Prosthetic valve obstruction Prosthetic valve thrombosis Bileaflet mechanical prosthetic valve Cinefluoroscopy Prosthetic valve leaflet motion

1. Echo Egypt 2014 Thursday, October 23, 2014

3. Does it have a place in the
echocardiography era?

4. Types of Prosthetic Heart Valves
• Mechanical
– Bileaflet (St Jude)(A)
– Single tilting disc (Medtronic Hall)(B)
– Caged-ball (Starr-Edwards) (C)
• Biologic
– Stented
CF »»»» Leaflet imaging depends on radio-opacity
• Porcine xenograft (Medtronic
Mosaic) (D)
• Pericardial xenograft (Carpentier-
Edwards Magna) (E)
– Stentless
• Porcine xenograft (Medronic
Freestyle) (F)
• Pericardial xenograft
• Homograft ( allograft)
– Percutaneous
– Expanded over a balloon
(Edwards Sapien) (G)
– Self –expandable
(CoreValve) (H) Circulation 2009, 119:1034-1048

5. Three Types of Mechanical
Prosthetic Heart Valves
Newer models Older models
n
Bileaflet (St Jude) Single tilting disc (Medtronic Hall) Caged-ball (Starr-Edwards)
Preferred Choice

6. Despite the recent
improvements in prosthetic
valve design and surgical
procedures,
valve replacement does
not provide a definitive
cure to the patient;
instead it gives rise to
development of a new
disease—
“prosthetic valve disease.”
“Native Valve Disease”
is traded for
“Prosthetic Valve Disease”

7. Prosthetic valves explanted
for severe dysfunction.
Pibarot P , and Dumesnil J G Circulation. 2009;119:1034-1048
Outlet strut Inlet strut
Leaflet
Copyright © American Heart Association, Inc. All rights reserved.
Obstructive
thrombosis
Pannus
ingrowth
interacting with
leaflet opening
Rupture of the
outlet strut
and leaflet
escape

8. Imaging of Prosthetic Heart valves
Chest X-ray ( CXR )
Valve type and position often easily determined on CXR
Cinefluoroscopy ( CF )
CF optimal for assessing mechanical valve leaflet
motion(radiopaque), unable to see bioprosthetic leaflets
Echocardiography
– TTE will often best allow optimal Doppler angles
– TEE( 2D/RT3D )will often best allow optimal direct
visualization
Multi Detector Computed Tomography ( MDCT )
Allows full evaluation with less artifacts from metal
compositions as compared to echo.

9.  The location of the
cardiac valves is best
determined on the
lateral radiograph.
 A line is drawn on the
lateral radiograph from
the carina to the
cardiac apex.
 The pulmonic and
aortic valves generally
sit above this line and
the tricuspid and mitral
valves sit below this line.
Sometimes the aortic root
can be inferiorly displaced
which will shift the aortic
valve below this line.
Chest X-ray
AoV & PV
MV & TV

10. Chest X-ray
aortic valve
mitral valve
Bjork Shiley valve

11. Bileaflet Mechanical Prosthetic Heart Valve
Hinge
Leaflets
( Occluder )
Housing
Normal motion ,
Restricted motion
Suture Ring
Well seated ,
Dehisced
Role of Cine-Fluoroscopy
Identify type of valve
Determine disc mobility
Assess stability of sewing ring

12. Bileaflet Mechanical Prosthetic Heart Valves
Each model has its own cinefluoroscopic
features which allow its identification

13. Cinefluoroscopy as the gold standard for
mechanical valve mobility

14. *Evaluation is considered appropriate when the
prosthesis “tilting disk” optimal projection is
obtained.
*This view allows proper visualization of leaflet
motion so that both opening angle (OA) and
closing angle (CA) can be calculated.
C-arm fluoroscope
The “en face”
projection
The “tilting disk”
projection
Side ( Pivot )
view

15. Cinefluoroscopy : Obtaining optimal view
Right anterior oblique,
cranial
Mitral prosthesis
Right anterior oblique,
caudal
Left anterior oblique,
cranial
Aortic prosthesis
Aortic prosthesis
Tricuspid prosthesis

16. Bileaflet Mechanical Prosthetic Heart Valves
The opening angle (0), closing angle (C), The
excursion of each leaflet (E l, E 2), and the total
leaflet excursion (E total)
Opening and closing
angles are defined as
the distance between
the 2 leaflets in the fully
open and closed
position.

