Prosthetic Valves Flashcards by Tim Montrief

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

Bioprosthetic
Mechanical
Composite
Homograft

How well did you know this?

Not at all

Perfectly

What are the 3 subclasses of bioprosthetic valves?

Stented
Stentless
Transcatheter

How well did you know this?

Not at all

Perfectly

What are the 3 subclasses of mechanical valves?

Bi-leaflet

Mono-leaflet

Ball-cage

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

Larger valve can fit and can be sewn above the nanulus

How well did you know this?

Not at all

Perfectly

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

Low Lying coronary arteries (bicuspid valves) can be problematic

How well did you know this?

Not at all

Perfectly

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

Aortic Regurgitation (Especially with RSR)

How well did you know this?

Not at all

Perfectly

What does porcine mean?

Derived from pigs

How well did you know this?

Not at all

Perfectly

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

Carpentier Edwards
Med Hancock
Med Mosaic
SJM Biocor

How well did you know this?

Not at all

Perfectly

What are type types of stented bioprosthetic valves?

Porcine

Pericardial

How well did you know this?

Not at all

Perfectly

What are the disadvantages of supra annular prosthetic valves?

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

How well did you know this?

Not at all

Perfectly

How are the mitral and aorta pericardial valves different?

Mitral = Flat

Aortic = Curved (Scalloped to conform to aortic root)

How well did you know this?

Not at all

Perfectly

The Sorin Mitroflow valve is only approved for what positon?

Aortic Position

How well did you know this?

Not at all

Perfectly

What is the advantage of stentless bioprosthetic valves over stented?

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

- Decreased gradient

- Less stress on the valves

How well did you know this?

Not at all

Perfectly

What is the disadvantage of stentless bioprosthetic valves over stented?

More complicated surgery

How well did you know this?

Not at all

Perfectly

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

Sino Tubular Junction Size

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

What are the 3 main classes of mechanical valves?

Bileaflet

Single Leaflet

Ball-cage

How well did you know this?

Not at all

Perfectly

What is the most common type of mechanical valve?

Bileaflet Mechanical Valve

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

See picture attached

Aortic Position = Pivot Guard in LVOT

Mitral Position = Pivot Gaurd in the LA

What is the main unique factor of Sorin valve?

Leaflets exposed and not protected by a guard

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

(Medtronic Hall and Bjork Shiley)

Medtronic Hall = Central aperature

“MH is a Central disease to know in Anesthesia”

Bjork Shiley = No central aperature

(“No BS”)

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

55-70 degrees

What is the major complications from Starr Edwards Valves?

High profile and thus High gradients

High risk of thrombosis

When would you want to use a homograft?

Treatment for **aortic root abscess**

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

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

How do you tell the difference between a *_freestyle*_ vs. _*homograft_* on echo?

See images (2 attached) **Freestyle** = Dacron graft with acoustic shadowing is **Homograft** = No acoustic shadowing, but increased thickness where homograft is (ME LAX)

What is seen here?

Acoustic Reverberation Pattern in TAVR valves

What is the difference in a mechanical valve placed: ***_Anatomically_*** vs. ***_Anti-anatomically_***?

**Anatomic** = Normal orientation (Anterior and posterior position) **Anti-anatomic** = Not positioned anterior/posterior

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

Commissural View

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

**If placed anti-anatomically** 1. Blood flow more likely to move leaflets equally 2. Subvalvular apparatus more likely to interfere with the leaflet motion

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

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

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

**1. Closure backflow** - Short duration **2. Leakage backflow** - After valve closes - Low veloicty and uniform color - Low signal strength with CWD

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

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

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

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)

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

2 Lateral Jets

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

Small Central jet Lateral jets

The **Medtronic Hall** has how many jets and which direction?

1 Large Central jet 2 lateral jets

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

2 lateral jets

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

2 curved closing jet No washing jets

The final step in prosthetic valve assessment post-bypass is hemodynamics. What specifically are we looking for?

Velocity (Peak and Mean) Gradients Area Calculation Doppler Velocity Index Effective Orifice area (EOA) and Index (EOAI)

What is a normal Doppler Velocity Index native valves?

0.75 - 0.90

What is a normal Doppler Velocity Index prosthetic valves?

0.35 - 0.50

What is the formula for EOA?

EOA = 0.785 (D²) x (VTI_LVOT / VTI_{Aortic Valve}) D = LVOT diameter

What formula allows you to calculate EOA indexed?

EOA / BSA

What is a normal EOAI? What is a marginal EOAI? What is an unacceptable EOAI?

**Normal** \> 0.85 **Marginal** 0.75 - 0.85 **Unacceptable** \< 0.75