Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Based on the principle that the distal coronary pressure measured during vasodilation is directly proportional to maximum vasodilated perfusion.
FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow in the same artery if there were no stenosis.
FFR is simply calculated as a ratio of mean pressure distal to a stenosis (Pd) to the mean pressure proximal stenosis, that is the mean pressure in the aorta (Pa), during maximal hyperaemia.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
RHD is prevalent in India, many patients requires valve replacement. understanding of prosthetic valve anatomy, morphology and early detection of valve related complication is very important for saving life. TTE and TEE are important tool for identifying these complications.
Our concepts of heart disease are based on the enormous reservoir of physiologic and anatomic knowledge derived from the past 70 years' of experience in the cardiac catheterization laboratory.
As Andre Cournand remarked in his Nobel lecture of December 11, 1956, the cardiac catheter was the key in the lock.
By turning this key, Cournand and his colleagues led us into a new era in the understanding of normal and disordered cardiac function in huma
Based on the principle that the distal coronary pressure measured during vasodilation is directly proportional to maximum vasodilated perfusion.
FFR is defined as the ratio of maximum blood flow in a stenotic artery to maximum blood flow in the same artery if there were no stenosis.
FFR is simply calculated as a ratio of mean pressure distal to a stenosis (Pd) to the mean pressure proximal stenosis, that is the mean pressure in the aorta (Pa), during maximal hyperaemia.
Various coronary physiological measurements can be made in the cardiac catheterization laboratory using sensor-tipped guidewires; they include the measurement of poststenotic absolute coronary flow reserve, the relative coronary flow reserve, and the pressure-derived fractional flow reserve of the myocardium. Ambiguity regarding abnormal microcirculation has been reduced or eliminated with measurements of relative coronary flow reserve and fractional flow reserve. The role of microvascular flow impairment can be separately determined with coronary flow velocity reserve measurements. In addition to lesion assessment before and after intervention, emerging applications of coronary physiology include the determination of physiological responses to new pharmacological agents, such as glycoprotein IIb/IIIa blockers, in patients with acute myocardial infarction. Measurements of coronary physiology in the catheterization laboratory provide objective data that complement angiography for clinical decision-making
RHD is prevalent in India, many patients requires valve replacement. understanding of prosthetic valve anatomy, morphology and early detection of valve related complication is very important for saving life. TTE and TEE are important tool for identifying these complications.
Prosthetic Heart Valves from Research Paperdocmutaher
Over the past sixty years, advancements in heart valve replacement surgery have revolutionized patient outcomes, enhancing both survival rates and functional recovery. Innovations in prosthetic valve design, surgical techniques, and multidisciplinary approaches have broadened the scope of treatment options for diverse patient populations. Today, minimally invasive procedures and primary valve repair techniques are commonplace in leading medical centers, ensuring tailored care for individual needs. Collaboration among heart valve teams enables comprehensive evaluation and personalized treatment plans, including the utilization of transcatheter therapies when suitable. Despite these strides, selecting the optimal valve prosthesis remains a complex decision, balancing durability against the risk of complications such as thromboembolism and the need for long-term anticoagulation. Thus, the pursuit of the ideal heart valve substitute continues, driving ongoing research and innovation in cardiovascular medicine.
This presentation is about procedure called TAVI (Transcatheter Aortic Valve Implantation ) as a new alternative treatment to surgical valve replacement for patient with symptomatic severe Aortic stenosis who can't undergo surgery ..
Imaging for Predicting and Assessing Patient Prosthesis Mismatch after AVRJunhao Koh
Echocardiographic evaluation to prevent, detect and intervene on patient prosthesis mismatch in aortic valve replacement, including TAVR / TAVI and valve-in-valve cases.
Wellens syndrome. Wellens syndrome (also referred to as LAD coronary T-wave syndrome) refers to an ECG pattern specific for critical stenosis of the proximal left anterior descending artery. The anomalies described occur in patients with recent anginal chest pain, and do not have chest pain when the ECG is recorded.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
A post-splenectomy patient suffers from frequent infections due to capsulated bacteria like Streptococcus
pneumoniae, Hemophilus influenzae, and Neisseria meningitidis despite vaccination because of a lack of
memory B lymphocytes. Pacemaker implantation after splenectomy is less common. Our patient underwent
splenectomy for splenic rupture after a road traffic accident. He developed a complete heart block after
seven years, during which a dual-chamber pacemaker was implanted. However, he was operated on seven
times to treat the complication related to that pacemaker over a period of one year because of various
reasons, which have been shared in this case report. The clinical translation of this interesting observation
is that, though the pacemaker implantation procedure is a well-established procedure, the procedural
outcome is influenced by patient factors like the absence of a spleen, procedural factors like septic measures,
and device factors like the reuse of an already-used pacemaker or leads.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
3. Introduction
The introduction of valve replacement surgery in the
early 1960s has dramatically improved the outcome of
patients with valvular heart disease.
