014 // Prosthetic Valves

Type of Valves
Mechanical Valves
Metal case/occluders
Types: ball cage, tilting disc,
bileaflet
Anticoagulation necessary
High durability

NOTE:
Mechanical
valves for the
younger
patients!

Composite graft (prosthesis +

aortic root replacement)

Types of Mechanical Valves Few Examples

Manufacture

Model

Year

Ball

Baxter

Starr-Edwards

1965

Disk

Medtronic

Medtronic Hall

1977

Medical

Omniscience

1978

Alliance

Monostrut

1982

St. Jude

St. Jude

1977

Baxter Edwards

Duromedics

1982

Carbomedics

Carbomedics

1986

Sorin Biomedica

Sorin Bicarbon

1990

Bileaflet

Biological Valves
Ring (Struts)/ stentless valve
No anticoagulation
Less durable than mechanical
valves
Homograft (cadaver)
Autograft (pulmonic valve)
Ross OP

NOTE:
Biological valves
for the elderly
(but not
exclusively)

014 // Prosthetic Valves

Types of Biological Valves Few Examples

Type

Manufacture

Porcine

Medtronic

Pericardial

Model

Year

Hancock Standard

1970

Hancock MO

1978

Baxter Edwards

CE Standard

1971

Baxter Edwards

CE Supraannular

1982

St. Jude

Toronto Stentless

1991

Medtronic

Stentless Freestyle

1992

Baxter Edwards

CE

1982

Echo Assessment of Prosthetic Valves

Assessment of Valve Prosthesis

NOTE:
Dont forget to
look at the
ventricle and
sPAP in mitral
valve
prosthesis!!

Morphology!
Gradients
Color Doppler

Flow Patterns in Mechanical Valve Prosthesis

Forward flow

Physiologic regurgitation

Bileaflet Prosthesis

Tilting Disc

Tilting Disc (Medtronic Hall)

014 // Prosthetic Valves

Common Findings
Residuals of subvalvular apparatus

Cavitations

Abnormal septal motion

Normal regurgitations

Image Problems in Patients with Mechanical Valves

Artefacts

Shadowing

Decreased visibility of LA
(MV prosthesis)

Decreased visibility of
regurgitant jet

Dicult diagnosis of
endocarditis

Thrombi visualization
dicult

Dicult to see leaflet motion

Flow convergence?

NOTE: In TEE atrial side is visible. Use therefore if in doubt both, TTE and TEE!

Reference Values for Prosthetic Aortic Valves

Bioprosthesis

Vmax (m/s)

Grad.max
(mmHg)

Grad. mean
(mmHg)

Carpentier-Edwards

2.37 0.46

23.18 8.72

14.4 5.7

Hancock

2.38 0.35

23.0 6.71

11.0 2.29

Mitroflow

2.0 0.71

17.0 11.31

10.8 6.51

Vmax (m/s)

Grad.max
(mmHg)

Grad. mean
(mmHg)

2.8 0.5

28.65 6.6

17.72 6.35

5.35 1.5

Toronto Porcine

1.74 1.19

38.6 11.7

24 4

Mechanical prosthesis

Vmax (m/s)

Grad.max
(mmHg)

Grad. mean
(mmHg)

St. Jude Medical

2.37 0.27

25.5 5.12

12.5 6.35

Bjrk-Shiley

2.62 0.42

23.8 8.8

14.3 5.25

3.1 0.47

38.6 11.7

24.0 4.0

Stentless bioprosthesis
(25mm)
Biocor Stentless
Medtronic Freestyle

Starr-Edwards

NOTE: Consider prosthetic aortic valve dysfunction if the maximal velocity is

> 3 m/s and the mean Gradient is > 20mmHG

014 // Prosthetic Valves

Reference Values for Prosthetic Mitral Valves

Vmax (m/s)

Grad.max
(mmHg)

Grad. mean
(mmHg)

PHT (ms)

Hancock

1.54 0.26

9.7 3.2

4.29 2.14

128.6
30.9

CarpentierEdwards

1.76 0.24

12.49 3.64

6.48 2.12

89.8
25.4

Ionescu-Shiley

1.46 0.27

8.53 2.91

3.28 1.19

93.3
25.0

Mechanical
prosthesis

Vmax (m/s)

Grad.max
(mmHg)

Grad. mean
(mmHg)

PHT (ms)

1.56 0.29

9.98 3.62

3.49 1.34

76.5
17.1

Bjrk-Shiley

1.61 0.3

10.72 2.74

2.9 1.61

90.2
22.4

Starr-Edwards

1.88 0.4

14.56 5.5

4.55 2.4

109.5
26.6

Bioprosthesis

St. Jude Medical

NOTE: Consider prosthetic mitral valve dysfunction if the maximal velocity is

> 2 m/s and the mean Gradient is > 8mmHG

Eective Orifice Area

NOTE:
Geometric
orifice area
is not
eective
orifice
area!!

