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DMST 367 Echo 3 > Prostethic Valves > Flashcards

Prostethic Valves Flashcards

1
Q

What does this image represent?

A

Single tilting disk - Bork Shiley valve

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2
Q

What does this image represent?

A

Bileaflet Tilting disk

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3
Q

What does this image represent?

A

Bileaflet mechanical mitral valve

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4
Q

What does this image represent?

A

Mechanical Valve hemodynamics

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5
Q

What does this image represent?

A
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6
Q

What does this image represent?

A

Scented Bioprosthetic valve

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7
Q

What does this image represent?

A

Bioprosthetic stentless freestyle valves

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8
Q

What does this image represent?

A

Ross procedure

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9
Q

What does this image represent? What does the arrow point to?

A
  1. Annuloplasty ring
  2. The arrow Mimics MAC
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10
Q

What does this image represent?

A

TAVR (Transcatheter AV replacements)

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11
Q

What does this image represent?

A

Edge to edge repair

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12
Q

Why would someone have a prostatic valve?3

A

Implanted when the patient has hemodynamically significant valvular disease such as

  1. Stenosis
  2. Regurgitation
  3. Aortic dissection/ severe AI
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13
Q

In terms of prosthetic valves, when are valvular rings or other devices used?

A

When possible

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14
Q

What is the role of echo in prosthetic valves during pre-procedure?2

A
  1. Assess the need for repair/replacement
  2. Assess suitability of the type of repair/ replacement
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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

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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

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17
Q

What are the advantages of mechanical valves?3

A
  1. Durable
  2. Due to durability, risk for reoperation is low
  3. Easier surgical implantation
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18
Q

Why is mechanical valves durable?

A
  1. Made from biocompatible metal, plastic or cermiclike material
  2. Lasts 10-25 years
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19
Q

What is the disadvantage of mechanical valves?

A
  1. Risk of thrombus formation and pannus growth
  2. Valve may make an audible click
  3. Produces a blood flow pattern that is resistant or high flow
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20
Q

What is the most common disadvantage of mechanical valves?

A

Thrombus formation which leads to lifelong anticoagulation

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21
Q

Pannus growth can lead to what?

A

Regurgitation or stenosis

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22
Q

How can we size the valve to use?

A

Echo used in pre-procedure to determine the choice of valve size

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23
Q

Reported size of the valve refers to what?

A

Outer diameter

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24
Q

What is valves measured in?

A

Milimeters

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25
Q

What is a single tilting disk made of?3

A
  1. Circular ring of metal
  2. Disk
  3. Sewing ring
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26
Q

Single tilting disks tilt at what degree?

A

60 degrees

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27
Q

What is flow like in a single tilting disk?

A

Eccentric

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28
Q

Single tilting disks have a history of what?

A

Fracture and sewing ring leak

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29
Q

What is the most common mechanical valve?

A

Bileaflet tilting disk

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30
Q

What does the bileaflet tilting disk consist of in terms of design?

A
  1. 2 Occluders + sewing ring
  2. Align parallel when opening
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31
Q

What does bileaflet tilting disk color doppler demonstrate?3

A
  1. 3 jets
  2. Central flow with peripheral turbulence
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32
Q

The bileaflet tilting disk is a valve made to have a built in what?

A

Regurg

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33
Q

What does the built in regurg of the bileaflet tilting disk do?

A
  1. “washes” the valve
  2. Decrease thrombus
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34
Q

What does MR look like for Bileaflet tilting disk?

A

2 jets

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35
Q

Why is it frustrating to image mechanical valves?

A

Can be frustrating due to artifacts such as
1. Reverberation
2. Shadowing

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36
Q

What should we do when we image mechanical valves? 3

A
  1. Account for the motion of the occluder’s
  2. Use zoom/ magnifaction
  3. Evaluate the sewing ring
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37
Q

What can we do in terms of imaging mechanical valves to help assess regurgitation?

A

Scanning off axis

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38
Q

What are three types of tissue valves in terms of bioprosthetic?

A
  1. Homograft (allograft)
  2. Autograft
  3. Heterograft (xenograft)
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39
Q

What is a homograft?

