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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
slide4

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
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
slide31

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 )
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
impression1
Impression
  • Tissue valve opening well
  • Tilting valve
  • Significant gradient across aortic end of valve
course
Course
  • Discharged for second opinion
  • Lost follow up
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.
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

slide87

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.
slide90

. 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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