Prosthetic Heart

Valves
AIM , Target , what do you
want exactly to know

Selection of the Optimal Prosthesis.

Long Term Management of the prosthetic
valve and its possible complications

we should realize that no perfect valve
substitute, The matter is it to choose the
optimal prosthesis for the individual patient
and careful medical management and follow-
up after implantation.
types of prosthetic
valves
A) Mechanical valves
bileaflet.
Monoleaflet
Cage and Ball
types of prosthetic
valves
A) Bioprosthetic valve s
Stented bioprothesis.
Stentless bioprothesis.
Percutaneous bioprothesis.

Homographt:
It provides no durability advantages over the
pericardial bioprothesis in metanalysis and
so, for a technical concerns, limited
availability, and increased complexity of
reoperation it is of restrict the use
the main indication for homograft's is acute
infective endocardities with perivalvular
lesions.


pulmonary autograft in the
aortic position
(Ross procedure)
its main advantage is in children, as
the valve and new aortic annulus
appear to grow with the child.


Bioprosthetic Versus Mechanical Valve



Selection of the Prosthesis Model and Size

step I: After the prosthesis type, i.e.,
mechanical versus biological, is
selected, one should contemplate the
prosthesis models that have a well-
established track record with regard to
long-term durability (bioprothesis) and
low thrombogenicity (mechanical
prostheses)

step II: is to prevent prosthesis patient
mismatch (PPM) , choosing the model
providing the largest valve effective orifice
area (EOA) in relation to the patients
annulus size, that determine the
hemodynamic performance of the
prosthetic)

prosthesis patient mismatch ,PPM:

It occurs when EOA of a normally
functioning prosthesis is too small in relation
to the patients body size (and therefore
cardiac output requirements), resulting in
abnormally high postoperative gradients.
Threshold Values of Indexed Prosthetic Valve
EOA for the Identification and Quantification
of PPM

proper Implantation of the prosthesis

for mitral valve replacement (MVR) :
it is recommended that:
- the chordae be preserved to prevent
postoperative deterioration in LV geometry and
function.
- implant the bileaflet valves in the
antianatomic position and monoleaflet valves
with their larger orifice oriented posteriorly to
ensure more physiological flow patterns

for Aortic valve replacement :
in the case of anticipated PPM, using,
aortic root enlargement to accommodate
a larger size of the prosthetic model.

Long-Term Management

I. Base line assessment and
follow up.
A complete baseline assessment
ideally, be performed 6-12 weeks after
surgery.

This includes clinical assessment, chest
X-ray, ECG, TTE, and blood testing.

A postoperative visit is, to improve
patient education on endocardities
prophylaxis and, if needed, on
anticoagulant therapy and to
emphasize that new symptoms should
be reported as soon as they occur.

patient with prosthetic valve require
lifelong follow-up , in order to detect
early deterioration in prosthetic
function or ventricular function, or
progressive disease of another heart
valve
Echocardiography is the method of
choice to evaluate prosthetic valve
function, Cine fluoroscopy and MSCT
provide useful additional information if
valve thrombus or pannus are suspected
Echocardiographic follow-up
Echocardiographic examination should be
performed at discharge and then 6 to 12
months after operation and/or when a clinical
suspicion of prosthetic valve dysfunction is
present.
yearly, regular follow-up is recommended
after 5 years in patients with a bioprosthesis.
Parameters of Prosthesis
Function
Leaflet Morphology and Mobility
Transesophageal echocardiography (TOE)
Improve the image quality and detection of cusp
calcification, thickening, valvular vegetations
caused by endocardities, thrombus or pannus, and
reduced leaflet mobility.
Quantitative Parameters
Transprosthetic Velocity and Gradient.
Effective Orifice Area
The Doppler velocity index (DVI):
a dimensionless ratio of the proximal velocity
in the LVOT to that of flow velocity through
the prosthesis: DVI= VLVOT/VPV.
> 0.35 in aortic valve / and >0.45 for mitral
valve

Interpretation of High Gradients:
Distinguishing Between High-Flow
States, PPM, and Pathological Valve
Obstruction
Prosthetic Valve Regurgitation


Mechanical prostheses have a normal
regurgitant volume known as leakage
Backflow , short in duration, narrow, and
symmetrical.
In the case of pathological regurgitation,
it is important to localize the origin of the
regurgitant jet(s) to distinguish
paravalvular from transvalvular
regurgitation.



