Asian Cardiovasc Thorac Ann 2003;11:193-197
© 2003 Asia Publishing EXchange Ltd
Doppler Echocardiographic Evaluation of Prosthetic Valves in Tricuspid Position
Shigeaki Aoyagi, MD,
Hiroshi Tomoeda, MD,
Hiroshi Kawano, MD,
Shogo Yokose, MD,
Shuji Fukunaga, MD
Department of Surgery, Kurume University School of Medicine, Kurume, Japan
For reprint information contact: Shigeaki Aoyagi, MD Tel: 81 942 35 3311 Fax: 81 942 35 8967 email: aoyagi{at}med.kurume-u.ac.jp Department of Surgery (2), Kurume University School of Medicine, 67 Asahi-machi, Kurume 830-0011, Japan.
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ABSTRACT
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Doppler echocardiographic characteristics of 29 normally functioning prosthetic valves (23 mechanical, 6 biological) and 8 obstructed mechanical prostheses in the tricuspid position are reported. In normally functioning prostheses, peak velocity, mean pressure gradient, and pressure-half time were 1.25 ± 0.18 m•sec-1, 2.6 ± 1.1 mm Hg, and 122.6 ± 30.7 msec, respectively. Although no significant differences were seen in peak velocity and mean pressure gradient between mechanical and biological valves, the pressure half-time was significantly greater in biological valves. All normally functioning prostheses had a mean pressure gradient 5.5 mm Hg and pressure half-time < 200 msec. In obstructed bileaflet valves, peak velocity was 1.66 ± 0.28 m•sec-1, mean pressure gradient was 6.1 ± 2.8 mm Hg, and pressure half-time was 265.8 ± 171.7 msec. These Doppler data were significantly greater than those in normally functioning valves where the mean pressure gradient was 5.1 mm Hg and the pressure half-time was 156 msec in all except one patient. Pathological obstruction of a tricuspid prosthesis can be strongly suspected in patients with a mean pressure gradient > 5.5 mm Hg and a pressure half-time > 200 msec on Doppler echocardiography.
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INTRODUCTION
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Although tricuspid valve replacement (TVR) is an occasional procedure, necessary in certain cases of acquired valve disease and congenital abnormalities of the tricuspid valve, the incidence of prosthetic valve dysfunction is more frequent in the tricuspid position than in the aortic or mitral positions, regardless of whether a mechanical or biological valve is used.1–3 Recently, Doppler echocardiography has become the method of choice for assessing prosthetic valve hemodynamics, and acceptable Doppler data for normally functioning prosthetic valves are available for those in the mitral and aortic positions.4–6 However, information regarding Doppler data for prosthetic valves in the tricuspid position is scarce.7–12 This study was performed to define a normal range of Doppler data for bileaflet mechanical and biological valves in the tricuspid position. In addition, the Doppler characteristics of 8 obstructed tricuspid mechanical valves are described.
