1. Echo Egypt 2014 Thursday, October 23, 2014

2. Does it have a place in theechocardiography era? 3. Types of Prosthetic Heart Valves Mechanical Bileaflet (St Jude)(A) Single tilting disc (Medtronic Hall)(B) Caged-ball (Starr-Edwards) (C) Biologic StentedCF Leaflet imaging depends on radio-opacity Porcine xenograft (MedtronicMosaic) (D) Pericardial xenograft (Carpentier-Edwards Magna) (E) Stentless Porcine xenograft (MedronicFreestyle) (F) Pericardial xenograft Homograft ( allograft) Percutaneous Expanded over a balloon(Edwards Sapien) (G) Self expandable(CoreValve) (H) Circulation 2009, 119:1034-1048 4. Three Types of MechanicalProsthetic Heart ValvesNewer models Older modelsnBileaflet (St Jude) Single tilting disc (Medtronic Hall) Caged-ball (Starr-Edwards)Preferred Choice 5. Despite the recentimprovements in prostheticvalve design and surgicalprocedures,valve replacement doesnot provide a definitivecure to the patient;instead it gives rise todevelopment of a newdiseaseprosthetic valve disease.Native Valve Diseaseis traded forProsthetic Valve Disease 6. Prosthetic valves explantedfor severe dysfunction.Pibarot P , and Dumesnil J G Circulation. 2009;119:1034-1048Outlet strut Inlet strutLeafletCopyright American Heart Association, Inc. All rights reserved.ObstructivethrombosisPannusingrowthinteracting withleaflet openingRupture of theoutlet strutand leafletescape 7. Imaging of Prosthetic Heart valvesChest X-ray ( CXR )Valve type and position often easily determined on CXRCinefluoroscopy ( CF )CF optimal for assessing mechanical valve leafletmotion(radiopaque), unable to see bioprosthetic leafletsEchocardiography TTE will often best allow optimal Doppler angles TEE( 2D/RT3D )will often best allow optimal directvisualizationMulti Detector Computed Tomography ( MDCT )Allows full evaluation with less artifacts from metalcompositions as compared to echo. 8. The location of thecardiac valves is bestdetermined on thelateral radiograph. A line is drawn on thelateral radiograph fromthe carina to thecardiac apex. The pulmonic andaortic valves generallysit above this line andthe tricuspid and mitralvalves sit below this line.Sometimes the aortic rootcan be inferiorly displacedwhich will shift the aorticvalve below this line.Chest X-rayAoV & PVMV & TV 9. Chest X-rayaortic valvemitral valveBjork Shiley valve 10. Bileaflet Mechanical Prosthetic Heart ValveHingeLeaflets( Occluder )HousingNormal motion ,Restricted motionSuture RingWell seated ,DehiscedRole of Cine-FluoroscopyIdentify type of valveDetermine disc mobilityAssess stability of sewing ring 11. Bileaflet Mechanical Prosthetic Heart ValvesEach model has its own cinefluoroscopicfeatures which allow its identification 12. Cinefluoroscopy as the gold standard formechanical valve mobility 13. *Evaluation is considered appropriate when theprosthesis tilting disk optimal projection isobtained.*This view allows proper visualization of leafletmotion so that both opening angle (OA) andclosing angle (CA) can be calculated.C-arm fluoroscopeThe en faceprojectionThe tilting diskprojectionSide ( Pivot )view 14. Cinefluoroscopy : Obtaining optimal viewRight anterior oblique,cranialMitral prosthesisRight anterior oblique,caudalLeft anterior oblique,cranialAortic prosthesisAortic prosthesisTricuspid prosthesis 15. Bileaflet Mechanical Prosthetic Heart ValvesThe opening angle (0), closing angle (C), Theexcursion of each leaflet (E l, E 2), and the totalleaflet excursion (E total)Opening and closingangles are defined asthe distance betweenthe 2 leaflets in the fullyopen and closedposition. 16. Normal values for opening and closing anglesClosingangle (CA)( cinefluoroscopy )Openingangle (OA)Bileaflet MechanicalProsthetic Heart ValvesCarbomedics 130Edwards Duromedics 148Sorin Bicarbon 135St.Jude Medical Standard 120Values of OA and CA is obtained by averaging the values over 3 or 5consecutive cardiac cycles, in the presence of sinus rhythm or atrialfibrillation, respectively.Normal reference values for OA and CA is obtained from the manufacturer 17. Fluoroscopy of a normally functioning CarboMedics bileaflet prosthesis in mitral position.Montorsi P et al. Circulation. 2003;108:II-79-II-84Copyright American Heart Association, Inc. All rights reserved.Opening angleClosing angle 18. Fluoroscopic criteria :*Persistent restriction of leaflet(s) motion*Opening angle greater than the normalreference value(obtained from the manufacturer)Opening angleNormal Obstruction 19. Example of a patient with obstructionof a St. Jude prosthetic aortic valve (size 19)Doppler shows aorticprostheticregurgitation & highpressure gradients70At fluoroscopy, openingangle (OA)reached 70,indicative of severelyhypomobile leaflets. 20. Stuck Mechanical Tricuspid Valve ProsthesisThe Valve That Does Not MoveFluoroscopy. A, Systolic and (B) diastolic frames indicate that both discs ofthe mechanical tricuspid valve (TV) are stuck in an open position.The mechanical mitral valve (MV) discs are closed in systole.Fadel B M et al. Circulation. 2012;126:e335-e336Copyright American Heart Association, Inc. All rights reserved. 