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MEDIC MSCT in the Evaluation of Prosthetic Heart Valves Dysfunction Nguyen Xuan Trinh, MD Prof Pham Nguyen Vinh, MD Department of Cardiology- Medic Medical Center Prosthetic Heart Valve (PHV) MEDIC  In 2003, approximately 290,000 patients worldwide underwent heart-valve replacement and received a Prosthetic heart valve (PHV) ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) Type of Prosthetic Heart Valves (PHV) MEDIC Mechanical PHV Biological PHV PHV Dysfunction MEDIC  PHV dysfunction is a rare, but potentially life-threatening complication  In clinical practice, PHV dysfunction poses a diagnostic dilemma ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) PHV Dysfunction MEDIC  Structural valve dysfunction: degeneration, wear, fracture, and disc escape  Nonstructural dysfunction: pannus formation , paravalvular leak, inappropriate sizing or positioning of the PHV, residual leak or obstruction after valve implantation ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) Imaging techniques MEDIC  Have a key role in PHV assessment and the detection of PHV dysfunction: TTE, TEE, 3D-TEE and fluoroscopy  Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice  These techniques sometimes fail to determine the specific cause of PHV dysfunction ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) Imaging techniques MEDIC  Over the past years, MSCT also has shown potential for PHV assessment  MSCT can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complementary information for surgical planning in case of reoperation  Cardiac MRI has limited value in the evaluation of biological PHV dysfunction ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) Evaluation of Native or Prosthetic Valves MEDIC MEDIC  MSCT With Mechanical PHV, opening and closing angles can be measured as accurately as with fluoroscopy  Biological leaflet thickening or calcification and leaflet restriction can also be detected ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) MEDIC Residual opening angle (normal limit ≤ 20°)-MSCT (Tsai et al AJR 2011; 196:353–360) PHV thrombus MEDIC ( Jonathan Chan et al Circulation 2009;120:1933-1934 ) Suggested Non-invasive Imaging Protocol in the Diagnostic Suspected PHV dysfunction MEDIC ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) Biological PHV dysfunction MEDIC  Most notably, biological PHVs degenerate after a variable time period (10–20 years)  TTE and TEE are the preferred imaging techniques to assess biological PHV dysfunction, but both techniques can fail to identify the exact cause of the PHV obstruction  Cardiac MRI and MSCT can have complementary value, especially by identifying pannus tissue or subvalvular obstruction ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) MEDIC Case  45F, Mechanical AVR and MVR (2009),  MV Prosthesis were stuck ( times)  Mechanical AVR and Bio-Prosthetic MV (2009)  Anticoagulation had been discontinued  Upon admission: increased Grd peak/ mean across the aortic valve: 74/33mmHg  TTE, TEE, Fluoroscopy, 640-slice MSCT suggestive of prosthetic valve dysfunction ( Pannus or Thrombus) Residual Opening Angle MEDIC MSCT Imaging of Mechanical Aortic Valveposterior leaflet restriction MEDIC Pannus Imaging MEDIC MEDIC MOVIE MEDIC Case  62M, Bio-Prosthetic AVR (2011)  Irregular check up  Upon admission: increased Grd peak / mean across the aortic valve: 220/140mmHg  TTE, TEE suggestive of prosthetic valve dysfunction ( Subvalvular mass ?)  640-slice MSCT suggestive of prosthetic valve dysfunction ( leaflet restriction, biological PHVs degenerate ) and severe paravalvular calcification  Reoperative repair : 12/ 2013 MEDIC Biological PHV Thickening and Degenerate MEDIC Biological PHV Thickening and Degenerate- leaflet restriction MEDIC Biological PHV Thickening, Degenerate and Severe Paravalvular Calcification MEDIC MOVIE CONCLUSIONS MEDIC  Echocardiography are commonly used diagnostic techniques but identification of the exact cause of PHV obstruction (thrombus vs pannus) is difficul  MSCT:  Additional diagnostic value in the evaluation of PHV dysfunction  More complete assessment of the cause of PHV dysfunction and the surrounding anatomy  Key role in preoperative surgical planning and exclusion of CAD MEDIC Thank you for your attention [...]... anatomical abnormalities causing PHV obstruction (Pannus)  Enable the differentiation between a pannus and a thrombus on density ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) Disadvantages of MSCT MEDIC  Radiation exposure  640 slice- MSCT: lower radiation doses  Need for contrast injection  Morbidity and mortality associated with PHV dysfunction is high and MSCT can help to... Diagnostic Suspected PHV dysfunction MEDIC ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) Biological PHV dysfunction MEDIC  Most notably, biological PHVs degenerate after a variable time period (10–20 years)  TTE and TEE are the preferred imaging techniques to assess biological PHV dysfunction, but both techniques can fail to identify the exact cause of the PHV obstruction  Cardiac... identifying pannus tissue or subvalvular obstruction ( Jesse Habets Computed Tomography of Prosthetic Heart Valves 2012 ) MEDIC Case 1  45F, Mechanical AVR and MVR (2009),  MV Prosthesis were stuck ( 2 times)  Mechanical AVR and Bio-Prosthetic MV (2009)  Anticoagulation had been discontinued  Upon admission: increased Grd peak/ mean across the aortic valve: 74/33mmHg  TTE, TEE, Fluoroscopy, 640-slice