Bioprosthetic Valve Degeneration

Philipp Emanuel Bartko, MD and Jutta Bergler-Klein, MD

Med. Univ. of Vienna, Dept. Of Cardiology, Vienna, Austriajutta.bergler-klein@meduniwien.ac.at

Clinical Presentation and Medical History

76 year old female

Seen at the outpatient clinic for general fatigue, atypical chest pain, dizziness and dyspnoea on exertion for several months.

No syncope or recent fever

She underwent cardiac surgery in 2007 • Replacement of the aortic valve using a Mitroflow 21mm (stented bovine

pericardial valve) and aortic root for severe aortic stenosis with calcified bicuspid aortic valve and aneurysm of the ascending aorta

• Single coronary artery bypass graft (LIMA to LAD)• Tricuspid valve annuloplasty with ring implantation

Paroxysmal atrial fibrillation

Clinical and biological Findings

Physical examination:• 159 cm, 58 kg• Blood pressure 150/90 mmHg; 78 bpm• Loud systolic heart murmur at 2nd right intercostal space with

transmission to the carotid arteries • No peripheral oedema

ECG• Sinus rhythm• Non-specific ST wave alterations• LV hypertrophy

Biology• Normal CRP, creatinine and thyroid hormones levels• NT-proBNP 213 pg/ml

Transthoracic Echocardiography

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Transthoracic Echocardiography Report

Bioprosthetic aortic valve • Significantly thickened cusps• Trivial central prosthetic regurgitation• Doppler parameters

Peak jet velocity 3.8m/sec Mean aortic gradient 37 mmHg Effective orifice area 1.1 cm² (0.7 cm²/m² of body surface area)

Left ventricle • Normal ejection fraction • No regional wall motion abnormalities• End diastolic volume 99mL• Stroke volume: 72ml (46ml/m²) by Simpson method, 79ml (50ml/m²) by

Doppler method

Compare to Discharge Echo after Valve Surgery

At discharge in 2007: • Aortic peak velocity 2.51m/sec• Mean gradient 11 mmHg• Effective orifice area 1.7 cm²

Increasing aortic valve gradient

Exact prosthesis morphology TEE

Bioprosthetic Degeneration? Patient-Prosthesis Mismatch?

Transoesophageal Echocardiography

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Transoesophageal Echocardiography Conclusion

• Degenerating bioprosthetic valve with fixed cusps and reduced valve area

• The patient was referred for redo surgery

Echocardiographic Assessment of Prosthetic Valves What should you know in advance?

Valve type• Bioprosthetic valve: stented, stentless or sutureless• Mechanical valve: bileaflet, tilting disc or ball in cage

Valve size• May cause differences in gradients and effective orifice area

BSA of the patient• Calculation of the indexed effective orifice area to assess

potential patient / prosthesis mismatch

Year of implantation • Median time to reoperation for structural valve deterioration is

age-dependent and varies from average 11 years in a 20-y old, to 25 years in a 65-y old.

Additional surgical interventions• Coronary bypass grafts, other valve surgery

Smedira NG, Blackstone EH, Roselli EE et al. J Thorac Cardiovasc Surg 2006;131:558-64 El-Hamamsy I, Clark L, Stevens LM et al. J Am Coll Cardiol 2010;55:368-76

Echocardiographic Assessment of Prosthetic Valves What to Report - I

Date of surgery

Type of valve prosthesis

Height, weight, BSA of patient

Blood pressure, heart rate

Haemodynamic conditions: left ventricular size and function, stroke volume (index)

Vahanian A, Alfieri O, Andreotti F et al. Guidelines on the management of valvular heart disease (version 2012). Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2012;33(19):2451-96

Echocardiographic Assessment of Prosthetic Valves What to Report -II

Valve• Seating (Abnormal motion? Tilting, Rocking?)• Leaflets or occluder motion • Morphology (Calcification? Abnormal echo densities? Valve sewing ring?

Ring integrity?)• Doppler: Peak jet velocity, peak and mean gradient, effective orifice area

compare to specified prosthesis normal values • Regurgitation (degree, para- or intravalvular location, mechanism)

A TTE should be performed at discharge or 30 days after surgery and will serve as a future reference

Zoghbi WA, Chambers JB, Dumesnil JG et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound. J Am Soc Echocardiogr 2009;22:975-1014

Daneshvar SA, Rahimtoola SH. Valve prosthesis-patient mismatch: a long-term perspective. J Am Coll Cardiol 2012 Sep 25;60(13):1123-35

Structural Valve Degeneration

Structural valve degeneration is the major cause of bioprosthetic valve failure

Age dependent, it occurs early in young patients.

Lipid-mediated inflammation contributes to structural valve degeneration.

Atherosclerotic risk factors (diabetes, smoking, hypercholesterolemia, metabolic syndrome) facilitate structural valve degeneration.

Modification of risk factors may help to reduce the incidence of structural valve degeneration

Transcatheter heart valve implantation (valve in valve) for failing surgical bioprosthesis is an emerging alternative to redo surgery

Mylotte D, Lange R, Martucci G, Piazza N. Transcatheter heart valve implantation for failing surgical bioprostheses: technical considerations and evidence for valve-in-valve procedures. Heart 2013;99:960-7

Summary

Echocardiography with Doppler is the method of choice in the evaluation and follow up of patients with valve prostheses.

Knowledge of the prosthesis type and size is essential to compare to reference prosthesis Doppler values.

A postop discharge echo should always be performed to document individual baseline Doppler values.

The occurrence of a significant increase in gradient and/or new regurgitation points to prosthetic valve degeneration.

TEE should be performed to clarify mechanism of degeneration and exclude endocarditis in (sub)febrile patients.

Transcatheter valve-in-valve implantation may be a good option in the future for the management of bioprosthetic valve failure in high-risk patients.

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