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PATIENTS AND METHODS
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Between May 1980 and January 2000, 31 patients underwent 39 operations for TVR at our hospital. There were 12 males and 19 females who ranged in age at each TVR from 5 to 70 years, with a mean age of 44.1 ± 15.5 years. At the initial TVR, 28 patients received a mechanical valve: St. Jude Medical (SJM; St. Jude Medical, Inc., St. Paul, MN, USA) in 23 patients, Advancing The Standard (ATS; ATS Medical, Inc., Minneapolis, MN, USA) in 5; and 3 had biological valves which were Carpentier-Edwards pericardial (CEP; Baxter Healthcare Corp., Irvine, CA, USA) in 2, and a Carpentier-Edwards supraannular valve (CE SAV) in the other. Among the 31 patients, 4 died before Doppler echocardiographic evaluation of their tricuspid SJM valves, and another died 100 days after triple-valve replacement with ATS valves. During follow-up, 9 patients developed obstruction of a tricuspid SJM valve; 8 underwent replacement of the prosthesis and the other underwent successful thrombolysis. Of the 8 redo patients, 5 received a biological valve (CEP in 4, CE SAV in 1) and 3 had a mechanical valve (SJM in 2, ATS in 1). In total, 31 mechanical valves (25 SJM, 6 ATS) and 8 biological valves (6 CEP, 2 CE SAV) were used for TVR in this series. Doppler echocardiographic examinations were performed for 23 mechanical valves (17 SJM, 6 ATS) and 6 biological valves (6 CEP) in the tricuspid position. In the patient who died after triple-valve replacement, Doppler echocardiographic evaluations of the ATS valves were repeatedly performed before his death, therefore, his Doppler data were included in this study. The Doppler data obtained from these 29 prosthetic valves form the basis of this study. The patients’ profile, valve pathology, and valves used for TVR are summarized in Table 1
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Prosthetic valve function was assessed by a routine physical examination, chest radiography, electrocardiogram, and M-mode and two-dimensional echocardiography in all patients. In those with a mechanical valve, leaflet movement was observed by cineradiography. An Aloka 870 SSD (Aloka, Inc., Tokyo, Japan) or a Hewlett-Packard 77025 (Hewlett-Packard, Andover, MA, USA) echocardiographic system was used in this series. A previously reported technique was employed for echocardiographic evaluation of prosthetic valves in the tricuspid position.7 Doppler data included peak velocity (PV), peak and mean pressure gradients (PG), and pressure-half time (PHT), and all calculations were the average of 5 cardiac cycles in patients with atrial fibrillation and 3 cycles in patients with sinus rhythm. Data from the earliest postoperative Doppler examination were used for each patient. Doppler examinations of ATS valves and CEP valves were performed within 30 days after surgery, but evaluation of SJM valves was obtained up to 146 months postoperatively (Table 1
) because Doppler echocardiography was unavailable in the early period of this series. Cineradiography was carried out as previously described, to obtain a tangential view of SJM valves in the tricuspid position.13 Leaflet movement was determined from frame-by-frame analysis of a single cardiac cycle, and opening and closing angles were measured in 3 cardiac cycles for each patient. Both angles were calculated as the distance (in degrees) between the two leaflets in the fully open and closed positions.
Results are expressed as mean ± standard deviation. Statistically significant differences between means of different groups were determined using the unpaired t test. A p-value of less than 0.05 was considered statistically significant.
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RESULTS
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Excellent Doppler recordings across the prosthetic valves were obtained and no significant tricuspid regurgitation was found in any patients. Doppler data for normally functioning prostheses are shown in Table 2. Although no significant differences were seen in PV and mean PG among the 3 types of normally functioning prostheses, the PHT was significantly longer in CEP valves than in SJM or ATS valves. All normally functioning prostheses had values of mean PG 5.5 mm Hg and PHT < 200 msec. When biological valves were excluded, the mechanical valves with normal function were found to have values of PV 1.55 m•sec-1 and mean PG 4.5 mm Hg. The PHT values in mechanical valves were < 150 msec in all patients except one who had a PHT of 195 msec.
On cineradiograms, restricted leaflet movement and fixation of at least one leaflet were confirmed in the 9 patients with obstruction of a SJM valve. Doppler data for the obstructed prostheses were obtained in 8 of these 9 patients (Tables 2 and 3). The mean opening angle is 12.3o ± 1.2o and the closing angle is 130.6o ± 1.2o in normally functioning tricuspid SJM valves.13 In the 8 obstructed SJM valves in this series, the mean opening angle was 60.0° ± 17.2° and the mean closing angle was 87.1° ± 32.6°. The individual Doppler data for PV, mean PG, and PHT obtained from the normally functioning and obstructed SJM valves are shown in Figure 1. The mean values of all Doppler data in patients with an obstructed valve were significantly higher (p < 0.01) than those in patients with a normally functioning valve. The values of mean PG were 5.1 mm Hg, and the PHT values were 156 msec in all but one of the patients with an obstructed SJM valve. The PV and mean PG values were significantly higher in obstructed SJM valves than in ATS and CEP valves (Table 2), but no significant differences were found in the PHT between obstructed SJM valves and ATS valves (p = 0.087), or between obstructed SJM valves and CEP valves (p = 0.189).