Despite the improvements in prosthetic valve design
and surgical procedures , valve replacement does not
provide a definitive cure. Instead, native valve disease
is traded for “prosthetic valve disease”.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
4. Introduction
After a valve is replaced, the prognosis for the patient
is highly correlated with the function of the
prosthetic valve like-
hemodynamics,
durability,
thrombogenicity.
Thus, early diagnosis of a prosthetic valve disorder is
crucial for reducing morbidity and mortality.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
5. Introduction
Symptoms of prosthetic valve dysfunction may be non
specific, making it difficult to differentiate the effects of
prosthetic valve dysfunction from
ventricular dysfunction,
pulmonary hypertension,
the pathology of the remaining native valves,
no cardiac conditions.
Although physical examination can alert clinicians to the
presence of significant prosthetic valve dysfunction,
diagnostic methods are often needed to assess the
function of the prosthesis.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
6. Types of prosthetic valves
Prosthetic Valves are classified as tissue or
mechanical
Tissue:
• Made of biologic tissue from an animal (bioprosthesis
or heterograft) or human (homograft or autograft)
source
Mechanical
Made of non biologic material (pyrolitic carbon,
polymeric silicone substances, or titanium)
Blood flow characteristics, hemodynamics, durability,
and thromboembolic tendency vary depending on the
type and sizeEVALUATION OF PROSTHERIC VALVE characteristics of
of the prosthesis and
the patient FUNCTION-METHODS AND CLINICAL UTILITY
8. Mechanical Valves
Extremely durable with overall survival rates of 94%
at 10 years
Primary structural abnormalities are rare
Most malfunctions are secondary to perivalvular leak
and thrombosis
Chronic anticoagulation required in all
With adequate anticoagulation, rate of thrombosis is
0.6% to 1.8% per patient-year for bileaflet valves.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
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 & failure
after 6-8 years
Stentless bioprostheses
Absence of stent & sewing cuff allow implantation of
larger valve for given annular size->greater EOA
Uses the patient’s own aortic root as the stent,
absorbing the stress induced during the cardiac cycle
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
10. Biologic Valves Continued
Homografts
Harvested from cadaveric human hearts
Advantages: resistance to infection, lack of need for
anticoagulation, excellent hemodynamic profile (in
smaller aortic root sizes)
More difficult surgical procedure limits its use
Autograft
Ross Procedure
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
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 other
reasons (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 most
suitable for a patient with a small valvular annulus in
whom a prosthesis with the largest possible effective
orifice area is desired.OF PROSTHERIC VALVE
EVALUATION
FUNCTION-METHODS AND CLINICAL UTILITY
12. Algorithm for choice of prosthetic
heart valve
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
13. Approach to prosthetic valve
function assesment
CLINICAL INFORMATION &CLINICAL EXAMINATION
IMAGING OF THE VALVES
CXR
2D echocardiography
TEE
3D echo
CineFluoro
CT
Cardiac catheterisation
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
15. HISTORY
Subtle symptoms of cardiac failure or neurologic
events can be clues to serious valve dysfunction.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
16. CLINICAL INFORMATION
Clinical data including reason for the study and the
patient’s symptoms
Type & size of replacement valve,
date of surgery
Patient’s height, weight, and BSA should be recorded
to assess whether prosthesis-patient mismatch (PPM)
is present
BP & HR
HR particularly important in mitral and tricuspid
evaluations because the mean gradient is dependent on
the diastolic filling period
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
20. CXR
chest x-ray are not performed on a routine basis in
the absence of a specific indication.
It can be helpful in identification of valve type if
information about valve is not available.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
21. The location of the cardiac
valves is best determined
on the lateral radiograph.
A line is drawn on the
lateral radiograph from
the carina to the cardiac
apex.
The pulmonic and aortic
valves generally sit above
this line and the tricuspid
and mitral valves sit below
this line.
