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Echocardiographic follow-up after heart valve

replacement
Tobias Pflederer and Frank A Flachskampf

Heart 2010 96: 75-85

doi: 10.1136/hrt.2008.152074

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VALVULAR HEART DISEASE
Echocardiographic follow-up after
heart valve replacement
Tobias Pflederer, Frank A Flachskampf
Med.Klinik 2, University of The number of patients with prosthetic valves is
Erlangen, Erlangen, Germany steadily increasing, in particular because of the
epidemic of aortic stenosis in the elderly. In
Correspondence to:
Professor Frank A Flachskampf, Germany alone, more than 24 000 patients
Med.Klinik 2, University of undergo valve replacement per year. In addition
Erlangen, Ulmenweg 18, 91054
to the patient’s history and physical examination,
Erlangen, Germany; frank.
flachskampf@uk-erlangen.de echocardiography is the key element in the follow-
up of individuals with a prosthetic valve (box 1).
The examination of the patient with a prosthe-
tic cardiac valve, however, is one of the most
challenging tasks in echocardiography. For several
reasons echocardiography in these patients is more
difficult than in others:
c Due to the valvular heart disease present before
valve replacement, these hearts are never
normal, even with a perfectly functioning valve
replacement.
c The prosthesis itself, especially in the case of a
mechanical prosthesis, invariably generates
artefacts and often is not well visualised. For
example, in aortic mechanical prostheses it is
often difficult or impossible to delineate
precisely the extent of occluder motion.
c Even normally functioning valve prostheses
present a variable degree of obstruction and
regurgitation.
Box 1 The following questions should be systematically answered when
examining a prosthesis by echocardiography
c Does the history or clinical presentation of the patient suggest a prosthesis
related disorder (for example, new onset of severe dyspnoea, fever, etc)?
c Is the prosthesis firmly implanted as a whole (absence of rocking)?
c In a bioprosthesis, are there morphologic signs of degeneration (thickened,
immobile or pathologically mobile leaflets or leaflet segments)? In a
mechanical prosthesis, do the occluder discs move normally?
c How much regurgitation is there, and is it transprosthetic or paraprosthetic?
c What are the mean and maximal transprosthetic gradients, are they in the
normal range, and have they changed substantially from baseline?
c Are there fixed or mobile mass lesions attached to the prosthesis (thrombus,
vegetation, pannus)?
c Are there other signs of endocarditis, in particular abscess formation at the
prosthetic ring, fistulae, or a pericardial effusion?
The first routine postoperative assessment is particularly important, since it
serves as baseline for later comparison, especially with regard to transprosthetic
gradients, prosthetic regurgitation, right ventricular peak pressure, left ventricular
function, and other aspects.
Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074
Education in Heart
This article provides an overview of procedures,
the problems that can arise, and recommendations
on how to deal with them.
TYPES OF VALVE PROSTHESES
Mechanical valves are the oldest and most durable
replacements for native cardiac valves. They
mainly differ by the mechanism by which the
occlusion of the valve is achieved. Currently,
mostly bileaflet prostheses are implanted, but
single disc valves (tilting disc) such as the
Medtronic-Hall or the Björk-Shiley valves exist in
substantial numbers, while the earliest type, the
‘‘ball-in-cage’’, has become a rarity. Biological
prostheses span a range from porcine or bovine
trileaflet valves in a rigid ring to stentless bio-
prostheses and finally homografts, which are
processed human cadaveric valves. In addition,
the Ross procedure uses an ‘‘autograft’’, the
patient’s own pulmonary valve to replace a
diseased aortic valve, while the pulmonary valve
is replaced by an ordinary bioprosthesis.
Mechanical prostheses are the most difficult to
image, since reverberations and artefacts from the
non-biological material mostly preclude detailed
morphologic assessment (fig 1A). However, in the
mitral (or tricuspid) position, the occluders (leaflets
or tilting discs) can often be seen quite well,
particularly by transoesophageal echocardiography
(TOE) (fig 2–4). Mechanical prostheses often
release echocardiographically detectable small gas
bubbles, apparently caused by cavitation in blood
due to the fast movement of the occluder. This
unique phenomenon should be considered normal.
Characteristically, Doppler recordings from
mechanical valves display the opening and closing
clicks as bright (high intensity), vertical lines
enclosing the transprosthetic forward flow profile
(fig 1B). Minor changes in the opening amplitude
of occluding discs, which may occur with partial
thrombosis or other obstruction, necessitate
fluoroscopy to exclude or document with cer-