A

Graft from one human to another

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40
Q

How common are homografts?

A

Rare

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41
Q

How do we obtain homografts?

A

From cadavers

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42
Q

How common are autografts?

A

Rare

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43
Q

What are autografts?

A

Graft of tissue from one site to another in the same patient

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44
Q

What is a heterograft?

A

Graft from different species?

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45
Q

What are examples of heterografts?

A
  1. Animal to human
  2. Porcine heart valve (pig)
  3. Bovine pericardium (cow)
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46
Q

How long does hetergrafts last?

A

5 years

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47
Q

What are the advantages of bioprosthetics? 3

A
  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
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48
Q

What are disadvantages of bioprosthetic valves?

A
  1. Not as durable as mechanical valves
  2. Prone to calcifications
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49
Q

Young person receiving a bioprosthetic valve may require what?

A

Reoperation

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50
Q

What happens with bioprosthetics in terms of calcifcaitons?

A

Stenosis with increased gradient across valve

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51
Q

What are components of bioprosthetic valves?

A
  1. Leaflet
  2. Sewing ring
    +/- stents/ struts
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52
Q

When we image bioprosthetic valves what is the structure of the leaflets?

A

Trileaflet structure

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53
Q

In terms of imaging bioprostetic valves, what might cause an artifact?

A

Sewing ring and struts

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54
Q

What do we evaluate the sewing rings for?2

A
  1. Dehiscence
  2. Paravalvular leak
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55
Q

Between bioprosthetic valves and mechanical prosthesis, which is easier to image?

A

Bioprosthetic valves

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56
Q

What are some considerations for choice of prosthetic valves?7

A
  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
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57
Q

What are 4 different types of valve replacement/ repairs?

A
  1. Ross procedure - AV replacement
  2. MV/TV annulplasty rings
  3. TAVR - transcatheter AV replacement
  4. Edge to edge repair
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58
Q

What components generally seen in a ross procedure?

A

Autograft + Homograft

  1. Patients PV and root becomes the new AV and root
  2. Donor PV valve and root is implanted
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59
Q

Who is ROSS procedure performed on?

A

Young people and women of childbearing years

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60
Q

What are some advantages of ross procedure?

A
  1. No long term anticoagulation
  2. Can grow with the patient
  3. Less immune response post operation
  4. Long surgery
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61
Q

What does Annuloplasty ring (for valve repair) treats?

A

Valve regurgitation such as MV and TV

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62
Q

What is annuloplasty ring designed to do?

A
  1. Restore the size and shape of the normal valve annulus
  2. Prevents recurrent dilation
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63
Q

Annuloplasty rings look like what?

A

May be full or partial rings

64
Q

What is often required prior to TAVR?

A

Balloon valvuloplasty

65
Q

What might transcatheter AV replacement lead to?

A

Stenosis but often leads to regurgitation

66
Q

What kind of procedure is transcatheter AV replacement? TAVR

A

Percutaneous procedure

67
Q

How is the TAVR procedure conducted?

A

Tissue valve mounted on balloon or self expandable stent

68
Q

What is interrogated with the echo assessment of TAVR?5

A
  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
Q

TAVI may also utilize what?

A

The echocardiographer to perform TEE during the procedure to evaluate prosthesis misplacement

70
Q

What is edge to edge repair used for?

A

To treat MR

71
Q

What is used for edge to edge repair?

72
Q

What does mitraclip?

A

Double orifice MV

73
Q

What does the Mitra clip clamp?

A

AMVL + PMVL

74
Q

Where does the mitra clamp attach?

A

In the middle avoiding any chordae

75
Q

What is patient prosthesis mismatch?

A

Implanted valve is too small for the patients body size

76
Q

What happens when the valve is too small?

A
  1. Hemodynamics consistent with prosthetic valve stenosis
  2. Abnormally high velocity and gradients with non-stenotic valve
77
Q

What are different types of prosthetic valve dysfunctions? 4

A
  1. Structural failure
  2. Regurgitation
  3. Thromboembolic complicaitons
  4. Endocarditis
78
Q

What type of valves is this and what is the significance of this?

