The following are key points to remember from this state-of-the-art review on bioprosthetic aortic valve hemodynamics:

1. Impaired functional performance of bioprosthetic aortic valve replacement (AVR) is associated with adverse patient outcomes; however, this assessment is complicated by the lack of standardization for labeling, definitions, and measurement techniques, both after surgical and transcatheter valve replacement.
2. Echocardiography remains the standard assessment methodology because of its ease of performance, widespread availability, ability to do serial measurements over time, and correlation with outcomes.
3. Current guidelines recommend echocardiography for the initial postoperative evaluation of prosthetic valves to establish baseline function and repeat echocardiography for the evaluation of suspected prosthetic valve dysfunction, a change in clinical status or examination, and when findings would change management or guide therapy.
4. Management of a high gradient after replacement requires integration of the patient’s clinical status, physical examination, and multimodality imaging in addition to shared patient decisions regarding treatment options.
5. A high residual gradient (mean gradient ≥20 mm Hg) on transthoracic echocardiography is a red flag for prosthesis-patient mismatch (PPM). However, a high transprosthetic gradient may also be related to a high flow state, aortic regurgitation, or acquired prosthetic valve stenosis caused by valve thrombosis or structural valve degeneration.
6. Suboptimal selection of a valve prosthesis for a given patient could be a contributing factor to high gradients and PPM post-AVR.
7. The International Organization for Standardization (ISO) Cardiac Valves Working Group has developed recommendations on surgical valve sizing and labeling.
8. This group recommended that the outer container for an surgical heart valve include a label in diagrammatic and/or tabular form with the following items:
• Intended valve to be replaced,
• Inflow orifice diameter,
• Effective orifice diameter (a virtual diameter derived from benchtop steady forward flow effective orifice area that serves as an indicator of size of the flow passage is inside a replacement heart valve device), and
• Valve housing external diameter.
9. Importantly, no such valve standards for sizing and labeling have been proposed for transcatheter heart valves, which represents a reasonable and necessary next step, as the proliferation of new and iterative transcatheter valve designs become commercially available in the future.
10. Future priorities that are underway include efforts to standardize prosthesis sizing and labeling for both surgical and transcatheter valves as well as trials to characterize the consequences of adverse hemodynamics.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound

Keywords: Aortic Valve Insufficiency, Bioprosthesis, Cardiac Surgical Procedures, Constriction, Pathologic, Diagnostic Imaging, Echocardiography, Heart Valve Diseases, Heart Valve Prosthesis, Hemodynamics, Physical Examination, Physical Functional Performance, Secondary Prevention, Thrombosis, Transcatheter Aortic Valve Replacement

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