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Non-Invasive Assessment of Prosthetic Valves Non-Invasive Assessment of Prosthetic Valves November 21, 2007 Alex Morss.

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Presentation on theme: "Non-Invasive Assessment of Prosthetic Valves Non-Invasive Assessment of Prosthetic Valves November 21, 2007 Alex Morss."— Presentation transcript:

1 Non-Invasive Assessment of Prosthetic Valves Non-Invasive Assessment of Prosthetic Valves November 21, 2007 Alex Morss

2 Terms and definitions Prosthetic valves: manmade replacements of heart valves, either mechanical (nonorganic) or bioprosthetic (organic materials used in construction, i.e. animal or human parts) Prosthetic valves: manmade replacements of heart valves, either mechanical (nonorganic) or bioprosthetic (organic materials used in construction, i.e. animal or human parts) Assessment: visual evaluation Assessment: visual evaluation Non-invasive: taking pictures of hidden things without using sharp objects (i.e., essentially nonviolent means of seeing them undressed) Non-invasive: taking pictures of hidden things without using sharp objects (i.e., essentially nonviolent means of seeing them undressed)

3 Main Characters (Protagonists) Mechanical Valves Mechanical Valves Ball-cage Ball-cage Tilting disc Tilting disc Bileaflet Bileaflet Bioprosthetic Valves Bioprosthetic Valves Stented Stented Unstented (aortic root) Unstented (aortic root) Homograft, allograft Homograft, allograft

4 The Antagonists Endocarditis +/- vegetations Endocarditis +/- vegetations Paravalvular leak (+/- dehiscence) Paravalvular leak (+/- dehiscence) Thrombosis Thrombosis Pannus formation Pannus formation Degeneration, +/- calcific stenosis or leaflet tear Degeneration, +/- calcific stenosis or leaflet tear Strut fracture, disc embolization Strut fracture, disc embolization Unseating of valve Unseating of valve

5 The Arsenal Roentgenography (X-Ray) Roentgenography (X-Ray) Fluoroscopy Fluoroscopy Cardiac MRI (?) Cardiac MRI (?) Echocardiography Echocardiography TTE will often best allow optimal Doppler angles TTE will often best allow optimal Doppler angles TEE will often best allow optimal direct visualization TEE will often best allow optimal direct visualization Intangibles Intangibles

6 The Main Characters Mechanical Valves Mechanical Valves Ball-cage (Starr-Edwards) Ball-cage (Starr-Edwards) Tilted-disc (Bjork-Shiley, Medtronic-Hall) Tilted-disc (Bjork-Shiley, Medtronic-Hall) * Note: the convexoconcave version of the Bjork-Shiley valve earned a bad name due to cases of strut fracture and disc embolization * Note: the convexoconcave version of the Bjork-Shiley valve earned a bad name due to cases of strut fracture and disc embolization Bileaflet (St. Jude, Carbomedics) Bileaflet (St. Jude, Carbomedics) All valves are sized by diameter, mm All valves are sized by diameter, mm O’Neill NEJM 1995

7 Main Characters, Part Deux Bioprosthetic Valves Bioprosthetic Valves Stented: Carpentier- Edwards, Hancock, Ionescu-Shiley, St. Jude Mosaic Stented: Carpentier- Edwards, Hancock, Ionescu-Shiley, St. Jude Mosaic Stentless: Biocor. Stentless: Biocor. Homografts/autografts: may not be able to detect noninvasively Homografts/autografts: may not be able to detect noninvasively Also sized by diameter, mm Also sized by diameter, mm Hancock Mosaic Stentless porcine

8 Unveiling the arsenal Old School: Roentgenography Mechanical and many stented bioprosthetic valves are radiopaque, allowing determination of valve type and position on chest X-ray. Mechanical and many stented bioprosthetic valves are radiopaque, allowing determination of valve type and position on chest X-ray. May be used to assess for device fracture in some cases May be used to assess for device fracture in some cases Starr-Edwards valve seen in aortic position in From Nery, Heart 2004

9 Up a Notch: Fluoroscopy Best methodology to assess mechanical leaflet motion due to outstanding spatial and temporal resolution. Best methodology to assess mechanical leaflet motion due to outstanding spatial and temporal resolution. May be used to assess stability of valve ring with the cardiac cycle May be used to assess stability of valve ring with the cardiac cycle May optimally position angle to best assess subtle fracture May optimally position angle to best assess subtle fracture O’Neill NEJM 1995

10 Disc embolization O’Neill NEJM 1995 disc

11 Cardiac MRI Cardiac MRI may visualize mechanical valves, but lacks the temporal resolution and Doppler capablities of echocardiography Cardiac MRI may visualize mechanical valves, but lacks the temporal resolution and Doppler capablities of echocardiography May show gross valve position, function, and regurgitation May show gross valve position, function, and regurgitation

12 More cardiac MRI

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14 Echocardiography Transthoracic Transthoracic Allows assessment of valve area and regurgitation via Doppler, which is generally adequate to exclude significant obstructive or regurgitant change. Flow velocity is the crucial measurement. Allows assessment of valve area and regurgitation via Doppler, which is generally adequate to exclude significant obstructive or regurgitant change. Flow velocity is the crucial measurement. Inadequate to assess infection or small structural changes (e.g. strut fracture, small vegetation, paravalvular leak) Inadequate to assess infection or small structural changes (e.g. strut fracture, small vegetation, paravalvular leak) Transesophageal Transesophageal Ideal for visual inspection of valve apparatus and seating; may not accurately quantify valve flow velocities. May directly measure aortic valve area via planimetry Ideal for visual inspection of valve apparatus and seating; may not accurately quantify valve flow velocities. May directly measure aortic valve area via planimetry