tainty. Stented bioprostheses are easier to image
(fig 5), and stentless bioprostheses, homografts,
and autografts are often indistinguishable morpho-
logically or by transvalvular flow velocities from
native valves, except for minor echodensities at the
valvular circumference, where the prosthesis has
been sewn in. The newly introduced three dimen-
sional TOE probe is able to generate ‘‘en face’’
views of prostheses, resembling visual inspection,
75
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Education in Heart
Figure 1 (A) Mechanical bileaflet prosthesis in the aortic position. Parasternal long axis
view. The prosthesis (solid arrow) is obscured by typical artefacts and reverberations
extending into the left atrium (dotted arrow). Asc, ascending aorta; LV, left ventricle.
(B) Corresponding continuous wave Doppler recording of aortic transprosthetic gradient.
Maximal velocity of 3.4 m/s, corresponding to a peak gradient of 46 mm Hg. Note clicks
(vertical lines) at the beginning and end of ejection.
which allow a more intuitive assessment of
prosthetic occluders and rings1 (fig 6).
Recently, interventionally deployable aortic
prostheses have been introduced. The CoreValve
prosthesis is a porcine pericardial trileaflet bio-
prosthesis mounted into a self expanding nitinol
frame. The Edwards-Sapien valve is a bovine
pericardial trileaflet valve mounted in a balloon
expandable steel stent. Thus, these prostheses
neither have a typical ring nor are they stentless.
After deployment, these prostheses frequently
have paraprosthetic leaks and also may leak
Figure 2 Mechanical bileaflet prosthesis in the mitral position, diastolic apical four
chamber view. The leaflets are in the open, parallel position (arrows). The small image on
the right shows the systolic, closed position (arrow), where the leaflets are not
individually discernible. LA, left atrium; LV, left ventricle.
76
centrally (fig 7). Details on peri-interventional
echocardiography can be found elsewhere.2
ECHOCARDIOGRAPHIC CHARACTERISTICS OF
SPECIFIC PROSTHETIC IMPLANTATION SITES
Aortic valve prostheses
Aortic prostheses should be examined in all cross
sections containing the aortic valve, in particular
the parasternal long and short axis. Zoom images
are helpful. Special attention should be paid to the
para-aortic tissue in order to rule out a para-aortic
abscess. While the discs of mechanical prostheses
are often insufficiently viewed, even by TOE,
bioprostheses or homografts pose no unusual
problems in imaging and should be examined by
transthoracic echocardiography or TOE, if neces-
sary, with regard to opening motion, thickening,
calcification, mobile components, masses, and
other abnormalities. In the parasternal long and
short axis views and the apical long axis view,
paraprosthetic (arising outside the prosthetic ring)
and transprosthetic (arising inside the prosthetic
ring) regurgitation can be detected by colour
Doppler. Differentiation of the two types of
regurgitation may be difficult, especially between
a small paraprosthetic leak and the eccentric, but
transprosthetic, normal regurgitation of bileaflet
prostheses.
Peak and mean gradients across prosthetic aortic
valves should be measured by continuous wave
Doppler in long axis views (fig 1B). Care should be
taken not to mistake a post-premature beat
ejection or the ejection after a long filling period
in atrial fibrillation as representative, since in these
instances the velocities will be atypically high.
Substantial aortic regurgitation or a high output
state, as in sepsis, also increase gradients. Normal
values vary drastically depending on type and size
of prosthesis (table 1).3
In patients who underwent replacement of the
aortic valve together with the ascending aorta by a
valved graft (Bentall procedure), typically due to
annulo-aortic dilatation or to dissection or aneur-
ysm of the ascending aorta, transoesophageal
echocardiography is advantageous to assess the
whole thoracic aorta including the graft.
Pseudoaneurysm formation at the site of re-
implantation of the coronaries has been described,
and the morphology of persistent dissection in the
arch and descending aorta may be assessed.4
The interpretation of transprosthetic aortic
gradients in mechanical prostheses is complicated
by the occurrence of significant pressure recovery
effects due to the design, especially of the bileaflet
prostheses. Pressure recovery also exists in other
prostheses (and, for that matter, in native aortic
stenosis), but usually to a minor degree. The
presence of localised high gradients, in particular
between the medial orifice of normally functioning
bileaflet valves, precludes the usual grading of
stenosis severity. For example, mean (SD) peak
velocities of 2.9 (0.5) m/s and attending peak
gradients up to 35 (11) mm Hg are found routinely
by continuous wave Doppler in St Jude Medical
Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074
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Education in Heart