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DISCUSSION
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Over the 20 years of this series, we changed our choice of prosthesis for TVR from the SJM to the ATS valve, and more recently, we have employed biological valves because of the high incidence of obstruction of mechanical valves.1,2 However, according to a recent report, obstruction of biological valves is also relatively frequent in the tricuspid position.3 Regardless of whether a mechanical or biological valve is used, prosthetic valve obstruction is considered to be a major risk after TVR. To screen for pathological obstruction of prosthetic valves by echocardiography, it is essential to establish normal ranges of Doppler data for the various prostheses. Little information regarding Doppler data for normally functioning prosthetic valves in the tricuspid position has been reported.7–12
Connolly and colleagues8 emphasized that normal hemodynamics of tricuspid prostheses should ideally be determined during the first month after implantation, and from the average data over 10 cardiac cycles. Marti and colleagues9 pointed out that Doppler data obtained in a second study after an interval of 10 months showed no significant differences from those obtained in the first study. Although Doppler evaluation was performed late after implantation of 10 SJM valves, the other 19 were assessed within 30 days after TVR, and the average of 5 cycles in patients with atrial fibrillation was used in the present study. This may carry the possibility of over- or underestimation of PV and PG. Regarding the hemodynamic profile of normally functioning tricuspid prosthetic valves, Connolly and colleagues8 demonstrated that the mean values of PV, mean PG, and PHT were 1.3 ± 0.2 m•sec-1, 3.2 ± 1.1 mm Hg, and 146 ± 39 msec, respectively, in biological valves, and those of SJM valves were 1.2 ± 0.3 m•sec-1, 2.7 ± 1.1 mm Hg, and 108 ± 32 msec, respectively. In their study, no significant differences were seen in the mean values of PV and mean PG, but PHT was significantly lower for SJM valves than for biological valves. Similarly, Marti and colleagues9 reported that PV was 1.30 ± 0.24 m•sec-1 (range, 0.85–1.6 m•sec-1), mean PG was 3.26 ± 1.39 mm Hg (range, 1–5 mm Hg), and PHT was 102 ± 38 msec (range, 40–167 msec) in SJM valves. Although the Doppler data of the two studies are slightly different, these values are very close to the Doppler data we obtained, and the mean PHT was also significantly longer in CEP valves than SJM and ATS valves in this study.
Doppler data in the 8 patients with obstructed tricuspid SJM valves were significantly greater than those obtained from normally functioning mechanical and biological valves. Pye and colleagues10 emphasized that in obstructed Björk-Shiley tricuspid valves, a PHT > 200 msec coupled with PV > 1.60 m•sec-1 without significant valve regurgitation indicates obstruction of the tricuspid prosthetic valve. However, Marti and colleagues9 experienced 2 patients who fulfilled these criteria without clinical signs or symptoms suggestive of prosthetic dysfunction, and concluded that normally functioning tricuspid mechanical prostheses have a mean PG 7 mm Hg and PHT 290 msec. Similarly, Connolly and colleagues8 advocated that for patients with mean PG and PHT significantly greater than 5.3 mm Hg and 238 msec, respectively, or for patients with increasing obstruction on serial studies, pathological stenosis of the tricuspid prosthesis must be seriously considered. Furthermore, Sezai and colleagues11 concluded that peak PG > 8 mm Hg or PHT > 160 msec indicated a high probability of dysfunction of tricuspid SJM valves. These results and our experience taken together indicate that Doppler data of PV > 1.60 m•sec-1, mean PG > 5.5 mm Hg, and PHT > 200 msec are suggestive of dysfunction of a prosthetic valve in the tricuspid position.
This study establishes normal ranges for Doppler hemodynamics of 3 types of prosthetic valve in the tricuspid position. Although data in patients with an obstructed prosthetic valve were significantly higher than in those with a normally functioning valve, an overlap of Doppler data between normally functioning and obstructed prosthetic valves has been frequently observed. Therefore, an early postoperative baseline study and serial echocardiographic evaluation should be helpful in the detection of tricuspid prosthetic valve dysfunction.
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REFERENCES
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ABSTRACT
Introduction