15 Echo by valve position Aortic Aortic Accurate TTE assessment relies on accurate Doppler assessments in multiple views Accurate TTE assessment relies on accurate Doppler assessments in multiple views Often many TTE views partially obscured by shadowing. Often TEE required to view leaflets Often many TTE views partially obscured by shadowing. Often TEE required to view leaflets Mitral Mitral Among the best positions for TTE visualization, usually able to see leaflets via apical views Among the best positions for TTE visualization, usually able to see leaflets via apical views Tricuspid Tricuspid Also usually adequately visualized by TTE directly and via Doppler Also usually adequately visualized by TTE directly and via Doppler Pulmonic Pulmonic Rarest position for valve replacement. Difficult to visualize for both TTE and TEE, no clear advantage Rarest position for valve replacement. Difficult to visualize for both TTE and TEE, no clear advantage

16 Aortic Prostheses Focus on Doppler imaging of aortic outflows to determine mean and peak gradients Focus on Doppler imaging of aortic outflows to determine mean and peak gradients Can identify prosthesis type by direct visualization Can identify prosthesis type by direct visualization As with all prostheses, need to know their SIZE to allow assessment of normal vs. pathologically increased transvalvular gradient. As with all prostheses, need to know their SIZE to allow assessment of normal vs. pathologically increased transvalvular gradient. Size varies from mm in diameter Size varies from mm in diameter Normal gradients for each valve type and size may be found on reference tables Normal gradients for each valve type and size may be found on reference tables

17 Normal aortic bileaflet valve

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21 Peak gradient 20mmHg, mean 12 mmHg Peak gradient 20mmHg, mean 12 mmHg Normal bileaflet gradients are dependent on valve size Normal bileaflet gradients are dependent on valve size

22 Normal mechanical aortic valve peak gradients Bileaflet Bileaflet 19mm: 33 +/ mm: 33 +/ mm: 13 +/- 5 29mm: 13 +/- 5 Tilting disc Tilting disc 19mm: 46 19mm: 46 29mm: 12+/- 8 29mm: 12+/- 8 Ball-cage Ball-cage 23mm: 33+/-13 23mm: 33+/-13 29mm: 29+/-9 29mm: 29+/-9 Full tables are available in echo texts or on fellowship echo website Feigenbaum 2005 Approximate flow velocities: 19mm 2.9 m/sec 29 mm 1.9 m/sec (+/- 0.5 m/sec)

23 Normal aortic bioprosthetic valve

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26 Peak gradient 17mm- need valve size and ideally baseline gradient at time of valve implantation to assess for normal value Peak gradient 17mm- need valve size and ideally baseline gradient at time of valve implantation to assess for normal value May also use continuity equation with measurement of LVOT to calculate effective aortic valve area May also use continuity equation with measurement of LVOT to calculate effective aortic valve area

27 Tilting disc AVR

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32 Ball-cage AVR

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36 Name the AVR type

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39 Aortic bioprosthetic valve with paravalvular leak, valvular regurgitation Aortic bioprosthetic valve with paravalvular leak, valvular regurgitation

40 What’s wrong?

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46 Tilting disc valve with thrombosis causing partial obstruction Talley, Can J Card 1986

47 Mitral prosthetic valves Better visualization on TTE Better visualization on TTE Much lower normal gradients than aortic valves due to lower flow velocities and larger size overall Much lower normal gradients than aortic valves due to lower flow velocities and larger size overall Sizes generally vary from 25-33mm in diameter Sizes generally vary from 25-33mm in diameter

48 Normal bioprosthetic MVR

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51 Peak mitral velocity of 1.30 m/sec, peak gradient 8 mmHg, mean 5mmHg (normal ~ 5 depending on valve size) Peak mitral velocity of 1.30 m/sec, peak gradient 8 mmHg, mean 5mmHg (normal ~ 5 depending on valve size)

52 Bileaflet MVR

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55 Appropriate regurgitation shown- 2 jets in bileaflet valve Appropriate regurgitation shown- 2 jets in bileaflet valve By design in mechanical valves to minimize thrombosis risk By design in mechanical valves to minimize thrombosis risk

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57 Ball-cage MVR

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60 Cage-ball valves have the highest nomal valve gradients due to design

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63 Mean gradient 9 mmHg Mean gradient 9 mmHg Standard mean gradient for ball-cage MVR is 5-7 +/- 3, depending on size Standard mean gradient for ball-cage MVR is 5-7 +/- 3, depending on size

64 Mitral endocarditis Kort, JASE 2006 (from Gelfand)

65 Mitral unpleasantries, part II

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70 A league of its own

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75 Summary Valve type and position often easily determined on CXR Valve type and position often easily determined on CXR Fluoroscopy optimal for assessing mechanical valve leaflet motion, unable to see bioprosthetic leaflets Fluoroscopy optimal for assessing mechanical valve leaflet motion, unable to see bioprosthetic leaflets TTE may identify flow velocities and gross structure, best suited for MVR and exclusion of obstruction due to good Doppler views. Doppler velocities and valve gradients are likely better than calculation of valve area due fewer variables TTE may identify flow velocities and gross structure, best suited for MVR and exclusion of obstruction due to good Doppler views. Doppler velocities and valve gradients are likely better than calculation of valve area due fewer variables TEE allows better visualization of smaller structural changes, vegetations, and paravalvular leaks. It is the study of choice for concerns of endocarditis in any prosthetic valve. TEE allows better visualization of smaller structural changes, vegetations, and paravalvular leaks. It is the study of choice for concerns of endocarditis in any prosthetic valve. CMR limited role and not generally used to assess prosthetic valves. CMR limited role and not generally used to assess prosthetic valves.

76 Thank you!


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