Echo Evaluation of Prosthetic valves

What is the first modality to assess prosthetic valves?

Transthoracic Echo is the first modality to assess prosthetic valves

Our assessment will includes reviewing for what? (name 5)

Our assessment will includes reviewing for valvular stenosis, valvular

regurgitation, endocarditis, and aortic dissections, and valve complications

Prosthetic Valve Complications

 Complications to consider: name 15

1. Calicification/degeneration (Bioprosthetic)

2. Thrombus (mechanical)

3. Infective endocarditis (vegetation, valve ring abcess, fistula)

4. Perivalvular leaks

5. Dehiscence

6. Stenosis

7. Pericardial Effusion

8. Regurgitation

9. Valve bed abnormalities (pseudoaneuysrm, hematoma)

10. Pannus

11. Ventricular dysfunction

12. Hemolysis/anemia

13. PPM

14. LVOT Obstruction

15. Ventricular Septal Defects

Prosthetic Aortic Valves, Interrogation in

1. PLAX what do you interrogate of the aortic root?

2. PSAX what do interrogate and give me an example of a prosthetic valve for the AV

3. talk about the appostion (the positioning of things or the condition of being side by side or close together.)

4. want to look for the presence of what two things

5. sweeping through the valve is necesssary to detect what and explain why

6. what 3 things you would want assess on the left side knowing there is a prosthetic AV?

1. PLAX Valve position in the aortic root

2. PSAX valve shape (TAVRs)

3. apposition of the valve stent to native aortic tissue

4. Presence of aortic annular injury or ventricular septal defects

5. Sweeping through the valve is necessary to detect valve regurgitation as regurgitant jets may not be seen adequately in a single valve plane

6. LV size, function, and hypertrophy

Prosthetic Aortic Valve

In valve stenosis what is performed in standard windows?

Valve Stenosis (pedoff performed in standard windows)

Prosthetic Aortic Valves:

Low deployment of a TAVI prosthesis:

1. can limit what of the valve

2. This increases the risk for what

3. what function can it affect causing what

1. can limit anchoring of the valve

2. This increases the risk for delayed migration of the valve into the LVOTor left ventricle

3. can affect mitral valve function, causing MR

What the slide is saying (simple)

👉 If the valve is placed too low
➡ It doesn’t anchor (stick) well
➡ So it can move later

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🧠 Break it step-by-step 1. “can limit anchoring of the valve”

👉 “Anchoring” = how well the valve stays fixed in place

• If it’s too low → ❌ not secured well

• Think: loose fit

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2. “This increases the risk for delayed migration”

👉 “Migration” = the valve moves after placement

• Not immediately

• But later on

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3. “into the LVOT or left ventricle”

👉 The valve can slip downward into:

• LVOT (left ventricular outflow tract)

• Or even into the left ventricle

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🔥 Put it together

👉 Valve placed too low
➡ Not secured properly
➡ Can slide downward later into the heart

📍 This is exactly what your slide shows (page 9)

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⚠ Why this is bad

If the valve moves:

• ❌ Can block flow

• ❌ Can cause regurgitation

• ❌ Can affect mitral valve (MR)

• ❌ Can require urgent intervention

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🧪 One-liner (exam ready)

“Low deployment of a TAVI valve can impair anchoring, increasing the risk of delayed migration into the LVOT or left ventricle.”

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🔥 Super simple version

👉 “If the valve is placed too low, it can come loose and slide down into the heart”

Prosthetic Aortic Valves:

Incomplete expansion of the TAVI valve because of what can result in what 3 things?

Incomplete expansion of the TAVI valve because of calcium can result in

paravalvular and valvular regurgitation and higher valve gradient

Prosthetic Aortic Valves:

Doppler interrogation and Quantitative assessment include what? name 6

1. peak velocity through the valve (TVI)

2. mean gradient

3. EOA

4. DVI

5. Contour of the jet

6. acceleration time

Prosthetic Aortic Valves

Color Doppler evaluation of the AR.

what measurement/things you need to do (3 things to name )

Flow convergence, VC, and proximal jet extension into the LVOT and left ventricle

Prosthetic Aortic Valves

Color Doppler evaluation of the AR.

Limitations of Flow convergence, VC, and proximal jet extension into the LVOT and left ventricle method include what (two things)

Limitations of this method include reverberation and shadowing from the prosthesis

Prosthetic Aortic Valves

Color Doppler evaluation of the AR.

