Echocardiographic Evaluation of Aortic Valve Prosthesis
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1 Echocardiographic Evaluation of Aortic Valve Prosthesis Amr E Abbas, MD, FACC, FASE, FSCAI, FSVM, RPVI Co-Director, Echocardiography, Director, Interventional Cardiology Research, Beaumont Health System Associate Professor of Medicine, OUWB School of Medicine ASCeXAM/ReASCE 2017 Philadelphia, PA Pre Questions (1) Regarding Aortic Prosthetic Valves A. A routine echocardiogram is required very two years after AVR B. An elevated gradient with a decreased EOA is always suggestive of valvular stenosis C. Transthoracic echocardiogram alone is always sufficient to diagnose valvular stenosis D. It is more challenging to quantify para-valvular versus valvular aortic regurgitation. Robert D. Safian, MD 1
2 Pre Questions (2) Patients with Prosthesis-Patient Mismatch A. Have abnormal prosthetic valve function B. Progressively worsen with time C. Have a small valve compared to the demands of their body and cardiac output D. Have a benign condition JASE September 2009 Robert D. Safian, MD 2
3 Topics of Discussion Types and Flow Profiles of Prosthetic Valves Echocardiographic Evaluation: Key Points Challenges for Evaluation Prosthetic Valves Evaluation Elevated gradients Regurgitation Endocarditis Thrombosis versus pannus Types & Flow Profiles of Prosthetic Valves Mechanical Vs. Bioprosthetic Vs. Autografts Copyright American Heart Association Pibarot P, Dumesnil J G Circulation 2009;119: Robert D. Safian, MD 3
4 Types & Flow Profiles of Prosthetic Valves Mechanical Vs. Bioprosthetic Flow Localized Pressure Loss and High Gradient in Central Orifice of Bileaflet Mechanical Valve (?Pressure Recovery) AV max3.6 m/s MIG = 53 mmhg P Mean=30 mmhg Fluoroscopy Robert D. Safian, MD 4
5 CLASS I ECHO EVALUATION Guidelines Initial TTE after AVR (2-4 weeks or sooner if concern for follow up and transfer) Repeat TTE for AVR if there is a change in clinical symptoms or signs suggesting dysfunction TEE for AVR if there is a change in clinical symptoms or signs suggesting dysfunction CLASS II Annual TTE in bioprosthetic valves after the first 10 years (5 years in prosthetic statement 2008) Nishimura et al 2014 but not mechanical valves ECHO EVALUATION: Key Points Clinical picture Baseline study Type and size of valve LV chamber BP/HR Height/weight/BSA Exercise echo may be helpful Cinefluoroscopy, CT, MRI Robert D. Safian, MD 5
6 ECHO EVALUATION: Key Points Opening and Closing of leaflets or occluders Abnormal densities (calcium/mass/vegetation) Stability versus rocking motion May use Modified versus Simplified Bernoulli 4V 22-4V 12 Vs. 4V 2 2 Attention to flow states & adequate Doppler signals Echo Evaluation: Key Points Adequate Doppler Signals LVOT obtained away from flow acceleration (0.5 to 1 cm below sewing ring) Multiple planes Off axis view in parasternal view to obtain LVOT diameter/tavr versus SAVR Eccentric aortic regurgitant jets may require different angles to Doppler Robert D. Safian, MD 6
7 Evaluation of Prosthetic Valves: Challenges Large range in what is considered normal Mean Gradients produced depend on size and type of valve. For any particular patient it is difficult to differentiate normal from abnormal, hence the need for comparison to older studies Shadowing may interfere with assessment of location and amount of regurgitation Bioprosthetic Valve Abnormalities Elevated Gradients Regurgitation Endocarditis Thrombosis Pannus Robert D. Safian, MD 7