So me time s the ao rtic ro o t
can be infe rio rly displace d
which will shift the ao rtic
valve be lo w this line . OF PROSTHERIC VALVE
EVALUATION
FUNCTION-METHODS AND CLINICAL UTILITY
23. For further localization
prosthetic valves involves
drawing a second line
which is perpendicular to
the patient's upright
position which bisects the
cardiac silouette.
The aortic valve projects
in the upper quadrant, the
mitral valve in the lower
quadrant ,the tricuspid
valve in the anterior
quadrant and pulmonary
valve in the superior
portion of the posterior
quadrant
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
24. On the frontal chest
radiograph ( AP or PA ) -
longitudinal line through the
mid sternal body. draw a
perpendicular line dividing
the heart horizontally.
The aortic valve -
intersection of these two
lines.
The mitral valve - lower
left quadrant (patient’s left).
The tricuspid valve - lower
right corner (the patient's
right)
The pulmonic valve- upper
left corner (the patient's OF PROSTHERIC VALVE This method is less reproducible
EVALUATION
left).
FUNCTION-METHODS AND CLINICAL UTILITY
25. Patients with cardiac valves often have chamber
enlargement and cardiac rotation which can displace
the positions of the valves as well as create difficulty
when drawing lines through the cardiac silouette.
These rules are meant as a guideline to better localize
cardiac valves although they do not always work.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
26. Some bioprosthetic valves have components that
determine the direction of flow which helps
localize the 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 VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
28. Radiologic Identification
Starr-Edwards caged
ball valve
Radiopaque base ring
Radiopaque cage
Silastic ball impregnated
with barium that is
mildly radiopaque (but
not in all models)
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
29. Appearance of
CarboMedics prosthesis
on plain radiography.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
30. Echo Imaging of Prosthetic Valves
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
31. TIMING OF ECHO CARDIOGRAPHIC
FOLLOW-UP
Ideally, a baseline postoperative transthoracic
echocardiography(TTE) study should be performed
3-12weeks after surgery, when the
chest wound has healed,
ventricular function has improved, and
anaemia with its associated hyperdynamic state has
resolved.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
32. Bioprosthetic valves Annual echocardiography is
recommended after the first 5years,
Mechanical valves, routine annual echocardiography is
not indicated in the absence of a change in clinical
status.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
33. challenges in echocardiography
The high reflectance leads to
shadowing
Reverberations
multiple echocardiographic windows must be used to fully
interrogate the areas around prosthetic valves.
transesophageal echocardiography is necessary to provide
a thorough examination.
For stented valves-ultrasound beam aligned parallel to
flow to avoid the shadowing effects of the stents and
sewing ring.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
35. The concept of pressure recovery
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
36. The primary goals of 2D echo
Valves should be imaged from multiple views, with
attention to
determine the specific type of prosthesis,
confirm the opening and closing motion of the
occluding mechanism,
confirm stability of the sewing ring(abnormal rocking
motion )
Presence of leaflet calcification or abnormal echo density
attached to the sewing ring, occluder, leaflets, stents, or
cage such as vegetations and thrombi
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
37. Primary goals of 2D echo
(cont)
Calculate valve gradient
Calculate effective orifice area
Confirm normal blood flow patterns
Detection of pathologic transvalvular and
paravalvular regurgitation.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
38. Starr-Edwards mitral prosthesis is shown. A: During systole, the poppet is
seated within the sewing ring (arrows). B: During diastole, the poppet moves
forward into the cageEVALUATION OF PROSTHERIC VALVE
(arrows), allowing blood flow around the occluder.
FUNCTION-METHODS AND CLINICAL UTILITY
39. St. Jude mitral prosthesis is demonstrated. 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).
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
40. St. Jude aortic prosthesis is demonstrated. The sewing ring is indicated
by the arrows. The walls of the aortic root (Ao) often obscure the
motion of the disks.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
41. M-Mode
M-Mode echocardiography enables better evaluation
of valve movements and corresponding time intervals
and recognition of quick movements and fibrillations.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
43. For bioprostheses, evidence of leaflet degeneration
can be 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 a
rocking motion of the entire prosthesis.
An annular abscess may be recognized as an
echolucent, irregularly shaped area adjacent to the
sewing ring of the prosthetic valve.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
44. Assessment of Flow Characteristics
of Prosthetic Valves
Normal functioning mechanical prosthetic valves
cause:
some obstruction to blood flow
closure backflow (necessary to close the valve)
leakage backflow (after valve closure)
The extent of normal obstruction and leakage of prosthetic
valves depends on prosthetic valve design
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
45. Valve type Flow Characteristics
Ball-in-cage prosthetic valve (Starr- much obstruction and little leakage.
