Assessment Of Prosthetic Valve Function Research Articles

P6302Normal values for doppler echocardiographic assessment of prosthetic valve function after TAVR - A systematic review and meta-analysis

P6302Normal values for doppler echocardiographic assessment of prosthetic valve function after TAVR - A systematic review and meta-analysis

Normal values for Doppler echocardiographic assessment of prosthetic valve function after transcatheter aortic valve replacement: a systematic review and meta-analysis.

Transcatheter aortic valve replacement has emerged as valuable treatment modality for patients with severe aortic stenosis and an unacceptable risk/benefit ratio for open heart surgery, but particularities specific to TAVR and a rapidly growing number of available TAVR prosthesis make post-procedural assessment of valve function challenging. Aim of the present analysis was to collect and pool all available data currently in the literature regarding normal doppler values for transcatheter prosthetic heart valves and to provide a comprehensive overview. A PRISMA checklist-guided systematic review and meta-analysis of prospective observational studies or national and device specific registries or randomized clinical trials was conducted. Studies were identified by searching PUBMED, SCOPUS, Cochrane Central Register of Controlled Trials and LILACs from January 2000 to March 2017. Out of 240 abstracts, 155 studies reporting echocardiographic parameter for twelve different valves prosthesis in a total of 27,159 patients were in included in this meta-analysis. The means and standard deviations of peak velocity, peak gradient, mean gradient and effective orifice were extracted and pooled from the included studies. The pooled means and standard deviations for all available TAVR prosthesis were classified according to implanted valve size and time since implantation. The present study firstly describes a pooled analysis of normal values for all available TAVR prosthesis in order to empower treating physicians with a reliable tool to perform follow-up echocardiographic assessment in TAVR patients and to safely identify patients with prostheses dysfunction.

Assessment of prosthetic valve function and para-valvular regurgitation after trans-catheter aortic valve replacement

To review the current literature on prosthetic valve function and para-valvular regurgitation (PVR) after trans-catheter aortic valve replacement (TAVR). TAVR is a new alternative for the treatment of severe aortic stenosis in patients at high risk for surgical aortic valve replacement and nonsurgical candidates. The innovations in three-dimensional trans-esophageal echocardiography have made it an integral part of the TAVR procedure. PVR is more frequent with TAVR than surgical aortic valve replacement and is associated with worse cardiovascular outcomes. Recent publications focus on echocardiographic techniques to better assess the structural components of aortic valve complex, and begin to define the mechanism and risks of PVR after TAVR. Imaging innovations before, during, and after TAVR may lead to improved patient selection, accelerated development of TAVR prostheses, and ultimately a fuller characterization of the performance and potential limitations of a new generation of prosthetic heart valves.

Real Time Triplane Echocardiography in the Assessment of the Functional Area of Prosthetic Aortic Valves: Reliability and Feasibility

Our study is aimed at evaluating the feasibility and reliability of a simple method for the measurement of the functional area of prosthetic aortic valves (EOA). Three-dimensional echocardiography has proven accurate for left ventricular volume, stroke volume, and aortic valve area measurement. We studied the feasibility and reliability of real time simultaneous triplane echocardiography (RT3P) for assessing the EOA with a fast formula based on the principle of continuity equation, in which we replaced Doppler-derived stroke volume (SV) with SV directly measured with RT3P. EOA of prosthetic aortic valves were measured in 23 consecutive patients requiring periodical follow up. EOA was calculated using Doppler continuity equation (DCE) and the RT3P method by replacing Doppler-derived SV with SV measured with real time triplane echocardiography. We compared functional areas obtained with the two methods with the prosthetic area indicated in the manufacturer's specifications and with the mean transprosthetic gradient. Both methods had a good correlation with the area indicated by the manufacturer. RT3P revealed an inverse correlation between functional area and mean gradient that was better than DCE (P = 0.0359). Inter- and intraobserver variability was not different between the two methods. Execution time was significantly shorter for RT3P. RT3P is a simple method that can be performed quite rapidly, and can complement the overall assessment of prosthetic valve function. Further studies can confirm our technique.

