Prostethic Valves Flashcards
1
Q
What does this image represent?
A
Single tilting disk - Bork Shiley valve
2
Q
What does this image represent?
A
Bileaflet Tilting disk
3
Q
What does this image represent?
A
Bileaflet mechanical mitral valve
4
Q
What does this image represent?
A
Mechanical Valve hemodynamics
5
Q
What does this image represent?
A
6
Q
What does this image represent?
A
Scented Bioprosthetic valve
7
Q
What does this image represent?
A
Bioprosthetic stentless freestyle valves
8
Q
What does this image represent?
A
Ross procedure
9
Q
What does this image represent? What does the arrow point to?
A
- Annuloplasty ring
- The arrow Mimics MAC
10
Q
What does this image represent?
A
TAVR (Transcatheter AV replacements)
11
Q
What does this image represent?
A
Edge to edge repair
12
Q
Why would someone have a prostatic valve?3
A
Implanted when the patient has hemodynamically significant valvular disease such as
- Stenosis
- Regurgitation
- Aortic dissection/ severe AI
13
Q
In terms of prosthetic valves, when are valvular rings or other devices used?
A
When possible
14
Q
What is the role of echo in prosthetic valves during pre-procedure?2
A
- Assess the need for repair/replacement
- Assess suitability of the type of repair/ replacement
15
Q
What is the role of echo for prosthetic valves during the procedure?
A
May be used during transcatheter procedure to assess prosthesis placement before procedure completion
16
Q
What is the role of echo post procedure for prosthetic valves?4
A
Assess for complications such as
1. Thrombus
2. Leakage
structural failure
3. Endocarditis
4. Dehiscence
17
Q
What are the advantages of mechanical valves?3
A
- Durable
- Due to durability, risk for reoperation is low
- Easier surgical implantation
18
Q
Why is mechanical valves durable?
A
- Made from biocompatible metal, plastic or cermiclike material
- Lasts 10-25 years
19
Q
What is the disadvantage of mechanical valves?
A
- Risk of thrombus formation and pannus growth
- Valve may make an audible click
- Produces a blood flow pattern that is resistant or high flow
20
Q
What is the most common disadvantage of mechanical valves?
A
Thrombus formation which leads to lifelong anticoagulation
21
Q
Pannus growth can lead to what?
A
Regurgitation or stenosis
22
Q
How can we size the valve to use?
A
Echo used in pre-procedure to determine the choice of valve size
23
Q
Reported size of the valve refers to what?
A
Outer diameter
24
Q
What is valves measured in?
A
Milimeters
25
What is a single tilting disk made of?3
1. Circular ring of metal
2. Disk
3. Sewing ring
26
Single tilting disks tilt at what degree?
60 degrees
27
What is flow like in a single tilting disk?
Eccentric
28
Single tilting disks have a history of what?
Fracture and sewing ring leak
29
What is the most common mechanical valve?
Bileaflet tilting disk
30
What does the bileaflet tilting disk consist of in terms of design?
1. 2 Occluders + sewing ring
2. Align parallel when opening
31
What does bileaflet tilting disk color doppler demonstrate?3
1. 3 jets
2. Central flow with peripheral turbulence
32
The bileaflet tilting disk is a valve made to have a built in what?
Regurg
33
What does the built in regurg of the bileaflet tilting disk do?
1. "washes" the valve
2. Decrease thrombus
34
What does MR look like for Bileaflet tilting disk?
2 jets
35
Why is it frustrating to image mechanical valves?
Can be frustrating due to artifacts such as
1. Reverberation
2. Shadowing
36
What should we do when we image mechanical valves? 3
1. Account for the motion of the occluder's
2. Use zoom/ magnifaction
3. Evaluate the sewing ring
37
What can we do in terms of imaging mechanical valves to help assess regurgitation?
Scanning off axis
38
What are three types of tissue valves in terms of bioprosthetic?
1. Homograft (allograft)
2. Autograft
3. Heterograft (xenograft)
39
What is a homograft?
Graft from one human to another
40
How common are homografts?