Edwards, Edwards Lifescience)
Tilting disc prosthetic valve (Björk- less obstruction and more leakage.
Shiley; Omniscience; Medtronic Hall)
Bileaflet prosthetic valves (St. Jude Less obstruction and more leakage.
Medical; Sorin Bicarbon; Carbomedics)
Bioprostheses. little or no leakage
Homografts, pulmonary autografts, and almost unobstructive to blood flow.
unstented bioprosthetic valves
(Medtronic Freestyle,
Toronto, Ontario, Canada)
Stented bioprostheses (leaflets obstructive to flow.
suspended within a frame)
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
46. Dopplar interogation
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
47. color flow imaging is
often helpful to define
the location and
direction of the various
flow patterns.
pulsed and continuous
wave Doppler imaging
can be oriented to
quantify flow velocity.
Whenever velocity is higher than expected,
consider the possibility of pressure recovery.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
48. 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
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
49. Challenges in doppler interogation
Because the signal-to-noise ratio for Doppler imaging
is lower compared with two-dimensional
echocardiographic imaging, the shadowing effect is
even more pronounced and the ability to record a
Doppler signal behind a prosthetic valve is very
limited
Multiple views m be used to fullyinterrogate the regurgitant signal.
ust
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
50. Primary goals of dopplar
interogation
ASSESMENT OF OBSTRUCTION OF
PROSTHETIC VALVE
DETECTION AND QUANTIFICATION OF
PROSTHETIC VALVE REGURGITATION
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
51. Doppler Assessment of Obstruction
of Prosthetic Valves
Quantitative parameters of prosthetic valve function
Trans prosthetic flow velocity & pressure gradients,
valve EOA,
Doppler velocity index(DVI).
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
52. Effective orifice area(EOA)
Continuity equation
EOA PrAV = (CSA LVO x VTI LVO) / VTI PrAV
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
55. EOA of mitral prostheses:
Pressure half time may be useful if it is significantly
delayed or shows significant lengthening from one
follow-up visit to the other despite similar heart rates.
continuity equation using the stroke volume
measured in the LVOT. However, this method cannot
be applied when there is more than mild concomitant
mitral or aortic regurgitation.
o better for bioprosthetic valves and single tilting disc
mechanical valves.
o underestimation of EOA in case bileaflet valves.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
57. PPM
PPM occurs when the EOA of the prosthesis is too
small in relation to the patient's body size, resulting
in abnormally high postoperative gradients.
EOA indexed to the patient’ s body surface area
. PPM AORTIC MITRAL
Insignificant >0.85 cm2/m2. >1.20 cm²/m²
moderate 0.65and0.85cm2/m2. 0.9-1.20 cm²/m²
severe <0.65 cm2/m2. <0.90 cm²/m²
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
58. Transprosthetic jet contour and
acceleration time
AT/ET > 0.4
AT and AT/ET, angle-independent parameters.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
60. Doppler velocity index
Dimensionless ratio of the proximal flow velocity in
the LVOT to the flow velocity through the aortic
prosthesis
DVI=VLVOT/VPrAv
• Time velocity time integrals may also be used in
Place of peak velocities
DVI= TVILVOT /TVIPrAv
• Prosthetic mitral valves, the DVI is calculated by
DVI=TVIPrMv/TVILVOT
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
61. DVI had a sensitivity, specificity, positive and negative predictive values,
and accuracy of 59%, 100%, 100%, 88%, and 90%, respectively.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
63. IMPORTENCE
DVI can be helpful to screen for valve
dysfunction, particularly when the
Crosssectional area of the LVO tract cannot be
obtained
Valve size is not known.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
64. Transprosthetic velocity and gradient
• The flow is
eccentric - monoleaflet valves multi-windows examination
three separate jets - bileaflet valves
Localised high velocity may be recorded by
continuous wave(CW) Doppler
Interrogation through the smaller central
orifice of the bileaflet mechanical prostheses
overestimation of gradient
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
67. Highvelocity or gradient alone is not proof of intrinsic
prosthetic obstruction and may be secondary to
prosthesis patient mismatch (PPM),
high flow conditions,
prosthetic valve regurgitation, or
localised high central jet velocity in bileaflet
mechanical valves.
