PROSTHETIC HEART

VALVES
TYPES OF PROSTHETIC VALVES

• 2 MAJOR TYPES
 MECHANICAL VALVE
 BIOPROSTHETIC VALVE / TISSUE VALVE
MECHANICAL VALVES

• CAGED BALL VALVE

• TILTING DISK
 Single Disc
 Bi leaflet Disc
• CAGED BALL
 Starr – Edwards.
 First type artificial valve.
 Circular ring on which is mounted a U shaped
cage with a silastic ball occluder.
 More chance of thrombus formation.
• TILTING DISC VALVE
 SINGLE TILTING DISK
 Has a round sewing ring and circular disc
fixed eccentrically to the ring via hinges.
 Disc move through an arc of less than
90degree(55-70 degree).
 Eg: Medtronic Hall
Chithra valve
 BI LEAFLET TILTING DISK
 Consist of two semicircular disk that open
and close on a hinge mechanism within the
sewing ring.
 Opening angle is more vertical than the
single tilting disk.
 Eg :St. Jude medicals
Carbo Medics
ADVANTAGES

• Small annulus.
• Can be given to younger patients.
• Life expectancy > 10 years.
• Low haemodynamic profile needed.
DISADVANTAGES

• Require life long anticoagulation.

• Cant be given to the patient if warfarin is
contra indicated.
INDICATIONS

• Pts with expected long life span.

• Pts with a mechanical prosthetic valve
already in a place , different position than
the valve to be placed. I
• Pts with renal failure on haemodialysis or
with hypercalcaemia. II
• Pts who require warfarin treatment due to
the risk factor for thrombo embolism.IIa
• Patients with age < 65 yrs for AV and < 70
yrs for MV. II a
BIOPROSTHETIC VALVES

• HETEROGRAFT
• HOMOGRAFT
• PULMONARY AUTOGRAFT
• ISOGRAFT
HETEROGRAFT

• PORCINE
 Made from pig tissue.
 Can be stented or un stented.
 Eg.Hancock
• BOVINE
 Made from bovine pericardium.
 Eg. Carpentiers and edwards perimount
HOMOGRAFT

• Derived from the human aortic or

pulmonary valve tissue that has
undergone cryopreservation.
PULMONARY AUTO GRAFT

• Pulmonary valve is taken and placed in

position of the aortic valve through ross
procedure.
ISOGRAFT.

• Graft of tissue between individuals who are

genetically identical.
• Transplant rejection between such
individuals virtually never occours.
ROSS PROCEDURE

• A form of aortic surgery which involve the

replacement of dysfunctional aortic valve
by patients own pulmonary valve followed
by the implantation of a homograft in the
pulmonary valve position.
ADVANTAGES

• Older age patients >70  MV

>65AV
• Can be given even if warfarin is
contraindicated.
• Do not require life long anticoagulation.
DISADVANTAGES

• Less life expectansy of the valve.

INDICATIONS
• Pts who cant or will not take warfarin treatment.I
• Pts >65 yrs needing AVR and have no risk factor
of thrombo embolism.I
• Pts considered to have compliance problem with
warfarin treatment. IIa
• Pts >70 yrs needing MVR and do not have the
risk factor of thrombo embolism.Iia
• Valve replacement for thrombosed mechanical
valve.IIb
ANTICOAGULATION AFTERPV
IMPLANTATION
• INR FOR MECHANICAL VALVE
• 3 – 4 AVR
• 3.5 – 4.5 MVR

• INR FOR BIOPROSTHETIC VALVE

• 3 – 4 AVR
• 3.5 – 4.5 MVR
ASSESSMENT BY ECHO

• 2D ECHO
 Structure of the prosthesis.
 Motion of the occluder.
 Stability of the valve ring.
 Calcifications of the bioprosthetic valves.
 Anatomy of cardiac structures adjacent to
the prosthesis.
 Cardiac size and function.
• M MODE
• Restricted amplitude of motion of the
valve.
• Intermittantly varying MV opening.
• E point : Normally sharp. But blunted and
rounded in obstructed tiltiting disk.
• Clouds of echo from various parts of PV.
• COLOUR DOPPLOR
 Regions of high velocity.
 Proximal flow convergence.
 Regurgitant jets.
• PW AND CW
• Trans valvular gradients and valve areas.
TEE