8 Echocardiographic Evaluation of Elevated Prosthetic Valve Gradients DVI 0.30 DVI DVI <0.25 Jet contour AT (ms) >100 <100 >100 <100 Consider PrAV stenosis with: Sub-valve narrowing Underestimated gradient Improper LVOT velocity Normal PrAV EOA index Suggests prosthetic aortic valve stenosis Consider improper LVOT velocity High flow PPM JASE 2009;22(9):975 Robert D. Safian, MD 8
9 Parameters Utilized Peak prosthetic aortic velocity Normal < 3 m/sec Abnormal > 3 m/sec Parameters Utilized Doppler Velocity Index Robert D. Safian, MD 9
10 Doppler Velocity Index 1.1/2.8 = 0.39 Normal > 0.3 1/5.5 = 0.18 Abnormal < 0.25 Jet Contour Parameters Utilized Triangular Rounded Robert D. Safian, MD 10
11 Parameters Utilized Acceleration Time 90 msec Normal < 100 msec 150 msec Abnormal > 100 msec Parameters Utilized Acceleration time/ ejection time AT/ET > 0.4: Prosthetic valve obstruction No Obstruction:0.31 Obstruction: Robert D. Safian, MD 11
12 Parameters Utilized Effective Orifice Area and ieoa A 2 (EOA)= A 1 x V 1 V 2 ieoa = AVA/BSA Normal > 1.2 cm 2 Abnormal < 0.8 cm 2 Abnormal < 0.6 cm 2 /m 2 Cause of Elevated Gradients Across Aortic Prosthesis Errors in Measurement Improper LVOT Velocity Taken too far from flow acceleration Improper AV Velocity (Gradient) Assessment Increased Flow Pressure Recovery Prosthesis patient mismatch Prosthesis stenosis Robert D. Safian, MD 12
13 NORMAL PROSTHESIS FUNCTION Robert D. Safian, MD 13
14 PROSTHETIC STENOSIS Robert D. Safian, MD 14
15 Doppler Parameters of Prosthetic Aortic Valve Function Normal Suggests Stenosis Peak Velocity < 3 m/s > 4 m/s Mean Gradient < 20 mmhg > 35 mmhg Doppler Velocity Index >= 0.3 < 0.25 Effective Orifice area > 1.2 cm2 < 0.8 cm2 Contour of Jet Triangular Early Peaking Rounded Symmetrical contour Acceleration Time < 80 ms > 100 ms Mechanisms of Prosthetic Valve Dysfunction Robert D. Safian, MD 15
16 CASE PRESENTATIONS CASE PRESENTATION (1): 81 Y/O with progressive DOE PMHx: Rheumatic valve disease, CABG + Mechanical AVR 2003 (19 St Jude Regent Valve) TTE: Difficult to visualize mechanical AV Robert D. Safian, MD 16
17 AV VEL=3.2 DI=0.58/3.2=0.18 AT=150msec Jet Contour: Circular An approach to prosthetic AV stenosis Robert D. Safian, MD 17
18 An approach to prosthetic AV stenosis Doppler Parameters of Prosthetic Aortic Valve Function Normal Suggests Stenosis Peak Velocity < 3 m/s > 4 m/s Mean Gradient < 20 mmhg > 35 mmhg Doppler Velocity Index >= 0.3 < 0.25 Effective Orifice area > 1.2 cm2 < 0.8 cm2 Contour of Jet Triangular Early Peaking ms Rounded Symmetrical contour Acceleration Time < 80 ms > 100 ms Robert D. Safian, MD 18
19 What is your diagnosis? A) Normal Prosthetic Valve Function B) Prosthesis Patient Mismatch C) High Flow State D) Prosthetic Valve Stenosis E) Errors of Measurement: Improper LVOT Velocity Additional Studies Needed? Robert D. Safian, MD 19
20 TEE Helpful with high gradients and normal motion by Fluoro Robert D. Safian, MD 20
21 CASE PRESENTATION (2): 67 Y/O F Hx AVR (Bi-Leaflet Mechanical Valve 1998) On Coumadin, difficulty maintaining therapeutic INR Progressive DOE 6 mos Robert D. Safian, MD 21
22 AV VEL = 3.6 DVI = 1.19 / 3.60 DVI = 0.33 Acceleration Time 0.11 sec Robert D. Safian, MD 22
23 An approach to prosthetic AV stenosis An approach to prosthetic AV stenosis Robert D. Safian, MD 23
24 Original LVOT Velocity Taken Too Close to the AV Prosthesis (region of subvalvular acceleration) DVI = LVO / AV Jet DVI = 0.82 / 3.60 DVI = 0.22 Original LVOT Velocity Taken Too Close to the AV Prosthesis Robert D. Safian, MD 24
25 An approach to prosthetic AV stenosis An approach to prosthetic AV stenosis Robert D. Safian, MD 25
26 Surgical Findings Well seated valve with a large amount of tissue ingrowth beneath the valve resulting in a frozen leaflet An approach to prosthetic AV stenosis Robert D. Safian, MD 26