Increased heart rate.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
68. Algorithm for interpreting abnormally high transprosthetic pressure gradients
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
72. DETECTION AND QUANTIFICATION OF
PROSTHETIC VALVE REGURGITATION
• Physiologic Regurgitation.
closure backflow (necessary to close the valve)
leakage backflow (after valve closure)- washing jets
o short in duration
o narrow
o symmetrical
o homogenous
Pathologic Prosthetic Regurgitation.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
73. Homogeneous in color, with aliasing mostly confined to the base of the jet
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
74. Pathologic Prosthetic Regurgitation
Pathologic regurgitation is either
central Pathologic jets tend to be high velocity,
paravalvular. intense, broad, and highly aliased.
Most pathologic central valvular regurgitation is seen
with biologic valves, whereas paravalvular regurgita-
tion is seen with either valve type and is frequently
the site of regurgitation in mechanical valves.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
82. Thrombus and Pannus
In one surgical study of 112 obstructed mechanical
valves,
pannus formation was the underlying cause in
11 percent of valves,
pannus formation in combination with thrombus was
present in 12 percent,
thrombus alone was the etiology in the remaining
cases.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
83. Distinction between thrombus and
pannus
Thrombus Large,
mobile,
less echo-dense,
associated with spontaneous contrast,
INR<2.5
Pannus Small
firmly fixed (minimal mobility) to the valve apparatus
highly echogenic, (fibrous composition)
common in aortic position
Para valve jet suggests pannus
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
88. Abnormal echoes
Abnormal echoes that may be found in patients with
prosthetic valves are
spontaneous echo contrast (SEC),
microbubbles or cavitations, strands,
sutures,
vegetations,
thrombus.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
89. Spontaneous echo contrast (SEC)is defined as smoke-
like echoes.
SEC is caused by increased red cell aggregation that
occurs 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 VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
90. Microbubbles are characterized by a discontinuous
stream of rounded, strongly echogenic, fast moving
transient echoes
Microbubbles occur at the inflow zone of the valve
when flow velocity and pressure suddenly drop at the
time of prosthetic valve closing, but may also be seen
during valve opening.
Microbubbles are probably due to carbon dioxide
degassing.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
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 they
reappeared after successful thrombolytic treatment
with relief of valvular obstruction in 69%
Microbubbles are not found in bioprosthetic valves.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
92. Strands are thin, mildly echogenic, filamentous
structures that are several mm long and move
independently 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 the
prosthetic valve
Strands are found in 6% to 45% of patients.
Have a fibrinous or a collagenous composition.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
93. Sutures are defined as linear, thick, bright, multiple,
evenly spaced, usually immobile echoes seen at the
periphery of the sewing ring of a prosthetic valve;
They may be mobile when loose or unusually long.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
94. TEE
Careful alignment of the transducer is essential to
fully display leaflet motion as comprehensively as
possible.
Multiplane imaging should be done at a minimum of
every 30˚from 0–180˚.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
95. TEE evaluation immediately after valve replacement
1. Verify that all leaflets or occluders move normally.
2. Verify the absence of paravalvular regurgitation.
3. Verify that there is no left ventricular outflow tract
obstruction by struts or subvalvular apparatus.
TEE diagnosis of prosthetic valve dysfunction
1. Identification of prosthetic valve type.
2. Detection and quantification of transvalvular or
paravalvular regurgitation.
3. Detection of annular dehiscence.
4. Detection of vegetations consistent with endocarditis.
5. Detection of thrombosis or pannus formation on the
valve.
6. Detection and quantification of valve stenosis.
7. Detection of tissue degeneration or calcification.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
96. TEE
Higher-resolution image than TTE
Proximity of the oesophagus to the heart .
Size of vegetation defined more precisely
Absence of interference with lungs and ribs, a very detailed image can
be obtained of the atrial side
of the mitral valve prosthesis and especially the posterior part of the
aortic prosthesis.
Peri annular complications indicating a locally uncontrolled
infection (abscesses, dehiscence, fistulas) detected earlier.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
97. limitation -inability to detect aortic prosthetic-valve
obstruction or regurgitation, especially when a mitral
prosthesis is present.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
98. CONSIDERATIONS IN TAVI
The echocardiographic evaluation of TAVI is , in
most ways same as that for surgically implanted
valves
But 2 areas of chalenges are
Caluculation of EOA
Quantification of post TAVI AR
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
99. CONSIDERATIONS IN TAVI
LVOT diameter and velocity should be measured
immediately proximal to the apical border of the
stent.
