1	Prosthetic heart valves Hemodynamics and complications Dr. Yaron Shapira, Dpt. of Cardiology, Rabin Medical Center, Beilinson hospital
2	שאלה 1 בן 57, 5 ימים לאחר AVR – תותב דו-עלי שלפי נתוני היצרן שטחו האפקטיבי 1.6 סמ"ר. באקו שגרה לפני שחרור: מפלי שיא וממוצע על המסתם – 50 ו-30 ממ"כ בהתאמה. קוטר LVOT – 2 ס"מ, ה-VTI על המסתם וב-LVOT הינם 30 ו-60 ס"מ, בהתאמה. האבחנה הכי סבירה: Patient-prosthesis mismatch Prosthetic valve thrombosis נבדק המפל של ה-MR במקום האאורטלי Non-thrombotic valve block
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7	Prosthetic valves
8	Prosthetic valves Occluder motion
9	Caged-ball valves
10	Caged-disc
11	Tilting disc valves
12	Bileaflet valves
13	Bileaflet valves
14	Stented xenografts
15	Stentless xenografts
16	Prosthetic valve imaging
17	Assessment of prosthetic valves Comparison of diagnostic modalities
18	Fluoroscopy
19	Fluoroscopy The most accurate tool for identifying leaflet motion abnormality Prerequisites: Valve identification Normal range of motion
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21	Bileaflet valve motion
22	Bileaflet valve motion
23	Bileaflet valve motion Travel angle
24	Bileaflet valve motion Closing angle
25	Bileaflet valve motion Opening angle
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27	Travel angle bileaflet valves
28	Piero Montorsi
29	Acquisition angles
30	Valve orientation
31	Valve orientation
32	Feasibility of achieving pivot view “1” – perpendicular to septum “2” – parralel to septum
33	Travel angle monoleaflet valves
34	Echocardiography
35	Assessment of prosthetic valves Pressure gradients Valve area Regurgitation (quantification & location) Leaflet motion Valve integrity Soft tissues (thrombus, vegetation, stitches) Perivalvular abscess / fistula / pseudoaneurysm General assessment of the heart (chamber size & function, other valves, PAP)
36	Pitfalls in echocardiographic prosthetic valve evaluation
37	Considerations in hemodynamic assessment of prosthetic valves Valve type Valve size CO HR (esp. in MVR) Pressure recovery Compare with previous values
38	Hemodynamics of prosthetic valves Quantitative tools Modified Bernoulli Equation Pressure recovery Continuity equation Doppler Velocity Index (DVI) * Valve resistance * P _1/2
39	Modified Bernoulli Equation DP = 4 * (V₂²-V₁²) DP @ 4 * V₂² (for V₁<1 m/s) V₁ is not negligible if >1 m/s !
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41	Pressure recovery E_k® E_p (downstream) “Overestimation” of gradients (Vs. cath) Pressure recovery - increased pressure distal to vena contracta Values up to 10 mmHg in small St Jude valves May be confused with valve stenosis
42	EOA Correction
43	Continuity equation
44	Continuity equation The equation: A₁ x TVI₁=A₂ x TVI₂ Modification: A₁ x V₁=A₂ x V₂ Pitfalls: Pressure recovery Imprecise measurements (esp. LVOT) Consider regurgitation at reference valve
45	P 1/2 Effective orifice area = 220/ P _1/2 Applies only for native, significantly stenosed mitral valves Unreliable measure of prosthetic MVA
46	Leakage backflow (seating regurgitation)
47	Leakage backflow Starr-Edwards: 2-5 cc, turbulent, surrounding ball Single disc: 5-9 cc, peripheral Medtronic-Hall: Large central jet Bileaflet: 5-10 cc, 2-4 jets Xenografts: only 10% show backflow
48	Leakage backflow
49	Echocardiography of prosthetic valves AHA/ACC guidelines Baseline - class I Change in cardiac status - class I Routine annual in stable pts. Bioprosthesis after >5 yrs - Class IIB Bioprosthesis during initial 5 yrs - Class III Mechanical – Class III
50	Echocardiography of prosthetic valves AHA/ACC guidelines Echocardiography is indicated in any patient with a prosthetic heart valve with Evidence of a new murmur Change in clinical status Questions about prosthetic valve integrity and function Concerns about ventricular function.
