Echocardiographic Evaluation of
Prosthetic Valves
Dr. Myla Gloria Salazar - Supe
The 1st valve replacement in 1960
There is no perfect valve
“they have introduced other, new problems into clinical medicine, so
that in effect, the patient is exchanging one disease process for another”
Basic Principles
By their design, almost all replacement valves are
obstructive compared with normal native valves
Most mechanical valves and many biologic valves are
associated with trivial or mild transprosthetic regurgitation
(physiologic regurgitation)
Because of shielding and artifacts, insonation of the
valve esp regurgitant jets may be difficult and requires
multiple angulations of the probe and the use of off-axis
view
Normal Values for Implanted Aortic Valves
Normal Values for Implanted Mitral Valves
Basic Principles
By their design, almost all replacement valves are
obstructive compared with normal native valves
Most mechanical valves and many biologic valves are
associated with trivial or mild transprosthetic regurgitation
(physiologic regurgitation)
Because of shielding and artifacts, insonation of the
valve esp regurgitant jets may be difficult and requires
multiple angulations of the probe and the use of off-axis
view
Physiologic Regurgitation
Washing jets to prevent
thrombus formation
10-15%
Jets low in momentum
homogeneous in color,
aliasing mostly confined
to the base of the jet.
Basic Principles
By their design, almost all replacement valves are
obstructive compared with normal native valves
Most mechanical valves and many biologic valves are
associated with trivial or mild transprosthetic regurgitation
(physiologic regurgitation)
Because of shielding and artifacts, insonation of the
valve esp. regurgitant jets may be difficult and requires
multiple angulations of the probe and the use of off-axis
view
Shadowing
Types of Prosthetic Valves
Valve Size is not equal to EOA
Doppler Echocardiography
Pressure Gradient
Simplified Bernoulli equation: 4V2
Effective Orifice Area
Continuity equation: EOA = stroke volume / VTI PrV
Better index of valve function than gradient alone
Dimensionless Index (DVI) = ratio of velocity proximal to
the valve, to the velocity through the valve
Doppler Echocardiography
Pressure Gradient
Simplified Bernoulli equation: 4V2
Effective Orifice Area
Continuity equation: EOA = stroke volume / VTI PrV
Better index of valve function than gradient alone
Dimensionless Index (DVI) = ratio of velocity proximal to
the valve, to the velocity through the valve
Effective Orifice Area
Pressure Half Time
not appropriate to use the pressure half-time formula
(220/pressure half-time) to estimate orifice area in
prosthetic valves.
valid only for moderate or severe stenoses (< 1.5 cm2).
For larger valve areas, PHT reflects atrial and LV
compliance characteristics and loading conditions and
has no relation to valve area.
Mitral Valve Continuity Equation
Doppler Echocardiography
Pressure Gradient
Simplified Bernoulli equation: 4V2
Effective Orifice Area
Continuity equation: EOA = stroke volume / VTI PrV
Better index of valve function than gradient alone
Dimensionless Index (DVI) = ratio of velocity proximal to
the valve, to the velocity through the valve
Dimensionless Valve Index (DVI)
Early and Late Complications of Prosthetic Valves
Normal Mechanical Prosthesis at Aortic Position
Normal Bi-leaflet Mechanical Aortic Valve (TEE)
Stented Bioprosthetic Mitral Valve
Prosthetic Valve Obstruction
Mechanical Valves: Thrombus or Pannus
Bioprosthetic: structural valve degeneration (SVD)
(Abnormal leaflet morphology / mobility)
Increased gradient for valve subtype and size
Decreased EOA and DVI
Significant deviation from baseline study
#Importance of “finger printing” iEOA and DVI typically
unchanged compared to baseline
Prosthetic Valve Obstruction: Thrombus
Systole: Diastole:
both leaflets left disc
doesn’t opens fully,
close fully right disc
immobilized
High velocity Elevated
flow through transmitral
single orifice gradient =
11.2 mmHg
Abnormal Mechanical Valve at Mitral Position
Decreased
occluder
motion and
thrombus at the
LV side of the
prosthesis
Pre- & post-thrombolysis of SJM mitral valve
Pannus Formation in Mechanical Valve
Pannus Ingrowth Mitral Bioprosthesis
systole diastole
Pannus Bioprosthetic Valve
Elevated
gradients
across a
bioprosthetic
mitral valve
Pannus by TEE
(echogenic
area on the
atrial side of the
prosthesis)
Pannus formation
Evaluation of Prosthetic Valves by Location
Doppler parameters of prosthetic AV stenosis
Inday – 41 year old female
Ht 149 cm Wt 53 kg BSA 1.46 m2
Concentric LVH LVMI = 119 gm/2,
RWT = 0.53, LVEF 74%
Aortic root = 2.8 cm
LVOT dia = 2.1 cm
LVOT VTI = 26.7
Ao VTI = 98.1
DVI = 0.27
EOA = 0.94 cm2
iEOA = 0.64
MVG = 42 mmHg
PIG = 89 mmg
SPAP = 33 mmHg
Prosthesis Patient Mismatch
No detectable structural abnormality of the PV leaflets /
occluders
Normal EOA and DVI for subtype
iEOA < 0.85 (0.64)
Consequences of PPM
Worse hemodynamics
Less regression of LVH (and pulmonary HPN)
Worse functional class, exercise capacity, and quality of
life
More cardiac events
Lower survival
Indexed EOA is the only parameter
shown to have any correlation with post-
operative gradients &/or outcomes
in prosthetic valve mismatch
Determinants of Mismatch
larger BSA - higher cardiac output requirements
older age
smaller prosthesis size (< size19)
valvular stenosis as the predominant lesion before the
operation
Prevention of PPM
BSA x 0.85
1.64 x 0.85 =
1.394
Evaluation of Prosthetic Valve by Location
Doppler Evaluation of Mitral Stenosis
Doppler Evaluation of Mitral Prosthesis
Degenerated Mitral Bioprosthesis
diastole
PISA shell
Physiologic vs Pathologic Regurgitation
Washing jets to prevent Central
thrombus formation
Paravalvular
10-15%
Jets low in momentum
homogeneous in color,
aliasing mostly confined
to the base of the jet.
Severe Paravalvular MR in TEE vs TTE
Mild central MR across a bioprosthetic
Large paravalvular leak
Dehiscence
Paravalvular Leak
Periprosthetic Leak (CoreValve)
Significant Mechanical Mitral Regurgitation
Severity of Prosthetic Aortic Valve Regurgitation
Severity of Mitral Regurgitation
