Recommended
More Related Content
What's hot
What's hot (20)
Similar to PROSTHETIC HEART VALVES
Similar to PROSTHETIC HEART VALVES (20)
More from dibufolio
More from dibufolio (20)
Recently uploaded
Recently uploaded (20)
PROSTHETIC HEART VALVES
- 1. VALVE SURGERIES & PROSTHETIC HEART VALVES Dr. Dibbendhu Khanra SR2
- 2. BMV TAVI MITRACLIP CARDIOBAND TENDYNE VALVE REPAIR REPLACEMENT VALVE INTERVENTIONS When to refer? What to choose? How to follow up? How to catch complications? When to refer back? ECHO FLUORO CT NO PERCUTANOUS INTERVENTIONS CASE BASED APPROACH 2
- 3. CASE 1 21 year female Unmarried Poor background NYHA4 AF on warfarin Severe MR No h/o rheumatic fever LVEF 60% LVESD 42mm Severe TR (V/P 3.5/50) TC annulus 50mm 3
- 4. CASE 2 21 year female Unmarried Well-to-do NYHA4 Sinus rhythm Severe MR No h/o rheumatic fever LVEF 60% LVESD 36 mm Mod TR (V/P 2.4/24) TC annulus 28 mm 4
- 6. REPAIR VS REPLACEMENT 6 PREOPERATIVE ASSESSMENT OF REPAIRABLITY
- 7. SEVERE MR: NOT SUFFICIENT FOR SURGEONS Carpentier I: Func MR Carpentier II: MVP Carpentier IIIA: Rheumatic Carpentier IIIB: Ischaemic 7
- 10. 10 MITRAL VALVE REPAIR PML REPAIR MITRAL RING CHORDAL REPAIR CHORDAL TRANSFER CARPENTIER’S REPAIR COAPSYS
- 11. 11 MITRAL VALVE REPLACEMENT CHORDAL PRESERVATION DAVID’S FEIKE’S KHONSARI’S MICKI’S ROSE & OS’S
- 12. BACK TO OUR CASES Case 1 CIIIA MR: Rheumatic MVR TC annuloplasty Case 2 CII MR: P2 prolapse Repair No TC annuloplasty 12
- 14. MAZE: REDUCTION BUT NOT RESOLUTION OF AF 14 MAZE: NOT ALONG MVR
- 15. CABG: SEVERE MR MV REPAIR VS REPLACEMENT MV annuloplasty - Recurrence of MR (Mostly in Basal aneurysm) MVR - LV dysfunction - mortality 15 Treatment of choice IIb Not done Except Basal anurysm
- 16. OMV IN CONTEMPORARY WORLD 16 AS/MS PATIENTS UNDERGOING AVR OMV IS NOT A WISE CHOICE
- 17. CASE 3 71 year tall healthy male Financially well off Good QOL Symptomatic NSR Severe AS AVA 1.2 cm2 iAVA 0.6cm2 Mean PG 42 mmHg Mild AR LVEF 60% AOR 1.8 cm CAG: Prox LAD 90% Max PG 65 mmHg Max PG 32 mmHg 17
- 18. PRESSURE RECOVERY 18 ASIAN FEMALES SMALL STJ <3CM HIGHER AVA DOPPLER >1CM2 LOWER MEAN PG <30MMHG AVAPR
- 19. 19 AVA SHOULD ALWAYS BE INDEXED
- 20. AVR VS AVR+CABG HF Gen cond. 20 CABG: MOD TO SEVERE AS (EVEN ASYMPTOMATIC) = AVR IIA >80 years: High Mortality
- 21. CASE 4 21 year male Good financial state NYHA3 Sinus rhythm Severe AR LVD S/D 56 mm/66 mm LVEF 60% Bicuspid aortic valve AA 5 cm 21
- 22. 22 Repair is better than replacement
- 24. 24 AORTIC REPAIR BAV Commisurial angle b/w fused cusp <160’: REPAIR
- 25. AVR VS BENTAL •BAV: Bental •Marfan: Bental 25
- 26. BENTAL: INDICATION • CTD/ Marfan’s • BAV 26
- 27. BACK TO THE CASES 71 yr Severe symp AS Degenerative Prox LAD 90% AVR+CABG Young Severe symp AR Aorta dilated AVR+ AOR replacement Bental Case 3 Case 4 27
