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PTE Masters + A Practical Approach to Transesophageal Echocardiography > Prosthetic Valves > Flashcards

Prosthetic Valves Flashcards

1
Q

What are the 4 general classes of heart valves used in cardiac surgeries?

A
  1. Bioprosthetic
  2. Mechanical
  3. Composite
  4. Homograft
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2
Q

What are the 3 subclasses of bioprosthetic valves?

A
  1. Stented
  2. Stentless
  3. Transcatheter
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3
Q

What are the 3 subclasses of mechanical valves?

A

Bi-leaflet

Mono-leaflet

Ball-cage

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4
Q

What are the 3 aspects to a stented porcine bioprosthetic valve?

A

1. Valve tissue

2. Frame (Stent)

  • Elgiloy Struts serve as commissure supports

3. Sewing Ring

  • Suture ring for stitches
  • Cloth covering (PTFE or Dacron) to promote endothelial encapsulation
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5
Q

What the advantage of a supra-annular insertion of a valve?

A

Larger valve can fit and can be sewn above the nanulus

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6
Q

What the disadvantage of a supra-annular insertion of a valve?

A

Low Lying coronary arteries (bicuspid valves) can be problematic

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7
Q

If the aortic valve that is replaced is oversized, what can happen?

A

Aortic Regurgitation (Especially with RSR)

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8
Q

What does porcine mean?

A

Derived from pigs

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9
Q

What are the 4 types of manufacters of Porcine stented bioprosthetic valves?

A
  1. Carpentier Edwards
  2. Med Hancock
  3. Med Mosaic
  4. SJM Biocor
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10
Q

What are type types of stented bioprosthetic valves?

A

Porcine

Pericardial

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11
Q

What are the disadvantages of supra annular prosthetic valves?

A

May interfere with coronary ostia (Aortic position) or supravalvular structures

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12
Q

How are the mitral and aorta pericardial valves different?

A

Mitral = Flat

Aortic = Curved (Scalloped to conform to aortic root)

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13
Q

The Sorin Mitroflow valve is only approved for what positon?

A

Aortic Position

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14
Q

What is the advantage of stentless bioprosthetic valves over stented?

A

Allows larger valve size (1-2 sizes larger) to increase EOA

- Decreased gradient

- Less stress on the valves

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15
Q

What is the disadvantage of stentless bioprosthetic valves over stented?

A

More complicated surgery

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16
Q

For the St Jude Toronto SPV valve, what is the most important echocardiographic measurement that needs to be completed?

A

Sino Tubular Junction Size

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17
Q

What are the 5 steps to insertion of a TAVR through femoral artery?

A
  1. PAV (Percutaneous Aortic Valve) –> First break up calcium in the annulus with wire
  2. Catheter inserted across AV
  3. Valve slides into position
  4. Rapid V-pacing (160 - 180 bpm to decrease ejection)
  5. Inflated balloon to open the valve
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18
Q

What are the 3 main classes of mechanical valves?

A

Bileaflet

Single Leaflet

Ball-cage

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19
Q

What is the most common type of mechanical valve?

A

Bileaflet Mechanical Valve

20
Q

How is the St Jude Bileaflet Mechanical valve placed depending on position?

A

See picture attached

Aortic Position = Pivot Guard in LVOT

Mitral Position = Pivot Gaurd in the LA

21
Q

What is the main unique factor of Sorin valve?

A

Leaflets exposed and not protected by a guard

22
Q

What are the main differences between two types of Single Tilting Disc Valves?

(Medtronic Hall and Bjork Shiley)

A

Medtronic Hall = Central aperature

“MH is a Central disease to know in Anesthesia”

Bjork Shiley = No central aperature

(“No BS”)

23
Q

What is the opening arc angle on the Metronic Hall Valve?

A

55-70 degrees

24
Q

What is the major complications from Starr Edwards Valves?

A

High profile and thus High gradients

High risk of thrombosis

25
Q

When would you want to use a homograft?

