Alsharqia riyadh echo meeting
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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

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Alsharqia riyadh echo meeting

Alsharqia.riyadh Echo meeting

Dammam KSA

SAYED ABOU EL SOUD MD

SBCC


Case 1

Case 1


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


Alsharqia riyadh echo meeting

  • 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


Preoperative tee

PREOPERATIVE TEE


Impression

IMPRESSION

  • 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


Alsharqia riyadh echo meeting

  • GEOMETRIC ORIFICE AREA ( area blood flow through )

  • MOUNTING AREA (area occupied by the valve in the native annulus )


Implant technique

IMPLANT TECHNIQUE

  • 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

  • Aortic patch ( dilate aorta )

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

  • Myomectomy ( dilate LVOT )


Postoperative tee

POSTOPERATIVE TEE


Postoperative tte

POSTOPERATIVE TTE


Case 2

Case 2


History1

History

  • 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

  • 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


Alsharqia riyadh echo meeting

TTE


Alsharqia riyadh echo meeting

TEE


Impression1

Impression

  • Tissue valve opening well

  • Tilting valve

  • Significant gradient across aortic end of valve


Course

Course

  • Discharged for second opinion

  • Lost follow up


Case 3

Case 3


History3

History

  • 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.


Alsharqia riyadh echo meeting

TTE


Alsharqia riyadh echo meeting

TEE


Impression2

Impression

  • 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

  • very high risk for REDO surgery

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


Arguments

Arguments

  • 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

Left for respected panel


Alsharqia riyadh echo meeting

  • Published data about Doppler hemodynamic parameters of normofunctioning prosthetic valves in aortic position


Baseline valve assessment

Baseline valve assessment

  • 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.


Alsharqia riyadh echo meeting

  • . 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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