Paravalvular regurgitation one year after transcatheter aortic valve implantation

The aim of this study was to assess the natural history of paravalvular regurgitation at 1 year in patients undergoing TAVI. The immediate incidence of paravalvular regurgitation is estimated to be between 65 and 85% following transcatheter aortic valve implantation (TAVI). There is limited data as to whether this deteriorates during follow-up. Forty-six patients were recruited from a TAVI programme at our institute. All patients underwent an assessment of prosthetic valve function periprocedurally with aortography and immediately postprocedurally with transthoracic echocardiography. Twenty-one patients with a median age was 83 (66-91) years of whom 14 were male reached 1 year follow-up, 13 of whom were available for repeat transthoracic echocardiography. The incidence of paravalvular regurgitation immediately following TAVI was 86%. Of them 57% had < or = mild regurgitation and 29% had > mild regurgitation. At 1 year the incidence of paravalvular regurgitation was 77%. 54% had < or = mild regurgitation and 34% > mild regurgitation. No patient had severe regurgitation. The degree of regurgitation reduced in 6 (46%), stayed the same in 3 (23%), and increased in 4 (31%) of patients. Patients undergoing TAVI have an immediate postprocedural risk of regurgitation of 86%. In the majority of cases the degree of paravalvular CoreValve regurgitation is mild, and remains stable in 70% of patients during medium term follow-up.

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound: A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound: A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the

Intraoperative Assessment of Perivalvular Mitral Regurgitation: Utility of Three-Dimensional Echocardiography

THE APPLICATION OF transesophageal echocardiography (TEE) for the assessment of prosthetic valve function is considered a category II indication.1 Although direct surgical examination of the prosthetic mitral valve is considered the “gold standard,” TEE provides a “dynamic” assessment of the valve under varying loading conditions.2 Three-dimensional (3D) TEE imaging may provide additional information to improve the description of prosthetic valve function and the location of perivalvular leaks. The incorporation of color-flow Doppler information in the 3D image may also help visualize the complex and eccentric mitral regurgitation (MR) jets.

Use of intra-cardiac ultrasound in the diagnosis of prosthetic valve malfunction

A 46-year old lady was under regular follow up for aortic valve replacement done in 2002 for aortic stenosis. The valve was a Carbomedics 19 mm bi-leaflet aortic valve prosthesis for which she had adequate anticoagulation since implantation. She had a past history of end stage renal failure, type 2 diabetes, hypertension, cerebrovascular disease and systemic lupus erythematosus. She was asymptomatic and had a routine transthoracic echocardiogram performed which revealed that her aortic valve prosthesis was well seated with an elevated velocity across the valve; the aortic valve leaflets were poorly visualised but appeared to be mobile. A transoesophageal echocardiogram (TOE) confirmed the markedly increased forward velocity across the aortic valve (maximum velocity 4.6 m/s) with small aortic root raising the possibility of pressure recovery phenomenon. Once again the leaflets were not clearly seen but appeared mobile despite the use of deep trans-gastric view. Fluoroscopy was performed and revealed that one of the leaflets was not moving. The patient had an intra-cardiac ultrasound scan (ACUSON AcuNav; Siemens) with the probe of the scanner within the right atrium. A long-axis view demonstrated the prosthetic aortic valve leaflets clearly (Fig. 1). A short-axis view of the prosthetic valve revealed an echogenic area at the six o'clock position; this may be due to pannus formation (Fig. 2); colour flow across the valve during systole revealed absence of colour flow though one of the leaflets due to the leaflet being stuck (Fig. 3). The sewing cuff of the Carbomedics valve is coated with biolite carbon, which is an anti-thrombotic agent that prevents adhesion of thrombus or pannus on the sewing cuff. There are few reports of Carbomedics valve dysfunction by pannus formation in the mitral position but none in the aortic position. Fluoroscopy can be used to visualize mobility of valve leaflets but is unable to identify thrombus/pannus formation that may be causing the valve to stick. Intra-cardiac echocardiography (ICE) can provide additional information regarding potential causes of valve dysfunction such as pannus/thrombus formation. However, ICE does suffer from the same limitations as TOE in obtaining sufficiently adequate images of the aortic valve to allow appropriate assessment of leaflet motion and insight into flow channels; it is also more invasive and expensive compared with other imaging modalities. In our patient ICE provided better images than TOE, possibly due to the closer proximity of the probe to the aortic root compared with TOE. ICE is a novel tool in the assessment of prosthetic valve function, which can complement data obtained from transthoracic/transoesophageal echocardiography and fluoroscopy.

