Echo Evaluation of a Mitral Valve Prostheses Sunday, February 14, :50 2:10 PM 20 min

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1 2016 ASE State of the Art Echocardiography Course Tucson, AZ Echo Evaluation of a Mitral Valve Prostheses Sunday, February 14, :50 2:10 PM 20 min 1 M U H A M E D S A R I Ć, M D, P H D D i r e c t o r o f E c h o c a r d i o g r a p h y L a b D i r e c t o r o f O p e r a t i o n s, N o n i n v a s i v e C a r d i o l o g y A s s o c i a t e P r o f e s s o r o f M e d i c i n e N e w Y o r k U n i v e r s i t y L a n g o n e M e d i c a l C e n t e r NYU Leon H. Charney Division of Cardiology

2 Disclosures 2 Speakers Bureau Philips, Medtronic NYU Division of Cardiology

3 IMAGING OF PROSTHETIC VALVES St. Jude mitral valve in anti-anatomic position. Prosthetic valves have been in clinical use for about 50 years. Until recently, cross-sectional 2D imaging was practically the only way to visualize them. With 3D echocardiography images start to match the appearance of actual valves s 2000 s NYU Division of Cardiology 3

4 HISTORICAL DEVELOPMENT OF PROSTHETIC VALVES Clip Alfieri stitch Mitral Valve Repair Bioprosthetic Valves Mechanical Valves 1960 s 1970 s 1980 s 1990 s 2000 s NYU Division of Cardiology 4

5 Valve Prostheses Mechanical Bioprosthetic First implantation First implantation Trained at Bellevue Hospital, now part of NYU Medical Center Starr-Edwards mechanical valve Carpentier-Edwards bioprosthetic valve Albert Starr (b in New York) Miles Lowell Edwards ( ) Alain Carpentier (b in Toulouse) NYU Division of Cardiology 5

6 MECHANICAL VALVES (Year of First Introduction) Starr- Edwards (1960) Björk- Shiley (1969) >> Discontinued 1986 Hall- Kaster (1977) >> Medtronic Hall Omniscience (1978) Nicoloff- Posis (1977) >> St Jude Omnicarbon (1984) Carbomedics (198o s) BALL-IN-CAGE SINGLE LEAFLET BILEAFLET NYU Leon H. Charney Division of Cardiology 6

7 Mechanical Mitral Valve Prostheses 7 Ball-in-Cage Effective Orifice Area (cm2) Metal cage + silastic ball Single Tilting Disc Partly or fully made of pyrolytic carbon (originally used in nuclear reactors) Double Tilting Disc Based on data from N Eng J Med 1996;335(6): Increase in Valve Orifice Area Jack Bokros (b. 1935) Inventor of pyrolytic carbon NYU Leon H. Charney Division of Cardiology

8 QUESTION #1: How many prosthetic valves are implanted in the United States annually? QUESTION #2: What percentage of implanted valves are mechanical? A. 1,000 B. 10,000 C. 100,000 D. 1,000,000 A. 10% B. 30% C. 50% D. 70% Annually, approximately 100,000 prosthetic valves are implanted in the United States, approximately 50% of which are mechanical. United States represents approximately 1/3 of the world valve prosthesis market. NYU Leon H. Charney Division of Cardiology 8

9 Mechanical Prostheses 9 B A L L - IN- C A G E NYU Leon H. Charney Division of Cardiology

10 Starr-Edwards Ball-in-Cage Valve 10 Albert Starr (b in New York) American Surgeon Trained at Bellevue Hospital, now part of NYU Figure Bottle Stopper 1858 patent to JB Williams from New York Miles Lowell Edwards ( ) American Engineer

11 A B C LA DC LA D RA RA LV LV Figure 11

12 2D TEE: Starr-Edwards Mitral Valve year-old woman; s/p Starr-Edwards MVR (Model 6120; size 2M = 28 mm) 35 years earlier in Rochester, NY LA LAA RA LA LV RV LV NYU Leon H. Charney Division of Cardiology

