|Year : 2014 | Volume
| Issue : 4 | Page : 103-113
Echocardiographic assessment of heart valve prostheses
Chiara Sordelli1, Sergio Severino2, Luigi Ascione2, Pasquale Coppolino1, Pio Caso2
1 Chair of Cardiology, Second University of Naples, Italy
2 Unit of Cardiology, Vincenzo Monaldi Hospital, Azienda Ospedaliera di Rilievo Nazionale, Ospedali dei Colli, Naples, Italy
|Date of Web Publication||17-Dec-2014|
Via della Gioventý 12 80059, Torre del greco (NA)
Source of Support: None, Conflict of Interest: None
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: Prosthetic heart valves, transesophageal echocardiography, transthoracic echocardiography, 3D transesophageal echocardiography
|How to cite this article:|
Sordelli C, Severino S, Ascione L, Coppolino P, Caso P. Echocardiographic assessment of heart valve prostheses
. J Cardiovasc Echography 2014;24:103-13
|How to cite this URL:|
Sordelli C, Severino S, Ascione L, Coppolino P, Caso P. Echocardiographic assessment of heart valve prostheses
. J Cardiovasc Echography [serial online] 2014 [cited 2019 May 19];24:103-13. Available from: http://www.jcecho.org/text.asp?2014/24/4/103/147201
| Introduction|| |
Prosthetic heart valves have been successfully used in heart valve replacement over the past 40 years and can be classified into three categories: Mechanical, biologic, and transcatheter valves [Figure 1]. Despite numerous advances have been made for the development of better prostheses, remain several problems related to their use as thrombosis, thromboembolism, hemolysis, tissue overgrowth, regurgitation, and damage to endothelial lining. 
|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)|
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| Mechanical valves|| |
The three classes ofmechanical valves aretilting disk, bileaflet, and ball-and-cage which differ primarily in the type and function ofocclude [Figure 1]a-c. Tilting disk or monoleaflet valves consist of a circular occluder disk which typically opens to 60-80° resulting in two distinct orifices of different sizes. Bileaflet valves are made of two semilunar disks attached to a rigid valve ring by small hinges and are the most common valve. The opening angle of the leaflets relative to the annulus plane ranges from 75° to 90°, and the open valve consists of three orifices: A small, slit-like central orifice between the two open leaflets and two larger semicircular orifices laterally. Caged-ball valves are no longer implanted and consist of a silastic ball with a circular sewing ring and a cage formed by three metal arches. 
| Biologic valves|| |
Biologic valves are classified into three categories: Stented, unstented, and homograft valves [Figure 1]d-f. These valves are manufactured from biologic tissues which is less thrombogenic thanmechanical valves and do not require anticoagulation treatment. Bioprosthesis share the characteristics of flexible leaflets, a single orifice, and no leakage after valve closure; but suffer more easily from calcification. Stented bioprosthesis consists of three biologic leaflets made from the porcine aortic valve or bovine pericardium, mounted on a metal or polymeric stented ring. Unstented bioprosthesis are manufactured from porcine, bovine, or equine tissue and do not have rigid stents. Homograftsare cryopreserved human valves. ,
| Transcathetervalves|| |
Transcatheter valves are essentially bioprosthetic valve mounted in aortic and pulmonary position [Figure 1]g and h]. In particular, percutaneous aortic valve implantation is an alternative to standard aortic valve replacement in patients with symptomatic aortic stenosis at high operative risk. ,,, The valves are usually implanted using a percutaneous transfemoral approach or a transapical approach througha small thoracotomy. 
| Doppler-Echocardiographic Evaluation of Prosthetic Valves|| |
Doppler echocardiography is the method of choice to evaluate prosthetic valve function and follows the same principles used for the evaluation of the native valves. A completeechocardiography includes two-dimensional (2D) imaging of the prosthetic valve, evaluation of valve leaflet/occlude morphology and mobility, measurement ofthe transprosthetic gradients and effective valvar orifice area (EOA), estimation of the degree of regurgitation, evaluation ofleft ventricle left ventricle (LV) size and systolic function, and calculation of systolic pulmonary arterial pressure. , Before echocardiography, evaluation is extremely important to know some clinical data as:
- The type and size of the replacement valve
- The date of surgery
- Blood pressure and heart rate
- The patient's height, weight, and body surface area (BSA) to identify a possible patient prosthesis mismatch (PPM).
