Cases of Abnormal Prosthetic Valves€¦ · if the loud heart sounds bothered him. He replied,...
Transcript of Cases of Abnormal Prosthetic Valves€¦ · if the loud heart sounds bothered him. He replied,...
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Cases of Abnormal Prosthetic Valves
Sunil Mankad, MD, FACC, FCCP, FASEAssociate Professor of MedicineMayo Clinic College of Medicine
Director, Transesophageal EchcoardiographyAssociate Director, Cardiology Fellowship
Mayo Clinic, Rochester, [email protected]
@MDMankad
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DISCLOSURE
Relevant Financial Relationship(s)None
Off Label UsageNone
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“At the annual meeting of the AHA in California (late 1960’s), a patient who had received the Huffnagel
artificial valve was being questioned. He was asked the usual question by a member of the audience, i.e. if the loud heart sounds bothered him. He replied, “No.” Then after a second thought, he said, “Well
occasionally they do. I like to play poker and when I get an unusually good hand, the sounds get louder
and faster, and gives me away.”
Huffnagel Artificial Valve
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• 2009 TVR , MV repair• 2010 Endocarditis (S. aureus)
Redo MVR (St. Jude Epic) • 2012 Worsening fatigue, dyspnea
• Physical Exam• HR 77 BPM, BP 110/76 mmHg, Afebrile• JVP at earlobe sitting upright, prominent V-wave• Heart: RRR, S4, faint systolic murmur + diastolic
rumble at LLSB. Faint diastolic rumble at the apex• Lungs: clear• Abdomen: Shifting dullness• Extremities: 1+ edema
30 yo Woman With Ebstein’s Anomaly
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• Diastolic mean gradient: 8 mmHg (HR: 69 BPM)
• Blood cultures negative
Mitral Prosthesis
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What would you recommend?
1. Redo surgery (MVR)2. Valve-in-valve mitral3. Fibrinolytic therapy4. Warfarin
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Bioprosthetic Valve Thrombosis:Diagnosis
• Challenging• TTE: no set criteria
• Increased gradients• Thickened cusps, thrombus
• TEE• Soft echodensity in cusps
• CT
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Bioprosthetic Valve ThrombosisMayo Clinic Experience
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Misconceptions in BPVT• How good was TTE?
• Abnormal findings: all patients• Possibility of BPVT: 6 of 32• BPVT not suspected: 8 of 15
undergoing surgery• TEE
• Thrombus seen in all mitral / tricuspid• Challenging imaging for aortic BPV;
thrombus described in 9/12 patients
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Misconceptions in BPVT
EJCTS 2014
Peak incidence second yearLongest interval: 6.5 years
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Misconceptions in BPVT
EJCTS 2014
VKA as effective as surgery / lytics
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Diastolic mean gradient:3 mmHg (HR 66 BPM)
Our patient: One Month VKA
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BPVT: Mayo Surgical Experience
• All bioprosthetic re-operations 1994-2014
• 46 BPVT (11% of all reoperations)
• 92 structural failure (2:1 for age, gender, prosthetic position, and year of implantation)
Egbe et al. JACC 2015.
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Egbe et al. JACC 2015.
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Proposed Echo Criteria1. Increased gradient > 50% over
baseline, especially within first 5 years post-implant
2. Thickened, non-calcified leaflets3. Restricted leaflet mobility
All 3 parameters: 72% sensitivity, 90% specificity for BPVT
Egbe et al. JACC 2015.
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Bioprosthetic Valve ThrombosisTAVR: A Bigger Problem?
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Makkar et al, NEJM 2015
Symptomatic TAVR-related thrombosis is rare (<1%)
TOTAL STUDY PATIENT 187
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CT reconstruction – Portico TAV
Makkar et al, NEJM 2015
Corresponding TEE
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BPVT: Take Home Points
• BPVT diagnosis is challenging• What we know:
• BPVT may occur late after implantation• TTE increased gradient, may not show mechanism
• When to suspect:• BPV gradient > 50% over baseline, restricted cusp
mobility, thickened leaflets
• TEE/CT when in doubt
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Case: 58 Year-Old Woman
• Progressive Dyspnea (NYHA III)• Rheumatic heart disease• 2010
• Medtronic Mosaic (21mm) AVR• MV Repair (27mm Duran ring)
• Obesity• BNP not elevated
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AV Prosthetic Gradient
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The gradient across the prosthesis most likely reflects:
A. Patient-prosthesis mismatchB. Prosthetic obstructionC. Normal function for this prosthesisD. Pressure recoveryE. Cannot tell; need more information
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Normal Valve-Specific Parameters
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The Differential DiagnosisElevated Prosthetic Aortic Valve Gradient
• Obstruction• Dysfunction, thrombus, vegetation,
pannus, degeneration• Patient-prosthesis mismatch
• EOA too small for body size• High output state• Pressure Recovery
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Doppler parameter Expected* Stenosis PPM High Output Pressure Recovery
Gradient(mmHg)
14 ± 5 High High High High
Interpretation of Elevated Aortic PV Gradients
Slide adapted from Darryl Burstow, M.D.