27 What is your diagnosis? A) Patient Prosthesis Mismatch B) Normal Prosthetic Valve Function C) High Flow State D) Prosthetic Valve Stenosis E) Improper LVOT Velocity What is your diagnosis? A) Patient Prosthesis Mismatch B) Normal Prosthetic Valve Function C) High Flow State D) Prosthetic Valve Stenosis E) Improper LVOT Velocity (Prosthetic valve stenosis) Robert D. Safian, MD 27
28 CASE PRESENTATION (3): 66 Y/O F Hx AVR (St Jude Valve Conduit 2002 for AR) Progressive DOE Robert D. Safian, MD 28
29 LVOT VELOCITY = 0.85 AVA VELOCITY = 3.4 DVI= 0.85/3.4 = 0.25 AVA VELOCITY = 3.4 m/s AT= 0.09 sec Robert D. Safian, MD 29
30 Doppler Parameters of Prosthetic Aortic Valve Function Normal Suggests Stenosis Peak Velocity < 3 m/s > 4 m/s Mean Gradient < 20 mmhg > 35 mmhg Doppler Velocity Index >= 0.3 < 0.25 Effective Orifice area > 1.2 cm2 < 0.8 cm2 Contour of Jet Triangular Early Peaking Rounded Symmetrical contour Acceleration Time < 80 ms > 100 ms Doppler Parameters of Prosthetic Aortic Valve Function Normal Suggests Stenosis Peak Velocity < 3 m/s > 4 m/s Mean Gradient < 20 mmhg > 35 mmhg Doppler Velocity Index >= 0.3 < 0.25 Effective Orifice area > 1.2 cm2 < 0.8 cm2 Contour of Jet Triangular Early Peaking ms Rounded Symmetrical contour Acceleration Time < 80 ms > 100 ms Robert D. Safian, MD 30
31 An approach to prosthetic AV stenosis An approach to prosthetic AV stenosis EOA Index Robert D. Safian, MD 31
32 An approach to prosthetic AV stenosis Indexed EOA = 0.78 PPM occurs when: ieoa < 0.85 Severe if ieoa < 0.65 An approach to prosthetic AV stenosis Robert D. Safian, MD 32
33 What is your diagnosis? A) Prosthesis Patient Mismatch B) Normal Prosthetic Valve Function C) High Flow State D) Prosthetic Valve Stenosis E) Improper LVOT Velocity (Prosthetic valve stenosis) Patient Prosthesis Mismatch AVA velocity:4.6 DVI: 1.14/4.6 = 0.25, AVA= 0.4 cm 2 Acceleration Time: 60 msec B Robert D. Safian, MD 33
34 Patient Prosthesis Mismatch Patient Prosthesis Mismatch Q = Flow, K = Constant P = Q 2 /(K x EOA 2 ) For gradients to remain low, EOA has to accommodate and be proportionate to flow At rest, Q is determined by BSA, bigger people have bigger flow In patients with large BSA and increased flow, a too small of a valve with a small EOA will produce a high gradient: Small valves + Big people = High gradients Robert D. Safian, MD 34
35 Echocardiographic Evaluation of Prosthetic Valve Regurgitation Types of Regurgitation Regurgitation may be Physiological Pathological Physiological regurgitation Closing volume (blood displacement by occluder motion) At the hinges of occluder Robert D. Safian, MD 35
36 Pathological Central Types of Regurgitation Mostly with bioprosthetic Technical or infection related Paravalvular Either type, usually the site with mechanical Mild is common after surgery (5-20%) and likely insignificant in the absence of infection Usually after calcium debridement, redo, older patients Hemolytic anemia TAVR Central Aortic Regurgitation Robert D. Safian, MD 36
37 Central Aortic Regurgitation Central Aortic Regurgitation Robert D. Safian, MD 37
38 Paravalvular Aortic Regurgitation Paravalvular Aortic Regurgitation Robert D. Safian, MD 38
39 Assessment of Prosthetic Aortic Valve Regurgitation: TTE Challenging due to Shadowing Eccentric Jet Difficult to quantify paravalvular leak Width of vena contracta may be difficult to measure Off axis views may be required Assessment of Prosthetic Aortic Valve Regurgitation Jet diameter/lvo diameter <25% in PS views Pressure Half Time < 200 ms Holodiastolic flow reversal in Descending aorta Neck in the short axis view < 10% of sewing ring is mild 10-20% moderate > 20% severe > 40% rocking motion Robert D. Safian, MD 39