VTI of AV velocity
Stroke volume LVOT

Pressure Recovery
Leads to overestimation of
gradients by doppler
Relevant in small aortic root
(<30mm)
Common in small bileaflet
valves
Especially if high flow present

NOTE:
Nobody
unterstands
pressure recovery
anyway! Just
remember these
key issues!

014 // Prosthetic Valves

Prosthesis Mismatch
Indexed eective orfice area < 0.85cm2/m2
Calcified aortic annulus

Increased late mortality

Setting of LV dysfunction

Complications

Mechanical Valve Complications

Left ventricular failure

Paravalvular leaks

Valve obstruction

Thrombus/Pannus

Endocarditis

Mechanical failure

Biological Valve Complications

Left ventricular failure

Paravalvular leaks

Valvular regurgitation

Valve obstruction

Degenerative changes

Endocarditis

Predisposing Factors for Structural Failure in Bioprosthesis

Renal failure

Hemodialysis

Hypercalcemia

Adolecent (growing)

Porcine > pericardial

014 // Prosthetic Valves

Bioprosthesis Obstruction Echo Findings

Thickened calcified leaflets

Reduced mobility

Elevated gradients

PHT (MV-prosthesis)

Turbulent flow

Size of prosthesis (DD:

mismatch)

When implanted?
NOTE: Compair with previous studies and initial post-operative gradients!

Mechanical Valve Obstruction Echo Findings

Impaired/stuck leaflet

Echogenicity in valve region

(thrombus?)

Pathologic flow pattern

Elevated gradients

PHT (MV)
NOTE: Use Fluoroscopy to detect mechanical valve obstruction!

Mechanical Valve Obstruction Pannus vs. Thrombus

Pannus

Thrombus

INR normal

INR low

Slow onset of symptoms

Sudden symptom onset

Age of prosthesis

Stroke/ embolism

Stable gradients

Variable gradients

NOTE: In reality, often only the surgeon can give us the answer!

014 // Prosthetic Valves

Quantification of Obstruction
Aortic Valve Prosthesis

Mitral Valve Prosthesis

Morphologic findings

Morphologic findings

Symptoms

Symptoms

Velocity > 3.0 m/sec

Mean gradients
(>6-8 mmHg)

DVI < 0.3 (0.25)

PHT > 130ms

NOTE: Use color Doppler to guide the position of the CW Doppler (mitral
valve)! Use several windows to quantify prosthetic aortic valve obstruction!

Regurgitation in Valve Prosthesis

Normal/physiologic
Pathologic (paravalvular)
Valvular/ structural failure (bio)

NOTE:
Some degree of
paravalvular
regurgitation is
fairly common!

Valvular/ mechanical failure (mech)

Paravalvular Regurgitation
Prevalence: 6- 32% early, 7- 10% late
AVP > MVP Small atria
Determinents: Calcified annulus, endocarditis, suture
technique

Echo Evaluation of Regurgitation

Multiple/atypical views
Eccentric jets!
Short axis
CW- Doppler
Gradients

NOTE:
Patients with
relevant
paravalvular
regurgitation often
have hemolysis!

014 // Prosthetic Valves

Elevated Gradients Considerations

Compare with baseline/
normal values!!!

INR/ medical history/

follow up!

Regurgitation?

Mismatch?

Obstruction

Flow?

NOTE: An elevated gradient in MV prosthesis with a high PHT indicates an

obstruction. A normal PHT in the setting of elevated gradients indicates a
significant regurgitation. Use TEE for further quantification!!

Other Complications
Valve dehiscence

Look for rocking valve motion!

Pseudoaneurysm

Endocarditis predisposes, native and

prosthetic AV, fistula LV to LVOT

Iatrogenic VSD

Rare complication

TR after MV surgery

Predisposing factors: Pulmonary

hypertension, annular dilatation,
Afib, prior degree of TR

Endocarditis (See also Chapter 15)

3-6 % cumulative risk/
5 years

Bio > mechanical valves

Dicult to detect

Regurgitation and
obstruction

NOTE: TEE assessment is of utmost importance in patients with suspected

endocatditis!

014 // Prosthetic Valves

Mitral Valve Repair

Mitral Valve Repair - Ringimplantation (Annuloplasty)

Dierent types of rings
Prevents annular dilatation
Always in primary and secondary MR

Common Techniques of Mitral Valve Repair

Annuloplasty
(see above)

Quadrangular/Triangular
resection (with/without
sliding plasty)

Chordal transfer

Artificial Chords

Complications of MV Repair
Residual regurgitation

Obstructed LV inflow

Ring dehiscence
(partial dehiscence, origin
outside of ring)

LVOT obstruction/SAM
(redundant leaflets, small
hyperdynamic LV, small annulus)

NOTE:
Mitral valve
repair is
always
combined
with ring
implantation!