A Practical Approach to Prosthetic Valves
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1 A Practical Approach to Prosthetic Valves Bonita Anderson DMU (Cardiac), MApplSc (Med Ultrasound), ACS, AMS, FASE Disclosures None 1
2 Know the Product Know the Look Design type & size Flow characteristics Age of valve Structural appearance Mobility & seating Artifacts Know the Flow Maximum & mean gradients Effective orifice area (EOA) Normal regurgitation Know the Problems Patient-prosthesis mismatch Obstruction/stenosis Abnormal regurgitation Know the Product 2
3 Know the Each Product valve differs in it s design & flow characteristics Bileaflet titling disk Single tilting disk Ball-Cage Stented Stentless Transcatheter Surgical Hybrid Valve Design Bileaflet Mechanical Valves 3
4 Flow Characteristics Mechanical Valves - Inflow Bileaflet Single disk Ball-cage 2 large lateral orifices 1 smaller central orifice 1 major orifice 1 minor orifice Flow diverges around the ball Flow Characteristics Mechanical Valves - Regurgitation Bileaflet Single disk (Björk-Shiley) Ball-cage From John B Chambers Echo Res Pract 2016;3:R35-R43 4
5 Know the Look Prosthetic valves do not have the same look Know the Look Design influences 2D appearance CE AVR Stented CLOB AVR Stentless SAPIEN Transcatheter 5
6 Know the Look Design influences 2D appearance Mosaic Stented St Jude Bileaflet Starr-Edwards Ball-cage Know the Look Normal or Abnormal? Normal Björk-Shiley Abnormal ATS 6
7 Know the Look Check the valve bed & stability of valve Good: Stable Bad: Rocking Dehiscence Know the Look Artifacts: awareness avoids missing a diagnosis Acoustic shadow & reverberation artifacts Decreased resolution in far-field with reduced diagnostic accuracy 7
8 Know the Look Artifacts: awareness avoids over-diagnosis Beam path artifact in SE MVR (Normal) Microbubbles in St Jude MVR (Normal) Know the Flow 8
9 Know the Flow Zoghbi WA, et al. J Am Soc Echocardiogr Sep;22(9): Know the Flow Valve Parameter Normal AVR MVR Peak velocity Mean gradient Doppler velocity Index (DVI) Effective orifice area (EOA) Contour of the jet velocity Acceleration time (AT) Peak velocity Mean gradient Doppler velocity Index (DVI) Effective orifice area (EOA) Pressure half-time (PHT) < 3 m/s < 20 mmhg 0.30 > 1.2 cm 2 Triangular, early peaking < 80 ms < 1.9 m/s 5 mmhg < cm 2 < 130 ms Zoghbi WA, et al. J Am Soc Echocardiogr Sep;22(9):
10 Know the Flow Baseline study early post-op/post-procedure strongly recommended Know the Potential Problems Courtesy Dr Darryl Burstow, The Prince Charles Hospital 10
11 50 yo female, 21 mm St Jude AVR, presents with CCF PLAX PLAX PSAX APLAX AP 4-ch AP 2-ch LVEF 34% 50 yo female, 21 mm St Jude AVR, presents with CCF Peak PG 76 mmhg (normal mmhg) mpg 46 mmhg (normal mmhg) EOA 0.83 cm 2 (normal cm 2 ) IEOA 0.40 cm 2 /m 2 (abnormal 0.85 cm 2 /m 2 ) DVI 0.24 (normal 0.3) 11
12 Question What is the likely cause for increased gradients in this AVR? 1. Prosthesis-patient mismatch 2. LV flow acceleration 3. True obstruction 4. High flow rate due to significant AR Question What is the likely cause for increased gradients in this AVR? 1. Prosthesis-patient mismatch 2. LV flow acceleration 3. True obstruction 4. High flow rate due to significant AR 12
13 A Diagnostic Pathway for Elevated AVR Gradients EOA Normal DVI Normal ( 0.3) IEOA reduced ( 0.85 cm 2 /m 2 ) Abnormal leaflet/disc motion PPM High output AR Technical error LVOT flow acceleration Obstruction RPR Technical error Adapted from A Sonographer's Guide to the Assessment of Heart Disease. B. Anderson; 2014 Echotext Pty Ltd Our patient: EOA 0.83 cm 2 (normal cm 2 ) DVI 0.24 EOA Normal DVI Normal ( 0.3) IEOA reduced ( 0.85 cm 2 /m 2 ) Abnormal leaflet/disc motion PPM High output AR Technical error LVOT flow acceleration Obstruction RPR Technical error Adapted from A Sonographer's Guide to the Assessment of Heart Disease. B. Anderson; 2014 Echotext Pty Ltd 13