Rare
41
How do we obtain homografts?
From cadavers
42
How common are autografts?
Rare
43
What are autografts?
Graft of tissue from one site to another in the same patient
44
What is a heterograft?
Graft from different species?
45
What are examples of heterografts?
1. Animal to human
2. Porcine heart valve (pig)
3. Bovine pericardium (cow)
46
How long does hetergrafts last?
5 years
47
What are the advantages of bioprosthetics? 3
1. Anticoaguation not required, therefore may provide better quality of life
2. valves do not click
3. May be candidates for percutaneous valve in valve procedures at a later date
48
What are disadvantages of bioprosthetic valves?
1. Not as durable as mechanical valves
2. Prone to calcifications
49
Young person receiving a bioprosthetic valve may require what?
Reoperation
50
What happens with bioprosthetics in terms of calcifcaitons?
Stenosis with increased gradient across valve
51
What are components of bioprosthetic valves?
1. Leaflet
2. Sewing ring
+/- stents/ struts
52
When we image bioprosthetic valves what is the structure of the leaflets?
Trileaflet structure
53
In terms of imaging bioprostetic valves, what might cause an artifact?
Sewing ring and struts
54
What do we evaluate the sewing rings for?2
1. Dehiscence
2. Paravalvular leak
55
Between bioprosthetic valves and mechanical prosthesis, which is easier to image?
Bioprosthetic valves
56
What are some considerations for choice of prosthetic valves?7
1. Rate of structural failure
2. Effect of age very young or old
3. Co-morbid conditions
4. Anticoagulation with mechanical valves
5. Patient preference (young, religion)
6. Physical activity
7. Women of childbearing age
57
What are 4 different types of valve replacement/ repairs?
1. Ross procedure - AV replacement
2. MV/TV annulplasty rings
3. TAVR - transcatheter AV replacement
4. Edge to edge repair
58
What components generally seen in a ross procedure?
Autograft + Homograft
1. Patients PV and root becomes the new AV and root
2. Donor PV valve and root is implanted
59
Who is ROSS procedure performed on?
Young people and women of childbearing years
60
What are some advantages of ross procedure?
1. **No long term anticoagulation**
2. Can grow with the patient
3. Less immune response post operation
4. Long surgery
61
What does Annuloplasty ring (for valve repair) treats?
Valve regurgitation such as MV and TV
62
What is annuloplasty ring designed to do?
1. Restore the size and shape of the normal valve annulus
2. Prevents recurrent dilation
63
Annuloplasty rings look like what?
May be full or partial rings
64
What is often required prior to TAVR?
Balloon valvuloplasty
65
What might transcatheter AV replacement lead to?
Stenosis but often leads to regurgitation
66
What kind of procedure is transcatheter AV replacement? TAVR
Percutaneous procedure
67
How is the TAVR procedure conducted?
Tissue valve mounted on balloon or self expandable stent
68
What is interrogated with the echo assessment of TAVR?5
1. Pre-procedure measurement of the AV annulus
2. # of leaflets
3. Valve mobility
4. AS severity
5. LV fxn, hypertrophy and potential thrombus are also assessed pre-procedure
69
TAVI may also utilize what?
The echocardiographer to perform TEE during the procedure to evaluate prosthesis misplacement
70
What is edge to edge repair used for?
To treat MR
71
What is used for edge to edge repair?
Mitraclip
72
What does mitraclip?
Double orifice MV
73
What does the Mitra clip clamp?
AMVL + PMVL
74
Where does the mitra clamp attach?
In the middle avoiding any chordae
75
What is patient prosthesis mismatch?
Implanted valve is too small for the patients body size
76
What happens when the valve is too small?
1. Hemodynamics consistent with prosthetic valve stenosis
2. Abnormally high velocity and gradients with non-stenotic valve
77
What are different types of prosthetic valve dysfunctions? 4
1. Structural failure
2. Regurgitation
3. Thromboembolic complicaitons
4. Endocarditis
78
What type of valves is this and what is the significance of this?