A

This is a ball in cage valve, and it is covered in thrombus

79
Q

What does this image represent?

A

Pannus formation on the valves

80
Q

What does this image represent?

A

Valvular abscess on a Bioprosthetic AV

81
Q

Label

82
Q

What does this represent?

A

Valve identification chart

83
Q

The EOA formula is generally only used for which valve?

A

AV and sometimes PV

84
Q

What parameter confirms severe PI?

A

Reversal in the pulmonary branches

85
Q

How will the heart remodel with AI?

A

LV dilatation

86
Q

How will the heart remodel with PI?

A

RV dilatation

87
Q

Label the image

88
Q

What doe we use to measure EOA AV? And what is the formula?

89
Q

Label the image

90
Q

What does this image represent?

91
Q

What does this image represent?

A

Medtronic Mosaic Strut on a Bioprosthetic valve

92
Q

When does structural failure normally happen with bioprosthetic valves?

A

Typically occurs >10 years post implantation

93
Q

What does bioprosthetic failure look like?2

A
  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
Q

What would be a mechanical valve fail? 3

A
  1. Valve regurgitation
  2. Valve stenosis
  3. Design flaw
95
Q

What does design flaws in mechanical valves lead to?

A

Mechanical failure

96
Q

How do we get valve stenosis with mechanical failure?

A

Due to pannus or thrombus formation

97
Q

How do we get valve regurgitation with mechanical failure?

A

Due to pannus or thrombus formation

98
Q

What does normal prosthetic valve regurgitation look like?

A

Transvalvular

99
Q

What does transvalvular regurgitation look like?

A
  1. Normal “washing jets”
  2. Closing volume
100
Q

What does closing volume look like?

A

As valve closes, it displaces a small volume of blood backward

101
Q

What does abnormal prosthetic valve regurgitation look like? 3

A
  1. Paravalvular
  2. Transvalvular
  3. Dehiscence
102
Q

What does paravalvular regurgitation look like?

A

Through or around the sewing ring

103
Q

What does abnormal transvalvular regurgitation look like?

A

More than a washing jet

104
Q

What does dehiscence look like? 2

A
  1. Regurgitation seen around, instead of through the valve
  2. Urgent finding, requires immediate attention
105
Q

How does valvular dehiscence occur?

A

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
Q

What is the prognosis for valvular dehiscence?

A

Very serious

107
Q

Where is the regurgitation with dehiscence?

A

Significant regurgitation around the prosthesis

108
Q

How does a valvular dehiscence appear?

A
  1. Appears as instability or rocking
  2. Independent movement
109
Q

In terms of valvular dehiscence, as part of the valve becomes detached, what happens?

A

More force is applied to the intact sutures, which leads to more suture detachment

110
Q

What are some thromboembolic complications with prosthetic valves? 4

A
  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
Q

What is pannus?

A

Fibrous ingrowth of tissue

112
Q

Why do we have pannus formation?

A

Scarring respinse

113
Q

Pannus formation may result in what?

A

Stenosis/ regurgitation

114
Q

What might be required if there is a pannus formation?

A

TEE may be required

115
Q

Why must we differentiate between pannus/ thrombus?

A

Thrombus treated with thrombolytics

116
Q

What is the difference between pannus and thrombus in terms of occurrence?

A

Pannus: >12 months before malfunction

Thrombus: occurs shortly after surgery

117
Q

What is the difference between pannus and thrombus in terms of size?

A

Pannus is smaller

118
Q

What is the difference between pannus and thrombus in terms of echo texture?

A

Pannus is more echo dense and thrombus has more of a soft tissue appearance

119
Q

What is the difference between pannus and thrombus in terms of mobility?

A

Pannus is fixed vs thrombus which is mobile

120
Q

What is the difference between pannus and thrombus in terms of location?

A

Pannus usually occurs at annulus and thrombus mass extends beyond annular ring to adj structures

121
Q

What is the difference between pannus and thrombus in terms of common areas?

A

Pannus is located more common in AV (LVOT side) and Thrombus is more common in MV

122
Q

How serious is endocarditis?

