Prosthesis-Patient Mismatch or Prosthetic Valve Stenosis?
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1 EuroValves 2015, Nice Prosthesis-Patient Mismatch or Prosthetic Valve Stenosis? Philippe Pibarot, DVM, PhD, FACC, FAHA, FASE FESC Canada Research Chair in Valvular Heart Diseases Université LAVAL
2 Disclosure Statement - Edwards Life Science: Research grant for Echo Core Lab, transcatheter aortic and mitral valve replacement - V Wave Ltd.
3 Etiology of High Doppler Gradients in Prosthetic Heart Valves Prosthesis-patient mismatch i.e. too small a prosthesis in too large a patient Prosthesis dysfunction due to an acute (e.g. thrombus), subacute (e.g. endocarditis) or chronic process (e.g. pannus, calcific degeneration in bioprosthesis) Central localized high velocity jet in bileaflet prosthesis Occult mitral prosthesis regurgitation
4 Transvalvular Flow Pattern in Bioprosthesis vs. Mechanical Prosthesis Courtesy B. Little Zoghbi et al. J Am Soc Echocardiogr, 22: , 2009.
5 Zoghbi et al. J Am Soc Echocardiogr, 22: , 2009.
6 Gradient, EOA, and DVI for Evaluation of Aortic Prosthetic Valve Function Peak Gradient (mmhg) EOA (cm 2 ) DVI Zekry et al. J Am Coll Cardiol Img 2011;4:
7 Ratio of Acceleration Time to Ejection Time for Aortic Prosthetic Valve Function Criteria for PV stenosis: AT>100 ms AT/LVET>0.37 Zekry et al. J Am Coll Cardiol Img 2011;4:
8 Dysfunction of Bileaflet Aortic Valves: Doppler-Echo vs. Cinefluoroscopy Muratori et al. JACC Img 2013; 6:
9 Evaluation of Leaflet Morphology & Mobility: A Cornerstone of Identification of Prosthetic Valve Dysfunction Normal Abnormal Bioprosthesis Mechanical
10 Evaluation of Leaflet Mobility: Usefulness of Cinefluoroscopy in Mechanical Valves Normal Abnormal
11 High Gradient after AVR Prosthesis-Patient Mismatch Severity? <0.65: severe Yes Step 1 Predicted Indexed EOA<0.85cm 2 /m 2? Normal reference EOA / BSA Consider Prosthesis Stenosis Yes Step 2 Abnormal leaflet morphol/ mobility DVI<0.30 (<0.25) EOA<reference EOA (Δ>0.35 cm 2 ) Gradient increased during FU EOA & DVI decreased during FU AT/ET>0.37 Cinefluoro Pibarot & Dumesnil Heart ; 98:69-78, 2012 No Consider: High Flow state / aortic regurgitation Subvalvular obstruction Technical error Localized high gradient (bileaflet valve)
12 Case Study : High Doppler Gradient in Aortic Valve Prosthesis 72 y.o. patient with Carbomedic # 19 aortic prosthesis (3 years) : - NYHA class II-III - Moderate diastolic dysfunction - Pulmonary arterial hypertension (systolic PA pressure: 50 mmhg) Dumesnil & Pibarot, in Book: Transesophageal Echocardiography Multimedia Manual: 361, 2005 Peak Gradient = 69 mm Hg Mean Gradient = 40 mmhg
13 Question no. 1 What is the cause of the high gradient in this patient? a. Valve prosthesis dysfunction (thrombus / pannus)? b. Valve prosthesis-patient mismatch? c. Central localized high velocity jet?
14 High Gradient after AVR BSA= 1.95 m 2 Carbomedics 19 mm Reference EOA= 1.0 cm 2 Step 1 Predicted Indexed EOA<0.85cm 2 /m 2? = 0.51 cm 2 /m 2 Severe Prosthesis- Patient Mismatch! Pibarot & Dumesnil Heart; 98:69-78, 2012 Dumesnil & Pibarot, Curr Cardiol Rev 2011
