25 different brand names >44 different models Sizes mm

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2 Types of Prosthetic Valves BIOLOGIC STENTED Porcine xenograft Pericardial xenograft STENTLESS Porcine xenograft Pericardial xenograft Homograft (allograft) Autograft PERCUTANEOUS MECHANICAL Bileaflet Single tilting disc Caged-ball 25 different brand names >44 different models Sizes mm

3 Types of prosthetic valves Mechanical vales Biologic (tissue) valves Percutaneous biologic valves

4 Diagnostic methods for evaluating prosthetic valve function Echocardiography with Doppler is the modality of choice for anatomic and hemodynamic evaluation of prosthetic heart valves Cine fluoroscopy Cardiac Catheterization Computed Tomography

5 3-D echocardiography and Doppler Assessment of the whole valve apparatus and the annulus MITRAL POSITION > aortic position

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7 Cinefluoroscopy TEE sensitivity Mitral position 100% Aortic position 85% CF has a complementary diagnostic role in evaluating disc mobility of mechanical valves in the aortic position Muratori M, Montorsi P, Teruzzi G, et al: American Journal of Cardiology 2006

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9 Computed Tomography Pannus formation Residual angle 66 degrees Intra-operative findings Tsai I-C, Lin Y-K, Chang Y, et al: Eur Radiol 2009

10 Common physiologic characteristics of prosthetic valves Stentless, cadaveric homograft and autograft aortic valves may be indistinguishable from native valves by echocardiographic imaging Stentless aortic valve 2 years post-op Native aortic valve

11 Common physiologic characteristics of prosthetic valves Acoustic shadowing Acoustic shadowing is not a significant limitation of TTE to assess prosthetic aortic valves, as it is in mitral prosthetic valves Acoustic shadowing is more prominent with mechanical valves compared to biologic valves

12 Shadowing & Flow Masking

13 Common physiologic characteristics of prosthetic valves Physiologic stenosis Physiologic regurgitation

14 Causes of physiologic stenosis Valve design / Valve type Valve size Pressure recovery phenomenon Increased flow across the valve Patient-prosthesis mismatch

15 Causes of Physiologic regurgitation Backflow from the closing movement of the ball or disc(s) Bileaflet and single disc valves have built-in, additional leakage backflow The purpose of this design is to reduce the risk of valve thrombosis Biological valves have minimal or no intrinsic regurgitation at implantation Daniels CJ, Barbetseas J, Boudoulas H: ACC SAP, version 7, 2009

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18 Early and Late Complications of Prosthetic Valves Patient-prosthesis mismatch Dehiscence Primary failure Thrombosis and thromboembolism Pannus formation Pseudoaneurysm formation Endocarditis Hemolysis

19 Distinction between thrombus and pannus

20 Aortic St Jude Medical valve Pannus formation

21 TRANSESOPHAGEAL ECHOCARDIOGRAPHY INDICATIONS OF TEE IN PROSTHETIC VALVES Valvular regurgitation Mitral and tricuspid valves > aortic valves Suspected valve obstruction Assessment of valve motion, thrombus vs pannus, candidates for thrombolysis Evaluation of associated structural abnormalities Vegetations, thrombi, ring abscess, pseudoaneurysm, fistulas Atrial, atrial appendage thrombi Inadequate transthoracic echocardiographic study Barbetseas J & Zoghbi WA: Cardiology Clinics 1998

22 Parameters in the Comprehensive Evaluation of Prosthetic Valve Function CLINICAL INFORMATION Date of valve replacement Type and size of the prosthetic valve Height, weight, body surface area Symptoms and related clinical findings Blood pressure and heart rate

23 IMAGING OF THE VALVE Motion of leaflets or occluder Presence of calcification on the leaflets or abnormal echo densities on the various components of the prosthesis Valve sewing ring integrity and motion DOPPLER ECHOCARDIOGRAPHY OF THE VALVE Contour of the jet velocity signal Peak velocity and gradient Mean pressure gradient VTI of the jet DVI Pressure half-time in MV and TV EOA Presence, location and severity of regurgitation

