PROSTHETIC
VALVES
DYSFUNCTION
CASE STUDIES
Prof. P. Krishnam Raju MD DM FRCP(Ed)
Care Hospitals Hyderabad
Types of Prosthetic Heart Valves
Bioprostheses
Homograft
Mechanical
Prostheses
Porcine (Stented)
Porcine (Stentless)
Caged-ball
Hancock I
Toronto Stentless
Porcine Valve
Starr—Edwards
Hancock II
Medtronic Freestyle
Braunwald –Cutter
Hancock MO (modified orifice)
Smeloff-Cutter
Carpentier - Edwards
Magovern – Cromie
Medtronic Intact
Tilting -disk
Pericardial
Bjork –Shiley
Ionescu – Shiley
Bjork-Shiley convexoconcave
Carpentier-Edwards
pericardial
Medtronic – Hall
Mitroflow
Lillihei – Kaster
Omniscience
Sorin
CHITRA VALVE
Bileaflet
St Jude Medical
Carbomedics
On-X
PROSTHETIC VALVES ISSUES
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PROSTHETIC VALVE DYSFUNCTION
PANNUS VS THROMBUS
PATIENT PROSTHETIC MISMATCH
INFECTIVE ENDOCARDITIS
PROSTHETIC VALVE STRUCTURAL
DETERIORATION
HIGH PROSTHETIC VALVE GRADIENTS
CHOICE OF VALVE MECHANICAL VS
BIOPROSTHETIC VS STENTLESS VS
PERCUTANEOUS
ANTICOAGULATION REGIMENS
ANTIPLATELET THERAPIES
THROMBOLYTICS IN PROSTHETIC THROMBOSIS
ECHO
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DYSFUNCTION
OBSTRUCTION
REGURGITATION
VALVULAR
PERI VALVULAR
EMBOLISM
THROMBOSIS
HEMOLYSIS
ENDOCARDITIS
POPPET/ CAGE VARIANCE
VALVE BED ABNORMALITY
PSEUDO ANEURYSM
RING ABSCESS
PROSTHETIC
VALVES
Figure 6. Prosthetic valves explanted for severe dysfunction.
Pibarot P , and Dumesnil J G Circulation. 2009;119:10341048
Copyright © American Heart Association, Inc. All rights reserved.
PROSTHETIC VALVES
MASSES
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THROMBUS
• VEGETATIONS
• THROMBUS ON PANNUS
• SUTURES
• MICROBUBBLES(HITS)
• STRANDS (FIBRIN OR COLLAGEN)
• LAMBLs EXCRESCENSES
REDUNDANT CHORDAE TRAPPED IN MV PROS.
ECHO
CHECK LIST - I
Imaging
Forward Flow
PROSTHETIC
VALVES
- (Sewing ring / cusps / occluder)
- V Max P Max P Mean
EOA ; Colour Flow Pattern
Regurgitation
- Normal (or) Abnormal
Site ; Localization
Severity
Prosthetic valve - Motion / study of ArtiFacts
General
- Native valves
- LV / RV Function
- PA pressures
- Vegetations / Pannus
- Thrombus
ECHO
CHECK LIST- II
• Hemodynamic data
Peak Flow velocity
Pmax P mean
PHT
Effective Valve Area
PA Pressure
Diastolic Filling Profile
Jet Area
Flow Reversals
Des AO
PV
HV
RF ; ERO
PROSTHETIC
VALVES
AR
MR
TR
PROSTHETIC VALVES
CASE STUDIES
Mr . SR M/53 Yrs.