17. Normal values for opening and closing angles
Closing
angle (CA)
( cinefluoroscopy )
Opening
angle (OA)
Bileaflet Mechanical
Prosthetic Heart Valves
Carbomedics <24° >130°
Edwards Duromedics <29° >148°
Sorin Bicarbon <24° >135°
St.Jude Medical Standard <13° >120°
Values of OA and CA is obtained by averaging the values over 3 or 5
consecutive cardiac cycles, in the presence of sinus rhythm or atrial
fibrillation, respectively.
Normal reference values for OA and CA is obtained from the manufacturer

18. Fluoroscopy of a normally functioning CarboMedics bileaflet prosthesis in mitral position.
Montorsi P et al. Circulation. 2003;108:II-79-II-84
Copyright © American Heart Association, Inc. All rights reserved.
Opening angle
Closing angle

19. Fluoroscopic criteria :
*Persistent restriction of leaflet(s) motion
*Opening angle greater than the normal
reference value
(obtained from the manufacturer)
Opening angle
Normal Obstruction

20. Example of a patient with obstruction
of a St. Jude prosthetic aortic valve (size 19)
Doppler shows aortic
prosthetic
regurgitation & high
pressure gradients
70°
At fluoroscopy, opening
angle (OA)reached 70°,
indicative of severely
hypomobile leaflets.

21. Stuck Mechanical Tricuspid Valve Prosthesis
The Valve That Does Not Move
Fluoroscopy. A, Systolic and (B) diastolic frames indicate that both discs of
the mechanical tricuspid valve (TV) are stuck in an open position.
The mechanical mitral valve (MV) discs are closed in systole.
Fadel B M et al. Circulation. 2012;126:e335-e336
Copyright © American Heart Association, Inc. All rights reserved.

22. St. Jude prosthetic valve ( mitral ): One of the leaflets was stuck in the
closed position (Video 1).
Normal movement of the valve after streptokinase (Video 2)
N Engl J
Med
2009;
360:e22A
pril 16,
2009DOI:
10.1056/
NEJMicm
040909

24. Obstruction by pannus ,thrombus ,or both
Cine-Fluoroscopy
Cannot distinguish
pannus vs thrombus

25. T T E
T E E
C F
MDCT
Imaging modalities

26. •That is the
Question in
Prosthetic
Valve
Thrombosis
Thrombolysis
or
Operation
Thrombolytic therapy significantly reduces the
mean pressure gradient and improves valve leaflet
opening angle, so CF can detect the response to TT

27. Cinefluoroscopy showing leaflet motion
Before thrombolytic therapy After thrombolytic therapy
The views of the open valve
The views of the closed valve
One leaflet is seen to be immobilized
(arrow). The measured opening angle
is 59°(normal, 11±1°), and the closing
angle is 110° (normal, 120±2°).
Leaflet motion is seen to have
returned almost entirely to normal.
The opening angle is now 14° and
the closing angle 124°.
59°
110°
14°
124°

28. If lytic infusion is stopped at this time,
the remaining thrombus could be the trigger
CF : Guide duration for a late rethrombotic process.
of lytic therapy
An abnormal OA value
(greater than the normal)
OA improved
but not
normalized
OA completely
normalized
Montorsi P et al. Circulation.
2003;108:II-79-II-84 Normal Doppler study despite
significant restriction in leaflet(s) motion at CF
(so called “Doppler silent PVT”).

