Well, no. Not quite…This is a decent view of a bioprosthetic mitral valve. Remember, a ‘bioprosthetic’ valve, or ’tissue valve’, is actual tissue (bovine pericardium or pig valve leaflets) attached to a support structure. This support will be in the form of struts and a sewing ring. The first image appears normal. We can see the tissue leaflets as well as the 2 struts in the LV. We can see the sewing ring with sutures in the LA. The second image is a continuous wave doppler through this valve. A prosthetic valve of any type will generally have velocities (and gradients) that are higher than a normal valve as the struts take up space and decrease the effective valve area. The normal gradients for each type and size of valve can be found in a publication by the ASE (http://www.asecho.org/wp-content/uploads/2014/03/2009_Evaluation-of-Prosthetic-Valves.pdf) This is an example of normal.

This is a midesophageal 4 chamber, zoomed in on the bioprosthetic mitral valve. Is this normal? No and no. This valve is not thickened so much as it is infested (OK, it’s just infected.) The highly mobile irregular thickening represents nasty endocarditis.

OK, take another look. What stands out here is the rocking motion of the aortic valve. When we evaluate a normal prosthetic valve, we use the term ‘well-seated.’ This valve is not normal, and is not well-seated. This is a valve with partial dehiscence – bad news! Our suspicions are confirmed in the second image. Here we see an aortic valve short axis with color flow. Look in diastole. Do you see the flow in the 12 o’clock position? This is flow around the outside of the sewing ring, essentially a huge perivalvular leak. This valve is barely hanging on, absolutely unacceptable surgical result.

Well no, not quite. This is a continuous wave doppler image. You can tell because of 1. the filled in appearance of the envelope 2. the high velocity we’re sampling. This is transthoracic (you can tell because we don’t see a multiplane indicator in the upper right.) This image could be made from the apical 5 chamber or the apical long axis. In this case, it’s the 5 chamber as the sampling line is on the left of the screen (imagine how those 2 images look different.) As we discussed, there are multiple manufacturers that each make multiple valves in multiple sizes. It can be difficult to know what is normal for each, but you don’t have to keep it in your head. Just know where to look (the recent ASE publication.) In general, it’s rarely for a bioprosthetic aortic valve to have an effective orifice area, peak velocity, or mean velocity that would represent moderate stenosis or worse. This is a case of stenosis of a prosthetic valve, which was ultimately replaced.

OK, this is a little subtle. We’re looking at a not-quite-normal aortic valve long axis. We can see aortic valve tissue, so we know the aortic valve is not mechanical. We cannot see struts, so we don’t think the AV is a stented bioprosthetic type. The aortic root appears thickened around the valve. That is a clue in this case. What we’re looking at here is a stentless bioprosthetic aortic valve. The idea with these valves is that they have a larger effective orifice area since there are no struts taking up space.

Whoops, I’m sure that was a mouse misfire! The first image is a classic example of a bileaflet mechanical mitral valve. In systole we can see the two leaflets close simultaneously. Notice that the valve does not close completely flat, but rather at a slight angle toward the LV. Distal to the MV we see significant acoustic shadowing (so much of the ultrasound is reflected by the leaflets we don’t see the LV very well.) In diastole the valve opens well, and we see two paralell lines of reverberation in the LV. Notice the 3 orifices of the valve – two larger ones on either side and a more narrow one in the center. The multiplane angle is at 90 degrees, but this is not consistent. The surgeon will place this valve in whatever orientation fits best, so you may see this view at different angles. The valve is well seated, with no rocking motion to suggest dehiscence. The color flow doppler image shows no paravalvular leak or washing jets. Washing jets are normal for mechanical valves, and appear as small jets inside the sewing ring that are directed slightly toward the center. The 3D image is beautiful, isn’t it? In this view we’re in the left atrium looking down on the mechanical valve. This and all the other images are totally normal. It happens sometimes, even in the clip of the day.

Well, no. Not exactly. This is an apical 4 chamber, showing a mechanical mitral valve. You know this is a mechanical valve because of the significant acoustic shadowing, and because you can see a leaflet in the LV. In particular, this is a tilting disc (single leaflet) valve. It can actually be difficult to distinguish sometimes, but this is characteristic. As you scan through the valve, you will never see the double-leaflet look of a bileaflet valve. We also see the leaflet extend a little farther into the ventricle with a tilting disc. In this view the larger orifice would be on the left, the smaller on the right (lateral.)

Sorry, that dog won’t hunt. There are several sources of color flow in systole here. We see 2 normal washing jets from the valve – they are very small and centrally directed. To the right of them is a large jet of flow outside the sewing ring. This is the leak, and it must absolutely be fixed.

Nope, not this time. What we see in these images is a clear example of a stuck mechanical valve leaflet. You can see in the 2D and 3D image that one of the leaflets doesn’t close in systole. The color flow clearly shows regurgitation through this defect. Make sure you don’t see this after bypass for valve placement!

Another slip of the mouse I’ll wager…In this short axis of a mechanical aortic valve we can see flow at 2 o’clock and 10 o’clock. This flow is outside the sewing ring. This represents a large paravalvular leak. Not normal, not good.