Clinical Investigation
Mechanical Tricuspid Prosthetic Valve Function
Multiparametric Approach for the Assessment of Mechanical Prosthetic Tricuspid Leaflet Function

https://doi.org/10.1016/j.echo.2021.09.001Get rights and content

Highlights

  • MPTV dysfunction often involves disks stuck in the open or semiopen position.

  • TEE improves detection of MPTV thrombosis over TTE but not evaluation of disk motion.

  • Spectral Doppler variables show high accuracy in detection of MPTV disk malfunction.

  • Multiparametric TTE allows accurate assessment of MPTV disk function.

Background

There is a lack of comprehensive echocardiographic data to allow discrimination of normal versus abnormal mechanical prosthetic tricuspid valve (MPTV) leaflet function. The identification of such parameters is essential to optimize diagnostic and therapeutic measures.

Methods

The authors investigated bileaflet MPTV function by comparing transthoracic echocardiographic data from 21 episodes of leaflet dysfunction due to valve thrombosis in 12 patients with data from 56 individuals with normal MPTV function. All episodes of dysfunction were confirmed by transesophageal echocardiography and/or cine fluoroscopy. Transthoracic echocardiography–derived two-dimensional, color, and spectral Doppler variables, including MPTV peak early diastolic velocity (E velocity), mean gradient, pressure half-time, time-velocity integral (TVI) of the MPTV, ratio of TVIMPTV to TVI of the left ventricular outflow tract (LVOT) and TVI of the right ventricular outflow tract (RVOT), and continuity-derived effective orifice area, were measured in both groups.

Results

Most episodes of MPTV dysfunction resulted from simultaneous involvement of both leaflets (57%), with leaflet(s) often immobilized in the open or semiopen position (71%). Transthoracic and transesophageal echocardiography performed similarly in detecting abnormal leaflet motion (90% vs 88%, P = .68), whereas transesophageal echocardiography was better in identifying MPTV thrombosis (31% vs 14%, respectively, P = .01). Color Doppler demonstrated flow propagation abnormalities in 67% of episodes of leaflet dysfunction but not in the control group (P < .0001). Doppler variables associated with MPTV leaflet dysfunction included E velocity > 1.6 m/sec, mean gradient > 5 mm Hg, PHT > 157 msec, TVIMPTV > 42 cm, TVIMPTV/TVILVOT > 2.3, TVIMPTV/TVIRVOT > 3.0, and continuity-derived effective orifice area ≤ 1.1 cm2, with most variables showing high and similar accuracy (area under the curve ≥ 95%).

Conclusions

This study represents the first comprehensive echocardiographic assessment of MPTV leaflet dysfunction that provides parameters and criteria to distinguish normal versus abnormal prosthetic valve function.

Section snippets

Methods

The study was conducted at the King Faisal Specialist Hospital & Research Center, from which all patients were included. The study was approved by the institutional review board under the Heart Center valve registry. No industry support was provided.

Patient Characteristics

Patient characteristics in the control and leaflet dysfunction groups are listed in Table 1. At a mean follow-up of 53 ± 56 months (range, 3–249 months), 21 episodes of MPTV leaflet dysfunction were detected in 12 of 68 patients (18%). Most patients (76%) were women, and none was pregnant. Seven patients experienced single episodes of leaflet dysfunction, two patients experienced two episodes each, two patients experienced three episodes each, and one patient experienced four episodes. In the

Discussion

This report represents the largest and most detailed analysis to date that aimed to identify the echocardiographic parameters associated with normal as well as abnormal MPTV leaflet function due to valve thrombosis. We suggest that a comprehensive transthoracic echocardiographic approach incorporating 2D, color, and spectral Doppler imaging is essential for the optimal assessment of MPTV function. On the basis of comparison with normally functioning prostheses, we propose cutoff values for

Conclusion

This study represents the first comprehensive echocardiographic assessment of leaflet dysfunction due to valve thrombosis in patients with bileaflet MPTVs. Because of the small sample size and retrospective nature of our study, our findings require further confirmation. We suggest that MPTV dysfunction can be identified on TTE using a multiparametric approach, and we propose an algorithm integrating several transthoracic echocardiographic parameters to distinguish normal from abnormal MPTV

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Conflicts of Interest: None.

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