15 Question no. 2 Is there any intrinsic dysfunction in addition to prosthesis-patient mismatch?
16 Case Study : High Doppler Gradient in Aortic Valve Prosthesis 68 y.o. patient 3 Years post AVR Carbomedic # 19 Reference EOA 1.0±0.4 Measured EOA = 1.06 cm 2 Predicted Indexed EOA: 0.51 cm 2 /m 2 BSA = 1.95 m 2 Measured Indexed EOA: 0.55 cm 2 /m 2
17 High Gradient after AVR Prosthesis-Patient Mismatch Severity? <0.65: severe Yes Step 1 Predicted Indexed EOA<0.85cm 2 /m 2? Normal reference EOA / BSA Consider Prosthesis Dysfunction Yes Step 2 Abnormal leaflet morphol/ mobility DVI<0.30 (<0.25) EOA<reference EOA (Δ>0.35 cm 2 ) Gradient increased during FU EOA & DVI decreased during FU AT/ET>0.37 Cinefluoro No Pibarot & Dumesnil Heart ; 98:69-78, 2012 Consider: High Flow state / subvalvular obstruction Technical error Localized high gradient (bileaflet valve)
18 Intraoperative echo after prosthesis St. Jude Regent # 21 Suprannular (reference EOA: 2.0 cm 2 ) Stroke volume: 64 ml Heart rate: 98 bpm Peak gradient: 21 mmhg Mean gradient: 14 mmhg implantation Dumesnil & Pibarot, in Book: Transesophageal Echocardiography Multimedia Manual: 361, 2005
19 62 y.o. woman BSA: 1.3 m 2 Case Study #2 History of Barlow disease MVR 1 year ago with a MCRI OnX #25 mechanical valve INR within target since MVR Asymptomatic Recruited for a research project
20 Echocardiogram Peak Gradient = 11 mmhg Mean Gradient = 6 mmhg DVI : 2.4 Measured EOA = 1.1 cm 2
21 Doppler-Echo Evaluation of Mitral Prosthesis - Specifics Doppler Velocity Index: VTI mvp / VTI lvot (>2.2) EOA calculated using continuity equation as follows : EOA= SV lvot / VTI mvp (Not valid if significant aortic or mitral regurgitation) Pressure half-time not valid to calculate EOA (grossly overestimates) but may be useful for serial comparisons or if delayed (>130 msec)
22 Question no. 1 Is valve prosthesis-patient mismatch a consideration in this case?
23 High Gradient after MVR Prosthesis-Patient Mismatch Severity? <0.9: severe Yes Step 1 Predicted Indexed EOA<1.2 cm 2 /m 2? Normal reference EOA / BSA Consider Prosthesis Stenosis a/o Regurgitation Yes Step 2 Abnormal leaflet morphol/ mobility DVI>2.2 EOA<reference EOA (Δ>0.4 cm 2 ) Gradient increased during FU EOA decreased during FU Cinefluoro No Pibarot & Dumesnil Heart ; 98:69-78, 2012 Consider: High flow state Technical error Localized high gradient (bileaflet valve)
24 Normal Reference Values of EOAs for Mitral Prostheses Pibarot & Dumesnil Circulation, 119: , 2009
25 Answer: Calculate predicted indexed EOA to exclude PPM Predicted EOA for OnX # cm 2 BSA = 1.30 m 2 Predicted Indexed EOA = 1.7 cm 2 /m 2 SEVERE MODERATE MILD/NONE (non significant) Indexed EOA (cm 2 /m 2 )
26 Question no. 2 Should we suspect a prosthesis dysfunction?
27 Answer : Compare the measured EOA to the normal reference EOA Measured EOA= 1.1 cm² Reference value= 2.2 cm²!!
28 Question no. 3 Differential diagnosis: a- Prosthesis dysfunction in this case? b- Central high velocity jet in bileaflet mechanical prosthesis?
29 Answer Evaluate leaflet mobility using either TEE / fluoroscopy / CT
30 Leaflet Mobility by TTE
31 Cinefluoroscopy
32 Transthoracic Echocardiogram
33 Transesophageal Echocardiogram
34 Zoghbi et al. J Am Soc Echocardiogr, 22: , 2009.
35 High Gradient after MVR Prosthesis-Patient Mismatch Severity? <0.9: severe Yes Step 1 Predicted Indexed EOA<1.2 cm 2 /m 2? Normal reference EOA / BSA Prosthesis Stenosis & Regurgitation Yes Step 2 Abnormal leaflet morphol/ mobility DVI>2.2 EOA<reference EOA (Δ>0.4 cm 2 ) Gradient increased during FU EOA decreased during FU Cinefluoro No Pibarot & Dumesnil Heart ; 98:69-78, 2012 Consider: High flow state Technical error Localized high gradient (bileaflet valve)
36 YES YES YES YES Pibarot & Dumesnil, Circ 119: , 2009
37 3D Echo for Evaluation of Prosthetic Valve Function
38 Case #1 3 yr. post AVR Carbomedics 19 NYHA III Echo Gradients: 69/40 EOA: 1.1 cm 2 Severe PPM Case #2 1 yr. Post MVR OnX 25 Asymptomatic Echo Gradients: 11/6 EOA: 1.1 cm 2 Severe dysfunction: Thrombus
39 Key Points High gradient does not always mean prosthesis dysfunction Low gradient does not always mean normal prosthesis function Multi-parametric approach is key to appropriately differentiate normal function vs. PPM vs. dysfunction
40 Key Points PPM High Gradient Small indexed EOA EOA ~ normal Intermediate DVI Intermediate AT/LVET Normal leaflet morphology / mobility Dysfunction High Gradient Small indexed EOA EOA << normal Small DVI Low AT/LVET Abnormal leaflet morphology / mobility
41
42
43 Useful References Zoghbi et al. J Am Soc Echocardiogr, 22: , 2009 Pibarot & Dumesnil Heart 2012; 98:69-78, 2012 Zamorano JL; J Am Soc Echocardiogr 2011;24:937-65
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