In patient with mechanical mitral
prosthesis regurgitation is suspected when
flow convergence downstream of the prosthesis
during systole.
increased mitral peak E-wave velocity (_2 m/s)
and/or mean gradient (_5 to 7 mm Hg).
DVI _0.45.
unexplained or new worsening of pulmonary
arterial hypertension
TOE may provide important causal
information such as flail bioprosthetic cusp,
presence of pannus or thrombus interacting
with leaflet closure, prosthesis dehiscence,
and location and size of paravalvular jets.

Identifying TTE Indirect
Signs of Dysfunction

The size and function of the LV and atrial
chambers.
level of systolic pulmonary arterial pressure.
these measurements can be compared
with previous measurements and often are
the first sign to alert attention when the
regurgitation is difficult to visualize
II. Antithrombotic
management:

Target INR for mechanical
prosthesis
Self-management of anticoagulation
has been shown to reduce INR
variability and clinical events,
although appropriate training is
required.
Anticoagulation during
non-cardiac surgery

It is recommended not to interrupt
oral anticoagulation for most minor
surgical procedures (including dental
extraction, cataract removal) and
those procedures where bleeding is
easily controlled
(recommendation class I, level of
evidence C).
Major surgical procedures require an INR
<1.5. In patients with a mechanical
prosthesis, oral anticoagulant therapy should
be stopped before surgery and bridging,
using heparin, is recommended
(recommendation class I, level of evidence C).
UFH remains the only approved heparin
treatment in patients with mechanical
prostheses; intravenous administration
should be favoured over the
subcutaneous route.
(recommendation class IIa, level
of evidence C).
Despite The widespread use of
subcutaneous LMWH as an alternative to
UFH for bridging and the positive results
of observational studies , their use are
not approved in patients with mechanical
prostheses, due to the lack of controlled
comparative studies with UFH.
If LMWH used ,
twice a day using therapeutic doses, adapted to
body weight,
monitoring of anti-Xa activity with a target
of 0.51.0 U/ml.
LMWHs are contraindicated in cases of severe
renal failure.
The last dose of LMWH should be administered
12 hours before the procedure, whereas UFH
should be discontinued 4 hours before surgery.
Aspirin therapy should be discontinued 1 week
before a non-cardiac procedure.
Subcutaneous UFH , 17,500 to 20,000 U /12H
with target aPTT 1.5-2 times the control
6hours after the injection till the 12
TH
week.

Then resume warfarin till 36week then back
to heparin use.
Anticoagulation during
pregnancy
The patient with prosthetic valve is considered
high risk patient that is indicated for
endocardities prophylaxis on major surgical
intervention.
Thromboembolic and
Bleeding Complications
VALVE THROMBOSIS
Annual incidence 0.2- 1.8%.

tricuspid> mitral> aortic.

Presentation; a cute onset of dyspnea , embolic
event especially after a period of inadequate
anticoagulation or a cause for increased
coagulability (e.g. dehydration, infection, etc).

The diagnosis should be confirmed by TTE and/or
TOE or cinefluoroscopy
Management of left-sided
obstructive prosthetic
thrombosis.
Management of left-sided
non-obstructive prosthetic
thrombosis
Management of thromboembolism
Prevention of further Thromboembolic
events involves:

Treatment or reversal of risk
factors such as AF, hypertension,
hypercholesterolemia, diabetes, smoking,
infection, and prothrombotic blood test
abnormalities.



