Evaluation of prosthetic valve function and clinical utility.Ramachandra Barik
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 prosthetic valve function and clinical utility.Ramachandra Barik
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.
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASEPraveen Nagula
MITRAL VALVE ANATOMY , M MODE FINDINGS IN MITRAL STENOSIS,EVALUATION OF THE SEVERITY OF LESION,CALCIFIC MS,CCMA,CONGENITAL LESIONS,GUIDELINES ALL IN DETAIL....
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.
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.
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASEPraveen Nagula
MITRAL VALVE ANATOMY , M MODE FINDINGS IN MITRAL STENOSIS,EVALUATION OF THE SEVERITY OF LESION,CALCIFIC MS,CCMA,CONGENITAL LESIONS,GUIDELINES ALL IN DETAIL....
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.
Although right ventricular (RV) apical pacing is an established practice since the first pacemaker implant in early sixties, recent studies have highlighted its deleterious effects. This has led to a concept of ‘minimizing RV pacing’ to prevent long term negative effects of RV pacing. New features have been added to pacemaker models to achieve this aim. This article looks at negative effects of RV pacing and how to minimize it.
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 ..
Prosthetic paravalvular leaks (PVL) is an uncommon but serious complication after surgical valve replacement. Although surgery has been the traditional treatment of choice in hemodinamically significant PVL, percutaneous transcatheter closure is emerging as a novel and less invasive option for patients with high operative risk. Cardiac imaging, especially two- and three-dimensional transoesophageal echocardiography, plays an essential role in the diagnosis, guidance of intervention and subsequently in the evaluation of the outcomes of the procedure. The aim of this manuscript is to review the role of cardiac imaging techniques in the interventional management of patients with symptomatic PVL.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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
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.
2. OUTLINE
Approch
Clinical Examination
CXR
2Decho
Doppler
TEE
3D echo
CineFluoro
CT
Cardiac catheterisation
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
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 dysfunntion may be
nonspecific, making it difficult to differentiate the effects
of prosthetic valve dysfunction from
ventricular dysfunction,
pulmonar hypertension,
the pathology of the remaining native valves,
noncardiac 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 size of the prosthesis and characteristics of the
patient EVALUATION OF PROSTHERIC VALVE
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.
EVALUATION OF PROSTHERIC VALVE
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.
Sometimes the aortic root
can be inferiorly displaced
which will shift the aortic
valve below this line.
EVALUATION OF PROSTHERIC VALVE
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 left). This method is less reproducibleEVALUATION OF PROSTHERIC VALVE
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 cage (arrows), allowing blood flow around the occluder.EVALUATION OF PROSTHERIC VALVE
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-
Edwards, Edwards Lifescience)
much obstruction and little leakage.
Tilting disc prosthetic valve (Björk-
Shiley; Omniscience; Medtronic Hall)
less obstruction and more leakage.
Bileaflet prosthetic valves (St. Jude
Medical; Sorin Bicarbon; Carbomedics)
Less obstruction and more leakage.
Bioprostheses. little or no leakage
Homografts, pulmonary autografts, and
unstented bioprosthetic valves
(Medtronic Freestyle,
Toronto, Ontario, Canada)
almost unobstructive to blood flow.
Stented bioprostheses (leaflets
suspended within a frame)
obstructive to flow.
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 must be used to fully interrogate the regurgitant
signal.
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’sbody 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
EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
AT and AT/ET, angle-independent parameters.
AT/ET > 0.4
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. EVALUATION OF PROSTHERIC VALVE
FUNCTION-METHODS AND CLINICAL UTILITY
DVI had a sensitivity, specificity, positive and negative predictive values, and
accuracy of 59%, 100%, 100%, 88%, and 90%, respectively.
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
three separate jets - bileaflet valves
multi-windows examination
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
paravalvular.
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.
Pathologic jets tend to be high
velocity, intense, broad, and highly aliased.
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. Importance of TEE
Higher-resolution image than TTE
Proximity of the esophagus 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 angleEVALUATION 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
• For a single-leaflet
prosthetic valve, the
maximal opening angle is
recorded.
Normal limit (≤ 20°)
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
119. 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
Editor's Notes
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
measurementisoften difficult because of the reverberations andartefactscausedbytheprosthesisstentorsewingring
usually requires a position 0.5 to 1 cm below thesewing ring (toward the apex)
Schematic representation of the concept of the DVI.Velocity across the prosthesis is accelerated through the jetfrom the LVO tract. DVI is the ratio velocity in the LVO (Vlvo)tothat of the jet (Vjet)
DVI is always less than unity, because velocity will alwaysaccelerate through the prosthesis. A DVI < 0.25 is highly suggestive ofsignificant valve obstruction.Similar to EOA, DVI is not affectedby high flow conditions through the valve, including AR, whereas bloodvelocity and gradient across the valve are.
Localized high gradient in a mitralbileaflet valve. A, Visualization of lateral (narrow arrow) and central (large arrow) jets oncolor Doppler image. B, C, Two Doppler envelopes are superimposed. The highest one, which presumably reflects the velocity withinthe central orifice, yields a value of peak gradient of 21 mm Hg, whereas the smallest one (lateral orifices) provides a gradient of12 mm Hg.
Examples of bileaflet, single-leaflet, and caged-ball mechanical valves and their transesophagealechocardiographic char-acteristics taken in the mitral position in diastole(middle)and in systole(right). The arrows in diastole point to the occluder mechanismof the valve and in systole to the characteristic physiologic regurgitation observed with each valve. Videos 1 to 6 show the motion andcolor flow patterns seen with these valvesStarr-Edwards valve,there is a typical small closing volume and usually little or no truetransvalvular regurgitationsingle tilting disc valveshave both types of regurgitation, but the pattern may vary: theBjork-Shiley valve has small jets located just inside the sewing ring,where the closed disc meets the housing, while the Medtronic Hallvalve has these same jets plus a single large jet through a centralhole in the discThe bileaflet valves typically have multiplejets located just inside the sewing ring, where the closed leaflets meet the housing, and centrally, where the closed bileaflets meet eachother
The white or black arrows indicate the regurgitant jet(s). (A, B)Transoesophagealechocardiographic (TOE) views of normal physiological regurgitant jets (thin white arrows; A and B) and paravalvularregurgitant jets(thick white arrows; B) in mitralbileaflet mechanical valves
(G) TTE short axis view of a mild paravalvular regurgitation (one single jet occupying<10% ofcircumference) in a stented aortic bioprosthetic valve. (H) TOE short axis view of a severe paravalvular regurgitation (two jets occupying>20% ofcircumference) in a transcatheterbioprosthetic aortic valve
Pannus formation on a St Jude Medical valve prosthesis in the aortic position as depicted by TEE. The mass is highly echogenicand 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 ofthe valve. After thrombolysis, leaflet mobility is restored, and the mean gradient (Gr) is significantly decreased.
De-gassing involves separation of the gas containedin 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 normalpressure is re-established.
ie, the atrial side of a mitral pros-thesis or the ventricular side of an aortic pros-thesisStrands have been found to be morecommon in patients undergoing TEE for evalu-ation of the source of embolism than in patientsexamined for other reasons the thera-peutic implications of prosthetic valve-associat-ed strands remain unclear. Importantly, ifstrands 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 leafletsinsystole (A) and in diastole (B).
Real-time three-dimensional transesophageal echocardiography of a bioprostheticmitral valve with vegetation on the atrial side of the leaflet asvisualized 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 thevegetation
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°)