14 Case #1: Follow-up AT Value of AVR Acceleration Time (AT) for Elevated AVR Gradients DVI 0.3 DVI DVI <0.25 AT >100ms AT <100ms AT >100ms AT <100ms Consider AVR stenosis with: Sub-valve narrowing Underestimated gradient Improper LVOT velocity Normal AVR: Normal IEOA High flow Reduced IEOA PPM Suggests AVR stenosis Likely normal AVR: Consider improper LVOT velocity Adapted from Zoghbi WA, et al. J Am Soc Echocardiogr Sep;22(9):
15 AT Cut-off AT = 100 ms for identifying AVR stenosis: Sens. 86% PPV 66% Spec. 86% NPV 95% Ben Zekry S, et al. JACC Cardiovasc Imaging Nov;4(11): yo male, 31mm ATS MVR, 27mm ATS AVR, SOBOE PLAX PSAX AP4 PLAX CFI PSAX CFI AP4 CFI 15
16 61 yo male, 31mm ATS MVR, 27mm ATS AVR, SOBOE Peak E velocity 2.6 m/s mpg 10 mmhg (normal mmhg) PHT 54 ms EOA 2.1 cm 2 (normal cm 2 ) IEOA 0.83 cm 2 /m 2 (abnormal 1.2 cm 2 /m 2 ) DVI 2.8 (normal 1.8) Question What is the likely cause for increased gradients in this MVR? 1. Technical error 2. Significant MR 3. True obstruction 4. Prosthesis-patient mismatch 16
17 Question What is the likely cause for increased gradients in this MVR? 1. Technical error 2. Significant MR 3. True obstruction 4. Prosthesis-patient mismatch A Diagnostic Pathway for Elevated MVR Gradients EOA Normal DVI Normal (< 2.2) IEOA reduced ( 1.2 cm 2 /m 2 ) PHT prolonged (> 130 ms) PPM High output Technical error Obstruction MR RPR (rare in MVR) Adapted from A Sonographer's Guide to the Assessment of Heart Disease. B. Anderson; 2014 Echotext Pty Ltd 17
18 Our patient: EOA 2.1 cm 2 (normal cm 2 ) DVI 2.8 EOA Normal DVI Normal (< 2.2) IEOA reduced ( 1.2 cm 2 /m 2 ) PHT prolonged (> 130 ms) PPM PHT 54 ms High output Technical error Obstruction MR RPR (rare in MVR) Adapted from A Sonographer's Guide to the Assessment of Heart Disease. B. Anderson; 2014 Echotext Pty Ltd Value of Mitral Valve Prosthesis (MVP) Ratio (or DVI) All MVRs (n=971) Luis SA, et al. Am J Cardiol 2017;120:
19 Case #2: Follow-up 61 yo male, 31mm ATS MVR, 27mm ATS AVR, SOBOE Peak E velocity 2.6 m/s mpg 10 mmhg (normal mmhg) PHT 54 ms EOA 2.1 cm 2 (normal cm 2 ) IEOA 0.83 cm 2 /m 2 (abnormal 1.2 cm 2 /m 2 ) DVI 2.8 (normal 1.8) EOA is T accurate in this case due to MR 19
20 Continuity Equation for EOA* * Assumes MVR stroke volume = LVOT stroke volume Know the Product Design type & size Flow characteristics Age of valve Know the Look Structural appearance Mobility & seating Artifacts Know the Flow Maximum & mean gradients Effective orifice area (EOA) Normal regurgitation Know the Problems Patient-prosthesis mismatch Obstruction/stenosis Abnormal regurgitation 20
21 Extra: Pannus versus thrombus Parameters Thrombus Pannus Clinical shorter ( 2 months) Symptom duration before reoperation shorter (< 1 month) Inadequate anticoagulation * Echocardiography Larger Soft tissue appearance (similar to myocardium) Mobile Extension of mass beyond limits of prosthetic valve ring to adjacent cardiac structures More common in MVR than AVR Time from valve surgery to valve malfunction longer (> 12 months) Symptom duration before reoperation longer ( 10 months) Adequate anticoagulation* Smaller Echo dense appearance Firmly fixed Annular location (along valvular plane) More common in AVR than MVR * Adequate anticoagulation defined as International Normalized Ratio (INR) 2.5 at the time of diagnosis Barbetseas J, et al. J Am Coll Cardiol Nov;32(5):
22 Extra: Calculation of the EOA EOA = CSA LVOT* X LVOT VTI LVOT Stroke Volume AVR VTI or MVR VTI For MVR, grade 1/4 AR or MR * CSA LVOT = LVOT diameter 2 x Extra: DVI for AVR & MVR DVI (AVR) = V 1 V 2 DVI (MVR) = MVR VTI LVOT VTI PW Doppler LVOT peak velocity (V 1 ) CW Doppler MVR VTI V 1 VTI VTI V 2 CW Doppler AVR peak velocity (V 2 ) Normal 0.30 Abnormal 0.25 PW Doppler LVOT VTI Normal 1.8 Abnormal
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