area by the continuity equation does not circum-

vent the problem, because it utilises the maximal
transprosthetic velocity which is not representative
for the whole prosthetic orifice(s); the area
calculated will therefore be much lower than the
expected orifice area or the orifice area provided by
the manufacturer, even if there is no malfunction.
The use of alternative measures of obstruction is
not routinely recommended.
Therefore, interpreting these findings correctly
requires at least one of the following additional
pieces of information:

c A baseline continuous wave Doppler study

Figure 3 Mitral mechanical bileaflet prosthesis in the transoesophageal four chamber
view in diastole. The leaflets are in the open, parallel position (arrows). The small image
on the right shows the leaflets during systole in a tent-like, closed configuration. LA, left
atrium; LV, left ventricle.
bileaflet number 19 prostheses without evidence of
dysfunction, with corresponding effective orifice
areas by continuity of only 1.0 (0.2) cm2.3
Moreover, because malfunction of such a valve
may lead to a breakdown of such localised
gradients, a partially stenotic bileaflet valve may
show only a minor or no increase in velocities and
gradients. Calculation of the effective valve orifice
providing values for comparison from a time in
which the prosthesis was presumably working
well.
c Fluoroscopy of the valve allowing exact visua-
lisation of the maximal opening angle of each
disc. Finding the optimal projection (often a
cranially tilted left anterior oblique projection)
may be cumbersome.
c Reconstruction of functional datasets of a non-
contrast enhanced multi-detector cardiac com-
puted tomography, which allows very precise
analysis of the discs’ motion.
Assessing the degree of more than mild mechan-
ical prosthetic aortic regurgitation is extremely
difficult (even with TOE) and requires utmost
caution. Short of detecting a visibly large para-
prosthetic leak, a rocking, dehiscent prosthesis, or
torrential regurgitation filling the entire outflow
tract during diastole, secondary signs of severe

Figure 4 Mitral tilting

disc prosthesis (Medtronic-
Hall) in the
transoesophageal four
chamber view. (A) Two
dimensional (2D) image in
systole with disc in closed
position. Arrow points at
central strut. (B) 2D image
in diastole with disc in
open position. (C) Systolic
colour Doppler image of
normal central regurgitation
around central strut. LA,
left atrium.

Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074 77

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Education in Heart
Figure 5 Biological prosthesis in the aortic position.
Parasternal long axis view. The bright reflexes of the
prosthetic ring are seen (arrows). LV, left ventricle.
regurgitation should be sought, such as a short
(,250 ms) pressure half time of the continuous
wave Doppler signal of aortic regurgitation, or
holodiastolic backward flow in the descending
aorta by pulsed wave Doppler from the supraster-
nal notch. It remains sometimes impossible, how-
ever, to be confident about whether an aortic
prosthetic regurgitation is moderate or severe.
Another sign of haemodynamic improvement
after aortic valve replacement is regression of left
ventricular mass and improvement in function.
Wall thickness decreases and ejection fraction and
tissue Doppler parameters of myocardial function
Figure 6 En face view from the left atrium of a bileaflet
mechanical mitral prosthesis by three dimensional
transoesophageal echocardiography. The two occluders
and the sewing ring are clearly discernible.
78
improve after replacement of a stenotic aortic
valve, with functional improvement beginning as
soon as 24 h after the procedure. After replacement
for aortic regurgitation, left ventricular diameters,
volumes, and mass decrease and ejection fraction
usually improves.5 6
EXAMINATION OF MITRAL VALVE PROSTHESES
Compared to aortic prostheses, the larger size of
mitral prostheses and the presence of large blood
filled heart chambers on both sides of the
prosthesis make echocardiographic assessment
easier. The left atrial side of the prostheses and
the left atrium are obscured by mechanical mitral
prostheses when viewed from the apex (compare
fig 2). Therefore, examination should include
especially subcostal views which often visualise
the left atrium well. The most important func-
tional parameter is the mean diastolic Doppler
gradient by continuous wave Doppler (table 1). It
should be kept in mind that this gradient is very
sensitive to heart rate and may be substantially
elevated in spite of a perfectly normal prosthesis
during atrial fibrillation with a rapid ventricular
response. The pressure half-time (PHT, in ms)
depends heavily on prosthesis type and the formula
220/PHT for native mitral valve orifice area in cm2
cannot be used for prostheses; however, intra-
individual serial comparisons can be performed
using the PHT. Furthermore, when searching for
paraprosthetic regurgitation special attention
should be paid to the presence of proximal
convergence zones on the ventricular side of the
mitral prosthetic ring; in fact, the presence of a
reproducible, well formed proximal convergence
zone by itself signals substantial paraprosthetic
regurgitation.7 TOE affords excellent visualisation
of mitral prostheses and the left atrium, including
occluder mobility, but the ventricular side of
mechanical prostheses is obscured (figs 3 and 4).
A secondary sign of haemodynamic improvement
after mitral valve replacement is postoperative
reduction in systolic right ventricular pressures,
estimated by maximal tricuspid regurgitant velo-
city.
TRICUSPID POSITION
Replacement of the tricuspid valve is avoided
whenever possible in favour of reconstructive
surgery, typically with a ring. Because of the
relatively slow right atrial and trans-tricuspid flow
velocities, tricuspid prostheses are at a particularly
high risk of thrombosis. Imaging is performed in
the typical cross sections for the tricuspid valve
(parasternal right ventricular inflow view, para-
sternal short axis view of aortic valve, apical and
subcostal four chamber views). TOE is helpful by
supplying additional transgastric (for example,
right ventricular long axis views) and transoeso-
phageal images (four chamber, aortic valve short
axis, and others). Functional performance is
evaluated by continuous wave Doppler measure-
ment of mean transtricuspid gradient8 (table 1).
Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074
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Education in Heart

Figure 7 Transapically
implanted aortic
bioprosthesis (Edwards-
Sapien).
(A) Transoesophageal
colour Doppler image in a
long axis view. There is a
paraprosthetic leak in the
area of the non-coronary
cusp. Ao, ascending aorta;
LA, left atrium; LV, left
ventricle.
(B) Transoesophageal two
dimensional image in a
short axis view. Note
circumferential stent
material.