24 OTHER ECHOCARDIOGRAPHIC DATA LV and RV size, function, and hypertrophy LA and right atrial size Concomitant valvular disease Estimation of pulmonary artery pressure PREVIOUS POSTOPERATIVE STUDIES Comparison of above parameters is particularly helpful in suspected valvular dysfunction

25 Normal Prosthetic Valves DETERMINANTS OF VELOCITY/GRADIENT Valve size Valve type Flow rate

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28 Normal Doppler echocardiographic values for PrAVs St Jude Aortic Size(mm) Peak Vel Mean Gr DVI EOA (ECHO) EOA (SR AREA) ± ±0.6 17±7 10±6 0.37± ± ± ± ± ±1.40 Chafizadeh ER & Zoghbi WA: Circulation 1991

29 Doppler Echocardiographic Evaluation of Prosthetic Aortic Valves DOPPLER ECHOCARDIOGRAPHY OF THE VALVE Peak velocity/gradient Mean gradient Contour of the jet velocity (AT) DVI EOA Presence, location, and severity of regurgitation PERTINENT CARDIAC CHAMBERS LV size, function, and hypertrophy

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35 Normal vs obstructed prosthetic aortic valve

36 Doppler Parameters of Prosthetic Aortic Valve Function SUGGESTS STENOSIS Peak Velocity > 4 m/s Mean Gradient > 35 mmhg DVI < 0.25 EOA < 0.8 cm2 Contour of the jet Rounded, symmetrical Acceleration Time > 100 ms

37 Echocardiographic and Doppler Parameters in Evaluation of Prosthetic Mitral Valve Function (Stenosis or Regurgitation) DOPPLER ECHOCARDIOGRAPHY OF THE VALVE OTHER PERTINENT ECHOCARDIOGRAPHIC AND DOPPLER PARAMETERS Peak early velocity Mean gradient Heart rate at the time of Doppler Pressure half-time DVI=VTI PrMV/VTI LVO EOA Presence, location, and severity of regurgitation LV size and function LA size RV size and function Estimation of PASP

38 Prosthetic Mitral Valve

39 BEFORE AND AFTER THROMBOLYSIS

40 Doppler Parameters of Prosthetic Mitral Valve Stenosis Peak Velocity Mean Gradient EOA (continuity equation) Pressure half-time SUGGESTS SIGNIFICANT STENOSIS > 2.5 m/s > 10 mmhg < 1 cm2 > 200 ms

41 Prosthetic Mitral Valve Limitations of Pressure Half-time Method Merging of E and A velocities ( PR, tachycardia) Delayed LV relaxation Decreased LV compliance Atrio-ventricular coupling Significant aortic insufficiency

42 Parameters for Evaluation of the Severity of Prosthetic Aortic Valve Regurgitation VALVE STRUCTURE AND MOTION Mechanical or bioprosthetic STUCTURAL PARAMETERS LV size DOPPLER PARAMETERS (qualitative or semiquantitative) Jet width in central jets (% LVO diameter): color Jet density: CW Doppler Jet deceleration rate (PHT, ms): CW Doppler LVO flow vs pulmonary flow: PW Doppler Diastolic flow reversal in the Desc Ao: PW Doppler DOPPLER PARAMETERS (quantitative) Regurgitant volume (ml/beat) Regurgitant fraction (%) SEVERE Abnormal Dilated Large ( 65%) Dense Steep(<200) Greatly increased Prominent, holodiastolic >60 >50

43 TEE Paravalvular significant AR

44 Transthoracic Echocardiographic Findings Suggestive of Significant Prosthetic MR in Mechanical Valves with Normal Pressure Half-time FINDING Peak mitral velocity 1.9 m/s VTI PrMV / VTI LVO 2.5 Mean gradient 5 mmhg LV stroke volume (2D or 3D imaging) is > 30% higher than systemic stroke volume by Doppler Maximal TR jet velocity > 3m/s Systolic flow convergence seen in the LV toward the prosthesis COMMENTS Also consider high flow, PPM Measurement errors increase in AF due to difficulty in matching cardiac cycles; also consider PPM At physiologic heart rate; also consider high flow, PPM Validation lacking; significant MR is suspected when LV function is normal or hyperdynamic and VTI LVO is < 16 cm Consider residual postop pulmonary hypertension or other causes Validation lacking; technically challenging to detect readily