13 Starr-Edwards Mechanical Valve (Model 6120) Used since 1960 s Still in production and implanted mostly in developing countries due to its reasonable cost. NYU Division of Cardiology 13

14 3D TEE: Starr-Edwards Valve AV 14 Atrial Septum LA LAA Coronary Sinus LV LA Side NYU Leon H. Charney Division of Cardiology

15 Starr-Edwards Valve on Fluoroscopy 15 N Engl J Med. 2008;358(21):e24 NYU Leon H. Charney Division of Cardiology

16 Mechanical Prostheses 16 S I N G L E T I L T I N G D I S C NYU Leon H. Charney Division of Cardiology

17 SUMMARY: SINGLE TILTING DISC MECHANICAL PROSTHESES Björk-Shiley central struts Medtronic Hall central strut Omniscience No central struts NYU Division of Cardiology 17

18 Björk-Shiley Single Tilting Disc Valve 18 Viking Björk ( ) Swedish Cardiac Surgeon Donald Shiley ( ) American Engineer Figure

19 Björk-Shiley Single Tilting Disc Valve Used , discontinued after a series of strut fractures. NYU Division of Cardiology 19

20 Fluoroscopy: Björk-Shiley MVR 20 NYU Leon H. Charney Division of Cardiology

21 B LA A C * LV AV MV D AV MV 21 Figure

22 2D Echo: Björk-Shiley Mitral Prosthesis year-old woman; s/p Björk-Shiley MVR in 1980 s Now presents with progressive dyspnea LA RV LV LV Aorta Aorta LA 2D TEE 2D TTE NYU Division of Cardiology

23 2D TEE: Björk-Shiley MVR 23 LA LAA LV NORMAL Mild Mitral Regurgitation (Washing Jets) ABNORMAL Paravalvular Mitral Regurgitation NYU Leon H. Charney Division of Cardiology

24 3D TEE: Björk-Shiley Mitral Prosthesis 24 DIASTOLE: Valve Open SYSTOLE: Valve Closed SYSTOLE: Paravalvular Leak NYU Leon H. Charney Division of Cardiology

25 3D TEE: Björk-Shiley Mitral Prosthesis 25 LAA AV Atrial Septum Coronary Sinus Severe paravalvular mitral regurgitation NYU Division of Cardiology

26 3D TEE: Björk-Shiley Valve year-old woman; s/p Björk-Shiley MVR in 1980 s Now presents with hemolytic anemia AV LAA Atrial Septum PVL Coronary Sinus NYU Leon H. Charney Division of Cardiology

27 Hall-Kaster (Medtronic Hall) Singe Tilting Disc Valve 27 Karl Victor Hall (b. 1917) Norwegian Surgeon Robert Kaster (b. 1933) American Engineer Figure

28 Medtronic Hall (Hall-Kaster) Singe Tilting Disc Valve 28 Karl Victor Hall ( ) Norwegian Surgeon Robert Kaster (b. 1933) American Engineer Figure

29 Medtronic Hall Single Tilting Disc Valve Used since 1977; still in production NYU Division of Cardiology 29

30 Fluoroscopy: Medtronic Hall MVR + AVR 30 NYU Division of Cardiology

31 2D TEE: Medtronic Hall MVR 31 LA RA LV Single-disc mechanical prosthesis with a centrally protruding shaft Physiologic central mitral regurgitation ( donut hole regurgitation ) NYU Leon H. Charney Division of Cardiology

32 Medtronic Hall Valve 32 LAA AV Atrial Septum LA Coronary Sinus LV Single-disc mechanical prosthesis with a centrally protruding shaft NYU Division of Cardiology Physiologic central mitral regurgitation ( donut hole regurgitation )

33 Omniscience Single Tilting Disc (Derived from Lillehei-Kaster Valve) 33 C. Walton Lillehei ( ) American Surgeon Robert Kaster (b. 1933) American Engineer Figure

