Doppler and echocardiographic features of normal and dysfunctioning bioprosthetic valves

Echocardiographic and Doppler studies were performed on 183 clinically normal and 58 severely dysfunctioning bioprosthetic mitral, aortic and tricuspid valves. The valve dysfunction resulted from spontaneous cusp degeneration in 49 instances and from paravalvular regurgitation in 9. The pulsed Doppler study demonstrated regurgitant flow in 36 (92%) of 39 regurgitant valves and 8 (90%) of 9 paravalvular regurgitant valves. Diagnostic echocardiographic features were present in only 51 and 10% of the patients, respectively. Although the Doppler regurgitant jet was peripheral in seven of the nine patients with paravalvular regurgitation, it was not possible to differentiate these patients from those who had valve degeneration and cusp tear at the periphery of the valve ring. Eight patients presented with a musical holosystolic murmur of mitral insufficiency. In all eight there was a characteristic honking intonation on the audio signal and a striated shuddering appearance on the video Doppler signal.Ten stenotic mitral bioprosthetic valves (≤1.1 cm2valve orifice) were identified by Doppler study. Diagnostic echocardiographic features were present in only two of these patients. The Doppler-derived valve orifice dimension correlated well (r = 0.83) with cardiac catheterization values. Fourteen asymptomatic or minimally symptomatic patients had echocardiographically thickened mitral cusps (≥3 mm). These patients had a significantly (p < 0.0001) smaller valve area as compared with normal control valves, and during 4 to 24 months of follow-up, five of these patients developed severe valve regurgitation or stenosis.Doppler ultrasound is more sensitive than echocardiography in diagnosing bioprosthetic valve stenosis and regurgitation. Patients with paravalvular regurgitation could not be differentiated from those with valvular regurgitation. The presence of echocardiographically thickened valves in the absence of endocarditis probably represents valve degeneration and poses a higher risk for subsequent dysfunction