Most mechanical valves will have some built in “physiologic” regurgitation (Fig. 13-2). Knowing the type of valve will help determine the expected pattern of regurgitation. Some common examples:

Perivalvular leak (typically unilateral, eccentric, turbulent jet) is in contrast pathologic (Fig. 13-3) and occurs most often in redo valve replacement surgery or when extensive calcium debridement is required prior to valve implantation (newer percutaneously inserted valves will not uncommonly have a small perivalvular regurgitant jet).

Start your evaluation by identifying the valve and confirming the expected appearance. Look for stability of the valve and ring. Excessive movement of the entire prosthesis (“rocking”) suggests dehiscence. Evaluate leaflet/disk motion when they are visible. Pay attention to the presence of calcifications, thrombi, or vegetations.

Prosthetic valves will cause shadowing distal to the ultrasound beam and make those areas difficult to inspect visually. Standard and off-axis views should be selected to interrogate areas of interest first and then the prosthesis to minimize shadowing (e.g., for evaluating MR for a mitral prosthesis the PLAX and subcostal images can visualize the LA without significant artifact compared to the apical four-chamber view). TEE is often necessary when clinical suspicion of prosthetic valve dysfunction is high especially when multiple prostheses are present (Fig. 13-4).