The VC width, area, and circumferential extent could be assessed from a carefully obtained what view?

The VC width, area, and circumferential extent could be assessed from a carefully obtained short-axis view

Prosthetic Aortic Valves

Color Doppler evaluation of the AR.

Measuring the width of an what jet in the what view may overestimate or underestimate ? - which one? regurgitation severity

Measuring the width of an eccentric jet in the outflow tract may overestimate

regurgitation severity

Prosthetic Aortic Valves

Color Doppler evaluation of the AR.

Wall-impinging aortic paravalvular jet may lead to over or underestimation because why?

Wall-impinging aortic paravalvular jet may lead to underestimation because of an unimpressive color Doppler jet area

A paravalvular leak jet that hugs the wall
➡ can look smaller than it actually is on color Doppler

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🧠 Break it down 1. “Wall-impinging jet”

👉 The regurgitant jet:

• Sticks to the wall of the vessel (aorta or LVOT)

• Instead of shooting straight out

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2. “Unimpressive color Doppler jet area”

👉 On color Doppler:

• The jet looks small / weak / not obvious

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3. “Underestimation”

👉 You might think:

• “Oh this is mild regurgitation”

❗ But actually:

• It could be moderate or severe

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🔥 Why does this happen?

👉 When the jet hugs the wall:

• It loses energy

• It spreads less

• It doesn’t show a big color area

➡ This is called the Coandă effect (high-yield concept)

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⚠ Clinical mistake

👉 If you rely ONLY on:

• Color jet size

❌ You will underestimate severity

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💡 What should you do instead?

Look at:

• Vena contracta

• Flow convergence

• Aortic flow reversal

• Multiple views

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🧪 One-liner (exam ready)

“Wall-impinging paravalvular jets may appear small on color Doppler, leading to underestimation of regurgitation severity due to the Coandă effect.”

“If the jet hugs the wall, it looks smaller than it really is”

what is the severe VC area and % circ?

Greater than 30%

Prosthetic Aortic Valves

PHT <200 msec or what flow BLANK in the abdominal aorta suggests

the presence of severe regurgitation?

PHT <200 msec or holodiastolic flow reversal in the abdominal aorta suggests

the presence of severe regurgitation greater than 15

Prosthetic Aortic Valves

AR severity may be more complicated because of the presence of combined

what jets? name 4

AR severity may be more complicated because of the presence of combined

valvular and paravalvular regurgitant jets, multiple regurgitant jets, or eccentric jets

Prosthetic Aortic Valves

1. Differentiate between what 3 things

2. other causes of elevated doppler gradients such as 3 things should be excluded

3. what are essential for prosthetic AV

4. Patients with poor LV function, elevated blood pressures may not show what despite significant stenosis

1. Differentiate between Stenosis, SVD, or PPM

2. Other causes of elevated Doppler gradients such as high-flow states,

supra- or subvalvular obstruction, and pressure recovery should be excluded

3. Comparison to baseline echos and serial echos are essential

4. Patients with poor LV function, elevated blood pressures may not show high gradients despite significant stenosis

Special Considerations for TAVRs

Special consideration for TAVI; In-stent flow acceleration occurs at two locations, where are these locations?

In-stent flow acceleration occurs at two locations, below the valve and at the

level of the cusps

Special Considerations for TAVRs

Special consideration for TAVI;

LVOT diameter and flow measurements should be obtained immediately where to the stent to prevent over or underestimation of the what by flow acceleration within the stent

LVOT diameter and flow measurements should be obtained immediately

proximal to the stent to prevent overestimation of the EOA by flow acceleration within the stent

Special Considerations for TAVRs

Special consideration for TAVI;

It is recommended that what measurement be used to

assess prosthetic aortic valve stenosis?