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47 Echocardiographic and Doppler Criteria for Severity of Prosthetic MR Using Findings from TTE and TEE STRUCTURAL PARAMETERS LV size Prosthetic valve DOPPLER PARAMETRS Color flow jet area Flow convergence Jet density: CW Doppler Jet contour: CW Doppler Pulmonary venous flow QUANTITATIVE PARAMETERS VC width (cm) R vol (ml/beat) RF (%) EROA (cm2) SEVERE Usually dilated Abnormal Large central jet (usually > 8 cm2 or > 40% of LA area) or variable size wall-impinging jet swirling in the left atrium Large Dense Early peaking, triangular Systolic flow reversal

48 Imaging and Doppler Parameters in Evaluation of Prosthetic Pulmonary Valve Function DOPPLER ECHOCARDIOGRAPHY OF THE VALVE Peak velocity/peak gradient Mean gradient DVI, EOA (few data exist) Presence, location, and severity of regurgitation RELATED CARDIAC CHAMBERS RV size, function, hypertrophy, and RV systolic pressure

49 Findings Suspicious for Prosthetic Pulmonary Valve Stenosis Cusp or leaflet thickening or immobility Narrowing of forward color map Peak velocity through the prosthesis >3 m/s or 2 m/s through a homograft (suspicious but not diagnostic of stenosis) Increase in peak velocity on serial studies Impaired RV function or elevated RV systolic pressure

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51 Evaluation of Severity of Prosthetic Pulmonary Valve Regurgitation Valve structure RV size Jet size by color Doppler (central jets) Jet density by CW Doppler Jet deceleration rate by CW Doppler Pulmonary systolic flow vs systemic flow by PW Doppler Diastolic flow reversal in the pulmonary artery SEVERE Abnormal or valve dehiscence Dilated (unless there are other reasons) Usually large, with a wide origin; jet width >50% of pulmonary annulus; may be brief in duration Dense Steep deceleration (not specific for severe PR), early termination of diastolic flow Greatly increased (cutoff values are not well validated) Present

52 Echocardiographic and Doppler Parameters in Evaluation of Prosthetic Tricuspid Valve Function DOPPLER ECHOCARDIOGRAPHY OF THE VALVE Peak early velocity Mean gradient Heart rate at time of Doppler assessment Pressure half-time VTI PrTV / VTI LVO EOA Presence, location, and severity of TR RELATED CARDIAC CHAMBERS, IVC AND HEPATIC VEINS RV size and function Right atrial size Size of IVC and response to inspiration Hepatic vein flow pattern

53 Doppler Paramters of Prosthetic Tricuspid Valve Function Peak velocity (increased also with TR) Mean gradient (increased also with TR) Pressure half-time EOA and VTI PrTV/VTI LVO CONSIDER VALVE STENOSIS (average 5 cycles) > 1.7 m/s 6 mm Hg 230 ms No data yet available for tricuspid prosthesis

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55 Echocardiographic and Doppler Parameters Used in Grading Severity of Prosthetic Tricuspid Valve Regurgitation Valve structure Jet area by color Doppler, central jets only (cm2) VC width (cm) (for valvular TR jet, extrapolated from native TR, unknown cutoffs for paravalvular TR) SEVERE Abnormal or valve dehiscence > 10 > 0.7 Jet density and contour by CW Doppler Dense with early peaking Doppler systolic hepatic flow Right atrium, right ventricle, IVC Holosystolic reversal Markedly dilated

56 Comprehensive Evaluation of Prosthetic Valve Function Clinical evaluation, know valve type and size Baseline echo/doppler study after surgery Transthoracic 2D/Doppler evaluation of structure and function is the first line diagnostic method In cases with high velocity jet/gradient and suspected stenosis or regurgitation: - Compare with previous studies - TEE, fluoroscopy (if needed for aortic mechanical prosthetic valve), CT (?)

57 THANK YOU