1. Alsharqia.riyadh Echo meeting Dammam KSA SAYED ABOU EL SOUD MD SBCC

2. Case 1

3. History 48 y old Saudi lady Hypothyroidism,ch. Spondylisis H/O intracranial HTN 6 years before admission & ventriculoperitoneal shunt ( removed later ) Labarscopic cholecystecomy & RT modified mastectomy Now neurologically grossly intact

4. 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

5. Preoperative TTE

18. PREOPERATIVE TEE

29. 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 1 st operation

31. GEOMETRIC ORIFICE AREA ( area blood flow through ) MOUNTING AREA (area occupied by the valve in the native annulus )

32. 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

33. Surgery Aortic patch ( dilate aorta ) Valve replacement (tissue valve ) has Hx of intracranial HGE Myomectomy ( dilate LVOT )

34. POSTOPERATIVE TEE

39. POSTOPERATIVE TTE

47. Case 2

48. 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

49. 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

50. TTE

59. TEE

62. Impression Tissue valve opening well Tilting valve Significant gradient across aortic end of valve

63. Course Discharged for second opinion Lost follow up

64. Case 3

65. 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.

66. TTE

76. TEE

81. 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

83. Course very high risk for REDO surgery Pt preferred to be referred back to the hospital where he performed 1 st surgery

84. Arguments Partially supra annular implantation to incraese GVA IS OPTIMAL ??? Why gradients not usually appear immediate postoperative and appear later in follow up???

85. Home message Left for respected panel

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

89. 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.

90. . 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, perivalvular oedema 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