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Valvular heart disease
Echocardiographic follow-up after heart valve replacement
  1. Tobias Pflederer,
  2. Frank A Flachskampf
  1. Med.Klinik 2, University of Erlangen, Erlangen, Germany
  1. Correspondence to Professor Frank A Flachskampf, Med.Klinik 2, University of Erlangen, Ulmenweg 18, 91054 Erlangen, Germany; frank.flachskampf{at}uk-erlangen.de

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The number of patients with prosthetic valves is steadily increasing, in particular because of the epidemic of aortic stenosis in the elderly. In Germany alone, more than 24 000 patients undergo valve replacement per year. In addition to the patient’s history and physical examination, echocardiography is the key element in the follow-up of individuals with a prosthetic valve (box 1).

Box 1 The following questions should be systematically answered when examining a prosthesis by echocardiography

  • Does the history or clinical presentation of the patient suggest a prosthesis related disorder (for example, new onset of severe dyspnoea, fever, etc)?

  • Is the prosthesis firmly implanted as a whole (absence of rocking)?

  • In a bioprosthesis, are there morphologic signs of degeneration (thickened, immobile or pathologically mobile leaflets or leaflet segments)? In a mechanical prosthesis, do the occluder discs move normally?

  • How much regurgitation is there, and is it transprosthetic or paraprosthetic?

  • What are the mean and maximal transprosthetic gradients, are they in the normal range, and have they changed substantially from baseline?

  • Are there fixed or mobile mass lesions attached to the prosthesis (thrombus, vegetation, pannus)?

  • Are there other signs of endocarditis, in particular abscess formation at the prosthetic ring, fistulae, or a pericardial effusion?

The first routine postoperative assessment is particularly important, since it serves as baseline for later comparison, especially with regard to transprosthetic gradients, prosthetic regurgitation, right ventricular peak pressure, left ventricular function, and other aspects.

The examination of the patient with a prosthetic cardiac valve, however, is one of the most challenging tasks in echocardiography. For several reasons echocardiography in these patients is more difficult than in others:

  • Due to the valvular heart disease present before valve replacement, these hearts are never normal, even with a perfectly functioning valve replacement.

  • The prosthesis itself, especially in the case of a mechanical prosthesis, invariably generates artefacts and often is not well visualised. For example, in aortic mechanical …

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