Clinical manifestations and diagnosis of surgical aortic and mitral prosthetic valve regurgitation
- Alvaro Marco del Castillo, MD
Alvaro Marco del Castillo, MD
- Professor of Medicine
- University Hospital Ramon and Cajal
- Pepe Zamorano, MD
Pepe Zamorano, MD
- Head of Cardiology
- University Hospital Ramon y Cajal
Prosthetic valve dysfunction encompasses prosthetic valve obstruction (stenosis) and prosthetic valve regurgitation. Regurgitation associated with prosthetic heart valves includes regurgitation through the valve (transvalvular) as well as paravalvular regurgitation (also known as paravalvular leak). Symptomatic severe prosthetic valve regurgitation is an uncommon complication of surgical valve replacement. However, it is associated with poor outcomes with both conservative management and surgical treatment.
This topic will discuss clinical manifestations and diagnosis of surgical prosthetic aortic and mitral valve regurgitation. Transcatheter heart valve regurgitation and prognosis and management of surgical prosthetic valve regurgitation are discussed separately. (See "Transcatheter aortic valve implantation: Complications" and "Management and prognosis of surgical aortic and mitral prosthetic valve regurgitation".)
DEFINITIONS AND PREVALENCE
Normally functioning mechanical valves and some normally functioning bioprosthetic valves have trivial to mild transvalvular regurgitation, which should be distinguished from pathological regurgitation. On color Doppler echocardiographic imaging of normally functioning mechanical prosthetic valves, two types of retrograde jets are seen: a closing volume caused by motion of the occluder and true trivial or mild regurgitation at the edges of the occluder. Mechanical prosthetic valves are designed to cause trivial to mild transvalvular regurgitation when functioning normally as a safety mechanism known as leakage backflow or washing jets; this mechanism is thought to reduce the risk of valve thrombosis. Trivial regurgitation is also normal for some types of bioprosthetic valves (particularly stentless valves), due to minimal leaflet retraction once placed.
The principal types of pathologic prosthetic valve regurgitation are transvalvular regurgitation (due to structural valve deterioration or non-structural valve dysfunction) and paravalvular leakage:
●Transvalvular regurgitation − Pathologic transvalvular regurgitation is much more common with bioprosthetic valves compared with mechanical valves. With conventional stented bioprostheses, 10 to 30 percent had significant structural valve deterioration at 10 years, and 20 to 50 percent at 15 years . However, structural valve deterioration includes both regurgitation and stenosis, and the prevalence of patients with regurgitation is unknown. The rate of structural failure decreases with age, probably in part due to less activity in older patients.
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- DEFINITIONS AND PREVALENCE
- CLINICAL MANIFESTATIONS
- Symptoms and signs
- Blood tests
- Chest radiograph
- APPROACH TO DIAGNOSIS AND EVALUATION
- When to suspect prosthetic valve regurgitation
- Overview of diagnosis and evaluation
- Approach according to prosthetic regurgitation type
- - Aortic transvalvular regurgitation
- - Aortic paravalvular regurgitation,
- - Mitral transvalvular regurgitation
- - Mitral paravalvular regurgitation
- - Multiple leak approach
- Identifying the cause of prosthetic valve regurgitation
- - Transvalvular regurgitation
- - Paravalvular regurgitation
- - Echocardiography
- Transthoracic echocardiography
- Transesophageal echocardiography
- - Cardiovascular magnetic resonance (CMR)
- - Computed tomography
- - Nuclear imaging
- - Cardiac catheterization
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS