Types of Prosthetic ValvesBIOLOGIC� STENTED

Porcine xenograftPericardial xenograft

� STENTLESSPorcine xenograftPericardial xenograftHomograft (allograft)Autograft

� PERCUTANEOUS

MECHANICALBileafletSingle tilting discCaged-ball

25 different brand names>44 different modelsSizes 17-35 mm

Types of prosthetic valves

� Mechanical vales

� Biologic (tissue) valves

� Percutaneous biologic valves

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

3-D echocardiography and Doppler

Assessment of the whole valve apparatus and the annulus

MITRAL POSITION > aortic position

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

Computed Tomography

Tsai I-C, Lin Y-K, Chang Y, et al: Eur Radiol 2009

Pannus formationResidual angle 66 degreesIntra-operative findings

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

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

Shadowing & Flow Masking

Common “physiologic” characteristics of

prosthetic valves

�“Physiologic” stenosis

�“Physiologic” regurgitation

Causes of “physiologic” stenosis

�Valve design / Valve type

�Valve size

�Pressure recovery phenomenon

�Increased flow across the valve

�Patient-prosthesis mismatch

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

Early and Late Complications of

Prosthetic Valves� Patient-prosthesis mismatch

� Dehiscence

� Primary failure

� Thrombosis and thromboembolism

� Pannus formation

� Pseudoaneurysm formation

� Endocarditis

� Hemolysis

Distinction between thrombus and pannus

Aortic St Jude Medical valvePannus formation

TRANSESOPHAGEAL ECHOCARDIOGRAPHY

INDICATIONS OF TEE IN PROSTHETIC VALVESINDICATIONS OF TEE IN PROSTHETIC VALVES�� Valvular regurgitationValvular regurgitation

Mitral and tricuspid valves Mitral and tricuspid valves >> aortic valvesaortic valves�� Suspected valve obstructionSuspected valve obstruction

Assessment of valve motion, thrombus vs pannus, Assessment of valve motion, thrombus vs pannus, candidates for thrombolysiscandidates for thrombolysis

�� Evaluation of associated structural abnormalitiesEvaluation of associated structural abnormalitiesVegetations, thrombi, ring abscess, pseudoaneurysm, Vegetations, thrombi, ring abscess, pseudoaneurysm,

fistulasfistulas�� Atrial, atrial appendage thrombiAtrial, atrial appendage thrombi�� Inadequate transthoracic echocardiographic studyInadequate transthoracic echocardiographic study

Barbetseas J & Zoghbi WA: Cardiology Clinics 1998

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

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

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

Normal Prosthetic Valves

DETERMINANTS OF VELOCITY/GRADIENT

� Valve size

� Valve type

� Flow rate

Normal Doppler echocardiographic values

for PrAVs

St Jude St Jude

AorticAortic

Size(mm)Size(mm)Peak VelPeak Vel Mean Mean

GrGrDVIDVI EOAEOA

(ECHO)(ECHO)

EOA EOA

(SR AREA)(SR AREA)

1919

3131

3.03.0±±0.60.6

2.12.1±±0.60.6

1717±±77

1010±±66

0.370.37±±0.070.07

0.490.49±±0.190.190.990.99±±0.200.20

3.083.08±±1.091.09

1.041.04±±0.190.19

3.723.72±±1.401.40

Chafizadeh ER & Zoghbi WA: Circulation 1991

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

Normal vs obstructed prosthetic aortic valve

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

Echocardiographic and Doppler Parameters

in Evaluation of Prosthetic Mitral Valve

Function (Stenosis or Regurgitation) DOPPLER ECHOCARDIOGRAPHY OF THE VALVE

Peak early velocityMean gradientHeart rate at the time of DopplerPressure half-timeDVI=VTI PrMV/VTI LVOEOAPresence, location, and severity of regurgitation

OTHER PERTINENT ECHOCARDIOGRAPHIC AND DOPPLER PARAMETERS

LV size and functionLA sizeRV size and functionEstimation of PASP

Prosthetic Mitral Valve

BEFORE AND AFTER THROMBOLYSIS

Doppler Parameters of Prosthetic

Mitral Valve StenosisSUGGESTS SIGNIFICANT STENOSIS

Peak Velocity > 2.5 m/s

Mean Gradient > 10 mmHg

EOA (continuity equation) < 1 cm2

Pressure half-time > 200 ms

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

Parameters for Evaluation of the Severity of

Prosthetic Aortic Valve Regurgitation

SEVERE

VALVE STRUCTURE AND MOTIONMechanical or bioprosthetic Abnormal

STUCTURAL PARAMETERSLV size Dilated

DOPPLER PARAMETERS (qualitative or semiquantitative)Jet width in central jets (% LVO diameter): colorJet density: CW DopplerJet deceleration rate (PHT, ms): CW DopplerLVO flow vs pulmonary flow: PW DopplerDiastolic flow reversal in the Desc Ao: PW DopplerDOPPLER PARAMETERS (quantitative)Regurgitant volume (mL/beat)Regurgitant fraction (%)

Large (≥65%)DenseSteep(<200)Greatly increasedProminent, holodiastolic

>60>50

TEEParavalvular significant AR

Transthoracic Echocardiographic Findings

Suggestive of Significant Prosthetic MR in

Mechanical Valves with Normal Pressure Half-time

FINDING COMMENTS

Peak mitral velocity ≥ 1.9 m/s Also consider high flow, PPM

VTI PrMV / VTI LVO ≥ 2.5 Measurement errors increase in AF due to difficulty in matching cardiac cycles; also consider PPM

Mean gradient ≥ 5 mmHg At physiologic heart rate; also consider high flow, PPM

LV stroke volume (2D or 3D imaging) is > 30% higher than systemic stroke volume by Doppler

Validation lacking; significant MR is suspected when LV function is normal or hyperdynamic and VTI LVO is < 16 cm

Maximal TR jet velocity > 3m/s Consider residual postop pulmonary hypertension or other causes

Systolic flow convergence seen in the LV toward the prosthesis

Validation lacking; technically challenging to detect readily

Echocardiographic and Doppler Criteria for Severity

of Prosthetic MR Using Findings from TTE and TEE

SEVERE

STRUCTURAL PARAMETERSLV sizeProsthetic valve

Usually dilatedAbnormal

DOPPLER PARAMETRSColor flow jet area

Flow convergenceJet density: CW DopplerJet contour: CW DopplerPulmonary venous flow

Large central jet (usually > 8 cm2 or > 40% of LA area) or variable size wall-impinging jet swirling in the left atriumLargeDenseEarly peaking, triangularSystolic flow reversal

QUANTITATIVE PARAMETERSVC width (cm)R vol (mL/beat)RF (%)EROA (cm2)

≥ 0.6≥ 60≥ 50≥ 0.50

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

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

Evaluation of Severity of Prosthetic

Pulmonary Valve RegurgitationSEVERE

Valve structure Abnormal or valve dehiscence

RV size Dilated (unless there are other reasons)

Jet size by color Doppler (central jets) Usually large, with a wide origin; jet width >50% of pulmonary annulus;may be brief in duration

Jet density by CW Doppler Dense

Jet deceleration rate by CW Doppler Steep deceleration (not specific for severe PR), early termination of diastolic flow

Pulmonary systolic flow vs systemic flow by PW Doppler

Greatly increased (cutoff values are not well validated)

Diastolic flow reversal in the pulmonary artery

Present

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 TRRELATED CARDIAC CHAMBERS, IVC AND HEPATIC

VEINS� RV size and function� Right atrial size� Size of IVC and response to inspiration� Hepatic vein flow pattern

Doppler Paramters of Prosthetic

Tricuspid Valve FunctionCONSIDER VALVE STENOSIS (average ≥5 cycles)

Peak velocity(increased also with TR)

> 1.7 m/s

Mean gradient(increased also with TR)

≥ 6 mm Hg

Pressure half-time ≥ 230 ms

EOA and VTI PrTV/VTI LVO No data yet available for tricuspid prosthesis

Echocardiographic and Doppler Parameters Used

in Grading Severity of Prosthetic Tricuspid Valve

Regurgitation

SEVERE

Valve structure Abnormal or valve dehiscence

Jet area by color Doppler,central jets only (cm2)

> 10

VC width (cm)(for valvular TR jet, extrapolated from native TR, unknown cutoffs for paravalvular TR)

> 0.7

Jet density and contour by CW Doppler Dense with early peaking

Doppler systolic hepatic flow Holosystolic reversal

Right atrium, right ventricle, IVC Markedly dilated

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 (?)

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