A

Very serious clinical problem

123
Q

What is endocarditis?

A

Vegetations on bioprosthetic valves are similar in appearance to vegetations on native valves

124
Q

In terms of endocarditis and prosthetics, vegetations on mechanicals are often what? 2

A

Paravalvular which is
1. Irregularly shaped
2. Independently mobile structures

125
Q

What is indicated if endocarditis suspected?

126
Q

What might we see on the valve identification card?

A
  1. Valve size
  2. Type
  3. Physician
127
Q

Who carries the identification card?

128
Q

Where might you find valves chart?

A

In echo departments or online

129
Q

In terms of values chart, once you know the patient’s valve model, what can you do?

A

Use these charts as a reference

130
Q

What is some clinical information of patient information?

A
  1. Date of valve replacement
  2. Type and size
  3. Height/ Weight/ BSA
  4. Symptoms
  5. BP/HR
131
Q

What do we look at with 2D valve imaging in terms of prosthetic valve echo?

A
  1. Motion of leaflets/ occluder
  2. Calcification/ abnormal echodensities
  3. Sewing ring integrity
132
Q

What is some other 2D echo data seen with prosthetic valve echo assessment?2

A
  1. Chamber sizes (dilatation may indicate excessive regurg)
  2. Previous post-op studies for comparison
133
Q

When we are doing an assessment of prosthetic valve echo, what do we need to do that is usually a great source of error?

A

Note the size of LVOT/ RVOT when comparing to previous echo

134
Q

In terms of prosthetic valve doppler, when assessing prosthetic valves, we want to know if they are what?4

A
  1. Functioning adequately
  2. Need replacement
  3. Do they have significant stenosis
  4. Do they have significant regurgitation
135
Q

All prosthetic valves have some degree of what?

A

Gradient by nature of their design

136
Q

Almost all prosthetic valves will show what?

A

Normal degree of regurg

137
Q

What equations will we use in prosthetic valve assessment frequently?2

A
  1. DVI (Doppler velocity index)
  2. EOA (effective orifice area)
138
Q

What is the DVI formula and what is it?

A
  1. Simple ratio between 2 velocities or WTI
  2. DVI = V1/V2
139
Q

What is EOA?

A

Essentially our valve area

140
Q

What is EOA formula similar to?

A

Continuity equation

141
Q

What are some doppler considerations of the prosthetic valve? 5

A
  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
Q

When imaging the MV prosthetic valve for regurgitation what must we take into account?

A
  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
Q

What is something that we must take into consideration when looking the TV valve for regurg?

A
  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
Q

What are two things to remember to make valve calculations simply?

A
  1. Always obtain a CW of the highest velocities through the trace
  2. Always obtain a PW trace throug hthe outflow
145
Q

VTI trace will give you what? 3

A
  1. Peak velocity
  2. Mean velocity
  3. VTI for ratio and continuity equation
146
Q

What is the AS DVI?

A

Dimensionless ratio of LVOT versus AV peak velocity or VTI

147
Q

When is AS DVI used?

A

Especially when LVOT diameter cannot be obtained

148
Q

What is AS DVI used for?

A

Prosthetic AV

149
Q

What is the normal AV:DVI?

150
Q

What do we use to calculate stenosis in the prosthetic mitral valve area?

151
Q

In terms of stenosis: of prosthetic TV, what does velocity vary with?

A

Respiration

152
Q

What does ASE recommend for prosthetic TV stenosis? 4

A
  1. Peak E (TV inflow - PW)
  2. TV VTI (CW)
  3. P 1/2t
  4. Regurgitation
153
Q

In terms of ASE how do we calculate PV VTI?

A

Trace PV VTI (CW)

154
Q

Some sites will use what hethod for evaluation of bioprosthetic MV or TV Only?

155
Q

We should never assign an LVOT of 20m, why?

A

There are assignable LVOTd based on BSA available on ASE website

156
Q

ID cards are becoming less needed for evaluation due to what?

A

Similar hemodynamics between valve types

DMST 367 Echo 3 (27 decks)

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