PATHOLOGIC FINDINGS IN VALVULAR
PROSTHESES
Obstruction
Flow velocities across a prosthetic valve should be
assessed by continuous wave Doppler as in a native
valve and peak and mean gradients calculated. The
use of PHT in mitral or tricuspid prostheses is
hampered by the fact that the classic formula for
mitral orifice area A = 220/PHT does not hold.
However, serial changes in PHT may be useful to
detect obstruction if the pressure half-time
increases substantially in a given valve.
Transprosthetic velocities are always elevated in
comparison to the native valve. They are particu-
larly high in small bileaflet prostheses in the aortic
position, where localised high pressure gradients
may exist which exceed the net pressure difference
between the left ventricle and the ascending aorta.
These localised pressure gradients are recorded by
continuous wave Doppler and are indistinguishable
from gradients generated by true prosthetic
obstruction.9 10 Therefore, correct motion of the
leaflets/occluder should be ascertained. This is best
achieved by fluoroscopy; a systematic comparison
between fluoroscopy, transthoracic and transoeso-
phageal echocardiography showed that occluding
disc angles of mitral prostheses could be ascertained

Table 1 Selection of published ranges of mean transprosthetic Doppler gradients (¡

range of standard deviations) in normally functioning prostheses
Mean transprosthetic
Doppler gradients
mm Hg

Aortic position (prosthesis sizes 19–25):

Mechanical bileaflet prostheses 10219 (226)
Stented bioprostheses 16224 (529)
Mitral position:
Mechanical bileaflet prostheses 425 (122)
Mechanical tilting disc prostheses 326 (122)
Stented bioprostheses 325 (122) Figure 8 Small thrombus (full arrow) on the atrial side of
Tricuspid position: a mitral tilting disc prosthesis. The thrombus resolved
All types 3 (1) under an improved anticoagulatory regimen. The dotted
For further detail according to type and size of prosthesis, see Rosenhek et al 3 and Connolly et al.8 arrows point at the sewing ring. LA, left atrium.

Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074 79

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Education in Heart
transthoracically and by TOE in 85% and 100%,
respectively, but that aortic prostheses were not
sufficiently assessed.11 It is also helpful to compare
with transvalvular gradients from the postoperative
period, when the valve was presumably functioning
normally. Therefore, it is important to record such
gradients or velocities early after surgery in order to
have these baseline values ready for later compar-
ison. This problem does not arise in mitral pros-
theses (mainly because of different ‘‘receiving
chamber’’ morphology). Normal values for trans-
prosthetic gradients have been published and depend
on valve position, type, and size (table 1), but the
normal ranges are wide and, as mentioned above,
especially in the aortic position, high gradients can
be both ‘‘by design’’ and thus normal or due to
malfunction. By exercise or dobutamine stress
echocardiography, the range of transprosthetic
pressure gradients occurring in real life can be further
estimated, but there is no universally accepted
indication for stress echocardiography to assess
prosthetic function.
True obstruction in a mechanical prosthesis is
caused by impaired occluder opening due to
thrombosis or pannus (tissue ingrowth), both of
which may or may not be directly visible on TOE
(fig 8). While thrombus is often associated with
dense surrounding spontaneous echo contrast, a
history of suboptimal anticoagulation, and occurs
more often on mitral than aortic prostheses due to
higher flow velocities across the latter,12 pannus
tends to be more echodense than thrombus, arises
Figure 9
(A) Degenerative stenosis
in a mitral bioprosthesis.
Transoesophageal view.
Note reduced opening of
the thickened leaflets. LA,
left atrium; LV, left
ventricle.
(B) Corresponding
transprosthetic continuous
wave Doppler recording,
showing notably elevated
mean diastolic gradient of
15 mm Hg.
80
from the prosthetic ring suture line, and only rarely
occurs early postoperatively.13 Nevertheless, both
pathologies may coexist and often cannot be
differentiated with confidence.
The management options for prosthetic throm-
bosis have been studied in a number of observa-
tional studies.12 It seems that small, asymptomatic
thrombi not causing embolism or haemodynamic
instability can be treated conservatively by ensur-
ing adequate anticoagulation. Laplace et al, using
routine postoperative transoesophageal echocardio-
graphy, have observed an incidence of 9.4% of
thrombi early postoperatively in 680 mechanical
mitral valve replacements.14 Except for two
obstructive thrombi treated surgically, all non-
obstructive thrombi were treated medically in a
non-standardised fashion by re-initiation of
heparin, re-adjustment of oral anticoagulation, or
addition of aspirin. If patients were stratified by
thrombus size, 22% of patients with thrombi
>5 mm experienced complications (including neu-
rologic ischaemic events) over the next month, but
only one patient (3.4%) with a thrombus ,5 mm.
Elaborate management algorithms have been
recommended for the choices between anticoagu-
lation, thrombolysis, and reoperation, depending
on the presence of obstruction, embolism, or
haemodynamic compromise.11 12 15 16
Bioprosthetic ageing leads to degenerative
changes which manifest as leaflet thickening and
reduced mobility, with the consequence of func-
tional obstruction (fig 9).
Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074
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Figure 10 Mechanical
prosthesis in the aortic
position with
paraprosthetic leak in the
region of the left coronary
sinus (arrows).
(A) Transoesophageal
colour Doppler long axis
view.
(B) Transoesophageal
colour Doppler short axis
view. Ao, ascending aorta;
LA, left atrium.
Patient–prosthesis mismatch
If the size of a prosthesis is too small for the size of
the patient (‘‘a mosquito valve in the heart of a
whale’’), it will cause functional obstruction
despite mechanically functioning well. This con-
cept, originating from Rahimtoola,17 has received
attention especially in aortic valve prostheses, but
is also applicable to mitral prostheses. Crucial for
mismatch considerations is the effective orifice area
of the prosthesis, which is indexed by body surface
area to yield the ‘‘indexed effective orifice area’’ in
an individual patient. This effective orifice area is
not to be confused with the manufacturer’s
‘‘internal geometric area’’, which, like the valve
ring size, has only a loose relationship to effective
orifice area. For example, for a bileaflet Sorin
Bicarbon mechanical prosthesis size 21, the effec-
tive orifice area is only 1.66 cm2,18 less than half the
number calculated by assuming a circle of 21 mm
diameter (which would come to 3.46 cm2). For
aortic prostheses, an area of 0.85 cm2/m2 body
surface area is an accepted cut-off value below
which patient–prosthesis mismatch is assumed,
and a cut-off of 0.65 cm2/m2 has been proposed for
severe mismatch. Mild mismatch has been found in
one third to one half of aortic valve replacements,19
and severe mismatch (indexed orifice area
,0.65 cm2/m2) is present in ,10% of patients.19 20
The presence of patient–prosthesis mismatch
has been reported to predict less reversal of
hypertrophy and lower postoperative ejection
fraction (in aortic prostheses19 20), persistent pul-
monary hypertension (in mitral prostheses21), and
Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074
Education in Heart
in general an adverse prognosis.19–21 Different
findings, however, have been reported by other
researchers and a vivid debate surrounds the
definition, grading, and clinical relevance of mis-
match.22–25 Moreover, the estimation of effective
orifice area is difficult, at least in vivo, since it may
not be flow independent and the calculation of
effective orifice area, especially in bileaflet mechan-
ical prostheses, is unreliable due to localised
pressure gradients, as discussed in the section on
obstruction. Effective orifice areas calculated by the
continuity equation therefore are likely to under-
estimate true effective orifice area substantially.
Importantly, in a mechanical aortic prosthesis it is
not possible to distinguish from Doppler data alone
(that is, without additional baseline data and/or
direct imaging of occluding disc motion):
1. High gradients due to localised pressure
gradients in a normally functioning and not
mismatched prosthesis
2. High gradients due to mechanical obstruction
(thrombus, pannus)
3. High gradients due to patient–prosthesis
mismatch, with a normally functioning valve,
or
4. Any combination of 1–3.
Regurgitation
Regurgitation in a prosthetic valve is often difficult
to assess. Mitral prostheses, especially mechanical
ones, create acoustic shadowing of the left atrium
81
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Education in Heart

