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Preoperative Assessment of Degenerative
Bioprosthetic Valves and Paravalvular Leaks
Sunil Mankad, MD, FACC, FCCP, FASEAssociate Professor of MedicineMayo Clinic College of Medicine
Director, Transesophageal EchocardiographyAssociate Director, Cardiology Fellowship
Mayo Clinic, Rochester, MN
[email protected]@MDMankad
DISCLOSURE
Relevant Financial Relationship(s)None
Off Label UsageNone
Prosthetic vs ParavalvularRegurgitation
• Importance– Determines whether we do a valve-in-valve
procedure or paravalvular leak closure
• Severity of Leak• Shape and Size of Paravalvular Leak
Bioprosthetic MV: Torn Cusp
Bioprosthetic MV: Torn Cusp
Bioprosthetic MV: Torn Cusp
Bioprosthetic Aortic Valve
Bioprosthetic Aortic Valve
Bioprosthetic Aortic Valve:Deep Transgastric View
Paravalvular Regurgitation• Paravalvular prosthetic regurgitation occurs in
8% to 18% of patients after heart valve surgery • For symptomatic patients, repeat surgery has
been the traditional treatment of choice, but has high operative risk and variable results
• Recently, percutaneous treatment of paravalvularprosthetic regurgitation has emerged as a less invasive alternative, with feasibility demonstrated in early studies
1. Da´vila-Roma´n VG et al. J Am Coll Cardiol 2004;44:1467–72.2. Miller DL. et al. J Heart Valve Dis 1995;4:160 –5. 3. Akins CW et al. J Heart Valve Dis 2005;14:792– 800.4. Sorajja P et al. Cathet Cardiovasc Interv 2007;70:815–23. 5. Nietlispach F et al. J Am Coll Cardiol Intv 2010;3:759–65.
Case 1• 55 year old female with prior history of
bioprosthetic mitral valve replacement in 2003 for endocarditis– Required re-operation for bleeding
• Underwent redo MV replacement (31 mm St. Jude bileaflet mechanical prosthesis) and TV repair in 2014 – Difficult operation, long post-operative recovery– Mitral annular tissue fragile
• Now with class IIIb HF secondary to paravalvular mitral regurgitation– Referred for paravalvular closure attempt
Pre-procedural 2D TEE
Pre-procedural 2D TEE
3D Full Volume (4 beat breath-hold acquisition)
Pre-procedurel 3D TEE: Dual View
LA View LV View
Measurements
3D Full Volume Color (6 beat breath-hold acquisition)
3D Color: Wall Filter HighView from the LA
Case 2• 66 year old male• Hx of bioprosthetic MVR and AVR 12/09 for
infective endocarditis• Severe mitral periprosthetic leak • NYHA class III-IV CHF• Chronic renal failure (dialysis)• Hemolytic anemia – transfusion dependent• Paroxysmal atrial fibrillation• Depression
2D TEE
3D Full Volume: View from LA
3D Color DopplerView from LA View from LV
Case 3• 68 year old male with rheumatic valvular
heart disease• S/P #29 CE mitral valve prosthesis, #21
CE aortic valve prosthesis, tricuspid valve annuloplasty repair, MAZE procedure
• "never did well" after surgery• NYHA class III CHF • PMH: DM type II, stage III CKD, migraine
headaches, HTN, rheumatoid arthritis (steroid dependent)
How many separate peri-prosthetic leaks?
One aortic peri-prosthetic leak
3D TEE
View from LA
Full Volume 3D: Multi-beat Acquisition
LA View LV View
HVR: High Volume Rate Color Doppler
Single Beat 3D Color
Good Candidate for Periprosthetic Closure
Importance of 3D Color DopplerPoor Candidate for
Periprosthetic Closure
UFO: Complications May Happen
Difference in PerspectiveEcho vs Fluoro
“medial”“lateral”
“medial”“lateral”
Spoon DB et al. JACC Cardiovasc Imaging. 2013 Nov;6(11):1212-1214
AV
IAS
44 43
17
11
0
10
20
30
40
50
Num
ber o
f pat
ient
s
NoneMildModerateSevere
Residual Regurgitation
100
110
120
130
140
150
160Pr
oced
ure
time
(min
)
*
1st Half 2nd Half
Procedural Time
3D TEE
44 43
17
11
0
10
20
30
40
50
Num
ber o
f pat
ient
s
NoneMildModerateSevere
Residual Regurgitation
0
20
40
60
80
100
0 5 10 15 20 25 30 35Follow-up (months)
Survival (%)
67No. at risk
36 21 17295090126
n = 126
Long-Term Follow Up
0
20
40
60
80
100
0 5 10 15 20 25 30 35Follow-up (months)
Survival free of death or surgery
(%)
No hemolytic anemia
Hemolytic anemia
P=0.02
45No. at risk
24 15 12203156No anemia
24 14 9 6102033Anemia
Presence of Hemolytic Anemia
Conclusions• Paravalvular prosthetic regurgitation is
not uncommon• Redo surgery is risky, especially in
patient with co-morbities• Percutaneous closure is feasible and
has a high success rate • Improvement in CHF in majority of
cases, less successful with respect to hemolysis
• Multidisciplinary approach necessary
“Your vision will become clearonly when you can look into your own heart -
He who looks outside, dreams
He who looks inside, awakens”
Carl Gustav Jung (1875-1961)
“Dream every night as if you will live forever, but live everyday as
if it could be your last”
James Dean
