduced valve area. The patient was referred for redo surgery. The document also reviews the use of echocardiography to evaluate prost

1. Bioprosthetic Valve
Degeneration
Philipp Emanuel Bartko, MD and
Jutta Bergler-Klein, MD
Med. Univ. of Vienna, Dept. Of
Cardiology, Vienna, Austria
jutta.bergler-klein@meduniwien.ac.at

2. Clinical Presentation and Medical History
 76 year old female
 Seen at the outpatient clinic for general fatigue, atypical
chest pain, dizziness and dyspnoea on exertion for several
months.
 No syncope or recent fever
 She underwent cardiac surgery in 2007
• Replacement of the aortic valve using a Mitroflow 21mm (stented bovine
pericardial valve) and aortic root for severe aortic stenosis with calcified
bicuspid aortic valve and aneurysm of the ascending aorta
• Single coronary artery bypass graft (LIMA to LAD)
• Tricuspid valve annuloplasty with ring implantation
 Paroxysmal atrial fibrillation

3. Clinical and biological Findings
 Physical examination:
• 159 cm, 58 kg
• Blood pressure 150/90 mmHg; 78 bpm
• Loud systolic heart murmur at 2nd right intercostal space with
transmission to the carotid arteries
• No peripheral oedema
 ECG
• Sinus rhythm
• Non-specific ST wave alterations
• LV hypertrophy
 Biology
• Normal CRP, creatinine and thyroid hormones levels
• NT-proBNP 213 pg/ml

4. Transthoracic Echocardiography
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5. Transthoracic Echocardiography Report
 Bioprosthetic aortic valve
• Significantly thickened cusps
• Trivial central prosthetic regurgitation
• Doppler parameters
•
Peak jet velocity 3.8m/sec
•
Mean aortic gradient 37 mmHg
•
Effective orifice area 1.1 cm² (0.7 cm²/m² of body surface area)
 Left ventricle
•
•
•
•
Normal ejection fraction
No regional wall motion abnormalities
End diastolic volume 99mL
Stroke volume: 72ml (46ml/m²) by Simpson method, 79ml (50ml/m²)
by Doppler method

6. Compare to Discharge Echo after Valve Surgery
 At discharge in 2007:
• Aortic peak velocity 2.51m/sec
• Mean gradient 11 mmHg
• Effective orifice area 1.7 cm²
 Increasing aortic valve gradient
Bioprosthetic Degeneration?
Patient-Prosthesis Mismatch?
Exact prosthesis morphology  TEE

7. Transoesophageal Echocardiography
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8. Transoesophageal Echocardiography Conclusion
• Degenerating bioprosthetic valve
with fixed cusps and reduced
valve area
• The patient was referred for redo
surgery

9. Echocardiographic Assessment of Prosthetic Valves
What should you know in advance?
 Valve type
• Bioprosthetic valve: stented, stentless or sutureless
• Mechanical valve: bileaflet, tilting disc or ball in cage
 Valve size
• May cause differences in gradients and effective orifice area
 BSA of the patient
• Calculation of the indexed effective orifice area to assess potential patient /
prosthesis mismatch
 Year of implantation
• Median time to reoperation for structural valve deterioration is agedependent and varies from average 11 years in a 20-y old, to 25 years in a
65-y old.
 Additional surgical interventions
• Coronary bypass grafts, other valve surgery
 Smedira NG, Blackstone EH, Roselli EE et al. J Thorac Cardiovasc Surg 2006;131:558-64
 El-Hamamsy I, Clark L, Stevens LM et al. J Am Coll Cardiol 2010;55:368-76

10. Echocardiographic Assessment of Prosthetic Valves
What to Report - I
 Date of surgery
 Type of valve prosthesis
 Height, weight, BSA of patient
 Blood pressure, heart rate
 Haemodynamic conditions: left ventricular size and
function, stroke volume (index)
 Vahanian A, Alfieri O, Andreotti F et al. Guidelines on the management of valvular heart disease (version
2012). Joint Task Force on the Management of Valvular Heart Disease of the European Society of
Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J
2012;33(19):2451-96

11. Echocardiographic Assessment of Prosthetic Valves
What to Report -II
 Valve
• Seating (Abnormal motion? Tilting, Rocking?)
• Leaflets or occluder motion
• Morphology (Calcification? Abnormal echo densities? Valve sewing ring?
Ring integrity?)
• Doppler: Peak jet velocity, peak and mean gradient, effective orifice area
 compare to specified prosthesis normal values
• Regurgitation (degree, para- or intravalvular location, mechanism)
A TTE should be performed at discharge or 30 days after
surgery and will serve as a future reference
 Zoghbi WA, Chambers JB, Dumesnil JG et al. Recommendations for evaluation of prosthetic valves
with echocardiography and doppler ultrasound. J Am Soc Echocardiogr 2009;22:975-1014
 Daneshvar SA, Rahimtoola SH. Valve prosthesis-patient mismatch: a long-term perspective. J Am
Coll Cardiol 2012 Sep 25;60(13):1123-35

12. Structural Valve Degeneration
 Structural valve degeneration is the major cause of
bioprosthetic valve failure
 Age dependent, it occurs early in young patients.
 Lipid-mediated inflammation contributes to structural valve
degeneration.
 Atherosclerotic risk factors (diabetes, smoking,
hypercholesterolemia, metabolic syndrome) facilitate
structural valve degeneration.
 Modification of risk factors may help to reduce the incidence of
structural valve degeneration
 Transcatheter heart valve implantation (valve in valve) for
failing surgical bioprosthesis is an emerging alternative to
redo surgery
Mylotte D, Lange R, Martucci G, Piazza N. Transcatheter heart valve implantation for failing surgical
bioprostheses: technical considerations and evidence for valve-in-valve procedures. Heart 2013;99:960-7

13. Summary
 Echocardiography with Doppler is the method of choice in the
evaluation and follow up of patients with valve prostheses.
 Knowledge of the prosthesis type and size is essential to
compare to reference prosthesis Doppler values.
 A postop discharge echo should always be performed to
document individual baseline Doppler values.
 The occurrence of a significant increase in gradient and/or new
regurgitation points to prosthetic valve degeneration.
 TEE should be performed to clarify mechanism of degeneration
and exclude endocarditis in (sub)febrile patients.
 Transcatheter valve-in-valve implantation may be a good option
in the future for the management of bioprosthetic valve failure
in high-risk patients.

14. Join the ESC Working Group
on Valvular Heart Disease
and take part in its
activities !
Membership is FREE!