Optimization of anticoagulation control, if
possible with patient self-management, on
the basis that better control is more effective
than simply increasing the target INR.

Low-dose aspirin (100 mg daily) should
be added, if it was not previously prescribed,
after careful analysis of the risk-benefit
ratio, avoiding excessive anticoagulation
Embolic stroke:
there is increased risk of stroke over first
2weeks 1% per day , so
if no evidence of hemorrhage is detected
on CT 24-48 hours IV heparin with small
to moderate stroke.
In large infarcts withhold anticoagulant
for 5 to 7 days and for 1-2 weeks in case of
hemorrhagic transformation .


Bleeding complications :

In patients on long-term
anticoagulation, the annual risk of a
hemorrhagic event is ~1% per patient-year.

In patients with mechanical valves, the
bleeding events are most often due to
excessive anticoagulation,

In the absence of bleeding, (or minor
bleeding), its reasonable to stop oral
anticoagulation and allow the INR to fall
gradually and/or to give oral vitamin K in
increments of 1 or 2 mg and If the INR is .10,
higher doses of oral vitamin K (5 mg).

.
Immediate reversal of anticoagulation is
required only for severe bleeding,
Intravenous prothrombin complex
concentrate When available, is preferred
over fresh frozen plasma, and if used,
should be combined with oral vitamin K
Hemolysis & PVL
A large proportion of patients with
mechanical valves have some
degree of intravascular hemolysis.

clinical hemolysis is associated
with ; multiple prosthetic valves ,
periprothetic leakage and PVE.
Blood tests for hemolysis (lactate
dehydrogenase) should be part of routine
follow-up.

Echocardiographic findings consistent with
mechanical hemolysis include : abnormal
rocking and paravalvular leakage ( so TOE
may be needed).
Reoperation is recommended if PVL is
related to endocardities, or if PVL causes
hemolysis requiring repeated blood
transfusions or leading to severe symptoms
(recommendation class I, level of evidence
C).


Medical therapy iron supplementation,
beta-blockers and erythropoietin, is
indicated in patients with severe hemolytic
anemia and PVL not related to
endocardities, where contraindications to
surgery are present, or in those patients
unwilling to undergo reoperation.

Transcatheter closure of PVL is feasible but
experienceis limited and there is presently
no conclusive evidence to show a
consistent efficiency. It may be considered
in selected patients in whom
reintervention is deemed high-risk or is
contraindicated.



Infective endocardities
Early (<60 days following implantation) :
staph epidermities, fulminant with high
mortality rate.
Late: streptococci followed by gram
negative bacteria and enterococci.
Patient with mechanical prosthetic
endocardities should continue on oral
anticoagulant
Management of bioprosthetic
failure
Predictors of SVD
Risk factors previously found to be associated
with bioprosthetic SVD include;
younger age at time of implantation, mitral
valve position, renal insufficiency, and
hyperparathyroidism.

Hypothetical model for the
structural deterioration of
bioprosthetic valves.
.

Early signs of SVD include
leaflet stiffening, calcification, reduced
effective orifice area, and/or regurgitation.
Reoperation is recommended in
symptomatic patients with a significant
increase in trans-prosthetic gradient or
severe regurgitation
(recommendation class I, level of
evidence C)
Reoperation should be considered in
asymptomatic patients with any significant
prosthetic dysfunction, provided they are
at low risk for reoperation.
(recommendation class I, level of
evidence C)
Prophylactic replacement of a
bioprosthesis implanted .10 years ago,
without structural deterioration, may be
considered during an intervention on
another valve or on the coronary arteries
(recommendation class IIb, level of
evidence C).
Future Perspective

Percutaneous implantation of a new
bioprosthesis within the failed bioprosthesis
implantation (valve in valve) may provide a
good alternative to surgical replacement of
the prosthesis, particularly in high-risk
patients.
Echocardiography assessment
of prosthetic valves
http://www.youtube.com/watch?v=3ftvT-
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