However, if the border of the stent sits low in the
LVOT, which may occur more frequently with self-
expandable prostheses (such as the CoreValve), it may
be preferable to measure the LVOT diameter and
velocity within the proximal portion of the stent at
approximately 5-10 mm below the bioprosthetic valve
leaflets.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
100. CONSIDERATIONS IN TAVI
Paravalvular regurgitation is more common following
transcatheter aortic valve implantation versus
standard valve replacement– 30-80% with 5-
14%being moderate or severe.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
101. CONSIDERATIONS IN TAVI
Delayed migration and embolisation of the prosthesis
have been reported following transcatheter valve
implantation.
The distance between the ventricular end of the
prosthesis stent and the hinge point of the mitral
valve measured in the parasternal long axis view can
be used to monitor the position of the prosthesis
during follow-up.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
102. Considerations for Intraoperative
Patients
TEE and epicardial and epiaortic ultrasound
TEE remains the most widely used
American Society of Anesthesiologists has recommended
intraoperative TEE as a category II indication in patients
undergoing valve surgery
Current ACC & AHApractice guidelines recommend
TEE as a class 1 indication for patients undergoing valve
replacement with stentless xenograft, homograft, or
autograft valves.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
103. Considerations for Intraoperative
Patients
Multiple echocardiographic views are obtained to
determine
Appropriate movement of valve leaflets,
Color flow Doppler should exclude the presence of
paravalvular leaks
• Immediate surgical attention
Any regurgitation that is graded moderate or severe,
‘Stuck’’ mechanical valve leaflets,
Valve dehiscence,
Dysfunction of adjacent valves
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
104. Stress Echocardiography in Evaluating
Prosthetic Valve Function
Stress echocardiography should be considered in
patients with exertional symptoms for which the
diagnosis is not clear.
Dobutamine and supine bicycle exercise are most
commonly used.
Treadmill exercise provides additional information
about exercise capacity but is less frequently used
because the recording of the valve hemodynamics is
after completion of exercise, when the
hemodynamics may rapidly return to baseline.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
105. Stress Echocardiography(cont)
Prosthetic Aortic Valves
Guide to significant obstruction would be similar to
that 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 gradient
rises > 18 mm Hg after exercise, even when the
resting mean gradient is normal.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
106. RT-3D TEE
Excellent spacial imaging
Ease of use
Enables enface viewing(surgical view)
adds to the available information provided by
traditional imaging modalities.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
107. Limitations of 3D echo
poor visualization of anterior cardiac structures,
poor temporal resolution,
poor image quality in patients with arrhythmias
tissue dropout
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
110. Cinefluoroscopy
Structural integrity
Motion of the disc or poppet
Excessive tilt ("rocking") of the base ring - partial
dehiscence of the valve
Aortic valve prosthesis - RAO caudal
- LAO cranial
Mitral valve prosthesis - RAO cranial .
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
111. Fluoroscopy of a normally functioning CarboMedics
bileaflet prosthesis in mitral position
A=opening angle B=closing angle
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL
UTILITY
112. St. Jude medical
bileaflet valve
Mildly radiopaque
leaflets are best seen
when viewed on end
Seen as radiopaque
lines when the leaflets
are fully open
Base ring is not
visualized on most
models
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
113. MULTISLICE CT
Because of its high temporal and spatial resolution,
MDCT has recently shown good potential in
assessing prosthetic valve disorders.
to evaluate the prosthetic valve motion in various
planes, with a focus on leaflet motion and on the
residual opening angle between leaflets.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
114. The residual
openingangle, the angle
between two leaflets when
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. EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
115. Special attention is also
paid to the relationship
between the suture ring and
the surrounding valve
annulus for detecting
thrombosis,
paravalvular leak (suture
loosening),
pannus,
pseudoaneurysm formation.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
118. Thrombolysis impact
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
119. MDCT
In IE MDCT clarify the extent of the damage to the
valve and paravalvular region to provide the surgeon
the information required for débridement and a redo
of the valve replacement.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
120. Cardiac Catheterization
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.
In clinical practice, it is not commonly performed.
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.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
121. TAKE HOME
Many of the prosthesis-related complications can be
prevented or their impact minimized through optimal
prosthesis selection in the individual patient and
careful medical management and follow-up after
implantation.