It is recommended that one highly flow-dependent (e.g., peak velocity, mean

gradient) and one less flow-dependent (e.g., EOA) measurement be used to

assess prosthetic aortic valve stenosis

Special Considerations for TAVRs VIV

For TAVI ViV,

1. Note the type and size of both what?

2. Look for what echocardiographic ViV gradients? (mean gradient of what mmhg) are found in 28% of Patients after ViV

3. Significant what has also been observed after ViV,with moderate or greater what in 60% of pateints and severe what in 25%

1. Note the type and size of both the original implanted surgical or TAVI valve and the second implanted valve

2. Look for elevated echocardiographic ViV gradients (mean gradient > 20

mm Hg) are found in 28% of patients after ViV

3. Significant PPM has also been observed after ViV, with moderate or greater PPM in 60% of patients and severe PPM in 25%

Special Considerations for TAVRs VIV

1. Sweeps in both what -axis views are often needed to ensure that all jets are identified?

2. what-axis views may be needed to determine jet origin. and tell me why?

1. Sweeps in both the parasternal long- and short-axis views are often

needed to ensure that all jets are identified

2. Off-axis views may be needed to determine jet origin.

Because of reverberation and shadowing from the prosthesis, posterior paravalvular AR may be obscured with TTE,

Prosthetic Mitral Valves

what valves are prone to pressure recovery from the small orifice between what?

Bileaflet mechanical valves are prone to pressure recovery from the small

orifice between the two tilting disks

Prosthetic Mitral Valves

Bileaflet mechanical valves are prone to pressure recovery from the small

orifice between the two tilting disks, result in a slight over or underestimation of the what by doppler and over or underestimation of what with the continuity equation?

Result in a slight overestimation of the gradient by Doppler and underestimation of EOA with the continuity equation

Prosthetic Mitral Valves

EOA of mechanical mitral valves is in the what range and the mean gradient ranges from what mmhg?

EOA of mechanical mitral valves is in the 2- to 3-cm2 range and the mean

gradient ranges from 2 to 3 mm Hg

Mitral bioprosthetic valves are what only

 Mitral bioprosthetic valves are stented only

 Mitral bioprosthetic valves are stented only.

they have an expected EOA of 2.2 to 3.5 cm ² and a mean gradient of what mmhg at physiologic heart rate ?

They have an expected EOA of 2.2 to 3.5 cm 2 and a mean gradient of 3

to 5 mm Hg at physiologic heart rate

Prosthetic Mitral Valves

Comprehessive evaluation of the mitral valve prothestis includes: name 8

1. heart rate

2. peak early velocity ( E- wave )

3. Mean gradient

4. PHT

5. Presence or absence of significant regurgitation

6. LV, right ventricular (RV), and left atrial size

7. Estimation of PA pressure and right atrial (RA) pressure

8. EOA and DVI

Prosthetic Mitral Valves

Diagnostic criteria of prosthetic mitral stenosis by Doppler

echocardiography remain the same, name 4 Severe numbers

1. Mean gradient

2. PHT

3. DVI

4. EOA

1. Mean gradient >10 mm Hg at a normal heart rate

2. PHT >200 msec

3. DVI >2.5 (VTI PrMV /VTI LVOT)

4. EOA <1 cm 2 (EOA = stroke volume/VTI PrMV)

Causes of mitral prosthetic stenosis include: what 4 things

1. Degeneration

2. Thrombus

3. Pannus

4. Vegetations

PPM is significantly less common in the what valve compared with the what valve

position

PPM is significantly less common in the mitral compared with the aortic

position

Evaluation of MR: MR jets by TTE is frequently limited by what artifacts from the mitral prosthesis?

MR jets by TTE is frequently limited by acoustic reverberation or shadowing from the mitral prosthesis

Evaluation of MR: what is often the optimal view for evaluation of prosthetic MR jets?

Parasternal window is often the optimal view for evaluation of prosthetic MR jets, PLAX

Apical views may be helpful to identify what for MR?

Apical views may be helpful to identify a suspected eccentric regurgitant jet or

paravalvular regurgitation

for MR, Apical views may also provide better visualization of what 5 things

Apical views mayalso provide better visualization of the prosthetic valve

leaflets for identification of vegetation, thrombus, pannus, or leaflet

degenerative changes

Prosthetic Mitral Valves

Spectral Doppler is key for evaluation of Mitral Prosthesis Regurgitation, name 7 things

