Evaluation of Prosthetic Valves

For patients with what? it will be inevitable they receive intervention. (should need a prosthetic valves)

For patients with significant valvular stenosis/regurgitation, it will be in inevitable they receive intervention.

Types of Interventions: name 3 types of repair and for one of them tell me especially for what valves with what conditions?

• Valvular Repair

• Especially for mitral and tricuspid regurgitation

• Surgical Valve Replacement

• Percutaneous Valve Replacement

Percutaneous valves are what type of valves?

Percutaneous valves are bioprosthetic

Surgically implanted prosthetic valves can be either what?

Surgically implanted prosthetic valves can be either bioprosthetic or mechanical

Surgically implanted prosthetic valves can be either bioprosthetic or

mechanical;

Both are associated with what durability

Both need chronic what meds

Mechanical valve implantation has what over the past 10 years

• Both are associated with greater durability

• Both need chronic anticoagulation.

• Mechanical valve implantation has declined over the past 10 years

which valve repair and replacement have changed the demographics

and clinical characteristics of patients undergoing surgical valve

replacements.

Transcatheter valve repair and replacement have changed the demographics

and clinical characteristics of patients undergoing surgical valve

replacements.

Idk how to ask this?

Need for concurrent procedures such as aortic root and ascending aorta

modification, as well as left ventricular outflow tract (LVOT) or right

ventricular outflow tract (RVOT) alteration may also affect PHV choice

what is the first-line method for noninvasive evaluation of prosthetic alve function.

Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function.

This is complemented with two-dimensional and three- dimensional transesophageal echocardiography for further refinement of valve morphology and function

what is the best method to evalute MV and TV prosthetic valve

TEE

What other two have also enhanced their roles in evaluating valvular heart disease (gets rid of the artifact)

Computed tomography and cardiac magnetic resonance have also enhanced their roles in evaluating valvular heart disease

Types of Prosthetic valves

A wide variety of PHV types and sizes are available,

Selection is dependent upon what name 4 things

• Implantation location

• Underlying valvular pathology

• Implantation technique

• Patient-specific factors

Types of Prosthetic valves

• Selection for Patient-specific factors*** name 6

• Patient anatomy

• Procedural risk

• Expected patient longevity

• PHV durability

• Patient preferences

• Patient lifestyle

Mechanical vs. Bioprosthesis vs. Homograft:

• Mechanical describe two things

• Durability

• Hemodynamics

Mechanical vs. Bioprosthesis vs. Homograft:

• Bioprosthetic

• No anticoagulation

Mechanical vs. Bioprosthesis vs. Homograft:

Homograft

• No anticoagulation

• SBE prevention

Prosthetic Valve Regurgitation:

Mechanical Prosthesis

what should you see physiologic MR

and what is abnormal regurigitant flow

Physiologic mitral regurgitation is a low velocity

jet and seen in small amounts between and

around the valve assembly.

Abnormal regurgitant flows have high velocities.

Prosthetic Valve Regurgitation

Bioprosthesis, what well you see in normal functioning valves?

• In normal functioning valves, backflow is less Bioprosthesis common.

Prosthetic Mechanical Valves, name 3

Bileaflet tilting disk valve

• Single tilting disk valves with low thrombogenicity

• The Starr-Edwards ball-in-cage valve is no longer implanted

what is the most common type Prosthetic Mechanical Valves?

• Bileaflet tilting disk valve

Give me examples of Bileaflet tilting disk valve

Examples inlude St. Jude Medical, Carbomedics, On-X

what does Bileaflet tilting disk valve offer of the currently available mechanical valves

Offer the best hemodynamics of currently available mechanical valves

• Single tilting disk valves with low thrombogenicity

tell me an example of one?

infrequenctly used in what practice ?

• Example is Medtronic-Hall

• Infrequently used in contemporary practice

The Starr-Edwards ball-in-cage valve is no longer implanted

• Given its durability, some of these valves continue to function

satisfactorily and may be encountered in clinical practice.

• Mechanical valves typically have how much regurgitant jets.

• Mechanical valves typically have minor regurgitant jets.

