Transesophageal echocardiographic (TEE) evaluation of the mitral and tricuspid valves

In skilled hands, multiplane TEE provides a comprehensive assessment of the anatomy and function of the mitral and tricuspid valves. TEE is uniquely effective in the evaluation of the diverse pathophysiologic processes that cause valvular heart disease.     

Serial Doppler echocardiographic evaluation of bioprosthetic valves in the tricuspid position

Objectives. This study sought to evaluate bioprosthetic valve dysfunction in the tricuspid position by serial Doppler echocardiography.

Background. Few reports on the long-term results of tricuspid valve replacement with bioprosthetic valves are evaluated by serial Doppler echocardiography.

Methods. Between September 1979 and December 1993, 95 patients underwent tricuspid valve replacement with bioprosthetic valves at our facility. Sixty patients who underwent serial Doppler echocardiographic examination at intervals of at least 2 years after operation were included in the final analysis. These patients were followed up from 1.5 to 13.0 years (mean 5.8 ± 2.5).

Results. The actuarial rates of freedom from bioprosthetic valve stenosis and regurgitation at 10 years were 46% and 51%, respectively. The prevalence of bioprosthetic valve stenosis and regurgitation increased progressively in a linear manner beginning 1 or 2 years after tricuspid valve replacement. Right heart failure developed during follow-up in 20 of the 25 patients with bioprosthetic valve dysfunction.

Conclusions. The long-term durability of bioprosthetic valves in the tricuspid position was substantially lower in our study than that reported in previous studies. Tricuspid bioprosthetic valve dysfunction increased progressively in a linear manner beginning 1 to 2 years after tricuspid valve replacement.     

Effectiveness of balloon percutaneous valvuloplasty for stenotic bioprosthetic valves in different positions

Percutaneous balloon valvuloplasty has been used as treatment for native valvular stenosis in the mitral, aortic, pulmonary and tricuspid positions. ^1–4 It has also been used as palliative therapy for stenotic bioprosthetic valves.^5–8 In this study we present the immediate results and midterm follow up of percutaneous balloon valvuloplasty of 5 bioprosthetic valves in different positions.     

Doppler and echocardiographic features of normal and dysfunctioning bioprosthetic valves

Echocardiographic and Doppler studies were performed on 183 clinically normal and 58 severely dysfunctioning bioprosthetic mitral, aortic and tricuspid valves. The valve dysfunction resulted from spontaneous cusp degeneration in 49 instances and from paravalvular regurgitation in 9. The pulsed Doppler study demonstrated regurgitant flow in 36 (92%) of 39 regurgitant valves and 8 (90%) of 9 paravalvular regurgitant valves. Diagnostic echocardiographic features were present in only 51 and 10% of the patients, respectively. Although the Doppler regurgitant jet was peripheral in seven of the nine patients with paravalvular regurgitation, it was not possible to differentiate these patients from those who had valve degeneration and cusp tear at the periphery of the valve ring. Eight patients presented with a musical holosystolic murmur of mitral insufficiency. In all eight there was a characteristic honking intonation on the audio signal and a striated shuddering appearance on the video Doppler signal. Ten stenotic mitral bioprosthetic valves (less than or equal to 1.1 cm2 valve orifice) were identified by Doppler study. Diagnostic echocardiographic features were present in only two of these patients. The Doppler-derived valve orifice dimension correlated well (r = 0.83) with cardiac catheterization values. Fourteen asymptomatic or minimally symptomatic patients had echocardiographically thickened mitral cusps (greater than or equal to 3 mm). These patients had a significantly (p less than 0.0001) smaller valve area as compared with normal control valves, and during 4 to 24 months of follow-up, five of these patients developed severe valve regurgitation or stenosis. Doppler ultrasound is more sensitive than echocardiography in diagnosing bioprosthetic valve stenosis and regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraoperative transesophageal echocardiographic diagnosis of a stuck bioprosthetic mitral valve leaflet

Stuck (immobilized) leaflet of a metallic mitral prosthetic valve due to obstruction by mitral subvalvular apparatus is a well recognized complication after placement of prosthetic valves. However, a stuck mitral valve leaflet involving a bioprosthetic valve has not been reported so far most likely because of increased pliability of tissue leaflets. We describe the first case of a stuck bioprosthetic mitral valve leaflet in which intraoperative transesophageal echocardiography was useful to make a definitive diagnosis and helped to resolve the problem immediately.     

Cross-sectional echocardiographic features of Ebstein's anomaly of the tricuspid valve

Multicrystal real time-motion echocardiographic studies of 10 patients with Ebstein's anomaly of the tricuspid valve are reported. Eight patients also underwent hemodynamic and angiographic study. All but one of the patients had inferior and leftward displacement of the tricuspid valve. In seven patients multiple echoes were obtained from the tricuspid valve; all seven manifested elongated tricuspid valve leaflets, and in six the leaflets were thickened. Excessive excursion of the tricuspid valve was noted in five patients and a “whipping” motion seen in three. Nonspecific findings in nine patients included an increased right ventricular dimension and systolic anterior septal motion. Thus, cross-sectional echocardiography provides distinctive diagnostic findings that are specific for Ebstein's anomaly.     

Doppler echocardiographic characteristics of normal and dysfunctioning prosthetic valves in the tricuspid and mitral position

The Doppler echocardiographic characteristics of 70 prosthetic valves in 35 patients are reported. Twenty nine patients had a Bj?rk-Shiley prosthesis in both mitral and tricuspid positions and six had Carpentier-Edwards valves in both sites. Five of the patients had abnormal tricuspid prostheses on the basis of clinical and echocardiographic criteria. Pulsed wave Doppler echocardiography was used in all examinations. The pressure half times for the normal tricuspid prosthetic valves, 105 (40) ms (Bj?rk-Shiley) and 97 (53) ms (Carpentier-Edwards), were significantly longer than those of normal mitral prosthetic valves, 75 (18) ms (Bj?rk-Shiley) and 83 (15) ms (Carpentier-Edwards). The range of pressure half times for the abnormal tricuspid valves (237-530 ms) was distinct from that of the apparently normal tricuspid prosthetic valves (38-197 ms). There was an increase in the peak velocity of the obstructed tricuspid prosthetic valves (1.69 (0.12) m/s) in comparison with normal prostheses (1.06 (0.26) m/s). The normal range of pressure half times for the Bj?rk-Shiley and Carpentier-Edwards valves in the mitral position is not applicable to the same valves in the tricuspid position. The valve appears to function well with very long pressure half times but a pressure half time of greater than 200 ms coupled with a peak velocity of greater than 1.60 ms without significant valve regurgitation indicates tricuspid obstruction of the tricuspid prosthetic valve.