- 28. CASE 5 33 yr male IVDU RHF Fever Severe TR v/p 3.5/ 50 4 wk AB TC and RV Veg 5cm CASE 5: TVR +RESECTION OF RV VEG 28
- 29. 29 Repair is better than replacement
- 31. AVAILABLE PROSTHETIC VALVES Mechanical Bileaflet (St Jude)(A) Single tilting disc (Medtronic Hall)(B) Caged-ball (Starr-Edwards) (C) Biologic Stented Porcine xenograft (Medtronic Mosaic) (D) Pericardial xenograft (Carpentier- Edwards Magna) (E) Stentless Porcine xenograft (Medronic Freestyle) (F) Pericardial xenograft Homograft ( allograft) Percutaneous Expanded over a balloon (Edwards Sapien) (G) Self –expandable (CoreValve) (H) 31
- 32. BALL CAGE VALVE Durabilty upto 40 yr High profile Hemolysis High thrombogenecity Poor hemodynamics in small sizes Ball variance 32
- 35. Bjork Shiley valve mitral valve aortic valve Chest X-ray 35 TTK/ Bjork Shiley Annulus – radio-opaque Disc – radio-lucent
- 37. Bileaflet Mechanical Prosthetic Heart Valves Each model has its own cinefluoroscopic features which allow its identification Closing angle (CA) Opening angle (OA) Bileaflet Mechanical Prosthetic Heart Valves >130°<24°Carbomedics >148°<29°Edwards Duromedics >135°<24°Sorin Bicarbon >120°<13°St.Jude Medical Standard 37 St Jude Annulus – radio-lucent Disc – radio-opaque
- 38. 38 Fluoroscopy Medtronic Starr Edward St Jude
- 39. 39 CT: ST JUDE BILEAFLET Mitral Aortic
- 40. METALLIC VALVE: IS MRI SAFE? 40
- 41. MECHANICAL:TILTING DISC VS BILEAFLET Low profile Less thrombogenic Anticoagulation required Central laminar flow. Good hemodynamics even in small sizes One large eccentric jet One small eccentric jet Sudden catastrophic valve thrombosis Bileaflet Tilting disc Low profile Less thrombogenic Anticoagulation required Central laminar flow. Good hemodynamics even in small sizes Two large lateral jet One small central jet no Sudden catastrophic valve thrombosis 41
- 42. WARFARIN AND INR AVR/N EF/BL 2.5 MVR AF AVR/ LOW EF TTK H/O EMBOLUS 3 NOAC class III 42
- 43. MHV+WARFARIN+MAJOR BLEEDING IV VIT K (MAY BE REPEATED AFTER 12 HRS) PCC LARGE VOLUME FFP (DIURETIC COVERAGE) FVIIA INR 4HRLY FOR 1 DAY HOLD/ RESUME ICH 7-14 DAYS ECH 24-48 HRS 43
- 44. BIOLOGICAL VALVE Xenograft vs allograft Porcine vs bovine vs equine Aortic vs pericardial Stented vs stentless Homograft vs autograft 1g vs 2g vs 3g (fixative) High pressure vs zero-pressure Miniroot vs full-root Right sided valve 44 Pulmonary prosthetic valve - TOF absent PV - TOF ICR severe PR - preg/ severe PR/ RVE - Pericardial - Melody (BIJV)
- 46. WARFARIN X 3 MONTHS: CLASS II INDICATION NOAC under study Endothelialisation Postoperative AF 46
- 48. PROSTHETIC VALVE: COMPARISON Mechanical Bioprosthesis PPM more Reopertaion + +++ Infection +++ + Dehiscence + +++ Stenosis + ++ Degeneration + +++ Hemodynamics poor better 48
- 49. 49
- 50. SINGLE VALVE VS DOUBLE VALVE 50 DOUBLE VALVE REPLACEMENT WHEN INDICATED POOR OUTCOME IN LV DYSFUNCTION