Mechanical valves typically have minor regurgitant jets. Two types of

‘‘physiologic’’ regurgitation may be seen:

a closing volume (retrograde displacement of blood caused by the motion of the occluder) and true trivial or mild regurgitation at the hinges of the occluder

Mechanical Valve;

Bileaflet, tilting disc – St. Jude’s

2 pyrolytic carbon semicircular discs

attached to rigid valve ring by small hinges

• Opening angle 75-90 degrees

• 3 orifices - small central and 2 larger

lateral orifices

• Normal regurgitant volume 5-10 mL

Mechanical Valve;

Bileaflet, tilting disc – St. Jude’s. Auscilatation

• Softer opening and louder closing click

• Softer closing click could represent

malfunction

• Suspect regurgitation when diastolic

murmur with AVR

• Suspect mitral regurgitation when

holosystolic murmur with MVR

Mechanical

Prosthesis;

Single tilting disc

• Circular sewing ring

• Opening angle 60-80 degrees

• Flow occurs through major and minor

orifices

• Normal regurgitant volume 5-9 mL

Mechanical

Prosthesis;

Single tilting disc, Auscultation

Sounds similar to bileaflet disc, 2-3 washing jets

Mechanical Valve

• Ball-in-Cage (Starr-Edwards)

• No longer implanted

• Due to durability may still be

encountered

• Sewing ring with metal struts

forming a cage

• Hollow ball in cage

• Appearance of echoes in the left

atrium due to speed of sound in

the ball

• Flow occurs around the ball

• Normal regurgitant volume 2-5mL

• Ball-in-Cage (Starr-Edwards)

Mechanical Valve • Auscultation

• Loud opening click, followed by several

clicks of different intensity due to ball-in-

cage

• If closing click is louder, could suggest

dysfunction

• If a diastolic murmur is heard with AVR

suggests aortic regurgitation

• Suspect mitral regurgitation when holo-

systolic murmur with MVR

• Prolonged diastolic rumble suggests

prosthetic stenosis, high flow state, small

prosthesis

Bioprosthetic Valves

Xenografts

Most frequently used

• Made of porcine or bovine pericardial tissue

• Stented xenografts are most frequently used

• Pericardial leaflets are mounted onto either the inside or outside of a

stent frame

• Externally mounted leaflets and stentless bioprostheses have the

advantage of larger valve areas and lower transvalvular gradients

• high rates of early structural valve dysfunction (SVD), particularly in younger patients

Allografts vs, autografts

Allografts from cadaveric donors

Autografts (such as in the Ross procedure)

Bioprosthetic Regurgitation

Regurgitation is increasingly reported in normal biologic valves

• Stentless valves, including homografts and autografts, are more

likely than stented valves to have minor regurgitant jet

Stented heterograft valves

• Sewing ring with 3 semi-rigid stents or struts

• Normal regurgitant volume 1 mL

• 10% demonstrate a small degree of regurgitation

by color flow imaging

Stented Heterografts

• Auscultation

• Made of tissue and do not click

• Normal and abnormal opening and closing sounds

similar to native valves

• Aortic position - have a systolic ejection murmur

• Mitral position - have a early-mid systolic ejection

murmur attributable to turbulent flow in the LVOT

• Ejection murmur is followed by second heart

sound and then valve opening

• Low flow diastolic rumble maybe heard at the

apex

Bioprosthetic Valves

Stentless heterograft valves

• No rigid stents – larger

effective orifice area

• Better hemodynamic

performance as compared to

stented or biological valves

Bioprosthetic Valves, Homograft valves

• Antibiotic-sterilized,

cryogenically preserved

valves harvested from human

cadavers

• Favorable hemodynamics,

resistant to infection, no

anticoagulation requirement

• Usually implanted as a

complete root replacement

with coronary artery

reimplantation

Bioprosthetic Valves , Auscultation

• Sounds similar to native

valves

• Homografts with small

effective orifices may create

systolic ejection murmurs

Ross Procedure

Known as switch procedure

Donald Ross, MD pioneered this surgery in 1967 for diseased

aortic valves

Performed on patients younger then 40 to 50 to avoid long-term

anticoagulation

Patient’s own pulmonary valve (autograft) placed in aortic valve

position and coronaries reimplanted

Pulmonary allograft (cadaver valve) placed in pulmonic position

Ross Procedure Assessment

• 2D Echo

• Assess aortic and pulmonic valve leaflets for thickness

• Utilize multiple views

• Color Flow Doppler

• Assess for aortic and pulmonic valve regurgitation

• Doppler

• Assess peak/mean valvular and sub-valvular gradients

• Assess for diastolic flow reversal in aorta

Percutaneous Valve Replacement ( slide 37)

• Transcatheter heart valve technology has

continued to evolve with expanding

indications

• Transcatheter aortic valve implantation

(TAVI) prostheses in commercial use

include balloon-expandable intraannular

devices (e.g., SAPIEN valves; Edwards

Lifesciences)

• Self expanding supra-annular valves (e.g.,

Evolut valves; Medtronic)

• Intra-annular valves (Navitor valves;

Abbott Structural Heart)