*Prosthesis-specific: Medtronic Mosaic 21mm
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Ejection Time (ET) = 331 msec Acceleration Time (AT) = 88 msec
AT / ET = 0.27
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These AV systolic time intervals are most consistent with a:
A. Obstructed prosthesisB. Normal prosthesisC. I have no idea
AT = 88 msecAT / ET = 0.27
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Ben Zekry S, JACC Imaging 2011
Acceleration Time and Ejection Time
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Doppler parameter Expected* Stenosis PPM High Output Pressure Recovery
Gradient (mmHg) 14 ± 5 High High High High
Accel Time (msec) ≤ 100 > 100 ≤ 100 ≤ 100 ≤ 100
AT / ET ≤ 0.37 > 0.37 ≤ 0.37 ≤ 0.37 ≤ 0.37
Interpretation of Elevated Aortic PV Gradients
Slide adapted from Darryl Burstow, M.D.
*Prosthesis-specific: Medtronic Mosaic 21mm
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Dimensionless Index
Mean Gradient = 56 mmHg LVSVI = 54 cc / m2
(normal 32-58)
Effective Orifice Area (EOA) = 0.97 cm2
EOA Index = 0.57 cm2 / m2 (BSA 1.7 m2)Dimensionless Index (DI) = 0.28
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What is the most likely cause of the elevated gradient in this case?
A. Patient-prosthesis mismatchB. Prosthetic obstructionC. High output stateD. Pressure recoveryE. Need more information
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Doppler parameter Expected* Stenosis PPM High Output Pressure
RecoveryGradient (mmHg) 14 ± 5 High High High High
Accel Time (msec) ≤ 100 > 100 ≤ 100 ≤ 100 ≤ 100
AT / ET ≤ 0.37 > 0.37 ≤ 0.37 ≤ 0.37 ≤ 0.37Abn Leaflet
Motion No Yes No No No
EOA (cm2) 1.4 ± 0.4 Low Expected Expected VariesEOA Index (cm2/m2) > 0.85 Low Low > 0.85 Varies
DVI >0.25 ≤ 0.25 > 0.25 >0.25 Varies
Interpretation of Elevated Aortic PV Gradients
Slide adapted from Darryl Burstow, M.D.*Prosthesis-specific: Medtronic Mosaic 21mm
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Doppler parameter Expected* Stenosis PPM High Output Pressure
RecoveryGradient (mmHg) 14 ± 5 High High High High
Accel Time (msec) ≤ 100 > 100 ≤ 100 ≤ 100 ≤ 100
AT / ET ≤ 0.37 > 0.37 ≤ 0.37 ≤ 0.37 ≤ 0.37Abn Leaflet
Motion No Yes No No No
EOA (cm2) 1.4 ± 0.4 Low Expected Expected VariesEOA Index (cm2/m2) > 0.85 Low Low > 0.85 Varies
DVI >0.25 ≤ 0.25 > 0.25 >0.25 Varies ∆ in EOA & DVI from baseline No Yes No No No
Interpretation of Elevated Aortic PV Gradients
Slide adapted from Darryl Burstow, M.D.*Prosthesis-specific: Medtronic Mosaic 21mm
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Mean Gradient: 26 mmHg
Left Ventricle and Aorta
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Mean Gradient: 26 mmHgMean Gradient = 56 mmHg
Surgical Consultation
-AVR not advised-Medical Rx
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Sinotubular Junction Diameter: 2.1 cm
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J Am Soc Echocardiogr 2008
JACC 41(3) 435, 2003
Energy loss coefficient
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Take Home Points• Use Doppler data to identify the cause for a
high prosthetic AV gradient (remember AT and AT/ET)
• Pressure recovery may occasionally lead to significant Doppler overestimate of cathgradient
• Pressure recovery is most likely when the aorta is ≤ 3cm or in bileaflet mechanicalprostheses (19 or 21mm)
• Correct for pressure recovery with the Energy Loss Index; this may improve risk stratification in AS
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For a Patient with Mechanical Mitral Prosthesis, Which of the Following is NOTa sign of Significant Regurgitation?