1. what is the CW MR jet look like

2. How is the mitral E velocity

3. how is the systemic output and VTI LVOT despite a Hyperdynamic LV

4. how is the VTI PrMV/VTI Ratio

5. a large zone of what seen on the LV sie of the mitral prosthesis ****

6. a what in pressure compared with previous study

7. flow of the pulmonary veins

8. the shape changes from a trigu;nar shape to what

1. Dense CW MR jet

2. Elevation of the mitral E velocity (>1.9 m/sec in mechanical valves)

3. Low systemic output and VTI LVOT despite a hyperdynamic left ventricle

4. An elevated VTI PrMV/VTI LVOT ratio (>2.5)

5. A large zone of systolic flow convergence seen on the LV side of the mitral prosthesis

6. A significant rise in the PA pressure compared with a previous study

7. Reversal of flow in the pulmonary veins (signifcant MR)

8. to u shape

First — what do these mean? 👉 VTI PrMV

• Velocity Time Integral through the Prosthetic Mitral Valve

• = how much blood flow (velocity over time) across the mitral valve

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👉 VTI LVOT

• VTI in the Left Ventricular Outflow Tract

• = forward flow leaving the heart

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🔥 What the ratio compares

👉 It compares:

• Flow through the mitral valve (inflow)
  vs

• Flow out of the heart (outflow)

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⚡ What does > 2.5 mean?

👉 The mitral valve flow is much higher than it should be

➡ This suggests:
❗ Obstruction at the mitral valve

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🚨 Why does this happen?

If the mitral valve is:

• Narrow (stenosis)

• Blocked (thrombus, pannus)

• Too small (PPM)

👉 Blood speeds up → VTI increases

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💡 KEY concept

👉 High ratio = something is wrong with the mitral valve

Because:

• More resistance → higher velocity → higher VTI

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📍 From your slide context (mitral valve section)

👉 This is used to identify:

• Prosthetic mitral stenosis

• Significant dysfunction

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🧪 One-liner (exam ready)

“A VTI PrMV / VTI LVOT ratio >2.5 suggests prosthetic mitral valve obstruction or stenosis.”

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🔥 Super simple version

👉 “If flow across the mitral valve is way higher than normal compared to outflow → the valve is likely obstructed”

Evaluation of Mitraclip,

approves for what?

converts the MV in to a what MV by clipping the what leaflets

what is it the apparence on echo

Approved for degenerative mitral valve lesions

Converts the MV in to a double orifice mitral valve by clipping

the anterior and posterior leaflets together

echogenic clip

Post Mitraclip evalauation name 5

1. Peak velocity

2. Peak pressure gradient

3. Mean pressure gradient

4. EOA (planimetry, PHT, and continuity equations)

5. Severity of MR with native valve recommendations

mild MR after edge to edge MV repair

greater than or equal moderate MR after edge to edge MV repair

Prosthetic Pulmonary Valves

The prosthetic valve is what always in the what position as the native

pulmonary valve, especially when a what is involved

The prosthetic valve is not always in the same position as the native

pulmonary valve, especially when a conduit is involved

Prosthetic Pulmonary Valves, Anatomy of the what 5 things are important to include?

Anatomy of the RVOT and PA as well as RV size, function, and pressures

are important to include

pulmonary valve may be replaced either by a what for

complete repair of a congenital defect or by what

pulmonary valve may be replaced either by a valved conduit for

complete repair of a congenital defect or by a prosthetic valve

Prosthetic Pulmonary Valves, occurring more in what people (age)

Occurring more in younger people

Prosthetic Pulmonary Valves, The most common indication for a valved conduit is what? (condition)

The most common indication for a valved conduit is tetralogy of Fallot

Prosthetic Pulmonary Valves, what procedure for (congenital aortic valve stenosis)

 or as part of a Ross procedure (congenital aortic valve stenosis)

Prosthetic Pulmonary Valves, valved conduit is what tissue ( and give me two examples)

valved conduit is biologic tissue (e.g., homograft, xenograft)

Prosthetic Pulmonary Valves

Stented biologic prostheses are generally implanted for what?

Stented biologic prostheses are generally implanted for pulmonary valve

regurgitation

Prosthetic Pulmonary Valves: (Stented biologic prostheses are generally implanted for pulmonary valve

regurgitation)

most commonly occurs in patients who have previously undergone what reconstruction?

most commonly occurs in patients who have previously undergone RVOT

reconstruction

Prosthetic Pulmonary Valves

when evaluating the severity of prosthetic stenosis, that what flow velocities

may be encountered in locations other than the prosthetic valve?

what stenosis may also be present

when evaluating the severity of prosthetic stenosis, that high flow velocities

may be encountered in locations other than the prosthetic valve

Branch vessel stenosis or conduit edge stenosis may also be present

Prosthetic Pulmonary Valves

 Echocardiographic assessment of valve obstruction should include what 5 things

1. what about the prosthesis

2. observaation of qualitative indicators of what

3. quantitation of severity of what

4. any changes from what assessments in…

5. what does using the jet of TR determine?