A

Treatment for aortic root abscess

26
Q

What are the four 2-D steps of evaluation of a prosthetic valve exam?

A
  1. What type of valve?
  2. How is valve seated?
  3. Leaflet movement?
  4. Extraneous masses present?
27
Q

How do you tell the difference between a freestyle* vs. *homograft on echo?

A

See images (2 attached)

Freestyle = Dacron graft with acoustic shadowing is

Homograft = No acoustic shadowing, but increased thickness where homograft is (ME LAX)

28
Q

What is seen here?

A

Acoustic Reverberation Pattern in TAVR valves

29
Q

What is the difference in a mechanical valve placed:

Anatomically vs. Anti-anatomically?

A

Anatomic = Normal orientation (Anterior and posterior position)

Anti-anatomic = Not positioned anterior/posterior

30
Q

What position do you determine if a mitral bileaflet mechanical is in anatomic position vs. anti-anatomic positon?

A

Commissural View

31
Q

Why would you place an anti-anatomic position of the mitral valve?

A

If placed anti-anatomically

  1. Blood flow more likely to move leaflets equally
  2. Subvalvular apparatus more likely to interfere with the leaflet motion
32
Q

What are the 4 steps when evaluating color flow doppler of prosthetic heart valves?

A
  1. Antegrade flow normal?
  2. Normal washing jets present?
  3. Intravalvular pathological leak?
  4. Paraprosthetic leak?
33
Q

What factors are important to determine if you have normal washing jets post bypass?

A

1. Closure backflow

  • Short duration

2. Leakage backflow

  • After valve closes
  • Low veloicty and uniform color
  • Low signal strength with CWD
34
Q

What is critical to remember about carpentier edwards bioprosthetic pericardial valves when quantifying echo leak?

A

Trivial/trace - Mild Central Regurgitation is NORMAL

One or more trivial jets along coaptation edge of the leaflets originating at the stent posts

One of more trivial jets at the base of the valve through the cloth

35
Q

Regarding carpentier edwards bioprosthetic pericardial valves, when do you see ABNORMAL FLOWS that need to be addressed before protamine?

A
  1. Large, high velocity paravalvular leaks
  2. Eccentric Jets (Oversizing is usually reason)
  3. Moderate or Greater MR (Suture overlooping, oversizing, interference by subvalvular apparatus)
36
Q

The St Jude 1 leaflet mechanical valve has how many jets and which direction?

A

2 Lateral Jets

37
Q

The St Jude 2 leaflet mechanical valve has how many jets and which direction?

A

Small Central jet

Lateral jets

38
Q

The Medtronic Hall has how many jets and which direction?

A

1 Large Central jet

2 lateral jets

39
Q

The Bjork Shiley mechanical valve has how many jets and which direction?

A

2 lateral jets

40
Q

The Starr Edwards mechanical valve has how many jets and which direction?

A

2 curved closing jet

No washing jets

41
Q

The final step in prosthetic valve assessment post-bypass is hemodynamics.

What specifically are we looking for?

A

Velocity (Peak and Mean)

Gradients

Area Calculation

Doppler Velocity Index

Effective Orifice area (EOA) and Index (EOAI)

42
Q

What is a normal Doppler Velocity Index native valves?

A

0.75 - 0.90

43
Q

What is a normal Doppler Velocity Index prosthetic valves?

A

0.35 - 0.50

44
Q

What is the formula for EOA?

A

EOA = 0.785 (D2) x (VTILVOT / VTIAortic Valve)

D = LVOT diameter

45
Q

What formula allows you to calculate EOA indexed?

A

EOA / BSA

46
Q

What is a normal EOAI?

What is a marginal EOAI?

What is an unacceptable EOAI?

A

Normal > 0.85

Marginal 0.75 - 0.85

Unacceptable < 0.75

PTE Masters + A Practical Approach to Transesophageal Echocardiography (55 decks)

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