Evaluation of Prosthetic Valve Function With Cardiovascular Imaging
Summary of Key Points
Key Points for Assessing PHVs
- The different types of PHVs must be understood before assessing the hemodynamics of PHV function. Knowledge of the type and size of the valve in a particular patient is important.
- Bioprosthetic valve dysfunction can be divided into the following categories: SVD, nonstructural valve dysfunction, thrombosis, and endocarditis.
- A comprehensive assessment of prosthetic valve function includes echocardiographic imaging (2D and 3D), Doppler evaluation, and pertinent clinical information.
- Stress echocardiography can be useful to evaluate symptoms in patients with prosthetic valves.
- Two-dimensional TEE and 3D TEE remain the mainstay for intraoperative and intraprocedural guidance for PHV deployment.
- CT and CMR provide complementary and valuable information to a transthoracic echocardiographic evaluation of PHV. CT is particularly helpful in assessing valvular anatomy, while CMR can provide hemodynamic evaluation.
Key Points for Assessing Prosthetic Mitral Valves
- Assessment of prosthetic mitral valve function begins with knowledge of the type and size of the prosthetic valve implanted.
- Structural and hemodynamic evaluation with TTE and TEE provides key understanding of the function of the prosthetic mitral valve.
- From the Doppler interrogation of prosthetic mitral valves, peak velocity, mean gradient, PHT, EOA or DVI, and heart rate should be measured whenever feasible and reported.
- Because of shadowing and flow masking in the left atrium, particularly in mechanical mitral valves, significant prosthetic MR may be missed with color Doppler on TTE. Clues for significant MR from spectral Doppler include increased mitral peak early velocity, mean gradient, DVI, and a relatively low systemic stroke volume in relation to total LV stroke volume. TEE is indicated in suspected cases of significant MR.
- TEE (2D and 3D) provides an en face view of the prosthetic mitral valve which allows the evaluation of valve structure, occluder motion, and the presence, location, and extent of valvular regurgitation; the latter are crucial in guiding interventional procedures.
- CT and CMR provide complementary evaluation of prosthetic mitral valves, particularly when further information is needed regarding prosthetic structure, function, or associated complications. CT allows the evaluation of valve structure and mechanical valve occluder motion, as well as the localization of significant paravalvular regurgitation and identification of associated complications. CMR allows the evaluation of valvular structure of bioprosthetic valves and is particularly helpful in quantitation of prosthetic MR and LV remodeling.
Key Points for Assessing Prosthetic Pulmonary Valves and Conduits
- Assessment of a prosthetic pulmonary valve requires an understanding of the different types of valves and valved conduits that are placed.
- Evaluation with echocardiography may require off-axis, unconventional views.
- Doppler-derived peak velocity and mean gradient (and possibly DVI) where feasible should be measured and reported.
- For valve regurgitation, color Doppler interrogation, spectral Doppler recording of the jet with attention to its intensity and slope are necessary.
- CT and CMR offer better delineation of prosthetic pulmonary valves regarding thrombus and calcification. CMR is particularly helpful in quantitation of PR.
- There is a paucity of data evaluating PR in prosthetic valves; the information available is mostly extrapolated from assessment of native valves.
Key Points for Assessing Prosthetic TVs
- A comprehensive evaluation of TVR requires multiple imaging planes in which 2D and 3D and Doppler echocardiography are used to assess valvular structure and function, as well as right heart chamber size and function. Because of shadowing and flow masking in the right atrium, particularly in mechanical TVs, screening for TR should include modified RV inflow and subcostal views as well as PW Doppler interrogation of hepatic vein flow, where feasible.
- From the Doppler recordings of prosthetic TVs, peak velocity, mean gradient, PHT, and heart rate should be measured and reported whenever feasible. There is less experience with EOA and DVI of TVR.
- Several factors can affect mean TV gradient in the absence of prosthetic valve dysfunction, including heart rate, flow, prosthesis size and type; considering these confounders, we suggest use of prosthesis type-specific cutoffs for determination of prosthetic TV stenosis.
- A multiparametric echocardiographic approach for assessing prosthetic TV regurgitation is required, as validation of quantitative methods is lacking.
- CMR may be useful for quantifying regurgitant volume and fraction; however, validation of its use in prosthetic valve function is lacking.
- CT is helpful in identifying mechanisms of valve dysfunction, localization of significant PVLs and is essential in planning percutaneous interventions on the TV.
Key Points for the Evaluation of Prosthetic Valves in CHD
- Evaluation of prosthetic valves in CHD may require modifications to standard transthoracic and transesophageal echocardiographic views.
- An understanding of different CHD anatomy, conduits, and hemodynamics is required in the evaluation of PHV in CHD.
- Three-dimensional echocardiography can provide valuable anatomic information and en face views of the PHV in CHD.
- CT and CMR provide additional means of imaging PHVs in CHD.
Evaluation of Prosthetic Valve Function With Cardiovascular Imaging
January 3, 2024
Last Updated Month/Year
January 4, 2024
Country of Publication
In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Outpatient, Radiology services, Operating and recovery room
Nurse, nurse practitioner, physician, physician assistant
Assessment and screening, Management
D002318 - Cardiovascular Diseases, D000072226 - Computed Tomography Angiography, D003935 - Diagnostic Techniques, Cardiovascular, D006350 - Heart Valve Prosthesis
echocardiography, prosthetic valves, Doppler echocardiography, computed tomography
William A. Zoghbi, Pei-Ni Jone, Mohammed A. Chamsi-Pasha, Tiffany Chen, Keith A. Collins, Milind Y. Desai, Paul Grayburn, Daniel W. Groves, Rebecca T. Hahn, Stephen H. Little, Eric Kruse, Danita Sanborn, Sangeeta B. Shah, Lissa Sugeng, Madhav Swaminathan, Jeremy Thaden, Paaladinesh Thavendiranathan, Wendy Tsang, Jonathan R. Weir-McCall, Edward Gill, Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography, Journal of the American Society of Echocardiography, Volume 37, Issue 1, 2024, Pages 2-63, ISSN 0894-7317, https://doi.org/10.1016/j.echo.2023.10.004.