1. Type and size of prosthesis

2. Observation of qualitative indicators of obstruction (e.g., thrombus, pannus)

3. Quantitation of severity of stenosis

4. Any changes from previous assessments in serial examinations

5. RV systolic pressure should be determined using the jet of TR

Prosthetic Pulmonary Valves

Prosthetic valve failure or dysfunction predominantly manifests as what?

Prosthetic valve failure or dysfunction predominantly manifests as stenosis

rather than regurgitation

Prosthetic Pulmonary Valves

Identifying the location of stenosis is important

Obstruction may occur further along a what rather than at where?

what Doppler is helpful in determining the precise location of obstruction

Quantitative parameters are generally limited to what two things

Obstruction may occur further along a conduit or in the PA rather than at the

valve

PW Doppler is helpful in determining the precise location of obstruction

Quantitative parameters are generally limited to peak velocity and mean

gradient

Prosthetic Pulmonary Valves

 Echocardiographic assessment of PR should include: name 5

1. what of the prosthesis

2. the presence of relevant anatomic abnormalities such as what two things

3. quntitation of severity of what

4. any changes from what assessment….

5. assessment of the what 3 things during what cardiac cycle is needed?

The type and size of prosthesis

 The presence of relevant anatomic abnormalities, such as degeneration or

vegetations

 Quantitation of severity of regurgitation

 Any changes from previous assessments in serial exams

 Assessment of the RV size and interventricular septal position and motion during diastole is needed

Prosthetic Pulmonary Valves

 When a valved conduit is present, both what of the conduit and

what of the valve can occur,

what Doppler are used to assist with the evaluation?

Color Doppler demonstrates what flow into the what?

what assist in determining the severity?

When a valved conduit is present, both stenosis of the conduit and

regurgitation of the valve can occur,

Color, PW, and CW Doppler are used to assist with the evaluation

 Color Doppler demonstrates diastolic flow into the RVOT

 Jet duration and jet width assist in determining the severity

Severe PR has a what jet duration, as the PA and RV diastolic pressures do what

Severe PR has a short jet duration, as the PA and RV diastolic pressures equalize quickly

Prosthetic Pulmonary Valves

what flow in the distal main PA by what doppler is suggestive of at lease what level PR?

Reversal of flow in the distal main PA by PW Doppler is suggestive of at

least moderate PR

Prosthetic Pulmonary Valves

what is also suggestive of severe PR, but this is

also dependent on the compliance of the what

A brief diastolic deceleration time is also suggestive of severe PR, but this is

also dependent on the compliance of the right ventricle

Prosthetic Pulmonary Valves

A comparison of stroke volume obtained just below the PVR and stroke

volume obtained at the aortic or mitral valve can provide a measurement

of what? (in the absence of what?)

A comparison of stroke volume obtained just below the PVR and stroke

volume obtained at the aortic or mitral valve can provide a measurement

of regurgitant volume and fraction (in the absence of AR or MR)

Prosthetic Pulmonary Valves

A regurgitant fraction what % is considered mild, and what % is considered

severe

A regurgitant fraction <30% is considered mild, and >50% is considered

severe

The majority of TV repairs or TV replacements (TVRs) are performed at the time ofwhat surgery, most commonly what surgery?

The majority of TV repairs or TV replacements (TVRs) are performed at the time of

Most commonly mitral valve surgery

Almost 90% of TV procedures in the United States are what?

Almost 90% of TV procedures in the United States are repairs

The majority of TVRs are what

The majority of TVRs are bioprosthetic

Tricuspid Prosthetic Valves

Prosthetic valves and prosthetic rings have different presentations and modes

of failure:

Surgical bioprostheses can fail because of what?

Surgical bioprostheses can fail because of prosthetic stenosis or regurgitation

Tricuspid Prosthetic Valves;

Surgical bioprostheses can fail because of prosthetic stenosis or regurgitation;

the mean time period between what requiring what implantation was many years?