51	References for prosthetic valve gradients and area
52	Prosthetic valve malfunction
53	Complications of prosthetic valves Structural valve dysfunction Wear Fracture Poppet escape Calcification Leaflet tear
54	Complications of prosthetic valves Nonstructural dysfunction Entrapment of occluder by Pannus, tissue, suture Paravalvular leak Inappropriate sizing or positioning Residual leak / stenosis after replacement / repair Clinically important hemolytic anemia
55	Complications of prosthetic valves Valve thrombosis Any thrombus, in the absence of infection, that is attached to or near an operated valve that occludes part of the blood flow path or that interferes with the function of the valve Endocarditis according to customary clinical criteria
56	Potentially catastrophic valve complications Acute regurgitation Disk escape Non-thrombotic valve valve bloc Ruptured bioprosthesis Valve dehiscence Acute stenosis Obstructive valve thrombosis (stuck valve)
57	Prosthetic valve malfunction Classification by mechanism Prosthetic valve obstruction Obstructive thrombosis Obstructive vegetation Obstruction resulting from valve remnants or ball variance
58	Prosthetic valve malfunction Classification by mechanism Prosthetic valve regurgitation Intravalvular disruption of tissue leaflets Valve sticking in open position Strut fracture and occluder escape Ball wear Ball variance Paravalvlar Dehiscence
59	Assessment of prosthetic valve malfunction Patient’s history Physical examination Imaging TTE TEE Fluoroscopy Heart cath ???
60	Patient’s history Important clues Abrupt occurrence of shock in a patient who was previously in a good functional class Leaflet escape Acute blockage of a mechanical valve Acute perforation of a bioprosthesis. Valve thrombosis Systemic emboli Low INR Recent transient cessation of OAC
61	Patient’s history Important clues Muffled sounds - stuck valve A sudden intermittent EMD shortly after valve replacement Extrinsic valve block A history of fever and/or shaking chills – IE Embolic phenomena Thrombus Vegetation Valve remnants (rare)
62	Patient’s history Important clues Ascertain valve model if possible (medical chart, the patient, ID card) BS - susceptible to disc escape Avoid fruitless search for a missing second leaflet in a monoleaflet model
63	Patient’s history Important clues Identify causes of shock that are not directly valve related: Chest pain GI bleeding Recent trauma
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65	Physical examination Important clues Muffled / absent valve clicks Diastolic murmur over an atrioventricular valve Loud and prolonged systolic aortic murmur A new regurgitant murmur. Note: auscultatory findings may be intermittent e.g.: 2 cardiac cycles needed to develop sufficient pressure to open a stuck valve
66	Physical examination Important clues Signs of emboli Pallor Fever Stigmata of IE
67	TTE Advantages Bedside No patient preparation needed Provides most data needed to confirm the diagnosis of prosthetic valve malfunction
68	TTE Disadvantages Poor visualization & quantification of thrombotic material May display deceptively low or normal gradients in a state of shock D/T reliance on CO Limited visualization of valve leaflets Unreliable quantification of leaflet motion abnormality
69	TEE Improved imaging of soft tissue components Ability demonstrate & quantify leaflet motion: cinefluoroscopy > TEE > TTE Limited demonstration of aortic valves Valuable data on thrombus burden. Data on a thrombus attached to the affected valve or elsewhere in the heart, especially in the LAA Valve regurgitation (esp. mitral), DD between intra- & perivalvular
70	Non-thrombotic valve block
71	Non-thrombotic valve block Generally limited to tilting disk valves Incidence Mitral - 0.24% Aortic - 0.33% Timing: Very early in the P/O period Usually within the first 48 h and, occasionally, shortly after weaning from cardiopulmonary bypass.
72	Non-thrombotic valve block Clinical presentation: Sudden, unexpected, intermittent EMD Echocardiography: intermittent blockage of the valve opening, (M-mode, PW) Sometimes, a long observation period is needed because of the intermittent character of the blockage, and a TEE probe may left in situ for this purpose.