Figure 11 Mechanical bileaflet prosthesis in the mitral position. Transoesophageal view with the cross section aligned to leaflet axis orientation.
(A) Two dimensional (2D) image. LA, left atrium. (B) Colour Doppler visualisation of paraprosthetic leak (arrow); note well developed proximal
convergence zone of paraprosthetic leak; transoesophageal two chamber view. (C) Corresponding 2D zoom of discontinuity between sewing ring and
heart wall producing the leakage. (D) Continuous wave Doppler recording of transmitral flow. Peak regurgitant systolic velocity is approximately 4 m/s,
implying massively elevated peak systolic left atrial pressure at a systolic blood pressure of 100 mm Hg (100264 = 36 mm Hg). Note also elevated
diastolic transprosthetic velocities (maximal velocity .2 m/s) due to regurgitant volume.

when interrogated from the apical window, often
precluding colour Doppler assessment of the left
atrium. The parasternal and subcostal views
should be used with particular care to look for a
regurgitant jet in this situation. Moreover, more
than mild regurgitation often is detectable by the
proximal convergence zone on the ventricular, and
thus unobstructed, side of a mitral prosthesis, and
such convergence zones should be sought in all
apical views. TOE is of particular value to assess
mitral prosthetic regurgitation.26
All currently implanted mechanical prostheses
are designed to allow a minor amount of trans-
valvular leakage, which in the most common
bileaflet valves is supposed to prevent stasis and
thrombus formation at the leaflet hinges. This
leakage is detectable throughout the interval in
which the prosthesis is in the closed position, and
thus is different from the ‘‘closure leakage’’
occurring early when the leaflets move to the
closure position. Typically, the inbuilt prosthetic
leakage creates characteristic jet patterns detect-
able on colour Doppler, especially by TOE, which
arise at the hinge points in bileaflet valves or
centrally—for example, in the Medtronic-Hall
tilting disc valve.27 These jets are strictly transvalv-
ular—that is, they occur within the sewing ring.
They also are often too small to display a clearly
aliased turbulence zone.
Regurgitant jets arising outside the sewing ring are
due to paraprosthetic leaks, which can occur in any
size and position along the prosthetic circumference
(figs 10 and 11). Large paraprosthetic leaks lead to
prosthetic dehiscence, which is a term used if the
whole of the prosthesis develops a rocking motion
due to insufficient support. Small paraprosthetic

82 Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074

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Education in Heart

Figure 12 Severe
staphylococcal
endocarditis of
bioprosthetic aortic valve
replacement.
(A) Transoesophageal long
axis view. Upper arrow
indicates thickening of
posterior aortic wall
indicating abscess
formation. Lower arrow
points at vegetations in the
left ventricular outflow
tract. (B) Transoesophageal
short axis view. Solid
arrow indicates fistula to
right atrium. Dotted arrow
points at echolucent
abscess centre in the aortic
wall; the abscess is very
large and encompasses
almost half the
circumference of the
prosthesis (from
approximately 11 to 4
o’clock). Ao, ascending
aorta; LA, left atrium,
LV, left ventricle; RA, right
atrium; RV, right ventricle.