Intracardiac Echo Guided Valvuloplasty of a Stenotic Tricuspid Prosthetic Valve in a Patient with Idiopathic Hypereosinophilic Syndrome

A 52-year-old male with idiopathic hypereosinophilic syndrome (HES) was transferred to our institution following the development of acute respiratory failure and shock. He had previously undergone tricuspid valve replacement with bioprosthetic valves on two occasions: the initial surgery for severe native tricuspid valve stenosis and the redo surgery for severe prosthetic valve stenosis and regurgitation. Conventional imaging assessment using transoesophageal echocardiography was suboptimal and comprehensive assessment of prosthetic valve function was aided by the use of intracardiac echocardiography (ICE). ICE provided high quality 2D imaging of the prosthesis demonstrating thrombus-like material coating the inner surfaces of the prosthetic valve stents effectively forming a tunnel-like obstruction. Unusual hemodynamics secondary to severe tricuspid stenosis were demonstrated by CW Doppler with intermittent "signal fusion" resulting from blunted respiratory variation in the markedly elevated right atrial pressure relative to right ventricular pressure. Successful balloon valvuloplasty was performed with ICE proving highly valuable in guiding balloon position as well as monitoring the efficacy of the subsequent inflations.

Is Prosthesis–Patient Mismatch a Clinically Relevant Entity?

In this issue of Circulation , Koch and associates1 from the Cleveland Clinic published a study on the relationship between prosthetic valve size and the Duke Activity Status Index (DASI) after aortic valve replacement (AVR). The study was conducted with 1014 patients operated on from 1995 through 1998, completed 1 year later, and published now. DASI scores increased from a mean of 29 preoperatively to 46 postoperatively after a mean follow-up of 8.3 months. The investigators could find no obvious relationship between prosthetic valve size and postoperative DASI score. One of the limitations of the study was that prosthetic valve gradients and effective orifice areas were not measured by echocardiography to quantify prosthesis–patient mismatch. It is also interesting to note that more than two thirds of the patients were in New York Heart Association functional classes I and II preoperatively, and yet the DASI mean score before surgery was only 29 out of a maximum of 58.2. For this reason alone, it must be assumed that factors other than the aortic valve disease played a role in the DASI score. Nevertheless, this is not the first study to suggest that valve size plays no role in the clinical outcomes of AVR. See p 3221 Valve prosthesis–patient mismatch (PPM) is a term introduced by Rahimtoola in 1978 to describe a condition in which the in vivo prosthetic valve effective orifice area is smaller than that of the native valve.2 According to this broad definition, every patient with a prosthetic heart valve has PPM because the leaflets of both mechanical and bioprosthetic valves are mounted into frames that occupy …

Normal values for Doppler echocardiographic assessment of heart valve prostheses

Assessment of normal and abnormal function of heart valve prostheses remains challenging. Doppler echocardiography has been shown to allow hemodynamic evaluation in various clinical settings and has become the most widely used tool to assess prosthetic valve function. Prosthetic valves, even when they function normally, are to some degree obstructive to the blood flow. The normal values of gradients, pressure half-time, and effective orifice area depend on valve type and valve size. Doppler assessment of prosthetic valve function, thus, requires specification of valve type and valve size, and knowledge of the normal values. This study provides an updated overview on the available data of normal values to facilitate adequate interpretation of Doppler data.

Characteristics, evaluation, and complications of prosthetic valves and valvular repair.

The availability of prosthetic heart valves and advances in techniques for their installation have drastically changed the outcome of valvular heart disease. Problems remain, however, in the assessment of prosthetic valve function, durability of prosthetic valves, preservation of left ventricular performance, and the treatment of complications of prosthetic dysfunction. Recent reports have addressed these issues.

