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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
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 .
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.
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
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
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
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 .
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
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
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
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.
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.
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
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.
81.
82.
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
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.
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
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
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 .