29. Tricuspid mechanical prosthesis
CF showing both of the
leaflets fixed in a semiopen
position
After 25 mg tPA infusion, CF
revealed mild movement of
both leaflets
After heparin Infusion&a second TT
session with 25 mg tPA, restriction of
leaflets was completely resolved
Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol 2014;42(5):478-481
doi: 10.5543/tkda.2014.09804

30. On admission, CF of tricuspid
mechanical prosthesis showing
bileaflets fixed in a semiopen
position (A)
Minor alteration in leaflet positions
during systole and diastole
after 25 mg tPA infusion was
administered (B)
After 50 mg tPA infusion, restriction of
leaflets had completely resolved (C).
Türk Kardiyol Dern Arş - Arch Turk Soc Cardiol
2014;42(5):478-481 doi: 10.5543/tkda.2014.09804

31. Prosthetic Valve Thrombosis
CLASS IIa : Fluoroscopy or CT is reasonable in patients
with suspected valve thrombosis to assess valve motion.
(Level of Evidence: C)
*Fluoroscopy and CT are alternative imaging techniques for evaluation of
mechanical valve “leaflet” motion, particularly in patients with prosthetic
aortic valves, which are difficult to image by either TTE or TEE.
*CT is best suited for measurement of valve opening angles.
*CT imaging may also allow visualization of pannus or thrombus in patients
with mechanical or bioprosthetic valves.

33. Pseudo prosthetic valve
obstruction
Prosthetic valve gradients
It is an important lesson to learn ,
raised prosthetic gradient is not
equal to thrombus
Please remember flow across
prosthetic valve is governed
by delicate local hemodynamic
rules

34. The Am J Cardiol. 2000. Jan 1. Vol 85
Cinefluoroscopy
Doppler
echocardiography
Transesophageal
echocardiography
Normal opening angles High gradients
Absence of
thrombus and pannus

35. L'HUILLIER I et al. Heart 2001;85:513
Bileaflet prosthesis
( Only one leaflet at the mitral position )
Acute mitral valve dysfunction
Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

36. Ultrasound shows the escaped leaflet
(arrows) as a linear hyperechogenic
object in the lumen of terminal portion
of the abdominal aorta.
The surgically removed
mechanical valve

37. Dehisced
aortic valve
(Rocking )
Normal
mitral valve
Mitral and aortic valves (Medtronic Hall and ATS Medical, respectively

38. “A Few Words About
Multi Detector Computed
Tomography ”

39. St. Jude medical valves (bileaflet mechanical valves)
The geometric orifice area ( GOA), length, and
opening/closing angles determined by MDCT.

40. St. Jude bileaflet prosthetic AVR
A, obstructive acute thrombus
visualized as low-attenuation mass.
Chan J et al. Circulation. 2009;120:1933-1934
B, After thrombolysis with resolution
of thrombus.
Copyright © American Heart Association, Inc. All rights reserved.

42. Appropriate
Use
Score (1–9)
Prosthetic Heart Valves
*Characterization of prosthetic cardiac valves A (8)
*Suspected clinically significant valvular
dysfunction
*Inadequate images from other noninvasive
methods
Score 7 to 9 »»»» ( A ) Appropriate Indications
Appropriate test for specific indication (test is generally acceptable and
is a reasonable approach for the indication).

44. Fluoroscopy is the most widely used method
for
diagnosing stuck valves.
It is readily available in
most centers and can be performed rapidly,
particularly
in unstable patients.

45. Fluoroscopy is not useful
in distinguishing pannus from
thrombus since neither
pannus nor thrombus can be
identified fluoroscopically.
In the case of bileaflet valves, the disks
can be directly visualized, and opening and
closing angles can be measured using a
side (pivot) view.
pannus
Thrombus
10° OA 120° CA
Moreover, fluoroscopy may be particularly
utilized as an easily repeatable modality to
follow stable patients for evaluation of
valve motions during TT. Thrombolytic
Therapy

46. One should consider that both
echocardiography and CF provide
different kinds of information on
prosthesis function, and therefore
they should still be considered as
complementary and not alternative.