The Role of Multimodality Imaging in Left-Sided Prosthetic Valve Dysfunction

Prosthetic valve (PV) dysfunction (PVD) is a complication of mechanical or biological PV. Etiologic mechanisms associated with PVD include fibrotic pannus ingrowth, thrombosis, structural valve degeneration, and endocarditis resulting in different grades of obstruction and/or regurgitation. PVD can be life threatening and often challenging to diagnose due to the similarities between the clinical presentations of different causes. Nevertheless, identifying the cause of PVD is critical to treatment administration (thrombolysis, surgery, or percutaneous procedure). In this report, we review the role of multimodality imaging in the diagnosis of PVD. Specifically, this review discusses the characteristics of advanced imaging modalities underlying the importance of an integrated approach including 2D/3D transthoracic and transesophageal echocardiography, fluoroscopy, and computed tomography. In this scenario, it is critical to understand the strengths and weaknesses of each modality according to the suspected cause of PVD. In conclusion, for patients with suspected or known PVD, this stepwise imaging approach may lead to a simplified, more rapid, accurate and specific workflow and management.

Three-Dimensional Transesophageal Echocardiography in the Diagnosis and Treatment of Mitral Prosthetic Valve Endocarditis—A Narrative Review

Despite advances in diagnosis, imaging methods, and medical and surgical interventions, prosthetic valve endocarditis (PVE) remains an extremely serious and potentially fatal complication of heart valve surgery. Characteristic changes of PVE are more difficult to detect by transthoracic echocardiography (TTE) than those involving the native valve. We reviewed advances in transesophageal echocardiography (TEE) in the diagnosis of PVE. Three-dimensional (3D) TEE is becoming an increasingly available imaging method combined with two-dimensional TEE. It contributes to faster and more accurate diagnosis of PVE, assessment of PVE-related complications, monitoring effectiveness of antibiotic treatment, and determining optimal time for surgery, sometimes even before or without previous TTE. In this article, we present advances in the treatment of patients with mitral PVE due to 3D TEE application.

Technical Details of Redo Aortic Valve Replacement using St. Jude Medical Mechanical Prosthesis in a Patient with Thrombosed Aortic Mechanical Prosthesis: A Video Presentation

Current consensus guidelines of the AHA and ESC, uniformly recommend either type of prosthetic valve for patients aged 60 to 70 years and mechanical prosthesis for patients aged less than 60 years

Multimodality Imaging in the Diagnosis of Prosthetic Valve Endocarditis: A Brief Review

Infective endocarditis is a common and treatable condition that carries a high mortality rate. Currently the workup of infective endocarditis relies on the integration of clinical, microbiological and echocardiographic data through the use of the modified Duke criteria (MDC). However, in cases of prosthetic valve endocarditis (PVE) echocardiography can be normal or non-diagnostic in a high proportion of cases leading to decreased sensitivity for the MDC. Evolving multimodality imaging techniques including leukocyte scintigraphy (white blood cell imaging), 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), multidetector computed tomographic angiography (MDCTA), and cardiac magnetic resonance imaging (CMRI) may each augment the standard workup of PVE and increase diagnostic accuracy. While further studies are necessary to clarify the ideal role for each of these imaging techniques, nevertheless, these modalities hold promise in determining the diagnosis, prognosis, and care of PVE. We start by presenting a clinical vignette, then evidence supporting various modality strategies, balanced by limitations, and review of formal guidelines, when available. The article ends with the authors' summary of future directions and case conclusion.

Angioplasty balloon occlusion of LIMA graft in reoperations of patients with prosthetic valve endocarditis and patent LIMA-LAD graft

Background: Myocardial protection in reoperations in cardiac surgery is extremely difficult in patients with previous coronary surgery and a working LIMA-LAD graft, and it largely determines the outcome of surgery and long-term prognosis. We use a the method of percutaneous angiographic balloon LIMA occlusion and cardioplegic arrest. Aims: The aim of this study was to compare the data of patients with angiographic balloon LIMA-occlusion and those without occlusion in operations related to PVE, and previous coronary surgery with permeable LIMA graft, determining the degree of safety and benefits of method. Study design and Methods: A total of 20 patients undergoing surgery for prosthesis valve endocarditis with patent LIMA-LAD graft were analyzed retrospectively. We divide the patients into 2 groups. Group A patients - with LIMA occlusion and Group B patients - without LIMA occlusion). The pre-, intra- and postoperative results were compared and the degree of safety and benefits of the application of the method were studied. Results: 80% of patients in group A needed only dopamine infusion and 20% needed the addition of a second catecholamine (Adrenaline) at the end of CPB. In group B, the need for double catecholamine maintenance is in 50% of patients. The need for implantation of an intra-aortic balloon pump due to refractory heart failure was registered in 10% of patients in group A and in 20% of patients in group B. It was found that the average duration of mechanical ventilation in group A is 10.5 hours postoperatively, and in group B - 12.5 hours. The mean duration of catecholamine infusion in both groups was 3 days. The average stay in intensive care is shorter for patients in Group A - 2.5 days, and in Group B is 3.5 days. In terms of survival - mortality in the group with LIMA occlusion is 0%, while in the group without LIMA occlusion is 20%. Conclusion: Our reported results from the use of the LIMA balloon occlusion method in patients with prosthetic valve endocarditis who are high-risk and complicated patients and nevertheless the mortality in this group studied by us is 0% and no serious complications of the applied method have been registered. Therefore, we believe that the angiographic balloon LIMA occlusion is a reliable, easily applicable and relatively safe technique that improves the surgical results and prognosis of patients in need of reoperative cardiac surgery.

Fast versus ultra-slow thrombolytic infusion regimens in patients with obstructive mechanical prosthetic valve thrombosis: a pilot randomized clinical trial

Background Thrombolysis is an alternative to surgery for mechanical prosthetic valve thrombosis (MPVT). Randomized clinical trials have yet to test safety and efficacy of a proposed ultraslow thrombolytic infusion regimen. Methods and Results This single-center, open-label, pilot randomized clinical trial randomized adult patients with acute obstructive MPVT to an ultraslow thrombolytic regimen (25 mg of recombinant tissue-type plasminogen activator [rtPA] infused in 25h) and a fast thrombolytic regimen (50 mg of rtPA infused in 6h). If thrombolysis failed, a repeated dose of 25 mg of rtPA for 6h was administered in both groups up to a cumulative dose of 150 mg or the occurrence of a complication. Primary outcome was a complete MPVT resolution (>75% fall in the obstructive gradient by transthoracic echocardiography, <10° limitation in opening and closing valve motion angles by fluoroscopy, and symptom improvement). Key safety outcome was a BARC type III or V major bleeding. Overall, 120 patients, including 63 (52.5%) women, at a mean age of 36.3±15.3 years, were randomized. Complete thrombolysis success was achieved in 51 patients (85.0%) in the ultraslow-regimen group and 47 patients (78.3%) in the fast-regimen group (OR, 1.58; 95% CI, 0.25 to 1.63; P = 0.34). One case of transient ischemic attack and 3 cases of intracranial hemorrhage (absolute risk difference, −12.5%; 95% CI, −23.1% to −1.0%; P = 0.04). were observed only in the fast-regimen group. Conclusions The ultraslow thrombolytic regimen conferred a high thrombosis resolution rate without major complications. Such findings should be replicated in more adequately powered trials (IRCT20181022041406N2).