73	Etiology of nonthrombotic extrinsic Interruption of disk movement
74	Non-thrombotic valve block Approach Blocked mitral valve ® emergency redo surgery to remove the excess tissue. The valve may be Left in situ Replaced Reoriented Blocked aortic valves may undergo spontaneous release (LV pressure )
75	Obstructive valve thrombosis
76	Obstructive valve thrombosis
77	Obstructive valve thrombosis Incidence: Aortic - 0.1/100 patient-years Mitral- 0.5/100 patient-years Tricuspid - >1/100 patient-years Potential hazards: Valve obstruction and/or insufficiency Distal embolization Operative mortality in re-do surgery: 4.5-20% (15% in large series)
78	Obstructive valve thrombosis Patient History Variable time interval from valve implantation to its obstruction Mostly 3–4 yrs. Few days to 16 yrs. reported Variable symptom duration (Ds – >month) Progressive course Muffled valve clicks – noted by patients (may be unreliable) A history of inadequate anticoagulation (60–70%)
79	Obstructive valve thrombosis Physical Examination Congestive heart failure Valve clicks: muffled or absent Diastolic mitral murmur Regurgitant murmur (aortic or mitral) in case the leaflet is stuck in an open position.
80	Obstructive valve thrombosis Diagnostic issues Confirm leaflet motion abnormality Assess the extent of leaflet motion abnormality R/O high-risk left-sided thrombus that may embolize Assess hemodynamic consequences of leaflet immobilization Look for markers of high operative risk
81	Stuck prosthetic valve: therapeutic options Surgery Thrombolysis High intensity AC
82	Therapeutic considerations Extent of hemodynamic abnormality Availability of operation Likelihood of resolution with anticoagulants Thrombus size
83	AHA/ACC 2006 approach Class I TTE, TEE / fluoroscopy Class IIa Emergency surgery NYHA 3-4 Large thrombus Fibrnolysis for right-sided valves in NYHA 3-4 or a large thombus
84	AHA/ACC 2006 approach Class IIb Thrombolysis as first line if either FC 1-2, small thrombus FC 3-4, small thrombus, surgery unavailable FC 2-4, large thrombus, surgery unavailable IV UFH if FC 1-2 and a large thombus
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86	Obstructive valve thrombosis Impact of thrombus size AHA/ACC 5-10 mm – “small” Complication rate x2.41 for each cm² ESC No mention of thrombus size
87	Mid-term F-U After Thrombolytic Therapy for Obstructive Prosthetic Mitral Valve Thrombosis Beilinson experience 2003
88	Methods Study period- 1/1997-12/2002 (6y) 24 patients with mitral OPVT 4 - directly referral to surgery 20 – allocated to thrombolytic therapy Age 58.6±14.2 years M/F 10/10 TEE mandatory to exclude of high-risk thrombi
89	Stuck valve: diagnosis Gold standard: leaflet motion abnormality (2DE, fluoroscopy). Aids to diagnosis: Mean transvalvular gradient >6 mmHg >50% increase in transvalvular gradient compared with previous studies. Inability to visualize both leaflets moving properly in TTE in at least 1 view. Thrombus visualization not essential for diagnosis!
90	Thrombolytic regimens STK: 0.25 MU rapid infusion, 0.1 MU/h drip, 24-48h UK: 4.4 KU/kg rapid infusion, 4.4 KU/kg/h drip, 24-48h rt-PA: 10 mg bolus, 30 mg/h for 3h (total=100 mg)
91	Adjunctive therapy Heparin: Pre-thrombolysis: variable During thrombolysis: withdrawn Following thrombolysis: resumed Warfarin: Following thrombolysis: resumed Target INR - 3.0-3.5 ASA 100 mg/d Dipyridamole 75 mg TID - optional
92	Methods Interval since valve implantation to OPVT - 41±30 months Full success rate with thrombolytics – 15/20 (75%) Complications – 1 (5%) - minor stroke 5 (25%) referred to surgery after unsuccessful thrombolysis. 1 patient died shortly from carcinomatosis
93	Patients
94	Results F-U period - 38±21 months (range 4-71) 11/14 (78.6%) alive NYHA functional class 1.7±0.6. Mortality 1 - stroke (4 months) 2 – unavailable cause of death Both aged 72 years at the index episode Death - 2 and 5 yrs after the index episode
95	Medications The mean recommended INR was 3.5 Adherence to recommended INR - 85.7% Aspirin taken by 12 (85.7%) Dipyridamole taken by 1 (7.1%)
96	Re-thrombolysis 5 patients (35.7%), 10 episodes of OPVT All re-opened fully Repeated thrombolysis (9 episodes) Intensified anticoagulant regimen (1) 1 – re-do MVR as an adjunct to CABG
97	Summary
98	Initial success rate (%)
99	Success rate in recurrence (%)
100	Conclusions The mid-term outcome after thrombolysis for mitral OPVT is favorable. Repeated episodes are not uncommon, and can usually be treated with repeated thrombolysis. These findings underscore the need to follow-up patients with mitral OPVT closely.
