0:00

Okay. So this is this is

0:03

the second case. This is a patient who underwent mitral

0:06

valve replacement. You can

0:09

see the mitral valve here and I'm just gonna

0:12

let this play.

0:16

so this gentleman had mitral valve replacement and we

0:19

were asked to evaluate the

0:24

mechanical mitral valve

0:28

this is a cine obtained from a retrospectively gated CTA.

0:32

So my question now for you

0:35

is again, what is the most likely diagnosis? And if I could please ask

0:38

Ashley to bring up the poll?

0:40

Is this a normal appearance?

0:44

Is their valve to Hisense is their

0:47

valve disintegration meaning the valves is

0:50

just falling apart or is the valve simply not functioning is

0:53

their valve valve malfunction. Excellent. Wonderful.

0:58

So nobody thinks it's normal that's good, which actually reminds

1:01

me maybe I should just show normal case because people expect to

1:04

see something at normal and nobody

1:07

thinks that there's valve integration that is

1:10

also correct because it would be extremely unlikely for

1:13

these valves just to fall apart these valves have a shelf life

1:17

where basically an expected life expectancy of thousands

1:20

of years on the based on Benchmark bench

1:23

testing, but these

1:26

valves can be hiss and these can't valves can

1:29

malfunction and this is absolutely correct. And you

1:32

know, I was a little bit unfair to some degree because I

1:35

only gave you this image and this is basically the message that I

1:38

want to send out here.

1:41

because

1:43

so this is how these valves look before they

1:46

get implanted. They all have a metallic ring.

1:50

No matter what and then they have tilting discs

1:53

in the middle and this valves that is shown

1:56

is one of the Saint Jude with the tilting discs

1:59

in the middle.

2:02

And remember as with everything in Radiology one

2:05

view is no View and the

2:08

reason that is the case.

2:13

Is because looking at this video?

2:17

And I'm just going to stop here.

2:20

Here, it doesn't look this is the video that I showed you the lower

2:23

video. It doesn't look so bad, you

2:26

know those valve leaflets still seem to be oriented in

2:29

a parallel fashion, but if you look here

2:33

On the on The View that is perpendicular to

2:36

this View.

2:38

You can tell that this valve leaflet the superior

2:41

valve leaflet is actually moving whereas the

2:44

inferior valve leaflet is adhering to

2:47

the valve ring. And again, I apologize that this video is

2:50

not

2:51

operating in terms of running

2:54

but you can see it right you can see how the upper

2:57

leaflet is moving nicely in the

3:00

lower leaflet is simply not moving at all.

3:04

And also with the valves to hissins, this was actually a very good point

3:07

that you know, some of you made that maybe this is valve

3:10

to Hisense. You can't tell based on this one View.

3:13

And the reason why I'm going to say this is that whenever

3:16

you assess valve malfunction number

3:19

one, it is critical.

3:23

To evaluate those valves with retrospective ligated studies

3:26

because a prospectively gated study

3:29

meaning that you're only acquiring a

3:32

short period of the cardiac cycle will not show

3:35

you the full functionality of the valve. That's

3:38

one thing. The other thing is that when you assess those

3:41

vows, you really need cross-sectional oblique

3:44

images to look at the

3:47

valve in all planes. So you want to look at the

3:50

valve on fast as we are doing it here, but you

3:53

certainly want to look at the valve with respect

3:56

to the hinges and you want to look at the valve

3:59

on in laterally so that you can see

4:02

potential valve malfunction and

4:05

valve leaflet lack of motion, which

4:08

you would have otherwise not seen.

4:10

Now values of dehiscence also a very

4:13

feared complication would be would be

4:16

present. If this outer ring the

4:19

outer stiff ring would be

4:22

moving during the acquisition because that would

4:25

basically mean that the Stitch with which the valve is held

4:28

in place.

4:30

In the cardiac wall at the level of the each

4:33

of ventricular Junction is no longer

4:36

there. It's basically unraveled and

4:39

then the valve just swivels up and down and is

4:42

like it's like a flag in the wind that

4:45

is not the case here. If you look at it the ring stays nicely

4:48

in place and does move.

4:51

But the problem is that the leaflet the superior

4:54

leaflet is not moving and the

4:57

inferior leaflet. Sorry, the superior leaflet is moving

5:00

and yet the inferior lean is not moving.

5:02

And remember again one view is

5:05

no view. So you really want to make sure that you get the

5:08

cross-sectional obliques.

5:10

And when you report these in your report, you want

5:13

to be very descriptive you obviously want to talk about the Integrity of

5:16

the valve.

5:17

You want to talk about the Integrity of the Stitch within

5:20

the valve annulus? So you say that the

5:23

valve is in appropriately positioned without motion

5:26

with respect to the valular annulus

5:29

and then you want to describe whether the

5:32

leaflets are moving or not. And if

5:35

they're not moving you want to describe which of the

5:38

leaflets are not moving and I do

5:41

it usually in a very descriptive way. Like I did it

5:44

with you that I see the superior one the inferior

5:47

one and I describe it. Sometimes you can

5:50

actually see filling the effects surrounding the valve

5:53

leaflets almost a pen is like filling the

5:56

effect because that's what it is. It usually is a

5:59

penis that made this leaflet stuck

6:02

to the ring.

6:03

Oftentimes it's impatient who may

6:06

be a little bit. Let's say less than 100% compliant

6:09

with their anticoagulation. But we

6:12

also had this impatients were 100% compliant with

6:15

their with their coagulation and sometimes you

6:18

have two vowels and I'm just going to

6:21

show you this as an example. So this is a patient who had a mitral valve

6:24

and an aortic valve both

6:27

of which are mechanical valves replaced and if

6:30

you look at this you can see

6:34

that the mitral valve is moving.

6:37

Appropriately, see how they tilt up and down, but

6:40

if you look closely in the aortic valve and it's

6:43

stuck again, we're in this we're having the same problem.

6:48

See how the aortic valve leaflet the lateral

6:51

the one towards the directed towards

6:54

the left atrium is not moving. Where's

6:57

the anterior one is moving.

7:00

So again, you want to describe this you want to say that the

7:03

mitral leaflets are moving appropriately yet

7:06

with the aortic valve leaflet. The

7:09

anterior leaflet is moving appropriately in

7:12

the posterior leaflet is stuck.

7:14

Be descriptive and with

7:17

these things I tend to call my cardiac surgeons the

7:20

ones that I'm working with, they really appreciate the

7:23

call and it's often easier to

7:26

walk them through now with WebEx

7:29

and all the availability of telecommunication. I

7:33

I found myself even inviting

7:36

them to a WebEx and showing them the images so that

7:39

they can visualize what's going on that has

7:42

been greatly appreciated in the past.