MVR
- Year 2002
(Omniscience Valve)
SOB + PND - Year 2005
2D Echo
- PV Obstruction
↓
MV Pmax 18 mmHg
Pmean 8 mmHg
TR 3+; PASP = 64 mmHg
LMWH
↓
No Significant Response
↓
Reop MVR
↓
Extensive Pannus
CARDIAC CT
Mr. SR
M 40 Y
DVR
Fever 2 Months
DVR I E
Ao ANNULAR ABSCESS
PV DEHISCENCE
AMEENA BEGUM
YRS
F 32
MVR 3YRS POST OP
M-H VALVE
INTERMITTENT ALTERNATE CYCLE JAMMED PRO
VALVE
ABSOLUTE EOSINOPHIL COUNT 720 mm3
INR 5.6
Venkateshwara Raju
M 58 / YRS
MVR BIO PRO VALVE
POST OP A FIB
HAEMOPERICARDIUM
CARDIAC ARREST
Para prosthetic valvular regurg severe
Severe PAH CHF
Mr. MK
M 21 Y
AVR
FEVER 3 Months
SOB
PROSTHETIC IE
AO ANNULAR ABSCESS
LAD MYCOTIC ANEURYSM
Mr. RR
M 65 Y
AVR (6 months PO)
SOB (1 Wk)
AC LVF
CVS – ESM 4 6 gr ; EDM
PV disc stuck in semi open
Position Lytic Rx Normalised
HEMA HIRANANDANI F 57 YRS
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AVR BIO PROSTHETIC VALVE
VALVE DEHISCENCE
IE MULTIPLE VEGETATIONS ON BIO PRO VALVE
AO ROOT ABSCESS
SEVERE PARAVALVULAR AR
RVSP= 37mmhg
Hema Hirandani
Nagi Reddy
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M 59 / Yrs
AVR ; Tilting disc Pro. Mechanical Valve
Severe Paravalvular AR
Mod TR ; Mod severe PAH
RVSP = 71 mm Hg
NJ
F 30/Y
MVR
SOB
PND
Palpitation
Afebrile
MVR ; PROSTHETIC DEHISCENCE
SEVERE PARA PROSTHETIC MR
Mrs. PK
F 35 Y
MVR
Acute SOB / PND
Prosthetic Valve Sounds not audible
MVR stuck valve
Lytic Rx Given
MVR BIOMED VALVE
ECCENTRIC BALL VALVE
ORIENTATION
Ms PP
F 28 Y
Acute SOB
PRO MVR
AR+
Post Lytic Rx
LVOT orientation
Subrahmanyam
• DVR ( Mechanical Prosthesis)
• Mild Paravalvular MR
- 2 distinct MR JETS
AO. Pro Valve – OK
No PAH; RVSP = 26 mm Hg
M 28/ Yrs
Mrs. SF
F 45 Y
EBSTEINS ANOMALY
• TVR – BIOPROSTHESIS – 15 Yrs Back
• GROSS CHF
• PSM & MDM AT RLSB
Echocardiographic Findings in Infective Endocarditis
Echocardiographic
finding
Description
Vegetation
- Irregularly shaped, discrete echogenic mass
- Adherent to but distinct from endocardial surface
or
intra-cardiac device.
- Oscillation of mass (supportive, not mandatory)
Abscess
-Thickened area or mass within the myocardium or
valve annulus.
- Evidence of flow into region (supportive, not
mandatory)
Aneurysm
Echolucent space with thin surrounding tissue.
Fistula
Blood flow between two distinct cardiac blood
spaces or chambers through abnormal path/channel.
Leaflet perforation
Defect in body of valve leaflet with flow through
defect
Valve dehiscence
Prosthetic valve with abnormal rocking motion /
excursion > 150 in at least one direction
Adapted form Sachdev M et al. (113)
Mr. Vinoop Chandra N
26 Y / M
Quadricuspid
Severe AR
ATS Valve
AO Valve
AVR
POSTOP 9DAYS IE
Mr. Vinoop Chandra N
Echo date: 08/03/2013
26 Y / M
Vinoop Chandra N.
20/3/2013
26 Y/ M
Quadricuspid AO Valve
AVR (ATS Valve)
IE – Immediate Post OP PET FDG +
CULTURE STAPH. AUREUS
KSM
66 Y / M
AO Bio Prosthetic Valve
IE
Paravalvular AR
Periannular AO Root Abscess
Anjali Bhattacharya
MVR ( Tilting disc)
Pro Valve dysfunction
Pre and Post Lytic (Rx)
CSR
21 Y/ M
SOB FC II
AVR St. Jude April 2002 (Sev AR)
LV 6.8/4.9 cm LVEF 21%
INR 2-4; Ab Eos count = 4620 cells/µl
CVS ESM
+ Ve Hx = Recurrent PV thrombosis (4 events)
Severe AR
Postop AVR
Recurrent Prosthetic Valve Thrombosis
Hypereosinophilic Syndrome
1
2
CSR
21 Y/M
PRE Rx
Post Rx
Doppler Echo
P max 102 mmHg
P mean 80 mmHg
P max 22 mmHg
P mean 13mmHg
Ab Eos count
4620 cells/µl
204 cells/ µl
Rx
Diethylcarbamazine
Heparin
ACITROM
STEROIDS
CSR 21 Y / M
Pre Treatment
CSR 21 Y / M
Post Treatment
Mrs. D. Anasuya
F / 76 Yrs
• HOCM;
• MAC;
• MS
• MVR
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HITS
PATIENT PROSTHETIC
MISMATCH
RAMABHADRA RAJU.P
