Alsharqia.riyadh Echo meeting

Dammam KSA SAYED ABOU EL SOUD

MDSBCC

Case 1

History • 48 y old Saudi lady • Hypothyroidism,ch. Spondylisis• H/O intracranial HTN 6 years

before admission & ventriculoperitoneal shunt ( removed later )

• Labarscopic cholecystecomy & RT modified mastectomy

• Now neurologically grossly intact

• S/P AVR in other hospital with tissue valve size 21 ( mosaic valve ) in 6/2011 ( 2 ys ago )

• Presented to SBCC ( 2 month ago) with C/O chest pain , dyspnea and syncobal attacks

• O/E obese well oriented pt• Ejection syst . murmer • ECG LV hypertrophy & strain • HB is 12.6 , creatinine 1.5

Preoperative TTE

PREOPERATIVE TEE

IMPRESSION • 48 y lady , obese , multiple co

morbidities• Severely symptomatic relatively early

postoperative • Significant : – gradient across AV & OFT– Severe LVH , normal LV function – Tilting partially supra- annular valve – leaflets opening well – Remnants of the native valve in 1st operation

• GEOMETRIC ORIFICE AREA ( area blood flow through )

• MOUNTING AREA (area occupied by the valve in the native annulus )

IMPLANT TECHNIQUE

• TOATLLY INTRA ANNULAR : GOA/MOUNTING AREA = 40-70 %

• PARTIAL SUPRA-ANNULAR : GOA/MOUNTING AREA= 80 %-85 %

• TOTALLY SUPRAANNULAR : APPROACHES 100% MAXIMIZING BOOLD FLOW

Surgery • Aortic patch ( dilate aorta )• Valve replacement (tissue

valve ) has Hx of intracranial HGE

• Myomectomy ( dilate LVOT )

POSTOPERATIVE TEE

POSTOPERATIVE TTE

Case 2

History• 46 y old saudi female• K/C of HTN, hypothyroidism• K/C AVD, bicuspid AV with

sever AS• S/P AVR “tissue valve”1 year

ago

History• presented to our ER C/O– progressive exertional dyspnea up

to NYHA III. – She also c/o of chest pain & near

syncopal attacks

• O/E – Pt had mild pulm. congestion &

uncontrolled B/P 160/95– Ejection systolic murmur over the AV

TTE

TEE

Impression

• Tissue valve opening well• Tilting valve • Significant gradient across aortic end of valve

Course • Discharged for second opinion• Lost follow up

Case 3

History• 18 yeas old saudi male.• s/p AVR “ metalic valve” &

closure of VSD in another hospital

• Pt presented to OPD completely asymptomatic.

• Pt referred for echocardiography as baseline post operative echo.

TTE

TEE

Impression • Severely impaired LV function.

( normal preoperative ) • tilting valve with Significant

gradient across the aortic end . ( false moderate gradient due to LV dysfunction )

• Fluoroscopy showed freely mobile leaflets with full range of movement

Course • very high risk for REDO

surgery • Pt preferred to be referred

back to the hospital where he performed 1st surgery

Arguments

• Partially supra annular implantation to incraese GVA IS OPTIMAL ???

• Why gradients not usually appear immediate postoperative and appear later in follow up???

Home message

Left for respected panel

• Published data about Doppler hemodynamic parameters of normofunctioning prosthetic valves in aortic position

Baseline valve assessment

• Therefore, the optimal timing of the baseline assessment of valve prosthesis haemodynamics should be placed between the third and the sixth month (not later than 1 year) after surgery.

• . In patients undergoing aortic valve replacement, there is a relatively high output state immediately after the operation due to relative anaemia and sudden reduction of left ventricular afterload, which affects transprosthetic gradients. Moreover, perivalvular oedema and haematoma may reduce prosthetic EOA. Finally, left ventricular function will change significantly soon after aortic valve replacement due to regression of hypertrophy and adaptation to the changed pre- and afterload conditions