Echocardiographic Assessment of Heart Valve Prostheses

Abstract

Patients submitted to valve replacement with mechanical or biological prosthesis, may present symptoms related either to valvular malfunction or ventricular dysfunction from other causes. Because a clinical examination is not sufficient to evaluate a prosthetic valve, several diagnostic methods have been proposed to assess the functional status of a prosthetic valve. This review provides an overview of echocardiographic and Doppler techniques useful in evaluation of prosthetic heart valves. Compared to native valves, echocardiographic evaluation of prosthetic valves is certainly more complex, both for the examination and the interpretation. Echocardiography also allows discriminating between intra- and/or peri-prosthetic regurgitation, present in the majority of mechanical valves. Transthoracic echocardiography (TTE) requires different angles of the probe with unconventional views. Transesophageal echocardiography (TEE) is the method of choice in presence of technical difficulties. Three-dimensional (3D)-TEE seems to be superior to 2D-TEE, especially in the assessment of paravalvular leak regurgitation (PVL) that it provides improved localization and analysis of the PVL size and shape.

Keywords: 3D transesophageal echocardiography; Prosthetic heart valves; transesophageal echocardiography; transthoracic echocardiography.

Figure 1

Different types of prosthetic valves. (a) Bileaflet mechanical valve (St Jude); (b) monoleaflet mechanical valve (Medtronic Hall); (c) caged ball valve (Starr-Edwards); (d) stented porcine bioprosthesis (Medtronic Mosaic); (e) stented pericardial bioprosthesis (Carpentier- Edwards Magna); (f) stentless porcine bioprosthesis (Medtronic Freestyle); (g) percutaneous bioprosthesis expanded over a balloon (Edwards-Sapien); and (h) self-expandable percutaneous bioprosthesis (Core Valve)

Figure 2

Example of normal aortic biologic valve in systole as seen by TEE. TEE = Transesophageal echocardiography

Figure 3

Marked calcification of mitral biologic valve

Figure 4

Example of bileaflet mechanical valve

Figure 5

Mechanical aortic prostheses. High transprosthetic peak flow velocity and mean gradient

Figure 6

Mitral bioprostheses. High transprosthetic peak flow velocity and mean gradient

Figure 7

Calculation of the effective valvar orifice area (EOA) of prosthetic aortic valve with the continuity equation

Figure 8

Thrombosis of mechanical mitral prosthesis as seen by TEE

Figure 9

Dehiscence of mechanical mitral prosthesis as seen by TEE

Figure 10

Paravalvular aortic leak

Figure 11

Color Doppler images of severe paravalvular mitral regurgitation

Figure 12

CW Doppler signal of severe paravalvular mitral regurgitation CW = Continuous wave

Figure 13

Regurgitation mechanisms after transcatheter aortic valve implantation (a) Transvalvular regurgitation (arrow) (b) paravalvular (arrow); (c) supraskirtal regurgitation above the skirt (arrow) Adapted from Stähli et al. Aortic regurgitation after transcatheter aortic valve implantation: Mechanisms and implications. Cardiovasc Diagn Ther 2013;3:15-22.

Figure 14

Different types of regurgitation in transcatheter valves. (a) Transvalvular aortic regurgitation (b) Paravalvular aortic regurgitation, and (c) Supraskirtal regurgitation

Figure 15

Three-dimensional TEE ofa mitral prosthetic discs

Figure 16

(a) Three-dimensional TEE ofa mitral paravalvular leak (b) Three-dimensional colorDoppler imaging of the paravalvular leak with arrow identifying the regurgitant jet. (c) Measurements of length, width, and area Adapted from Chad Kliger et al. Review of surgical prosthetic paravalvular leaks: Diagnosis and catheter-based closure. European Heart Journal 2013; 34: 638-648.

Figure 17

Three-dimensional TEE ofa mitral paravalvular posteromedial leak as seen from surgical view

Figure 18

Aortic and mitral valves from a surgeon's perspective H = Head, LAA = Left atrial appendage, LC = Left coronary cusp, LM = Left main coronary artery, NC = Noncoronary cusp, P = Posterior, R = Right, RC = Right coronary cusp, RCA = Right coronary artery