Echocardiographic evaluation of prosthetic heart valves
- Elyse Foster, MD
Elyse Foster, MD
- Professor of Clinical Medicine
- University of California, San Francisco
- Section Editors
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
Echocardiography is the key noninvasive modality for evaluation of prosthetic valve structure and function . Transthoracic echocardiography (TTE) is the mainstay for monitoring prosthetic valves and can generally identify normal function as well as evidence of valve dysfunction (stenosis). Transesophageal echocardiography (TEE) is helpful particularly for assessment of valve structure and prosthetic valve regurgitation, especially involving mechanical mitral and tricuspid prostheses as well as assessment of endocarditis for all valves (figure 1).
This topic will review echocardiography of prosthetic heart valves. Management of patients with prosthetic heart valves and prosthetic valve complications are discussed separately. (See "Complications of prosthetic heart valves" and "Epidemiology, clinical manifestations, and diagnosis of prosthetic valve endocarditis" and "Antithrombotic therapy for prosthetic heart valves: Indications" and "Overview of the management of patients with prosthetic heart valves".)
Baseline transthoracic echocardiogram — We agree with the American Heart Association/American College of Cardiology (AHA/ACC) guideline recommendation to perform a transthoracic echocardiogram (TTE) six weeks to three months after valve implantation to evaluate valve hemodynamics and to establish a baseline for future comparison . The TTE should include Doppler measurements of transvalvular velocities as well as assessment of valvular and paravalvular regurgitation. Adequate Doppler velocity recordings can generally be obtained despite acoustic shadowing from valve prostheses.
Transvalvular gradients for normally functioning prosthetic valves are dependent upon valve type, location, and size (as compiled in the 2009 American Society of Echocardiography guidelines) as well as patient-specific factors . A higher than expected initial gradient is often due to a high output state (eg, due to anemia) or patient-prosthetic mismatch and is only rarely due to early dysfunction of the prosthesis. We suggest obtaining the postoperative baseline study after the patient’s hemoglobin has returned to baseline to avoid recording a gradient that is transiently higher than expected due to anemia.
Change in clinical status — The echocardiographer should be alert to the range of complications that can occur with prosthetic devices, including the following (see "Complications of prosthetic heart valves"):
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- MONITORING GUIDELINES
- Baseline transthoracic echocardiogram
- Change in clinical status
- Surveillance of old bioprosthetic valves
- KEY COMPONENTS OF THE ECHOCARDIOGRAM
- Role of TTE and TEE
- FEATURES OF VALVE DYSFUNCTION
- Prosthetic valve obstruction
- - Distinction between thrombus and pannus
- Prosthetic valve regurgitation
- - Physiologic regurgitation
- - Pathologic regurgitation
- Paravalvular regurgitation
- Prosthetic valve dehiscence
- SPECIFIC PROSTHETIC VALVE DISORDERS
- Prosthetic aortic stenosis
- Prosthetic aortic regurgitation
- Prosthetic mitral stenosis
- Prosthetic mitral regurgitation
- Prosthetic pulmonary valves dysfunction
- Prosthetic tricuspid valve dysfunction
- SUMMARY AND RECOMMENDATIONS