| Evaluation of prosthetic valve stenosis|| |
In the recognition of prosthetic valve stenosis, first it is extremely important to evaluate valve leaflet/occlude morphology and mobility. Generally, the leaflets oftissue valve appear thin with no evidence of prolapsed and unrestricted motion [Figure 2]. Stentless, homograft, or autograft valves may be indistinguishable from native valves. However, transesophageal echocardiography (TEE) allows a more detailed assessment about cusps calcification, endocarditis vegetations, thrombus, pannus, and reduced disk/ball/leaflet mobility. Prosthetic valve stenosis is generally associated with an abnormal valve morphology and mobility. In the case of mechanical valves there is a reduced or absent occluder mobility. For example, direct signs of prosthetic valve thrombosis include immobility or reduced leaflet mobility, and the presence of thrombus on either side of the prosthesis. Instead, pannus ingrowth appears as a progressive obstruction due to a subvalvular annulus. ,,, Biologic valves stenosis areoften associated with calcification, thickening, and reduced mobility of the leaflets [Figure 3].
|Figure 2: Example of normal aortic biologic valve in systole as seen by TEE. TEE = Transesophageal echocardiography|
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Quantitative parameters of prosthetic valve function include:
- Transprosthetic velocity and pressure gradient;
- Transprosthetic jet contour and acceleration time;
- Doppler velocity index (DVI);
Transprosthetic velocity and gradient
The flow velocity through a prosthetic valve is carried out with the Doppler as a native valve and includes pulsed-wave (PW) and continuous wave (CW) and color Doppler. Measurements of the prosthetic velocity and gradients must be performed by several windowsin order to minimize angulation between the Doppler beam and flow direction and to obtain the highest velocity. ,, However, the fluid dynamics of the mechanical valves may differ from those of the native valve. Generally, the flow is eccentric in monoleaflet valves and composed of three jets in bileaflet valves [Figure 4]. Sometimes, an abnormally high jet gradient may be detected by CW Doppler through the smaller central orifice ofbileaflet mechanical aortic or mitral prostheses leading to an overestimation of gradient. Pressure gradient is calculated with the use of the simplified Bernoulli equation: AP = 4 × V Pr 2 , where V Pr is the velocity of the peak transprosthetic flow jet in meters per second. Prosthetic valve stenosis is generally associated with increased transprosthetic peak flow velocity or mean gradient (at least 3 m/s or 20 mmHg for aortic prostheses and at least 1.9 m/s or 6 mmHg for mitral prostheses) [Table 1] and [Table 2], [Figure 5] and [Figure 6].
|Figure 5: Mechanical aortic prostheses. High transprosthetic peak flow velocity and mean gradient|
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|Figure 6: Mitral bioprostheses. High transprosthetic peak flow velocity and mean gradient|
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Transprosthetic jet contour and acceleration time
The contour of the velocity through the prosthesis can be used to evaluate prosthetic aortic valve function. Generally, in a normal valve, the contourof the CW flow velocity has a triangular shape with early peaking of the velocity and short acceleration time (time from the onset of flow to maximal velocity <80 ms). Inprosthetic valve stenosis, is observed a more rounded velocity contour with the velocity peaking in mid-ejection, prolonged acceleration time, and ejection time as well as the ratio of acceleration time to ejection time (greater than 0.4). ,,,
The DVI is the ratio between the velocity time integral (VTI) of the left ventricular outflow tract (LVOT) flow and the VTI of the transprosthetic flow: DVI = VTI LVOT /VTI PrAV . In the case of prosthetic mitral valve is calculated by dividing the VTI of the transprosthetic flow by that of the LVOT flow: DVI = VTI PrMv /VTI LVOT . The DVI is reduced (less than or equal to 0.3) in case of prosthetic aortic valve stenosis, while is increased (greater than or equal to 2.2 m/s) in case of prosthetic mitral valve stenosis. 
