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Alsharqia.riyadh Echo meeting. Dammam KSA SAYED ABOU EL SOUD MD SBCC. Case 1. History. 48 y old Saudi lady Hypothyroidism,ch . Spondylisis H/O intracranial HTN 6 years before admission & ventriculoperitoneal shunt ( removed later )

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Alsharqia riyadh echo meeting

Alsharqia.riyadh Echo meeting

Dammam KSA

SAYED ABOU EL SOUD MD

SBCC



History
History

  • 48 y old Saudi lady

  • Hypothyroidism,ch. Spondylisis

  • H/O intracranial HTN 6 years before admission & ventriculoperitoneal shunt ( removed later )

  • Labarscopiccholecystecomy & RT modified mastectomy

  • Now neurologically grossly intact


  • S/P AVR in other hospital with tissue valve size 21 ( mosaic valve ) in 6/2011 ( 2 ys ago )

  • Presented to SBCC ( 2 month ago) with C/O chest pain , dyspnea and syncobal attacks

  • O/E obese well oriented pt

  • Ejection syst . murmer

  • ECG LV hypertrophy & strain

  • HB is 12.6 , creatinine 1.5


Preoperative tte

Preoperative TTE mosaic valve ) in 6/2011 ( 2 ys ago )


Preoperative tee

PREOPERATIVE TEE mosaic valve ) in 6/2011 ( 2 ys ago )


Impression
IMPRESSION mosaic valve ) in 6/2011 ( 2 ys ago )

  • 48 y lady , obese , multiple co morbidities

  • Severely symptomatic relatively early postoperative

  • Significant :

    • gradient across AV & OFT

    • Severe LVH , normal LV function

    • Tilting partially supra- annular valve

    • leaflets opening well

    • Remnants of the native valve in 1st operation



Implant technique
IMPLANT TECHNIQUE mosaic valve ) in 6/2011 ( 2 ys ago )

  • TOATLLY INTRA ANNULAR : GOA/MOUNTING AREA = 40-70 %

  • PARTIAL SUPRA-ANNULAR : GOA/MOUNTING AREA= 80 %-85 %

  • TOTALLY SUPRAANNULAR : APPROACHES 100% MAXIMIZING BOOLD FLOW


Surgery
Surgery mosaic valve ) in 6/2011 ( 2 ys ago )

  • Aortic patch ( dilate aorta )

  • Valve replacement (tissue valve ) has Hx of intracranial HGE

  • Myomectomy ( dilate LVOT )


Postoperative tee

POSTOPERATIVE TEE mosaic valve ) in 6/2011 ( 2 ys ago )


Postoperative tte

POSTOPERATIVE TTE mosaic valve ) in 6/2011 ( 2 ys ago )


Case 2

Case 2 mosaic valve ) in 6/2011 ( 2 ys ago )


History1
History mosaic valve ) in 6/2011 ( 2 ys ago )

  • 46 y old saudi female

  • K/C of HTN, hypothyroidism

  • K/C AVD, bicuspid AV with sever AS

  • S/P AVR “tissue valve”1 year ago


History2
History mosaic valve ) in 6/2011 ( 2 ys ago )

  • presented to our ER C/O

    • progressive exertional dyspnea up to NYHA III.

    • She also c/o of chest pain & near syncopal attacks

  • O/E

    • Pt had mild pulm. congestion & uncontrolled B/P 160/95

    • Ejection systolic murmur over the AV


TTE mosaic valve ) in 6/2011 ( 2 ys ago )


TEE mosaic valve ) in 6/2011 ( 2 ys ago )


Impression1
Impression mosaic valve ) in 6/2011 ( 2 ys ago )

  • Tissue valve opening well

  • Tilting valve

  • Significant gradient across aortic end of valve


Course
Course mosaic valve ) in 6/2011 ( 2 ys ago )

  • Discharged for second opinion

  • Lost follow up


Case 3

Case 3 mosaic valve ) in 6/2011 ( 2 ys ago )


History3
History mosaic valve ) in 6/2011 ( 2 ys ago )

  • 18 yeas old saudi male.

  • s/p AVR “ metalic valve” & closure of VSD in another hospital

  • Pt presented to OPD completely asymptomatic.

  • Pt referred for echocardiography as baseline post operative echo.


TTE mosaic valve ) in 6/2011 ( 2 ys ago )


TEE mosaic valve ) in 6/2011 ( 2 ys ago )


Impression2
Impression mosaic valve ) in 6/2011 ( 2 ys ago )

  • Severely impaired LV function. ( normal preoperative )

  • tilting valve with Significant gradient across the aortic end . ( false moderate gradient due to LV dysfunction )

  • Fluoroscopy showed freely mobile leaflets with full range of movement


Course1
Course mosaic valve ) in 6/2011 ( 2 ys ago )

  • very high risk for REDO surgery

  • Pt preferred to be referred back to the hospital where he performed 1st surgery


Arguments
Arguments mosaic valve ) in 6/2011 ( 2 ys ago )

  • Partially supra annular implantation to incraese GVA IS OPTIMAL ???

  • Why gradients not usually appear immediate postoperative and appear later in follow up???


Home message

Home message mosaic valve ) in 6/2011 ( 2 ys ago )

Left for respected panel



Baseline valve assessment
Baseline valve assessment normofunctioning prosthetic valves in aortic position

  • Therefore, the optimal timing of the baseline assessment of valve prosthesis haemodynamics should be placed between the third and the sixth month (not later than 1 year) after surgery.


  • . In patients undergoing aortic valve replacement, there is a relatively high output state immediately after the operation due to relative anaemia and sudden reduction of left ventricular afterload, which affects transprosthetic gradients. Moreover, perivalvularoedema and haematoma may reduce prosthetic EOA. Finally, left ventricular function will change significantly soon after aortic valve replacement due to regression of hypertrophy and adaptation to the changed pre- and afterload conditions


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