- 51. Mechanical (Warfarin) Bleeding/ embryoptahy Bioprosthetic (reoperation) YOUNG FEMALE/ PFEGNANCY 51
- 52. WARFARIN EMBRYOPATHY IS A MYTH 52 ESC: <5mg = safe in Pregnancy IC TM1: <5mg =? fetal loss TM2: <5mg = No Embryopathy TM3: <5mg = No Embryopathy LOW DOSE WARFARIN SAFE IN PREGNANCY
- 53. BACK TO CASES REPLACE VALVE Severe rheumatic MR Severe AR Severe primary TR Severe AS 21/F/UM/AF/poor TTK SHRICHITRA + warfarin INR 3+ aspirin 75 71/M/NSR/ well-off Stentless bioprosthetic + warfarin 3m 21/M/BAV/NSR/poor BENTAL/ST JUDE BL + warfarin INR 2.5+ aspirin 75 33/M/IVDU Perimount + warfarin 3m 53
- 54. CLINICAL FINDING OF PROSTHETIC VALVE 54
- 55. PROSTHETIC FINGERPRINT 3m Clicks Shadowing effect Stenotic: Velocity/ Gradient/EOA TVI ratios Regurgitation pattern Regression of symptoms/ echo abnormalities Comparison for future 55
- 56. SHADOWING EFFECT St.Jude Aortic Prosthesis Reverberations extending into the left atrium. Obscure the presence of mitral regurgitation. 56
- 57. INHERENTLY STENOTIC MECHANICAL VALVES Sewing ring of the valve may be too small Functionally stenotic as the patient grows Patient Prosthesis Mismatch EOA < area of the sewing ring VALVE ASSEMBLY (OCCLUDER MECHANISM) Leaflets of bioprosthesis are stiffer PRESERVATION PROCESS/ HIGH PRESSURE Stented bioprosthetic valves>mechanical valves> stentless valves (size is kept similar). 57
- 58. ALL STENOSIS ARE NOT BAD 58
- 60. ALL REGURGITATIONS ARE NOT BAD Existence of multiple jets 60
- 61. INTRAVALVULAR REGURGITATION Closure backflow Flow reversal required to close the occluding mechanism Ends when the occluder mechanism is seated in the sewing ring Leakage after the prosthesis closed. Small retrograde flow between and around the occluding mechanism. Part of the design of the prosthesis Provide a washing mechanism and prevent thrombus formation. 61 Paravalvular leaks are pathological
- 63. INDIRECT MEASURES 63 AORTIC MITRAL <0.3 obstruction >0.3 regurgitation < 2.5 obstruction > 2.5 regurgitation >0.35 regurgitation >0.45 regurgitation
- 65. SIZE MATTERS LESSER THE SIZE MORE THE VELOCITY MORE THE GRADIENT LESSER THE EOA 65
- 66. SIZING 66
- 68. COMPLICATIONS OF PROSTHETIC VALVE 1.Primary mechanical failure - BALL VARIANCE - Fracture Struts - Disc Fracture 2. Nonstructural dysfunction - Pannus - PPM 3. Endocarditis (Vegetaton/ Abscess/ dehiscence) 4. Thrombus 5. Embolism 6. Hemorrhage 7. Hemolysis 68
- 69. BALL VARIANCE: STARR EDWARD VALVE 69
- 71. CASE 6 Severe MR St jude 25 MV 3yrs BACK S/O SOB MDM INR 1 THROMBUS 71
- 72. CASE 7 Severe MR AF Hancock 29 MV 3M BACK S/O SOB MDM THROMBUS 72
- 73. AHA/ACC 73
