ECHO IN THE ASSESSMENT OF PROSTHETIC HEART VALVE.pptx

Echocardiographic assessment OF PROSTHETIC HEART VALVE

1. ECHOCARDIOGRAPHY IN PROSTHETIC VALVE DR. INDRANIL GHOSH DM CARDIOLOGY RESIDENT

2. “IT WILL WORK” 1 st Mitral valve replacement-designed and performed by Dr. Nina s. Braunwald

3. Fig: hemodynamics in prosthetic valves

4. “NORMAL”

5. PROSTHETIC VALVES – INHERENTLY STENOTIC The EOA (effective orifice area) is smaller as the valve assembly occupies space Bioprosthetic valves by virtue of being preserved are stiffer HIGHER GRADIENT

6. PRESSURE RECOVERY Part of kinetic energy after passing through the vena contracta recovered as pressure distally. This is further exaggerated in case of a bileaflet valve , as the smaller cental orifice leads to higher flow.

7. PHYSIOLOGICAL REGURGITAION Minor regurgitation is normal for all mechanical valves. Two types of “physiological “ regurgitation may be seen- Closing volume Washing effect TYPE VOLUME (ml) Ball-cage 2-6 Single leaflet 5-9 Bileaflet 10 Bioprosthetic <1

8. SHADOWING Because of shielding & artefacts; insonation of the valve especially regurgitant jets become difficult . More pronounced with mitral valve.

9. PREREQUISITES

10. WHEN TO DO ECHOCARDIOGRAPHY?

11. PROSTHETIC MITRAL VALVE

12. PARAMETERS TO EVALUATE Zoghbi et al, JASE, September 2009

13. PEAK EARLY MITRAL VELOCITY Simple screening to evaluate prosthetic valve function Non-specific : Hyperdynamic states Tachycardia Stenosis Small valve size Regurgitation

14. MEAN GRADIENT Based on Bernoulli equation Mean gradient varies according to valve size and valve type Has the same pitfalls as mitral peak e velocity

15. PRESSURE HALF TIME Applicable only for moderate to severe stenosis. In mild stenosis or normal functioning valves, PHT depends on la/lv compliance Measured through the deceleration slope of E wave PHT=0.29* deceleration time

16. EOA (EFFECTIVE ORIFICE AREA) Stroke volume through MV equates that of LVO when there is no significant MR or AR

17. DVI – DIMENSIONLESS VELOCITY INDEX A simplification of the continuity equation. Consider FLOW VTI can increase in both with increase in flow or a decrease in area i.e. – stenosis and regurgitation DVI MV = VTI MV PR / VTI LVO Flow= area * VTI

18. DOPPLER PARAMETERS OF PROSTHESIS MITRAL VALVE FUNCTION - ASE PARAMETERS NORMAL POSSIBLE STENOSIS SIGNIFICANT STENOSIS PEAK VELOCITY <1.9 1.9-2.5 > / = 2.5 MEAN GRADIENT </= 5 6-10 >10 DVI <2.2 2.2-2.5 >2.5 EOA > / = 2 1-2 <1 PHT <130 130-200 >200

19. APPROACH TO HIGH TRANS-MITRAL PROSTHETIC GRADIENT

20. HOW TO DIFFERENTIATE?

21. SCENARIO 1

22. IMPRESSION : PATIENT-PROSTHESIS MISMATCH

23. ALGORITHM TO EVALUATE MITRAL PROSTHESIS WITH ELEVATED GRADIENT

24. Scenario 2 21 hear old female MVR 2 YEARS BACK Dyspnea NYHA III ON ORAL ANTICOAGULANTS

25. VELOCITY PROFILE IMPRESSION – PROSTHESIS STENOSIS

26. SCENARIO 3 POSSIBILITIES? FUNCTIONAL / PATHOLOGICAL STENOSIS/ REGURGITATION

27. EVALUATING FURTHER

28. IMPRESSION – MITRAL REGURGITATION

29. TEE : PROSTHETIC MR

30. ASSESSMENT OF PROSTHETIC MITRAL REGURGITATION

31. Zoghbi et al, JASE, September 2009

32. ASSESSMENT OF PROSTHETIC AORTIC VALVE

33. PARAMETERS TO EVALUATE-ASE

34. PEAK VELOCITY & GRADIENT A raised velocity and gradient ; though can raise the suspicion; it is not sufficient to confirm a prosthetic AV dysfunction. As with native aortic valve stenosis , to minimise angle error, multiple position needs to be interrogated. The highest values thus obtained are to be taken

35. JET CONTOUR & ACCELERATION TIME (AT) Normal prosthetic AV : even with high flow the contour of velocity profile is triangular with early peaking in systole— short AT. Obstructed prosthetic valve : a more rounded velocity contour with velocity peaking at mid-systole — prolonged AT Independent of beam angulation

36. ET : AT RATIO An ET:AT ratio >0.4 is consistent with prosthetic valve obstruction

37. EFFECTIVE ORIFICE AREA (EOA) Based on continuity equation. EOA is dependent on valve size and is to be referenced with the type of valve and it’s EOA. However, for any valve size , stenosis is suspected when EOA is <0.8 cm2