21. St. Jude prosthetic valve ( mitral ): One of the leaflets was stuck in theclosed position (Video 1).Normal movement of the valve after streptokinase (Video 2)N Engl JMed2009;360:e22April 16,2009DOI:10.1056/NEJMicm040909 22. Obstruction by pannus ,thrombus ,or bothCine-FluoroscopyCannot distinguishpannus vs thrombus 23. T T ET E EC FMDCTImaging modalities 24. That is theQuestion inProstheticValveThrombosisThrombolysisorOperationThrombolytic therapy significantly reduces themean pressure gradient and improves valve leafletopening angle, so CF can detect the response to TT 25. Cinefluoroscopy showing leaflet motionBefore thrombolytic therapy After thrombolytic therapyThe views of the open valveThe views of the closed valveOne leaflet is seen to be immobilized(arrow). The measured opening angleis 59(normal, 111), and the closingangle is 110 (normal, 1202).Leaflet motion is seen to havereturned almost entirely to normal.The opening angle is now 14 andthe closing angle 124.5911014124 26. If lytic infusion is stopped at this time,the remaining thrombus could be the triggerCF : Guide duration for a late rethrombotic process.of lytic therapyAn abnormal OA value(greater than the normal)OA improvedbut notnormalizedOA completelynormalizedMontorsi P et al. Circulation.2003;108:II-79-II-84 Normal Doppler study despitesignificant restriction in leaflet(s) motion at CF(so called Doppler silent PVT). 27. Tricuspid mechanical prosthesisCF showing both of theleaflets fixed in a semiopenpositionAfter 25 mg tPA infusion, CFrevealed mild movement ofboth leafletsAfter heparin Infusion&a second TTsession with 25 mg tPA, restriction ofleaflets was completely resolvedTrk Kardiyol Dern Ar - Arch Turk Soc Cardiol 2014;42(5):478-481doi: 10.5543/tkda.2014.09804 28. On admission, CF of tricuspidmechanical prosthesis showingbileaflets fixed in a semiopenposition (A)Minor alteration in leaflet positionsduring systole and diastoleafter 25 mg tPA infusion wasadministered (B)After 50 mg tPA infusion, restriction ofleaflets had completely resolved (C).Trk Kardiyol Dern Ar - Arch Turk Soc Cardiol2014;42(5):478-481 doi: 10.5543/tkda.2014.09804 29. Prosthetic Valve ThrombosisCLASS IIa : Fluoroscopy or CT is reasonable in patientswith suspected valve thrombosis to assess valve motion.(Level of Evidence: C)*Fluoroscopy and CT are alternative imaging techniques for evaluation ofmechanical valve leaflet motion, particularly in patients with prostheticaortic valves, which are difficult to image by either TTE or TEE.*CT is best suited for measurement of valve opening angles.*CT imaging may also allow visualization of pannus or thrombus in patientswith mechanical or bioprosthetic valves. 30. Pseudo prosthetic valveobstructionProsthetic valve gradientsIt is an important lesson to learn ,raised prosthetic gradient is notequal to thrombusPlease remember flow acrossprosthetic valve is governedby delicate local hemodynamicrules 31. The Am J Cardiol. 2000. Jan 1. Vol 85CinefluoroscopyDopplerechocardiographyTransesophagealechocardiographyNormal opening angles High gradientsAbsence ofthrombus and pannus 32. L'HUILLIER I et al. Heart 2001;85:513Bileaflet prosthesis( Only one leaflet at the mitral position )Acute mitral valve dysfunctionCopyright BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved. 33. Ultrasound shows the escaped leaflet(arrows) as a linear hyperechogenicobject in the lumen of terminal portionof the abdominal aorta.The surgically removedmechanical valve 34. Dehiscedaortic valve(Rocking )Normalmitral valveMitral and aortic valves (Medtronic Hall and ATS Medical, respectively 35. A Few Words AboutMulti Detector ComputedTomography 36. St. Jude medical valves (bileaflet mechanical valves)The geometric orifice area ( GOA), length, andopening/closing angles determined by MDCT. 37. St. Jude bileaflet prosthetic AVRA, obstructive acute thrombusvisualized as low-attenuation mass.Chan J et al. Circulation. 2009;120:1933-1934B, After thrombolysis with resolutionof thrombus.Copyright American Heart Association, Inc. All rights reserved. 38. AppropriateUseScore (19)Prosthetic Heart Valves*Characterization of prosthetic cardiac valves A (8)*Suspected clinically significant valvulardysfunction*Inadequate images from other noninvasivemethodsScore 7 to 9 ( A ) Appropriate IndicationsAppropriate test for specific indication (test is generally acceptable andis a reasonable approach for the indication). 39. Fluoroscopy is the most widely used methodfordiagnosing stuck valves.It is readily available inmost centers and can be performed rapidly,particularlyin unstable patients. 40. Fluoroscopy is not usefulin distinguishing pannus fromthrombus since neitherpannus nor thrombus can beidentified fluoroscopically.In the case of bileaflet valves, the diskscan be directly visualized, and opening andclosing angles can be measured using aside (pivot) view.pannusThrombus10 OA 120 CAMoreover, fluoroscopy may be particularlyutilized as an easily repeatable modality tofollow stable patients for evaluation ofvalve motions during TT. ThrombolyticTherapy 41. One should consider that bothechocardiography and CF providedifferent kinds of information onprosthesis function, and thereforethey should still be considered ascomplementary and not alternative.