- 74. FIBRINOLYSIS PROTOCOLS Pt unstable (SHORT PROTOCOL) Recombinant tissue plasminogen activator (rtPA) 10 mg bolus + 90 mg in 90 mins, or Streptokinase 1500000 U in 60 mins without heparin Pt stable (LONG PROTOCOL) Streptokinase 500000 IU in 20 mins followed by 1500000 IU for 10 h without heparin. rtPA 10 mg bolus, 50 mg during the first hour, 20 mg during the second hour and 20 mg during the third hour. 74
- 76. PSEUDORESPONDERS OF TLT (50%) Complete TLT: PG normalizes but abnormal leaflet motion at Fluoroscopy. Suggests incomplete resolution of valve obstruction . Trigger for a late rethrombotic process. Continue TLT until normalization of leaflet motion 76
- 77. FLUOROSCOPY GUIDED THROMBOLYSIS 77 St Jude: without radio-opaque annulus ring
- 78. Fluoro: Abnormal motion Unstable – 1 hr Stable – 12 hrs Fluoro: Stuck valve (unless proved otherwise) PVT TLT Acute onset Obstructive symp TLT to cont until normal Echo: OPVT Thrombus Primary failure Sx High risk TLT Keep INR high NOPVT INR low Warfarin non- compliant Sx If still symp Surgeon’s nightmare Pannus Vegetation PPM 78
- 79. PANNUS 79
- 81. THROMBUS PANNUS V/P High High Prevalence More Less Location Orificial Annular Frequency Mitral Aortic Echogenecity Less (TEE VIR> 0.7) High (TEE VIR> 0.7) Size (diameter) >2.8 cm <2.8 cm Mobility Mobile Fixed INR Deranged Normal SEC + - Presentation Acute Gradual (12m) TLT + - Sx +/- + Prosthetic (max) Ball cage Tilting disc> biological 81 PANNUS VS THROMBUS
- 82. THROMBUS VS PANNUS: PATHOLOGY TLT Sx 82
- 83. TWELVE YEAR OLD MITRAL PORCINE PROSTHESIS Severe Fibrocalcific Degeneration High Mean Pressure Gradient 83
- 84. Thickened & Fibrotic Leaflets With Decreased Mobility severe MR (eccentric) 84 TWELVE YEAR OLD MITRAL PORCINE PROSTHESIS
- 85. PRIMARY TISSUE GENERATION Seen with bioprosthetic valves. Can lead to stenosis as well as regurgitation. Fibrocalcific degeneration. Homografts are less durable . MITRAL > AORTIC > TRICUSPID 10 years: primary tissue failure 30%. 15 years: 40-70%. Pericardial valves have lower rates Rupture calcification: severe regurgitation: Em Sx After 10 yrs: TEE – class I indication 85
- 87. CASE 8 33F (AOR 1.8 cm) / Severe AS/ severe LVH AVR with 21mm ATS BL valve 5 yrs back LVH present, high AoVmax/ PG, Aortic ESM 87 Radio-opaque annulus Radio-opaque valves NOT ST JUDE
- 88. PPM Late> Early post-operative Aortic> mitral Small size vs large size Tissue valve> mechanical AVR for AS>AR Failure of regression of LV mass Exertional symptoms No evidence of primary valve dysfunction V/p high D/D: thrombus (mitral), pannus (aortic), obstruction 88
- 90. PPM: MITRAL PROSTHESIS PHT<130 ms iEOA<1.2 cm2 90
- 91. PPM: DIAGNOSIS & PREVENTION 91 Sizer Chart Dilatation Ross
- 92. CASE 9 21 F Married, planning to conceive Financial restraints Symptomatic NSR Severe AS AOR 1.8 cm LVEF 60% ROSS PROCEDURE 92
- 94. ST JUDE MVR: FUO FOR 2 MONTHS TTE-NO VEGETATION TEE – LARGE VEGETATION 94
- 95. 95 Post MV repair Post MV Hancock