38. DIMENSIONLESS VELOCITY INDEX (DVI) DVI is a dimensionless ratio of flow through LVO with the flow through prosthesis DVI incorporates the effect of flow on velocity and is much less dependant on valve size. DVI= VTI LVO / VTI PrAV

39. SUMMARY OF PARAMETERS AND RANGE PARAMETER NORMAL POSSIBLE STENOSIS SIGNIFICANT STENOSIS PEAK VELOCITY <3 3-4 >4 MEAN GRADIENT <20 20-35 >35 DVI > / =0.3 0.25-0.30 <0.25 EOA >1.2 1.2-0.8 <0.8 CONTOUR OF THE JET Triangular ,early peaking Triangular to intermediate Rounded ,symmetrical contour AT <80 80-100 >100

40. ALGORITHM TO APPROACH

41. AORTIC PROSTHESIS WITH HIGH PEAK VELOCITY / MG

42. SCENARIO 1 21 year female AVR 2 years back Stopped anticoagultion Vmax:3.2 DVI:0.18 AT:150 Circular contour

43. APPLYING THE ALGORITHM IMPRESSION : PROSTHESIS STENOSIS

44. SCENARIO 2 50 year old male DVR G.I BLEED Vmax:3.1 Mean gradient: 22 DVI:0.4 AT: 67 AT/ET: 0.27

45. Impression : high flow

46. SCENARIO 3 58 year old woman Dyspnea , NYHA III , background RHD AVR : medtronic mosaic 21 mm MVR : 27mm duran ring — 3 years back

47. VELOCITY PROFILE

48. INFERENCE ?? PATIENT-PROSTHESIS MISMATCH PROSTHESIS OBSTRUCTION NORMAL FUNCTION FOR THIS VALVE TYPE PRESSURE RECOVERY NEED MORE!!

49. NORMAL VALVE SPECIFIC PARAMETERS

50. INFERENCE ?? PATIENT-PROSTHESIS MISMATCH PROSTHESIS OBSTRUCTION PRESSURE RECOVERY

51. CONTINUING FORWARD ACCELERATION TIME 88 AT/ET 0.27

52. JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 11, 201 1

53. CONTINUING FORWARD

54. IMPRESSION : PATIENT-PROSTHESIS MISMATCH iEOA<00.85-0.65 : MODERATE PPM iEOA<0.65 : SEVERE PPM

55. NOT JUST PPM PRESSURE RECOVERY

56. ENERGY LOSS CO-EFFICIENT Pressure recovery can be accounted for and ppm can be avoided by calculating- energy loss co-efficient in cases of narrow aorta ( STJ<30). Indexed ELC <0.6-0.55 predicts ppm.

57. THROMBUS V/S PANNUS JACC Vol. 32, No. 5 November 1, 1998:1410–7

58. PROSTHETIC AORTIC VALVE REGURGITATION

59. CONSIDERATION OF ASSESSING PROSTHETIC AORTIC REGURGITATION Acoustic shadowing , though less of an issue with prosthetic aortic valve , still hampers evaluation and more so with with concomitant prosthetic mitral valve Difficult to measure jet width in LVOT and measure VC Paravalvular leak

60. PARAMETERS FOR QUANTIFICATION OF SEVERITY

61. JET:LVOT WIDTH

62. JET AREA:LVOT AREA

63. VENA CONTRACTA

64. DIASTOLIC FLOW REVERSAL

65. REGURGITANT VOLUME

66. PARAVALVULAR LEAK

67. Case scenario 66 year old s/p AVR with 23 mm medtronic-hall single tilting disc prosthesis progressive dyspnea

68. FOLLOW UP TEE Suggestive of severe AR

69. POST TAVR ECHOCARDIOGRAPHY

70. CONSIDERATIONS Post-TAVR regurgitation jets frequently arises from multiple sites with jets having irregular shapes and trajectories, thus challenging standard colour doppler measurements of AR severity. Acoustic shadowing of the far field ( posterior paravalvular in TTE and anterior in TEE). It is essential to use windows that not only avoid the acoustic shadowing but also image the jet parallel to the insonation beam . Apical & subcostal for TTE and mid-esophageal & deep transgastric for TEE. The paravalvular jet path and number of jets are significantly affected by native calcium and leaflets, and by the discontinuous nature of the stents. This is particularly important to understand when assessing the circumferential extent of the regurgitation — jet length or area should not be used to grade severity and rather to confirm the presence and location of jets

71. PARAVALVULAR AR - IMPORTANCE OF INTERROGATING MULTIPLE WINDOWES

72. STROKE VOLUME MEASUREMENT IN TAVR

73. SEVERITY BY VC AREA & % CIRCUMFERENCENCE As per VARC-2 criteria , % circumference <10 : mild 10-20 : moderate >30 : severe

74. ALGORITHM TO ASSESS POST-TAVR AR SEVERITY

75. THANK YOU