Echo Doppler principles, techniques and applications for the cardiac surgeon

Doppler echocardiography is increasingly used not only to identify disease in native heart valves, but also to assess the function of prosthetic valves. The purpose of this paper is to provide a summary of the principles of Doppler echocardiography for the cardiac surgeon which will lead to a discussion of assessment of prosthetic valve function. Solid cardiac structure imaging is first discussed in both one-dimensional (M-mode) and two-dimensional (B-mode) modalities. Measurements of blood cell velocities by conventional spectral Doppler echocardiography are then discussed, leading to two-dimensional flow imaging by color Doppler flow mapping. Assessment of prosthetic valve function is divided into two sections: normal prosthetic valve function and prosthetic valve dysfunction. Subtopics within each of these divisions are discussed in the context of conventional and color Doppler ultrasonography.

Clinical assessment of prosthetic valve function.

The advent of high-quality ultrasound technology has made the assessment of prosthetic valve function quicker, easier, and more accurate than ever before. By using cross-sectional imaging, colour flow mapping, and spectral Doppler techniques from both the precordium and the oesophagus, it is possible to assess a prosthetic valve fully. Cardiac catheterization with its attendant risks can be avoided. Echocardiography gives detailed morphological information, and it can be used for routine serial follow-up of individual patients. Using the patient as his or her own control avoids the problems caused by poorly-defined 'normal ranges' for prosthetic function.

Usefulness of coronary angiography in patients requiring repeat cardiac valve surgery

Widespread application of surgical treatment for valvular heart disease has made the diagnosis of prosthetic valve dysfunction of great clinical importance. Recent advances in cardiac imaging techniques, including color Doppler and transesophageal echocafdiography, provide such a detailed picture of valve anatomy and function that often cardiac catheterization adds little to the assessment. 1,2 Despite adequate noninvasive assessment of prosthetic valve function, adult patients continue to undergo cardiac catheterization before reoperation to rule out the development of new significant coronary artery disease. This is usually performed even if the patient has been shown to be free of coronary artery disease at the time of initial valve surgery. The frequency with which significant coronary artery disease develops or progresses in patients with valvular heart disease and the diagnostic yield of repeat coronary arteriography have not been adequately defined. This study examines a consecutive series of patients with prosthetic heart valves who underwent cardiac catheterization for recurrent symptoms to determine (1) the frequency with which new significant coronary disease develops in patients without previous disease, (2) the frequency with which new significant lesions appear in patients with known disease, and (3) clinical parameters that may identify patients with new significant coronary artery disease.

Doppler Echocardiographic Assessment of Prosthetic Valve Function: Promises and Pitfalls

Doppler Echocardiographic Assessment of Prosthetic Valve Function: Promises and Pitfalls

Doppler color flow evaluation of prosthetic mitral valves: Experimental epicardial studies

More than 300 epicardial Doppler color flow mapping studies on 23 different types of clinical and preclinical valves were performed after implantation in the mitral position in sheep. The transducers were placed directly on the heart to obtain the greatest possible resolution. Studies were performed in each animal under different hemodynamic conditions by varying heart rate and cardiac output. Eighty-six valves were studied late (20 to 52 weeks), whereas the remainder were studied early (0 to 10 days) after operation. The valves included 3 types of ball and cage valves, 3 types of disc and cage valves, 7 types of tilting disc valves, 1 type of bileaflet hemidisc mechanical valve, 13 types of porcine aortic valves and 5 types of bovine pericardial valves. The results of these studies were compared with those obtained in 40 studies of 20 native mitral valves. Doppler color velocity/flow profiles were imaged in real time with simultaneous electrocardiographic gating; the aortic flow was also displayed for the timing of velocity/flow events.Native normal mitral valves had no in-orifice flow disturbances and laminar low velocity/flow directed toward the left ventricular apex. Ball and cage and disc and cage valves had high velocity peripheral jets and vortices of velocity/flow reversals distal to the occluders. Tilting disc valves had differing velocity/flow patterns determined by their orientation in the mitral anulus. Bileaflet hemidisc valves had three jets, which decayed 1.5 cm downstream. Porcine aortic and bovine pericardial bioprosthetic valves had high velocity, turbulent, nonaxisymmetric jets (more severe for the latter).These observations are similar and complementary to those obtained by in vitro flow visualization techniques and those obtained by laser Doppler anemometry. As such, they provide an important interface between the in vitro assessment of prosthetic valve function and the clinical utility of Doppler color velocity flow imaging technology.