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
mechanical valves can be quite difficult to assess with two-dimensional echocardiography. Although gross abnormalities can be detected, more subtle changes are often missed, especially with transthoracic imaging.
M-Mode image of a Bileaflet prosthetic valve -- leaflets form two parallel lines while open, disappearing when closed
measurementis often difficult because of the reverberations and artefactscausedbythe prosthesisstentorsewing ring
usually requires a position 0.5 to 1 cm below the sewing ring (toward the apex)
Schematic representation of the concept of the DVI. Velocity across the prosthesis is accelerated through the jet from the LVO tract. DVI is the ratio velocity in the LVO (Vlvo)to that of the jet (Vjet )
DVI is always less than unity, because velocity will always accelerate through the prosthesis. A DVI < 0.25 is highly suggestive of significant valve obstruction. Similar to EOA, DVI is not affected by high flow conditions through the valve, including AR, whereas blood velocity and gradient across the valve are.
Localized high gradient in a mitral bileaflet valve. A, Visualization of lateral (narrow arrow) and central (large arrow) jets on color Doppler image. B, C, Two Doppler envelopes are superimposed. The highest one, which presumably reflects the velocity within the central orifice, yields a value of peak gradient of 21 mm Hg, whereas the smallest one (lateral orifices) provides a gradient of 12 mm Hg.
Examples of bileaflet, single-leaflet, and caged-ball mechanical valves and their transesophageal echocardiographic char-acteristics taken in the mitral position in diastole(middle)and in systole(right). The arrows in diastole point to the occluder mechanism of the valve and in systole to the characteristic physiologic regurgitation observed with each valve. Videos 1 to 6 show the motion and color flow patterns seen with these valves Starr-Edwards valve, there is a typical small closing volume and usually little or no truetransvalvular regurgitation single tilting disc valves have both types of regurgitation, but the pattern may vary: the Bjork-Shiley valve has small jets located just inside the sewing ring, where the closed disc meets the housing, while the Medtronic Hall valve has these same jets plus a single large jet through a central hole in the disc The bileaflet valves typically have multiple jets located just inside the sewing ring, where the closed leaflets meet the housing, and centrally, where the closed bileaflets meet each other
The white or black arrows indicate the regurgitant jet(s). (A, B) Transoesophageal echocardiographic (TOE) views of normal physiological regurgitant jets (thin white arrows; A and B) and paravalvular regurgitant jets (thick white arrows; B) in mitral bileaflet mechanical valves
(G) TTE short axis view of a mild paravalvular regurgitation (one single jet occupying<10% of circumference) in a stented aortic bioprosthetic valve. (H) TOE short axis view of a severe paravalvular regurgitation (two jets occupying>20% of circumference) in a transcatheter bioprosthetic aortic valve
Pannus formation on a St Jude Medical valve prosthesis in the aortic position as depicted by TEE. The mass is highly echogenic and corresponds to the pathology of the pannus at surgery
Prosthetic St Jude Medical valve thrombosis in the mitral position(arrow)obstructing and immobilizing one of the leaflets of the valve. After thrombolysis, leaflet mobility is restored, and the mean gradient (Gr) is significantly decreased.
De-gassing involves separation of the gas contained in the water (or blood). In the case of a tran-sient drop in pressure, the gas separates out be-fore redissolving in the water when normal pressure is re-established.
ie, the atrial side of a mitral pros-thesis or the ventricular side of an aortic pros-thesis Strands have been found to be more common in patients undergoing TEE for evalu-ation of the source of embolism than in patients examined for other reasons the thera-peutic implications of prosthetic valve-associat-ed strands remain unclear. Importantly, if strands consist of collagen, aggressive thera-peutic anticoagulation is not likely to com-pletely eliminate their embolic potential
Real-time three-dimensional transesophageal echocardiography of a normal mechanical mitral valve visualized from the left atrium with the leafletsin systole (A) and in diastole (B).
Real-time three-dimensional transesophageal echocardiography of a bioprosthetic mitral valve with vegetation on the atrial side of the leaflet as visualized from the left atrium (A) and left ventricle (B). In image B, the struts of the bioprosthetic valve are clearly visible. Black arrow points to the vegetation
Long-axis view of left ventricular outflow tract (LVOT) perpendicular to prosthetic valve leaflets in systolic phase shows residual opening angle (dashed lines) is 19°, which is still within normal limit (≤ 20°)