34 Fluoroscopy: Omniscience MVR 34 NYU Division of Cardiology

35 2D TEE: Omniscience Mitral Valve Prosthesis 35 LA LA LV LV Single-disc mechanical prosthesis with no protruding shaft Minimal physiologic regurgitation NYU Leon H. Charney Division of Cardiology

36 OMNISCIENCE Single Tilting Disc Mechanical Valve Used since 1978; still in production. OMNICARBON Variant of Omniscience, made purely of pyrolytic carbon; in production since 1984 NYU Division of Cardiology 36

37 3D TEE: Omniscience Valve 37 AV AV Ligated LAA Atrial Septum LAA Atrial Septum Coronary Sinus Coronary Sinus NYU Leon H. Charney Division of Cardiology

38 SUMMARY: SINGLE TILTING DISC MECHANICAL PROSTHESES Björk-Shiley central struts Medtronic Hall central strut Omniscience central struts NYU Division of Cardiology 38

39 Mechanical Prostheses 39 D O U B L E T I L T I N G D I S C NYU Leon H. Charney Division of Cardiology

40 St. Jude Bileaflet Tilting Disc Valve (Nicoloff-Posis-Villafaña Valve) 40 Named after St. Jude Thaddeus, patron saint of difficult cases by Manuel Villafaña whose son was recovering from serious disease at the time. Demetre Nicoloff ( ) American Surgeon Manuel Villafaña (b in New York) American Entrepreneur Apostle Jude Thaddeus by Anthony van Dyck c Figure

41 Fluoroscopy: St. Jude MVR 41 NYU Division of Cardiology

42 2D TEE: Normal St. Jude MVR 42 LA LA RA RV LV LV Double-disc mechanical prosthesis 2 out of 6 jets of physiologic regurgitation seen NYU Division of Cardiology

43 ST. JUDE Bileaflet Tilting Disc Mechanical Valve Used since 1977; still in production CARBOMEDICS Very similar to St. Jude valve NYU Division of Cardiology 43

44 3D TEE: St Jude MVR 44 AV LAA Atrial Septum PVL Physiologic Jets Coronary Sinus St. Jude mitral valve in anti-anatomic position. NYU Leon H. Charney Division of Cardiology Multiple jets of physiologic regurgitation + Paravalvular leak At 7 o clock

45 St. Jude Prosthesis 45 AV PVL LAA Atrial Septum Coronary Sinus St. Jude mitral valve in anatomic position. Paravalvular Leak (PVL) At 10 o clock NYU Leon H. Charney Division of Cardiology

46 3D TEE: St Jude MVR with Multiple Paravalvular Leaks 46 PVL PVL PVL NYU Leon H. Charney Division of Cardiology

47 3D TEE: St Jude MVR Closure of PVLs 47 NYU Leon H. Charney Division of Cardiology

48 Bioprostheses 48 NYU Leon H. Charney Division of Cardiology

49 Bioprostheses 49 He developed the concept and coined the term bioprosthesis. Alain Carpentier (b in Toulouse) French Surgeon Figure

50 Autograft Ross procedure Bioprostheses Homograft Cadaveric aortic valve Xenograft (Heterograft) Porcine Bovine The only type used in mitral position CARPENTIER S CONTRIBUTIONS Glutaraldehyde preservation Use of pig aortic valve in human mitral position Prosthetic stent Alain Carpentier (b in Toulouse) NYU Leon H. Charney Division of Cardiology 50 Coined the term bioprosthesis ( bioprothèse in French)

51 Bioprosthetic Valves 51 Bovine pericardium Porcine aortic valve Stentless Source: J Am Coll Cardiol Intv 2011;4: NYU Leon H. Charney Division of Cardiology