40 Assessment of Prosthetic Aortic Valve Regurgitation Assessment of Prosthetic Aortic Valve Regurgitation 75 ml 75 ml NORMAL Robert D. Safian, MD 40
41 Assessment of Prosthetic Aortic Valve Regurgitation 120 ml 70 ml AORTIC REGURGITATION R Volume = = 50 ml R Fraction = 50/120 = 42% Assessment of Prosthetic Aortic Valve Regurgitation: TEE Identifies: Location, Mechanism, AR width to LVOT width, Posterior jets may be identified LVOT obscured by accompanied MV prosthesis 3D: value? Especially for transcatheter repair, challenging for AV versus MV Robert D. Safian, MD 41
42 Echocardiographic Evaluation of Prosthetic Valve Endocarditis Endocarditis Incidence < 1% and has declined with perioperative antibiotics Form in valve ring and extend to and spread to stent, occluder, or leaflet Irregular and independently mobile Can not adequately differentiate between vegetations, thrombus, pledgets, sutures, etc Robert D. Safian, MD 42
43 Endocarditis TEE has better sensitivity and specificity for Vegetations Abscess in the posterior but not anterior location Combined TEE and TTE have a NPV of 95% If clinical suspicion high and studies negative, repeat studies in 7-10 days Parasternal Long Robert D. Safian, MD 43
44 Color TEE Short Robert D. Safian, MD 44
45 TEE Long Doppler Robert D. Safian, MD 45
46 Pathology Echocardiographic Evaluation of Prosthetic Valve Thrombosis/Pannus Robert D. Safian, MD 46
47 Thrombus Thrombus versus Pannus Larger Soft density similar to myocardium More likely to encounter abnormal valve motion Short duration of symptom Poor anticoagulation Size < 0.85 cm2 less likely to embolize More with mechanical Pannus Small Dense, 30% may not be visualized Longer duration More common in aortic Pannus TEE Robert D. Safian, MD 47
48 11.6 Prosthetic Valve Thrombosis Suspect Prosthetic Valve Thrombosis Class I Class IIa TTE to evaluate hemodynamic severity CT or fluoroscopy to evaluate valve motion Left Sided Prosthetic Valve Thrombosis Right Sided Prosthetic Valve Thrombosis TEE for thrombosis size NYHA III-IV symptoms Mobile or large (>0.8cm 2 ) thrombus Recent onset (<14d) NYHA I-II Small thrombus (<0.8cm 2 ) Emergency Surgery Emergency Surgery Fibrinolytic Rx if persistent valve thrombosis after IV heparin therapy Robert D. Safian, MD 48
49 Pre Questions (1) Regarding Aortic Prosthetic Valves A. A routine echocardiogram is required very two years after AVR B. An elevated gradient with a decreased EOA is always suggestive of valvular stenosis C. Transthoracic echocardiogram alone is always sufficient to diagnose valvular stenosis D. It is more challenging to quantify para-valvular versus valvular aortic regurgitation. Answer (1) D. It is more challenging to quantify para-valvular versus valvular aortic regurgitation. Robert D. Safian, MD 49
50 Pre Questions (2) Patients with Prosthesis-Patient Mismatch A. Have abnormal prosthetic valve function B. Progressively worsen with time C. Have a small valve compared to the demands of their body and cardiac output D. Have a benign condition Answer (2) C. Have a small valve compared to the demands of their body and cardiac output Robert D. Safian, MD 50
51 Conclusions Elevated gradients across prosthetic aortic valves may be due to other factors besides stenosis Regurgitation may be physiological or pathological and may be valvular or paravalvular Endocarditis, pannus, and thrombosis may be difficult to distinguish based solely on echocardiographic findings Please Let Them do Well on the Boards Zane Abbas Robert D. Safian, MD 51
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