leaks observed intraoperatively after valve replace-
ment may close over the next hours or days.28
Observation of a new paraprosthetic leak in a
prosthesis is very suspicious of infective endocarditis.
Finally, in rare instances, there may be massive
transprosthetic regurgitation due to loss of struc-
tural integrity of the prosthesis—notoriously this
occurred in a series of tilting disc valves that suffered
from strut fractures, with subsequent disc embolisa-
tion and catastrophic regurgitation. Massive regur-
gitation can also occur if mechanical obstruction
by thrombus or pannus freezes the occluder in a
Echocardiography follow-up after valve replacement: key points
c Echocardiography is the crucial and usually sufficient imaging technique in the
follow-up of patients with valvular prostheses. Whenever prosthetic
dysfunction or endocarditis is suspected, transoesophageal echocardiography
(TOE) due to its higher diagnostic yield should be harnessed. Especially in
aortic mechanical prostheses, occluder motion is often not well seen even by
TOE and may necessitate fluoroscopy for precise assessment.
c Even normally functioning prostheses, except homografts and autografts,
create some degree of obstruction to flow, and most exhibit some degree of
regurgitation. Therefore, baseline echocardiographic assessment early
postoperatively, when normal prosthetic function can be assumed, is
extremely valuable for later comparison. This is of particular importance in the
assessment of aortic transprosthetic gradients, which have a wide range of
normalcy.
c Echocardiography, if necessary including TOE, should be promptly performed
in newly symptomatic patients with valvular prostheses. Routine yearly
echocardiographic examination is recommended after the fifth year in patients
with a bioprosthesis.
semi-open position. In bioprostheses, minor regur-
gitation is frequent and may increase in severity if
degenerative changes (restricted leaflet motion or
leaflet tears) ensue. Endocarditis is always a concern
in a newly detected prosthetic regurgitation.
Grading of severity of regurgitation follows the
general principles for native valves.29
Infective endocarditis
Cardiac valve prostheses carry a high risk of
infective endocarditis. During the first year after
implantation, the rate has been estimated to be
3%, and approximately 0.5%/year thereafter.30 31
Especially in mechanical prostheses, identifying
small vegetations is very difficult. In bioprostheses,
on the other hand, the presence of degenerative
leaflet changes with thickening and increased
echogenicity often makes it difficult or impossible
to exclude incipient endocarditis with confidence.
Moreover, an unsatisfactory sensitivity for the
detection of paraprosthetic abscesses has been
noted, which has not decreased substantially in
spite of today’s higher image quality. Therefore,
the clinical suspicion of endocarditis in a patient
with a prosthetic valve should regularly lead to a
transoesophageal examination, as recommended
by the European guidelines.32 Much higher diag-
nostic accuracy for vegetations and in particular for
abscess detection (fig 12) has been well documen-
ted for TOE.33
FOLLOW-UP: WHEN AND HOW?
It is crucial that each patient who has received a
valve replacement should receive a ‘‘baseline’’ echo

Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074 83

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Education in Heart
You can get CPD/CME credits for Education in Heart
Education in Heart articles are accredited by both the UK Royal College of
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after the operation to be able to compare with
subsequent findings. The examination should be
performed at a time when the patient is haemo-
dynamically stable, off ventilator or circulatory
support and mobilised, with special attention to
transprosthetic gradients and the presence of
regurgitation; within 12 weeks after operation is
the current recommendation,16 although it seems
reasonable to perform this earlier—for example,
before discharge from hospital. TOE is not
routinely required if the prosthesis appears to
function normally. Recently, the routine post-
operative performance of TOE in patients with
mitral mechanical prostheses has been advocated
based on findings of clinically silent, postoperative
thrombi in 10%,14 which predicted a higher adverse
event rate during follow-up. However, it remains
to be proven whether such a strategy would entail
significant and beneficial changes in patient
management.
Further regular follow-up should be planned.
The intervals are largely arbitrary; current
European guidelines stipulate yearly clinical exam-
inations and ‘‘Transthoracic echocardiography
should be performed if any new symptoms occur
after valve replacement or if complications are
suspected. Yearly echocardiographic examination is
recommended after the fifth year in patients with
bioprosthesis’’.16
Competing interests: In compliance with EBAC/EACCME guide-
lines, all authors participating in Education in Heart have disclosed
potential conflicts of interest that might cause a bias in the article.
The authors have no competing interests.
Provenance and peer review: Commissioned; internally peer
reviewed.
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84
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Heart 2010;96:75–85. doi:10.1136/hrt.2008.152074
Education in Heart
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