This is a ball in cage valve, and it is covered in thrombus
79
What does this image represent?
Pannus formation on the valves
80
What does this image represent?
Valvular abscess on a Bioprosthetic AV
81
Label
82
What does this represent?
Valve identification chart
83
The EOA formula is generally only used for which valve?
AV and sometimes PV
84
What parameter confirms severe PI?
Reversal in the pulmonary branches
85
How will the heart remodel with AI?
LV dilatation
86
How will the heart remodel with PI?
RV dilatation
87
Label the image
88
What doe we use to measure EOA AV? And what is the formula?
89
Label the image
90
What does this image represent?
AR
91
What does this image represent?
Medtronic Mosaic Strut on a Bioprosthetic valve
92
When does structural failure normally happen with bioprosthetic valves?
Typically occurs >10 years post implantation
93
What does bioprosthetic failure look like?2
1. Failure of leaflets to open/ close
properly due to tissue degeneration
2. Acute valve regurgitation (leaflet tear), usually after trauma or aging of the valve
94
What would be a mechanical valve fail? 3
1. Valve regurgitation
2. Valve stenosis
3. Design flaw
95
What does design flaws in mechanical valves lead to?
Mechanical failure
96
How do we get valve stenosis with mechanical failure?
Due to pannus or thrombus formation
97
How do we get valve regurgitation with mechanical failure?
Due to pannus or thrombus formation
98
What does normal prosthetic valve regurgitation look like?
Transvalvular
99
What does transvalvular regurgitation look like?
1. Normal "washing jets"
2. Closing volume
100
What does closing volume look like?
As valve closes, it displaces a small volume of blood backward
101
What does abnormal prosthetic valve regurgitation look like? 3
1. Paravalvular
2. Transvalvular
3. Dehiscence
102
What does paravalvular regurgitation look like?
Through or around the sewing ring
103
What does abnormal transvalvular regurgitation look like?
More than a washing jet
104
What does dehiscence look like? 2
1. Regurgitation seen around, instead of through the valve
2. Urgent finding, requires immediate attention
105
How does valvular dehiscence occur?
Occurs when a valve becomes detached on one side of the sewing ring, leading to rocking motion of the valve, with regurgitation slipping around the valve
106
What is the prognosis for valvular dehiscence?
Very serious
107
Where is the regurgitation with dehiscence?
Significant regurgitation around the prosthesis
108
How does a valvular dehiscence appear?
1. Appears as instability or rocking
2. Independent movement
109
In terms of valvular dehiscence, as part of the valve becomes detached, what happens?
More force is applied to the intact sutures, which leads to more suture detachment
110
What are some thromboembolic complications with prosthetic valves? 4
1. Prone to thrombus formation
2. U/S density of thrombi are similar to myocardium
3. Thrombus may cause embolic events, Stenosis, regurgitation
4. All valve replacement patients have 6 weeks of heavy anticoagulation drugs
111
What is pannus?
Fibrous ingrowth of tissue
112
Why do we have pannus formation?
Scarring respinse
113
Pannus formation may result in what?
Stenosis/ regurgitation
114
What might be required if there is a pannus formation?
TEE may be required
115
Why must we differentiate between pannus/ thrombus?
Thrombus treated with thrombolytics
116
What is the difference between pannus and thrombus in terms of occurrence?
Pannus: >12 months before malfunction
Thrombus: occurs shortly after surgery
117
What is the difference between pannus and thrombus in terms of size?
Pannus is smaller
118
What is the difference between pannus and thrombus in terms of echo texture?
Pannus is more echo dense and thrombus has more of a soft tissue appearance
119
What is the difference between pannus and thrombus in terms of mobility?
Pannus is fixed vs thrombus which is mobile
120
What is the difference between pannus and thrombus in terms of location?
Pannus usually occurs at annulus and thrombus mass extends beyond annular ring to adj structures
121
What is the difference between pannus and thrombus in terms of common areas?
Pannus is located more common in AV (LVOT side) and Thrombus is more common in MV
122
How serious is endocarditis?
Very serious clinical problem
123
What is endocarditis?
