Early Biological Valve Failure: Structural Valve Degeneration, Thrombosis, or Endocarditis?

Figures

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  Figure 1. Biological aortic prosthesis at 1 year and 7 years after implantation. Top panels (1-year follow-up): normal gradients and normal morphology of the valve. Bottom panels (7-year follow-up): Significant increase in gradients and thickening of the valve associated with mild regurgitation; these findings are indicative of structural valve degeneration.

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  Figure 2. Biological mitral valve prosthesis degeneration. (A) TEE mid-esophageal views showing a marked thickening and degeneration of the MV prosthesis leaflets. (B)significant increase in the mean diastolic gradient of the prosthesis. (C) A 3D TEE surgical view of the MV prosthesis showing a marked reduction in the diastolic opening of the leaflets, as confirmed and further detailed by 3D TEE views from the LV or from the LA with the transillumination modality (D). MV, mitral valve; TEE, transesophageal echocardiography.

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  Figure 3. Biological aortic valve thrombosis. (A,B) Apical long axis and apical 5-chamber adapted views showing thrombosis of the prosthesis (arrows). (C) Marked increase of the Doppler systolic aortic gradient. (D) Anatomical appearance of the prosthesis (surgical specimen), the arrows indicate the presence of thrombosis of leaflets’ surface. (E) 3D TEE imaging of the valve. LA, left atrium; LV, left ventricle; TEE, transesophageal echocardiography.

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  Figure 4. Biological mitral valve thrombosis. (A) 3D TEE appearance of the LA and LV of a normal MV prosthesis compared with (C) a thrombosis of an MV prosthesis. Thickening and obstruction of the valve are clearly shown by 3D TEE imaging and confirmed by thickening and thrombosis at 2D TEE (B) associated with a marked increase in the mean diastolic gradient (D). MV, mitral valve; TEE, transesophageal echocardiography.

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  Figure 5. Transesophageal echocardiography of complex endocarditis in a patient with biological mitral and aortic prosthesis. (A,B) From a mid-esophageal view, there is a normal leaflet appearance (A), and in a systolic frame, there is the presence of vegetation (B, arrow). (C) The arrow indicates an aortic pseudoaneurysm in the mitral–aortic intervalvular region. (D,E) Short axes of the aortic valve (upper-esophageal view) showing a large abscess of the periaortic tissue (asterisks). (F) Color-Doppler also shows a LVOT/left atrial fistula located at the base of the mitral valve. Ao, aorta; LA, left atrium; LV, left ventricle; LVOT, left ventricle outflow tract.

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  Figure 6. Mitral prothesis endocarditis. (A) Diastolic-frame and (B) systolic-frame TEE: in these mid-esophageal images, color Doppler shows a pathologic systolic jet at the base of one of the leaflets. (C) Perforation (red arrow) and tear of the leaflet are clearly confirmed by surgical view of the valve (3D TEE). (D) Example of an anatomical specimen of a perforation (red arrow) of a biological prosthesis. TEE: transesophageal echocardiography.

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  Figure 7. Three cases of prosthetic valve endocarditis: (A,D) dehiscence and para-prosthetic leak of a mitral valve prosthesis (arrow), (B,E) pseudoaneurysm (arrow) of an aortic prosthesis, and (C,F) small vegetation (arrow) in a prosthetic MV visualized in 2D TEE and confirmed in 3D TEE from LV view. LA, left atrium; LV, left ventricle; MV, mitral valve; TEE, transesophageal echocardiography.

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  Figure 8. Contrast CT of a pseudoaneurysm (post endocarditis) of aortic root in a patient with aortic BV. (A,B) A 3D reconstruction of aortic root and thoracic aorta (AO). The asterisk shows the pseudoaneurysm adjacent to the left coronary sinus and the origin of left LAD. (C,D) Oblique planes of BV and aortic root: in (C), the white line shows the entrance of the pseudoaneurysm (*) right below the BV. BV, bioprosttic valve; LAD, left anterior descending artery; LV, left ventricle; RCA, right coronary artery.

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  Figure 9. Contrast CT in a patient with endocarditis of a bioprosthetic aortic valve (BAV). (A,B) Multiplanar reconstruction of LV long axis (A) and LV short axis (B). Arrowheads show the presence of hypodense masses adherent to BAV leaflets. AO, aorta; BMV, bioprosthetic mitral valve; LA, left atrium; LV, left ventricle.

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  Figure 10. Contrast CT in a patient with transcatheter aortic valve. Upper panels: oblique views of the prosthetic valve (PV); the asterisk indicates the presence of a hypodense mass adherent to prosthetic leaflets. Lower panels: transverse planes of PV showing complete obstruction of the valve; the HU at the level of the mass was 44, indicating the thrombotic nature of the mass. AO, aorta; LA, left atrium; LV, left ventricle.

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  Figure 11. Periprosthetic abscess and detachment in a patient with bioprosthetic aortic valve. (A,B) Transesophageal echocardiogram in mid-esophageal view showing iso-hypoechoic space posteriorly to the bioprosthetic aortic valve (BAV). (C) Transesophageal echocardiogram in mid-esophageal view, with color Doppler showing paravalvular posterior leak and regurgitation (light blue arrow). (D) Contrast CT 3D volume rendering: The struts of the BAV are hyperdense and clearly visible. (E,F) The abscess (white arrow) appears like an isodense region posterior to the BAV; the light blue arrow indicates the presence of multiple leaks with contrast inside.

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  Figure 12. Diagnostic algorithm of bioprosthetic valve dysfunction from a multimodality-imaging perspective. Continuous lines indicate the suggested pathway; dotted lines indicate alternative pathways with lower level of evidence. CMR, cardiac magnetic resonance; CT, computed tomography (both cardiac CT and extracardiac CT); ESC, European Society of Cardiology; FDG PET/CT, 18F-fluorodeoxyglucose positron emission tomography/computed tomography; HU, Hounsfield Unit; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography; WBC SPECT/CT: white-blood-cell single-photon emission CT/CT.