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      Cine-Computed Tomography for the Evaluation of Prosthetic Heart Valve Function

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          Abstract

          Background: After aortic valve replacement (AVR), suspected prosthetic valve dysfunction (mechanical or biological) may arise based on echocardiographic transvalvular velocities and gradients, leading to reoperative surgical intervention being considered. Our experience has found that 4-dimensional (space and time) image reconstruction of ECG-gated computed tomography, termed cine-CT, may be helpful in such cases. We review and illustrate our experience. Methods: Twenty-seven AVR patients operated previously by a single surgeon (who performs >100 AVRs/year) were referred for repeat evaluation of suspected aortic stenosis (AS) based on elevated transvalvular velocities and gradients. The patients were fully evaluated by cine-CT. Results: In all but 2 cases, the cine-CT strikingly and visually confirmed normal leaflet function and excursion, with no valve thrombosis, restriction by pannus, or obstruction by clot. In only 2 cases did cine-CT reveal decreased mechanical valve leaflet excursion. Repeat surgery was required in only 1 case while all other patients continued clinically without cardiac events. Conclusions: Echocardiography is an extraordinarily useful tool for the evaluation of prosthetic valve function. Increased pressure recovery beyond the valve and other factors may occasionally lead to exaggerated gradients. Cine-CT is emerging as an extremely valuable tool for further evaluation of suspected prosthetic valve AS. Our experience has been extremely helpful, as is shown in the dramatically reassuring images.

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          Most cited references 10

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          Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging.

          Prosthetic heart valve (PHV) dysfunction is rare but potentially life-threatening. Although often challenging, establishing the exact cause of PHV dysfunction is essential to determine the appropriate treatment strategy. In clinical practice, a comprehensive approach that integrates several parameters of valve morphology and function assessed with 2D/3D transthoracic and transoesophageal echocardiography is a key to appropriately detect and quantitate PHV dysfunction. Cinefluoroscopy, multidetector computed tomography, cardiac magnetic resonance imaging, and to a lesser extent, nuclear imaging are complementary tools for the diagnosis and management of PHV complications. The present document provides recommendations for the use of multimodality imaging in the assessment of PHVs.
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            Echo/Doppler evaluation of hemodynamics after aortic valve replacement: principles of interrogation and evaluation of high gradients.

             David S Bach (2010)
            Echocardiography/Doppler is the standard clinical tool for the assessment of hemodynamics after aortic valve replacement. Analysis can include mean and peak transvalvular gradients, dimensionless valve index, effective orifice area from the continuity equation, geometric orifice area from planimetry, and energy loss coefficient. High gradients after aortic valve replacement can be, but are not necessarily, caused by left ventricular outflow obstruction; and not all left ventricular outflow obstruction after aortic valve replacement is due to prosthesis dysfunction. Understanding the methods by which echocardiography and Doppler are used to noninvasively assess aortic valve hemodynamics, and the caveats associated with those methods, can help the clinician distinguish obstructive from nonobstructive causes of high gradients, and prosthesis dysfunction from other causes of obstruction.
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              Impact of obesity and nonobesity on grading the severity of aortic valve stenosis.

              We tested the hypothesis that the disproportionate increase of body surface area in obesity may lead to the overestimation of aortic stenosis (AS) severity when the aortic valve area (AVA) is indexed (AVAI) for body surface area in 1,524 patients enrolled in the Simvastatin and Ezetimibe in AS study. Obesity was defined as a body mass index of ≥30 kg/m(2). Peak aortic jet velocity, mean aortic gradient, AVA, and energy loss (EL) did not differ, although AVAI and EL indexed (ELI) for body surface area were significantly smaller in the obese group (n = 321) compared with the nonobese (n = 1,203) group (both p 1.0 cm(2); AVAI/AVA discordance) was found in 15% of the patients, whereas severe AS by ELI ( 1.0 cm(2); ELI/EL discordance) was found in 9% of the patients. Obesity was associated with a 2.4-fold higher prevalence of AVAI/AVA discordance and a 1.6-fold higher prevalence of ELI/EL discordance. Discordant grading was also associated with male gender, larger body size, higher mean aortic gradient, and stroke volume (all p <0.05). During a median follow-up of 4.3 years, 419 patients were referred for aortic valve replacement and 177 patients died or were hospitalized because of heart failure. In the Cox regression analyses, AVAI/AVA discordance was associated with a 28% higher rate of aortic valve replacement (p <0.05) but did not predict the rate of combined death and hospitalization for heart failure. In conclusion, using AVAI and ELI for the grading of stenosis in patients with obesity may lead to overestimation of true AS severity.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2020
                July 2020
                26 May 2020
                : 145
                : 7
                : 439-445
                Affiliations
                aAortic Institute at Yale-New Haven, Yale University School of Medicine, New Haven, Connecticut, USA
                bDepartment of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
                cDepartment of Surgical Diseases, Kazan State Medical University, Kazan, Russian Federation
                Author notes
                *John A. Elefteriades, MD, PhD (hon), Aortic Institute at Yale-New Haven, Yale University School of Medicine, 789 Howard Ave, Clinic Bldg CB317, New Haven, CT 06519 (USA), john.elefteriades@yale.edu
                Article
                507182 Cardiology 2020;145:439–445
                10.1159/000507182
                32454507
                © 2020 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 3, Tables: 2, Pages: 7
                Categories
                Valvular Heart Disease: Research Article

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