Vegetations on bioprosthetic valves are similar in appearance to vegetations on native valves
124
In terms of endocarditis and prosthetics, vegetations on mechanicals are often what? 2
Paravalvular which is
1. Irregularly shaped
2. Independently mobile structures
125
What is indicated if endocarditis suspected?
TEE
126
What might we see on the valve identification card?
1. Valve size
2. Type
3. Physician
127
Who carries the identification card?
Patient
128
Where might you find valves chart?
In echo departments or online
129
In terms of values chart, once you know the patient's valve model, what can you do?
Use these charts as a reference
130
What is some clinical information of patient information?
1. Date of valve replacement
2. Type and size
3. Height/ Weight/ BSA
4. Symptoms
5. BP/HR
131
What do we look at with 2D valve imaging in terms of prosthetic valve echo?
1. Motion of leaflets/ occluder
2. Calcification/ abnormal echodensities
3. Sewing ring integrity
132
What is some other 2D echo data seen with prosthetic valve echo assessment?2
1. Chamber sizes (dilatation may indicate excessive regurg)
2. Previous post-op studies for comparison
133
When we are doing an assessment of prosthetic valve echo, what do we need to do that is usually a great source of error?
Note the size of LVOT/ RVOT when comparing to previous echo
134
In terms of prosthetic valve doppler, when assessing prosthetic valves, we want to know if they are what?4
1. Functioning adequately
2. Need replacement
3. Do they have significant stenosis
4. Do they have significant regurgitation
135
All prosthetic valves have some degree of what?
Gradient by nature of their design
136
Almost all prosthetic valves will show what?
Normal degree of regurg
137
What equations will we use in prosthetic valve assessment frequently?2
1. DVI (Doppler velocity index)
2. EOA (effective orifice area)
138
What is the DVI formula and what is it?
1. Simple ratio between 2 velocities or WTI
2. DVI = V1/V2
139
What is EOA?
Essentially our valve area
140
What is EOA formula similar to?
Continuity equation
141
What are some doppler considerations of the prosthetic valve? 5
1. Peak velocity and gradient
2. Mean pressure gradient
3. Regurgitation
4. Effective orifice area
5. RVSP (for back up of pressures for left heart valves)
142
When imaging the MV prosthetic valve for regurgitation what must we take into account?
1. Mitral inflow peak velocity and VTI
2. P1/2t of MV inflow
3. Intensity of the MR CW doppler signal
4. Systolic flow reversal in pulmonary vein
5. Flow convergence size (PISA)
143
What is something that we must take into consideration when looking the TV valve for regurg?
1. Jet density and contour (CW) of TR jet
2. Systolic hepatic vein flow reversal
3. RA/RV/IVC size
4. Off axis views important
144
What are two things to remember to make valve calculations simply?
1. Always obtain a CW of the highest velocities through the trace
2. Always obtain a PW trace throug hthe outflow
145
VTI trace will give you what? 3
1. Peak velocity
2. Mean velocity
3. VTI for ratio and continuity equation
146
What is the AS DVI?
Dimensionless ratio of LVOT versus AV peak velocity or VTI
147
When is AS DVI used?
Especially when LVOT diameter cannot be obtained
148
What is AS DVI used for?
Prosthetic AV
149
What is the normal AV:DVI?
>0.3
150
What do we use to calculate stenosis in the prosthetic mitral valve area?
151
In terms of stenosis: of prosthetic TV, what does velocity vary with?
Respiration
152
What does ASE recommend for prosthetic TV stenosis? 4
1. Peak E (TV inflow - PW)
2. TV VTI (CW)
3. P 1/2t
4. Regurgitation
153
In terms of ASE how do we calculate PV VTI?
Trace PV VTI (CW)
154
Some sites will use what hethod for evaluation of bioprosthetic MV or TV Only?
P1/2T
155
We should never assign an LVOT of 20m, why?
There are assignable LVOTd based on BSA available on ASE website
156
ID cards are becoming less needed for evaluation due to what?
Similar hemodynamics between valve types
157