101	Non-obstructive valve thrombosis ESC 2007
102	Non-obstructive valve thrombosis Anticoagulation - first line Only the combination of a large thrombus and systemic embilization justifies surgery (IIA) Fibinolysis in the above situation – only when surgery is unavailable or too risky In a case of proven or suspected embolism, consider aspirin supplementation (cautiously)
103	Paraprosthetic leak Immediate Vs. late suture failure Predictors of leak: Operative technique Calcification Ring irregularity (previous operations) Endocarditis Often difficult to trace (eccentric) Hemolysis depends on shearing forces
104	Paraprosthetic leak AVR Parasternal color-Doppler assessment - accurate P1/2 - Imprecise in assessing severity Reversal of aortic flow - useful TEE for mechanism
105	Paraprosthetic leak MVR TEE - almost always mandatory PISA and EOA for quantification E >1.8 m/s - identifies severe MR Additional clues: P1/2, TVI, mean gradients, PHT Reversal of flow in PV Possible around annuloplasty ring
106	Para-prosthetic leak non-surgical options Iron & folate Beta blockers Percutaneous closure Erythropoietin Pentoxifylline
107	Para-prosthetic leak Percutaneous closure
108	Para-prosthetic leak Percutaneous closure
109	Patient characteristics
110	Technical details
111	Applicable Amplatzer devices
112	Results
113	Results
114	Results
115	Conclusions
116	Structural valve dysfunction Mechanical valves
117	Strut fracture – bjork Shiley convexo-concave
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120	BS - embolized disc
121	BS - embolized disc
122	BS - embolized disc
123	Ball variance Starr Edwards model 1000
124	Cloth cover tears
125	Where is the ball?
126	Biological valve dysfunction
127	Biological valve dysfunction Degeneration rate 30% will degenerate within 10 yr Actuarial freedom from bioprosthetic primary tissue failure by 15 yrs– 30- 60% Pathological findings Cuspal tears Fibrin deposition Disruption of the fibrocollagenous structure Perforation Fibrosis Calcifion
128	Predictors of structural dysfunction of xenografts Young age at implantation Long postoperative period Mitral position Hypercalcemia Chronic renal failure (not anymore!!!)
129	Dysfunction of biological valves History: High-risk category Previous evaluation revealed significant intravalvular regurgitation A sudden vibrating sensation in the chest Physical examination Hyperkinetic precordium A loud regurgitant murmur (tear) A “honking noise” coming from the chest
130	Dysfunction of biological valves Echocardiography TTE may be sufficient Intravalvular regurgitation of variable degrees. The audio signal of the valvular regurgitation may be honking TEE - better than TTE in Estimating bioprosthetic mitral valves Differentiating intravalvular from perivalvular regurgitation Demonstrating thickened valves resulting from degeneration
131	שאלה 1 בן 57, 5 ימים לאחר AVR – תותב דו-עלי שלפי נתוני היצרן שטחו האפקטיבי 1.6 סמ"ר. באקו שגרה לפני שחרור: מפלי שיא וממוצע על המסתם – 50 ו-30 ממ"כ בהתאמה. קוטר LVOT – 2 ס"מ, ה-VTI על המסתם וב-LVOT הינם 30 ו-60 ס"מ, בהתאמה. האבחנה הכי סבירה: Patient-prosthesis mismatch Prosthetic valve thrombosis נבדק המפל של ה-MR במקום האאורטלי Non-thrombotic valve block
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