- 96. VEGETATIONS o Fever Infective Regurgitative> stenotic Stenotic: V/P high Mitral> aortic Mechanical> biological TEE>TTE Commonest: sewing ring Complications: obstruction, dehiscence, abscess, fistula May lead to stuck valve D/D: Pannus, Loose suture, Thrombus Prolonged antibiotics - Sx 96
- 97. NVE PVE Str VGS/ Str. gallolyticus Pen 4w OR Cx 4w OR Cx + Genta 2w OR Vanco 4w (Pen/ BL Res) Pen 6w OR Cx 6w OR Cx + Genta 2w/ 6w (MIC<0.12/>0.12) OR Vanco 6w Str. Pneu/ Str. pyogens Pen 4w OR Cx 4w OR Vanco +Rifam 4w (Pen/ BL Res) Pen 6w OR Cx 6w OR Vanco +Rifam 6w (Pen/ BL Res) Str. Gr B, C, G Cx 4w +Genta 2w Cx 6w +Genta 2w Staph Oxacillin S Nafcillin 6w OR Cefazolin 6w Nafcillin >6w + Genta 2w + Rifam >6w Oxacillin R Vanco 6w OR Dapto 6w Vanco >6w + Genta 2w + Rifam >6w Septran if Vanco R Enterococcus Pen S + Genta S Pen S + Genta R Pen R + Genta S Pen R + Genta R Ampi+Genta 4-6w OR Ampi+Cx 6w Ampi+Strep 4-6 w OR Ampi+Cx 6w Vanco +Genta 6w LNZ/ Dapto >6w GNB HACEK Cx OR Ampi OR Cipro 4w Non HACEK Cx +Genta 6w + Surgery 97
- 98. PROPHYLAXIS IS A MYTH Peri-operative antibiotics 98
- 99. Double density in aorta Porcine aortic root within patient’s aortic root 99
- 100. PERIVALVULAR REGURGITATION Commonest due to infection D/D abscesses, dehiscence, fistulas All are Duke’s criteria May be hyperdense or hypodense Early dehisence: operative complication Late dehisence: infection or calcification Rocking motion of sewing ring (echo < fluoro) 100 Mitral Aortic
- 102. AORTIC VALVE DEHISENCE/ TILTING DISC 102 TTK Chitra: radioopaque annulus Radiolucent Disc
- 105. MYCOTIC ABSCESS LV-RV FISTULA 105 AVR HANCOCK: ABSCESS + FISTULA
- 106. HEMOLYSIS IN PROSTHETIC VALVE SETUP 106 Schistocytes Indirect Bilirubin Anaemia Jaundice Splenomegaly
- 107. SUMMARY: CHOOSING A VALVE Repair> Replacement Age Bleeding risk Cost Availability Small root Warfarin <5mg safe in pregnancy DVR when indicated CABG in <70 yrs OMV along with AVR carries poor outcome Tr.annuloplasty in severe TR or annulus>40mm 107
- 108. Prosthetic fingerprint at first visit Aortic –TTE Mitral - TEE 3D – dysfunction +pathology Fluoro – only dysfunction CT - dysfunction +pathology Vegetation – TEE Acute obstruction – thrombus – TLT Chronic obstruction – pannus Acute regurgitation – surgical complication Chronic regurgitation - infection 108 SUMMARY: IMAGING A VALVE
- 109. SUMMARY: MITRAL PROSTHETIC DYSFUNCTION 109
- 110. SUMMARY: AORTIC PROSTHETIC DYSFUNCTION 110
- 111. SUMMARY: THROMBUS VS PANNUS 111
- 112. SUMMARY: MANAGING COMPLICATION Primary failure Reoperation and repair Pannus Surgery PPM Prevention Thrombus Sx/ thrombolysis/ INR Vegetation Antibiotics Dehisence / fistula Reoperation Abscess AB/ Sx 112
Editor's Notes
- Exact role of warfarin not known..but it has been seen that ots on warf have less TIA or embolism
- Video intensity resistance