52 BIOPROSTHETIC VALVES: X-RAY IMAGING 52 HANCOCK standard Hancock modified MEDTRONIC Hancock II Medtronic Mosaic CARPENTIER- EDWARDS (CE) CE, supra-annular CE, pericardial CE, Perimount (Magna) Source: J Am Coll Cardiol Intv 2011;4: NYU Leon H. Charney Division of Cardiology

53 Carpentier-Edwards PERIMOUNT Stented Bovine Pericardial Valve One of many types of bioprosthetic valve. NYU Leon H. Charney Division of Cardiology 53

54 3D TEE: Normal Carpentier-Edwards MVR 54 AV AV LAA Atrial Septum Atrial Septum LAA Coronary Sinus LA Side Coronary Sinus LV Side NYU Leon H. Charney Division of Cardiology

55 3D TEE: Edward Magna Bio-MVR 55 LV Side LV Side NYU Leon H. Charney Division of Cardiology

56 3D TEE: Stenosed Mitral Bioprosthesis 56 AV AV LAA Atrial Septum Atrial Septum LAA Coronary Sinus Stenosed mitral bioprosthesis (LA side) Coronary Sinus Stenosed mitral bioprosthesis (LV side) NYU Leon H. Charney Division of Cardiology

57 Balloon Valvuloplasty of Stenosed Mitral Bioprosthesis 57 NYU Leon H. Charney Division of Cardiology Fluoroscopic Guidance of Balloon Valvuloplasty

58 Bioprosthetic Mitral Balloon Valvuloplasty 58 NYU Leon H. Charney Division of Cardiology

59 Mitral Valve Repairs 59 NYU Leon H. Charney Division of Cardiology

60 Ringless MV Repairs Ring (Full circle) Band (Partial circle) Alain Carpentier (b in Toulouse) Father of MV repair CARPENTIER S CONTRIBUTIONS Use of prosthetic ring Techniques of mitral repair NYU Leon H. Charney Division of Cardiology 60

61 Mitral Valve Repairs 61 R I N G L E S S R E P A I R NYU Leon H. Charney Division of Cardiology

62 Ringless Mitral Valve Annuloplasty Not commonly performed. A B LA Side LV Side Figure 62

63 Ringless Mitral Valve Repair 63 NYU Leon H. Charney Division of Cardiology

64 Ringless Mitral Valve Repair 64 LA LA LV LV AV NYU Leon H. Charney Division of Cardiology

65 Mitral Valve Repairs 65 R I N G A N D B A N D A N N U L O P L A S T I E S NYU Leon H. Charney Division of Cardiology

66 Annuloplasty Rings & Bands 66 Full annuloplasty ring Partial annuloplasty ring (band) NYU Leon H. Charney Division of Cardiology

67 Mitral Valve Repair With Annuloplasty Band 67 Stephen Colvin ( ) Aubrey Galloway Head, NYU CT Surgery Colvin-Galloway Future Band, a semi-rigid annuloplasty band (2001) Figure

68 Colvin-Galloway Future Band Mitral Valve Repair One of several types of annuloplasty bands LA Side LV Side NYU Division of Cardiology 68

69 Mitral Band Annuloplasty 69 NYU Leon H. Charney Division of Cardiology

70 Mitral Annuloplasty: Partial Ring (Band) 70 AV Atrial Septum LAA Coronary Sinus Normal Annuloplasty Band NYU Leon H. Charney Division of Cardiology

71 Mitral Annuloplasty: Partial Ring (Band) 71 AV Atrial Septum LA LAA LV Coronary Sinus Dehisced Annuloplasty Band NYU Leon H. Charney Division of Cardiology

72 3D TEE: Mitral Annuloplasty Band year-old man; s/p mitral band annuloplasty a year earlier Now presents with Staph aureus bacteremia AV LAA Coronary Sinus Atrial Septum Leak NYU Leon H. Charney Division of Cardiology

