P1579 Detection of mechanical prosthetic valve dysfunction: an integrated multimodality imaging approach
Authors: Fusini L , Muratori M , Teruzzi G , Corrieri N , Innocenti E , Tamborini G , Mapelli M , Ghulam Ali S , Alamanni F , Montorsi P , Pepi M 
Published: January 2020

Abstract

Background
Although the long-term outcome of mechanical mitral and aortic prosthetic valve (M-PV, Ao-PV), PV dysfunction (PVD) remains a very serious complication associated with high morbidity and mortality. PVD, in terms of thrombosis/pannus or paravalvular leak, is not associated with a peculiar clinical presentation. However, a prompt PVD detection is essential for referring the patient to the optimal treatment (clinical follow-up, thrombolysis, surgery). An integrated multimodality imaging approach, comprising several parameters by transthoracic echocardiography (TTE) and fluoroscopy (F), is mandatory to address the patient to the best therapeutic option.

Purpose
This study aims to evaluate the incremental diagnostic value of combined TTE + F over each imaging modality alone in pts with Ao-PV or M-PV symptomatic for dyspnea, embolic events, fever or haemolysis and therefore at high suspicion for PVD.

Methods
We enrolled 388 consecutive pts (62 ± 11y, 213 Ao-PV, 175 M-PV) suspected for PVD. All patients were imaged by TTE and F within 2 days after the admission to the hospital. TTE was defined positive for PVD in presence of intra/para-prosthetic regurgitation or high transprosthetic gradient (DP &gt; 20 mmHg in Ao-PV, DP &gt;10 mmHg in M-PV) combined with other altered Doppler parameters (for Ao-PV: DVI &lt; 0.25, AT &gt; 95ms; for M-PV: Peak Mitral Velocity &gt; 2.2m/sec, VTIPrMV/VTILVO &gt; 2.5, PHT &gt; 130ms). A positive F for PVD was defined by leaflet/s restriction. In all pts, PVD was confirmed by transoesophageal echocardiography (TOE), positive response of thrombolysis (T), or surgical inspection (S).

Results
PVD was found in 46% (99/213) of Ao-PV and in 56% (98/175) of M-PV at TOE/T/S. Sensitivity (SE), specificity (SP), negative predictive value (NPV), positive predictive value (PPV) and diagnostic accuracy (ACC) for TTE, F and combined TTE + F are reported in Table. The integration of TTE + F data significantly improved ACC both for Ao-PV and M-PV. At ROC analysis, the combined model of TTE + F showed the highest AUC for the detection of PVD compared with TTE and F alone (Figure).

Conclusions
In patients with clinical suspicion of PVD, the combined model of TTE + F had a significant incremental value over TTE or F alone to diagnose PVD. This multimodality imaging approach allows to overcome limitations of TTE or F alone and consequently provides a prompt PVD detection even though TOE remains the gold standard to diagnose paravalvular leak and non-obstructive thrombosis.
Table Ao-PV: TTE(n = 211) Ao-PV: F(n = 204) Ao-PV: TTE + F(n = 202) MV-PV: TTE(n = 175) MV-PV: F(n = 159) MV-PV: TTE + F(n = 159) Sensitivity/Specificity 86(79-93)/89(84-95) 59(49-68)/99(97-100) 94(89-99)/88(81-94) 83(75-90)/78(68-87) 45(35-55)/98(95-100) 87(81-94)/75(64-86) ACC 88(83-92) 79(74-85) 91(87-95) 81(75-90) 67(59-74) 82(76-88) Comparison of diagnostic accuracy between TTE, F, and TTE + F for detecting PVD
Abstract P1579 Figure. ROC curves