The EOA ofprosthetic aortic valves is calculated with the continuity equation: EOA= (CSA LVOT ΄ VTI LVOT )/VTI PrAV . CSA LVOT is the cross-sectional area of the LVOT, VTI LVOT the velocity-time integral obtained by PW Doppler in the LVOT, VTI PrAV the velocity-time integral obtained by CW Doppler through the aortic prosthesis. The cross-sectional area of the LVOT is obtained from diameter measurement just close the prosthesis from the parasternal long-axis view. For the assessment of LVOT velocity signal, it is important to locate the PW Doppler sample volume adjacent to the prosthesis. The VTI across the prosthesis is obtained from the same signals, usedfor measurement ofprosthesis peak velocity and gradient [Figure 7]. ,, The EOA ofprosthetic mitral valves is calculated as EOA = (CSA LVOT ΄ VTI LVOT )/VTI PrMV , where VTIPrMV is thevelocity-time integral obtained by CW Doppler through the mitral prostheses.  The EOAis the most validated parameter for identifying the PPM.
PPM occurs when the EOA of a normally functioning prosthesis is too small in relation to the patient's body size resulting in abnormally high postoperative gradients. Valve EOAs between 0.8 and 1.2 cm 2 and between 1.0 and 2.0 cm 2 suggest the presence of possible stenosis for aortic and mitral prostheses, respectively; whereas, values less than 0.8 cm 2 (aortic) and less than 1.0 cm 2 (mitral) indicate the presence of significant stenosis.  However, the recognition of prosthetic valve stenosis is better achieved by comparing the measuredEOA to the normal reference value ofEOA for the model and size of prosthesis implanted in the patient. ,,,,,, [Table 3] and [Table 4] shows the normal reference values of EOAs for the aortic and mitral prostheses. The most widely accepted parameter for identifying PPM is the indexed EOA, that is, the EOA of the prosthesis divided by the patient's BSA. A value of EOA <0.6 cm 2 /m 2 in aortic position and 0.9 cm 2 /m 2 in mitral position identify a sever PPM. ,,
|Table 3: Normal reference values of EOAs for the main aortic prostheses |
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| Other causes ofhigh transprosthetic gradients|| |
PPM is the principle cause of high gradient after valve replacement, but should be considered other causes of elevated transprosthetic gradient as: Intrinsic valve dysfunction, high flow state, technical errors, and central jet artifact in bileaflet valve. However, in the case of prosthetic aortic valve, to better appreciate the clinical impact of an elevated gradient, it also should considered that the net gradient is less in patients with a small aortic diameter (<3cm) because of pressure recovery and it is useful to calculate the energy loss index. ,,,,,, So in patients with small aortait could be possible an overestimate ofprosthesis valve stenosis [Figure 7]. ,,
|Figure 7: Calculation of the effective valvar orifice area (EOA) of prosthetic aortic valve with the continuity equation|
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| Evaluation of prosthetic valve regurgitation|| |
In the assessment ofprosthesis regurgitation is extremely important to distinguish physiologic from pathologic regurgitation. First, we must remember that mechanical prostheses have a normal regurgitant volume known as "leakage backflow". This "built-in" regurgitation theoretically prevents blood stasis and thrombus formation using a washing effect. Otherwise the pathologic regurgitant jets, the normal leakage backflow jets are characterized by being short in duration, narrow, and symmetric. ,
Prosthetic aortic valve regurgitation
Transthoracic echocardiography (TTE) generally provides a good visualization of both transvalvular and paravalvular aortic regurgitation. , However, regurgitant jets may be occulted by acoustic shadowing, especially in the noncoronary sinus region. When TTE is technically difficult, TEE may be useful to identify the origin and the mechanism of the regurgitant jets and to identify possible complications, such as flail bioprosthetic cusp, presence of pannus, thrombus, vegetations, abscess formation, or prosthesis dehiscence [Figure 8] and [Figure 9]. ,,
Parameters of the severity of prosthetic aortic valve regurgitation
The estimation of the severity of prosthetic aortic valve regurgitation can be performed similarly to native valve regurgitation.  However, there are limited data on the application and validation of quantitative parameters such as the width of the regurgitant jet or of the vena contracta, the effective regurgitant orifice area, and the regurgitant volume in the context of prosthetic valves. For this reasonis necessarya multiparametric approach [Table 5].