73 2D TEE: Mitral Annuloplasty Band year-old man; s/p mitral band annuloplasty a year earlier Now presents with Staph aureus bacteremia LA LAA AV LVOT Leak LV NYU Leon H. Charney Division of Cardiology

74 Mitral Valve Repair With Annuloplasty Ring 74 Figure

75 A B Carpentier Physio Mitral Valve Ring One of many types of annuloplasty rings C D Figure 75

76 Mitral Ring Annuloplasty 76 NYU Leon H. Charney Division of Cardiology

77 Mitral Annuloplasty: Full Ring 77 AV LAA Atrial Septum Coronary Sinus NYU Leon H. Charney Division of Cardiology

78 Percutaneous MV Repair (Mitral Valve Clipping) 78 MitraClip 4-mm wide Cobalt Chromium V-shaped clip covered with polyester cloth Figure

79 History of Mitral Valve Repair 79 Alain Carpentier Ottavio Alfieri 1970 s MV Repair with Annuloplasty Ring June 1991 Surgical Edge-to-Edge Repair (Alfieri stitch) 2000 s Percutaneous Edge-to-Edge Repair (Evalve; MitraClip) NYU Leon H. Charney Division of Cardiology

80 Mitral Valve Repairs 80 S U R G I C A L E D G E - TO- E D G E R E P A I R ( A L F I E R I S T I T C H ) NYU Leon H. Charney Division of Cardiology

81 Surgical Alfieri Stitch: 2D TEE year-old man; s/p surgical Alfieri stitch 9 years earlier LA LV NYU Leon H. Charney Division of Cardiology

82 Surgical Alfieri Stitch: 3D TEE year-old man; s/p surgical Alfieri stitch 9 years earlier LAA AV Atrial Septum Atrial Septum AV LAA Coronary Sinus Coronary Sinus LA Side LV Side NYU Leon H. Charney Division of Cardiology

83 Mitral Valve Repairs 84 P E R C U T A N E O U S E D G E - TO- E D G E R E P A I R ( M I T R A L C L I P ) NYU Leon H. Charney Division of Cardiology

84 PERCUTANEOUS MITRAL CLIPPING IS APPROVED IN THE UNITED STATES FOR THE FOLLOWING INDICATION Significant symptomatic degenerative mitral valve disease with mitral regurgitation 3+ who have too high a risk for surgery. NYU Leon H. Charney Division of Cardiology 85

85 Mitral Clipping: Clip Deployed 86 Left atrial side Left ventricular side NYU Leon H. Charney Division of Cardiology

86 Percutaneous Mitral Clipping: Clip Being Deployed 87 LA LA LV LV NYU Leon H. Charney Division of Cardiology

87 Percutaneous Mitral Clipping: Clip Positioning 88 Improper Clip Orientation Proper Clip Orientation NYU Leon H. Charney Division of Cardiology

88 Percutaneous Mitral Clipping: Clip Deployed 89 AV LAA Atrial Septum Coronary Sinus NYU Leon H. Charney Division of Cardiology

89 Percutaneous Mitral Valve Clipping 90 Single Clip Two Clips NYU Leon H. Charney Division of Cardiology

90 Percutaneous Mitral Clipping: Final Result 91 Post clipping: Only mild mitral regurgitation NYU Leon H. Charney Division of Cardiology

91 Bonus Feature 92 NYU Leon H. Charney Division of Cardiology

92 Valve-in-Valve App Available for ios; android version pending NYU Leon H. Charney Division of Cardiology 93

93 Thank You! 94 New York University Medical Center This presentation is a result of a collaborative effort of many members of the NYU medical community including Echo Lab, Cath Lab, EP Lab, Clinical Cardiology, Cardiac Surgery & Pediatrics. NYU Leon H. Charney Division of Cardiology

94 95 Christian Hall American Heart Association (AHA) Meeting, Los Angeles November 3, 2012 The son of Karl Victor Hall, the inventor of the Medtronic Hall valve NYU Leon H. Charney Division of Cardiology