1. Mitral E velocity 2.3 m/sec
2. Mitral T1/2 150 msec
3. Mitral diastolic mean gradient 10 mmHg
4. IVRT 60 msec
5. MV prosthesis TVI / LVOT TVI ratio 2.6
Question
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Doppler Clues to Severe Mechanical MVR Regurgitation
• Mitral E velocity ≥ 2.0 m/sec • Increased prosthesis mean
gradient• Normal pressure half-time• Decreased IVRT• Dense MR CW velocity profile
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Mitral St. Jude Medical ProsthesisCW Doppler
Severe Periprosthetic Regurgitation
t/2=55 msec
IVRT=55 msec
E=2.9 m/s
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Mechanical MVR
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•134 pt with mechanical mitral prostheses
•TTE and TEE within 3±5 days•73 normal valves•21 obstructed valves•40 regurgitant valves
Mechanical ProstheticMitral Valve Function
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Sens Spec PPV NPVDoppler index (%) (%) (%) (%)
E ≥1.9 m/sec 92 78 83 90
Mechanical Prosthetic Mitral Valve Dysfunction
CP1063784-4
Fernandes V: Am J Cardiol 89, 3/15/02
VTIPMV/VTILVO ≥ 2.2 91 74 80 87
PHT ≥130 msec 38 99 96 57
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Mechanical MVR with ↑Gradient
Increased T1/2 Normal T1/2
Prosthesis TVI / LVOT TVI ratio > 2.2
Significant MR or High OutputObstructed
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Case• 53 year old female
• Hx of CABG, Redo CABG & ST Jude MVR• CHF (LV EF 30%)
• NYHA class II• Chronic Atrial Fibrillation
• Coumadin held for colonoscopy• No LMWH bridging!
• Sudden onset severe dyspnea• SBP 85 mmHg• Muffled S1• Diastolic murmur
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No Change in Baseline EKG
•INR 1.7•CXR•Cardiomegaly•Pulmonary Edema
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Emergent TEEMean Gradient 20 mmHg
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Severe LV Systolic Dysfunction
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Cardiac Cath
Total Occlusion of LAD, LCx, and RCA
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Only One Patent Graft
Significant Collaterals
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What would you recommend now?
1. Immediate CT Surgery2. Thrombolysis3. Heparin and Prayer
Can TEE help decide ?
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Tong, A. T. et al. J Am Coll Cardiol 2004;43:77-84
PRO-TEE Registry
n = 107
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Tong, A. T. et al. J Am Coll Cardiol 2004;43:77-84
PRO-TEE Registry
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Follow-up TEE After Thrombolysis
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Follow-up at 1 year: NYHA Class III-IVMean Gradient 9 mmHg (INR 3.5-4.5)
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More Follow-up• Worsening angina in addition to HF• Inferolateral and anterior ischemia on
vasodilator stress testing• Placed on Plavix in anticipation of
cardiac cath & possible PTCA/Stent• Known single patent SVG to LCx
• All native vessels occluded proximally but LAD and RCA filled via collaterals
• Not candidate for 3rd CT surgery• Not candidate for Heart Transplant
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Sudden Onset Improvement in SymptomsTTE Performed
Another Miraculous “CURE”Mean Gradient 4 mmHg
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Prosthetic Valve Thrombosis: Medical Therapy
Recommendations COR LOEFibrinolytic therapy is reasonable for patients with a thrombosed left-sided prosthetic heart valve, recent onset (<14 days) of NYHA class I to II symptoms, and a small thrombus
IIa B
Fibrinolytic therapy is reasonable for thrombosed right-sided prosthetic heart IIa B
Nishimura RA et al. Circulation. 2014 Jun 10;129(23):e521-643
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Prosthetic Valve Thrombosis: Intervention
Recommendations COR LOEEmergency surgery is recommended for patients with a thrombosed left-sided prosthetic heart valve with NYHA class III to IV symptoms
I B
Emergency surgery is reasonable for patients with a thrombosed left-sided prosthetic heart valve with a mobile or large thrombus (>0.8 cm2)
IIa C
Nishimura RA et al. Circulation. 2014 Jun 10;129(23):e521-643
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Evaluation and Management of Suspected Prosthetic Valve Thrombosis
Suspected Prosthetic Valve Thrombosis
Fibrinolytic Rx if persistent valve thrombosis after
IV heparin therapy* (IIa)
Emergency Surgery
(IIa)
Right-sided prosthetic valve
thrombosis
CT or fluoroscopy to evaluate
valve motion (IIa)
Left-sided prosthetic valve
thrombosis
Mobile or large
(≥0.8 cm2) thrombus
NYHA class III-IV
symptoms
Recent onset (<14 d) NYHA class I-II symptomsSmall thrombus (<0.8 cm2)
TTE to evaluate hemodynamic severity
(I)
TEE for thrombus size
(I)
Class I
Class IIa
Emergency Surgery
(I)