|Table 5: Parameters for evaluation of the severity of prosthetic aortic valve regurgitation |
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Color Doppler parameters
The ratios of regurgitant jet diameter to LVOT diameter from the parasternal long-axis view and of jet area to LVOT area from the parasternal short-axis view just below the prosthesis can be used to estimate the severity of central regurgitation. A ratio of jet diameter to LVOT diameter greater than 25% suggests moderate regurgitation and > 65% severe regurgitation. However, using this approach, regurgitation severity may be overestimated in the case of eccentric jets and underestimated in the case of jets impinging the wall of the LVOT or of anterior mitral valve. Unlike the native valves, is difficult, in the long-axis view, to measure the vena contracta width because of the shadowing caused by the prosthesis ring or stent. For semiquantitative evaluation of the severity of paravalvular regurgitation, careful imaging of the neck of the jet in a short-axis view, at the level of the prosthesis sewing ring or stent, allows determination of the circumferential extent of paravalvular regurgitation. A regurgitant jet occupying less than 10% of the sewing ring or stent circumference suggests mild, 10-20% suggests moderate, and more than 20% suggests severe regurgitation. Rocking of the prosthesis is usually associated with greater than 40% dehiscence. ,, Moreover, the estimation of regurgitation severity becomes complex in the case ofmultiple jets so TEE may be helpful to better identify the origin of the regurgitant leak and to better estimate its circumferential extension [Figure 10].
Spectral Doppler parameters
Spectral Doppler parameters are useful to assess prosthetic aortic valve regurgitation because they are less sensitive to the prosthesis position, shadowing, and artifacts. The pressure half-time of the CW regurgitant jet signal is useful when the value is less than 200 ms, suggesting severe regurgitation, or greater than 500 ms, suggesting mild regurgitation. Moderate AR is associated with the presence of holodiastolic flow reversal in the descending thoracic aorta; severe AR is suspected when the VTI of the reverse flow approximates that of the forward flow and when the end-diastolic velocity is greater than 18 cm/s. 
Prosthetic mitral valve regurgitation
Evaluation of prosthetic mitral regurgitation by TTE is problematic because the left atrium (LA) is largely occulted by the acoustic shadowing due to the metallic components of the prosthesis. In contrast, TEE provides excellent visualization of the LA and mitral regurgitant jet, but acoustic shadowing limits visualization of the LV.  At TTE, the presence of "occult" mitral prosthesis regurgitation should be suspected in the presence of some signs as: Flow convergence on the LV side of the prosthesis during systole, increased mitral peak E wave velocity (greater than 2 m/s), mean gradient greater than 6 mmHg, DVI greater than 2.2, unexplained or new worsening of pulmonary arterial hypertension, and a dilated and hyperkinetic LV.  In the suspicion of pathologic mitral regurgitation, it is imperative to perform a TEE study. On color Doppler, paravalvular leaks have a typical appearance of a jet that passes from the LV into the LA outside the prosthesis ring and often projects into the atrium in an eccentric direction [Figure 11].