The mean time period between tricuspid bioprosthetic implantation and dysfunction requiring ViV implantation was 12 years

The assessment of prosthetic TV function this involves the evaluation of what 3 things

The assessment of prosthetic TV function thus involves the evaluation of

surgical and transcatheter TV repair and replacement, as well as ViV and

valve-in-ring procedures

Native and prosthetic TV velocity varies with what and therefore multiple cardiac sycles should be pbtained by doppler?

Native and prosthetic TV velocity varies with cycle length and respiration

and therefore multiple cardiac cycles should be obtained by Doppler

Tricuspid Prosthetic Valves

PHT is influenced by what 3 things and should be avoided?

PHT is influenced by heart rate, chamber compliance, and loading

conditions and should be avoided

TVR may fail early or late after what?

TVR may fail early or late after implantation

Echocardiographic evaluation of prosthetic TV function includes;

2D demonstrates what two things of bioprosthetic leaflets or what of one or more mechanical?

what should also be suspected when there is a narrowed, and what velocity color Doppler TV inflow pattern?

2D demonstrates thickened and/or restricted motion of bioprosthetic leaflets or reduced excursion of one or more mechanical

Stenosis should also be suspected when there is anarrowed, aliased high-

velocity color Doppler TV inflow pattern

Tricuspid Prosthetic Valves

 Complications include: name 4

 Degeneration

 Thrombosis

 Pannus

 Vegetation

Tricuspid Prosthetic Valves

Mean gradient values of what mmHg have been assoicated with with normal

bioprosthetic function across a wide variety of bioprosthesis and mechanical

valves

 Mean gradient values <6 to 9 mm Hg have been associated with normal

bioprosthetic function across a wide variety of bioprosthesis and mechanical

valves

Tricuspid Prosthetic Valves

In patients undergoing ViV or valve-in-ring procedures, a postimplantation

mean gradient of what mm Hg is considered evidence of what

In patients undergoing ViV or valve-in-ring procedures, a postimplantation

mean gradient of >10 mm Hg is considered evidence of stenosis

Mechanical bileaflet TV prostheses for PHT (<130 msec)

PHT is not recommended in the presence of what spectral Doppler contours?

PHT is influenced by what two things?

PHT is not recommended in the presence of rounded spectral Doppler contours

 PHT is influenced by both heart rate and right-sided chamber compliance

Tricuspid Prosthetic Valves, DVI equation is what

 DVI (DVI = VTI PrTV/VTI LVOT)

Tricuspid Prosthetic Valves,

EOA = calculated by what? Accurate if there is what?

EOA = calculated by dividing the stroke volume in the LVOT by the

diastolic tricuspid prosthetic VTI

Accurate if there is mild or less TR and AR

TR may be either what valvular?

TR may be either transvalvular or paravalvular

Tricuspid Prosthetic Valves TR

Color is needed for what 4 things , what views are needed

Color is needed for flow convergence, VC, and jet direction—as well as jet

effects on the right atrium

 Off axis views and Subcostals are needed

what at follow-up may also be indications of a change in

prosthetic valve function? for TV (name 3)

Progressive dilatation of cardiac chambers or alterations in hepatic vein

size and flow at follow-up may also be indications of a change in

prosthetic valve function

Tricuspid Prosthetic Valves

On color Doppler imaging, a large flow convergence, increased VC width

(>0.7 cm), EROA > 0.4 cm2, and regurgitant volume > 45 mL all suggest what level of TR

severe TR

A what CW Doppler tracing with a what shape , when peaking velocity as

well as increased or decreased transvalvular what peak velocity and mean gradient also suggests severe TR

A dense CW Doppler tracing with a triangular, early peaking velocity as

well as increased transvalvular diastolic peak velocity and mean gradient

also suggests severe TR

A DVI of >3.3 in the context of increased or decreased transvalvular gradient and normal or abnormal ? PHT help confirm the presence of significant TR

A DVI of >3.3 in the context of increased transvalvular gradient and normal

PHT help confirm the presence of significant TR

Large flow convergence =

signifacnt regur

Prosthetic Aortic Valves what are the views for interrogation

PSAX, PLAX< A3C, A5C

what is the AV peak velocity that stenosis is present

prosthetic Aortic jet velocity > 3 m/s