IN D IC A T IO N S F O R T E E IN
P R O S T H E T IC V A L V E A S S E S S M E N T
• A ssessm ent of valvar regurgitations esp M R , T R ,
A R etc
• A ssessm ent of valve obstruction
– E valuation of valve m otion
– U nderlying pathology – throm bus/calcificn /degn / pannus
• Suspected infective endocarditis
• A ssessm ent of associated structural anom alies
– V egetations /throm bi / abscess
– P seudoaneu rysm / fistu la
• Inadequate /nondiagnostic /borderline T T E
PROSTHETIC VALVE
COMPLICATIONS
• PANNUS FORMATION.
• PATIENT PROSTHESIS MISMATCH.
• PROSTHETIC VALVE DYSFUNCTION.
• PROSTHETIC VALVE THROMBOSIS.
 PANNUS FORMATION
• Tissue in growth at the site of a prosthesis.
 Foreign body reactions to the prosthesis.
 Inadequate anticoagulation.
 Endocarditis.
 Blood flow turbulence.
• Interfere with prosthetic occluder motion or
closure resulting in increased transvalvular
gradients.
PATIENT PROSTHESIS MISMATCH

• Prosthesis–patient mismatch occurs when the

indexed EOA is reduced.
• i.e., when the size of the prosthesis orifice is
too small in relation to the patient’s body size.
• Indexed EOA = EOA/ BSA
• an aortic valve prosthesis should ideally be no less
than 0.85 - 0.90 cm 2 /m 2 .
• The hallmark on TEE : Normal prosthetic
valve function despite high transvalvular
gradients.
PROSTHETIC VALVE THROMBOSIS

• Incidence—0.2% - 1.8% /yr.

• Tricuspid > mitral > aortic .
• Caged ball > single disc > bileaflet tilting -
disc valves.
• pts with a/c onset of symptoms, embolic
event or inadequate anticoagulation.
• May have an insidious onset and longer
duration of symptoms.
• Physical exam -Decreased intensity of one
or both metallic clicks or the presence of a
new murmur.
• Diagnosed by
• TEE - Large, irregular, mobile mass,
extending beyond the prosthesis ,soft
ultrasound density similar to that of
myocardium.
• Increased transvalvular pressure gradient,
reduced orifice area or valvular
regurgitation.
• Cinefluoroscopy -To document restriction
in occluder mobility.
`
• Thrombolytic therapy

1. Right-sided PrV thrombosis.

2. Hemodynamically unstable(NYHA-III/IV) left

sided PrV thrombosis for whom surgery carries
high risk.
• Streptokinase----250,000U bolus x 30
mts, followed by an infusion of
100,000 U/hr
• Urokinase--- 4,400 U/kg/hr infusion
• Duration
• Resolution of pressure gradient & valve
areas to near normal by doppler echo.
• Thrombolytic therapy should be stopped.
Pts with small clot and in NYHA-II/I &
L.V dysfunction

• Short term I.V heparin therapy.

• Combined therapy with s/c heparin and
warfarin for 3 months.
• Reoperation.
• To keep an INR of 3-4 for AVR & 3.5 – 4.5
for MVR plus low dose aspirin( 80-100
mg/day).
PROSTHETIC VALVE DYSFUNCTION

• OBSTRUCTION - MPV
 Patient prosthesis mismatch.
 Technical difficulties facing at the
implantation time.
 Thrombotic interference.
 Vegetation on the swing ring.
• OBSTRUCTION – BIO P.V
 Fibro calcific degeneration.
• IE
 Difficult to diagnose
 Vegetations are seen : Base and the
sewing ring.
• MECHANICAL FAILURE
 Primary failure or defect in the
manufacture.
 Ball varience : gradual change in the
shape of the occluder of the Star Edwards
valve.
PRESSURE RECOVERY
PHENOMENON.
• Dopplor assessment over estimate the
gradient across the valve.
• When the blood crosses the valve , portion
of the kinetic energy of the blood is
recovers in the form of pressure.
• Amount of the energy recovered depend
on how smoothly the blood flow through
the orifice.
• Localised gradient at the central orifice of
the prosthesis.
• As the pressure recovers down stream, the
gradient diminishes.
Thank you……..