|Figure 11: Color Doppler images of severe paravalvular mitral regurgitation|
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Parameters of the severity of prosthetic mitral valve regurgitation
Assessment of severity of prosthetic mitral regurgitation is complex so it is recommended a multiparametricapproach [Table 6]. The estimation of regurgitant jet area in the LA is often difficult due to the shadowing and artifacts created by the prosthesis. However, a small thin jet (jet area less than 4 cm 2 , less than 20% of the LA) usually reflects mild mitral regurgitation; whereas, a large, wide jet (8 cm 2 or larger, more than 40% of the LA) is often associated with severe regurgitation. A width of the vena contracta of less than 3, 3-6, and greater than 6 mm denotes mild, moderate, and severe regurgitation, respectively. Severemitral regurgitation is generally associated with swirling of the jet within the atrium and with retrograde systolic flow in the pulmonary veins that can be more accurately evaluated by TEE. Finally, also the density and contour of the regurgitant jet CW Doppler signal may be helpful to corroborate regurgitation severity [Figure 12]. Because mitral prosthetic regurgitation is often characterized by eccentric and/or multiple jets, the proximal isovelocity surface area method is difficult to achieve and may under- or overestimate regurgitation severity. For these reasons, the volumetric method is often preferred to the proximal isovelocity surface area method for quantitation of mitral prosthesis regurgitation. ,,,
|Figure 12: CW Doppler signal of severe paravalvular mitral regurgitation |
CW = Continuous wave
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|Table 6: Echocardiographic and Doppler criteria for severity of prosthetic MR |
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| Specific considerations for particular valve|| |
Prosthetic pulmonary valve
Prosthetic pulmonary valve are, generally, implanted in pediatric patients with congenital heart disease. Clues suspicion of prosthetic stenosis are marked thickening or immobility of the cusps, a small map to color Doppler, transvalvular peak velocity greater than 3 m/s, or 2 m/s, respectively for prosthesis and homograft, the presence of a depressed right ventricular functionor elevated right ventricular systolic pressure. In the presence of a severe pulmonary insufficiency, instead, there is a right ventricle volume overload associated with diastolic flattening and paradoxical movement of the interventricular septum. ,,
Prosthetic tricuspid valve
A suspicion of prosthetic tricuspid stenosis is given by the presence of an abnormal morphology and mobility of the leaflet, a transvalvular peak velocity greater than 1.7 m/sec, amean gradient equal or greater than 6 mmHg and a pressure half -time at least 230 msec. ,
Transcathether aortic valve
Two devices are most commonly used for transcathether aortic valve implantation. One device is the EdwardsS APIEN valve which consists of three pericardial leaflets, mounted within aballoon-expandable stent. The other device is the CoreValve ReValving system which has three pericardial leaflets mounted in a self-expanding, nitinol frame. The main approaches are transfemoral and transapical.  Aortic regurgitation is considered the most common drawback of transcatheter valves. ,, Traditionally, it is categorized as transvalvular, paravalvular, or combined [Figure 13]. A third form of regurgitation termed supraskirtal has recently been described. ,,,,
|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.
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Paravalvular AR is the result of incomplete apposition of the prosthesis to the aortic annulus [Figures 13]b and 14b]. Transvalvular AR is the result of restricted leaflet motion, leaflet destruction, and incorrect sizing or overdilatation of the valve [Figure 13]a and [Figure 14]a. Supraskirtal AR [Figure 13]c and [Figure 14]c may occur if the prosthesis is implanted too low in the aortic position. ,,,,,
|Figure 14: Different types of regurgitation in transcatheter valves. (a) Transvalvular aortic regurgitation (b) Paravalvular aortic regurgitation, and (c) Supraskirtal regurgitation|
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| Role of 3D-Echocardiography|| |
Three-dimensional (3D) TEE allows an accurate assessment of prosthetic discs and planimetric evaluation of the prosthetic area [Figure 15]. However, 3D-Eco is 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 [Figure 16], [Figure 17], [Figure 18]. ,,,, To facilitate the communication between the interventionalist and echocardiographer, it is recommended that leak location be reported in a clockwise format from a 'surgical view' [Figure 18]. Aortic PVLs are more commonly located in the right and noncoronary cusps.  Mitral PVL location can also be reported in a similar format as the aortic valve [Figure 18]. By rotation of the echocardiographic image, the aortic valve is brought to a position at the top of the mitral ring, as viewed from the atrium. ,, The most common locations for mitral PVLs are near the anterolateral commissure. ,,,,,
|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.
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|Figure 17: Three-dimensional TEE ofa mitral paravalvular posteromedial leak as seen from surgical view|
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|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
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]
[Table 1], [Table 2], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]