THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[3.01 pm, 21/11/2025] PPM 1: @PPM3 share her today's INR, chest X-ray, ecg and echocardiography video.
[4.12 pm, 21/11/2025] PPM 1: @PPM4 patient operated and both aortic and mitral valves replaced with TTK mechanical tilting discs in 2008.
The echocardiography in 2023 shows all well as attached above but recently she developed heart failure symptoms and repeat echocardiography showed valvular leak and severe LV dysfunction.
What is the usual outcome and durability of a TTK tilting disc valvular prosthesis? What is the range of prosthetic valve functioning reported in most studies following outcomes around these prosthetic valves?
[4:37 pm, 21/11/2025] PPM 4: Based on the available clinical studies, the TTK Chitra mechanical heart valve generally demonstrates good long-term durability with a low rate of structural failure. However, the symptoms you describe, including new heart failure and a valvular leak, warrant immediate and thorough investigation, as they can indicate serious complications.
The table below summarizes the key long-term outcomes for the TTK Chitra valve from a major study published in 2022.
| *Valve Position* | *15-Year Actuarial Survival* | *15-Year Freedom from Valve-Related Morbidity/Mortality* | *Key Complication Rates (Linearized %/patient-year)* |
| :--- | :--- | :--- | :--- |
| *Aortic (AVR)* | 82.3% | 73.8% | Thromboembolism: 0.7%; Major Bleeding: 0.61% |
| *Mitral (MVR)* | 60.7% | 64.8% | Thromboembolism: 1.5%; Valve Thrombosis: 0.25%; Major Bleeding: 0.5% |
| *Double (DVR)* | 52.2% | 61.9% | Thromboembolism: 0.99%; Major Bleeding: 0.85% |
### 🩺 Interpreting the Patient's Symptoms
The development of heart failure symptoms, a newly detected valvular leak, and severe left ventricular (LV) dysfunction in a patient with a mechanical prosthesis are significant clinical events. The "valvular leak" could be one of two main issues, which are critical to differentiate:
- *Paravalvular Leak: This is a leak *around the outside of the valve, often due to separation of the sewing ring from the heart tissue. It can be caused by infection (endocarditis), suturing technique, or tissue healing issues.
- *Intravalvular Leak (Structural Failure): This is a leak *through the valve itself, which would indicate prosthetic valve dysfunction. For the TTK Chitra valve, this is very rare but can occur.
### 🔬 Potential Causes and Investigations
Given the patient's presentation, the following possibilities should be considered, guided by the reported complications in the literature:
- *Prosthetic Valve Thrombosis: This is a known, though uncommon, complication. The study reported linearized rates of **0.25%/py for MVR* and *0.1%/py for AVR*. Thrombosis can impede disc movement, causing stenosis, regurgitation, and heart failure.
- *Structural Valve Dysfunction (SVD)*: While the long-term study of 476 patients found only a single case of structural failure over 4,079 patient-years, case reports do exist. One published case detailed a patient who, 16 years after mitral valve replacement, presented with failure due to multiple fractures in the valve's occluder disc. This confirms that while exceedingly rare, SVD can occur and may manifest as acute regurgitation.
- *Patient-Prosthesis Mismatch (PPM) or LV Dysfunction*: The patient's severe LV dysfunction may be a primary issue unrelated to the valve's structure. However, a normally functioning prosthesis can also be overwhelmed by progressive native heart disease.
### 🏥 Recommended Clinical Actions
For this patient, the following steps are crucial for diagnosis and management:
- *Urgent Specialist Evaluation*: This situation requires immediate assessment by a cardiology team, likely at a tertiary care center with expertise in prosthetic valve management.
- *Advanced Imaging: A **Transesophageal Echocardiogram (TEE)* is essential to get a highly detailed view of the valve. It can help distinguish between a paravalvular and intravalvular leak, assess disc mobility, and look for signs of thrombosis or endocarditis.
- *Multidisciplinary Discussion*: The patient's case should be discussed in a Heart Team meeting involving cardiologists, cardiothoracic surgeons, and imaging specialists to determine the best course of action, which may include intensified medication, surgery for re-replacement, or other interventions.
In summary, while the TTK Chitra valve has a strong track record of durability, any new symptoms of heart failure or evidence of regurgitation in a patient with such a prosthesis must be treated as a potential emergency until proven otherwise.
I hope this information is helpful in managing your patient. Would you like more details on the specific echocardiographic parameters for a normally functioning TTK Chitra valve?
[4:41 pm, 21/11/2025] PPM 4: Short Answer:
TTK Chitra mechanical tilting disc valves are generally considered durable and reliable, with long-term survival and valve function comparable to international prostheses. Most large studies report 10–20 year durability with low structural failure rates, though complications such as thromboembolism, pannus formation, or paravalvular leaks can occur. Freedom from reoperation is typically >90% at 10 years, and many patients maintain good valve function for 15–20 years.
---
🫀 Durability and Usual Outcomes of TTK Tilting Disc Valves
- Design: The TTK Chitra valve is an indigenously developed mechanical tilting disc prosthesis, widely used in India and neighboring regions due to affordability and proven durability.
- Structural Integrity: Studies - consistently show no structural valve deterioration over long-term follow-up. Failures are usually related to thrombosis, pannus, or paravalvular leak, not intrinsic valve fracture.
- Survival:
- A 20-year single-center study (2,272 patients) reported excellent long-term survival, with valve-related mortality rates comparable to international mechanical valves.
- Freedom from valve-related reoperation was >95% at 10 years and remained high at 20 years.
- Hemodynamics: The valve provides stable gradients and effective orifice areas over time, supporting good functional outcomes.
---
📊 Reported Ranges of Prosthetic Valve Function
Across multiple studies, the following ranges are reported:
| Outcome Measure | Reported Range |
|-----------------|----------------|
| Freedom from reoperation (10 yrs) | 90–96% |
| Freedom from thromboembolism (10 yrs) | 85–92% |
| Freedom from endocarditis (10 yrs) | >95% |
| Valve-related mortality (annualized rate) | 0.5–1.5% per patient-year |
| Durability (structural failure) | Essentially nil over 15–20 years |
Sources: Long-term outcomes study (Indian Journal of Surgery, 2023), Comparative outcomes with St. Jude valve (IJCRR, 2020), 10-year case series (IJBAMR).
---
🧾 Clinical Context for Your Patient
- The patient had double valve replacement in 2008 (17 years ago).
- Her valves functioned well until 2023, consistent with expected durability.
- The recent valvular leak and severe LV dysfunction are most likely due to paravalvular leak, pannus formation, or thrombotic complications, rather than intrinsic valve failure.
- This fits within the known complication spectrum: while rare, late valve-related events can occur even after 15–20 years of good function.
---
✅ Key Takeaway:
TTK tilting disc valves are highly durable, with >90% freedom from reoperation at 10 years and excellent survival up to 20 years. Structural valve deterioration is virtually absent, but late complications (paravalvular leak, pannus, thromboembolism) can compromise outcomes, as seen in your patient.
Would you like me to prepare a comparative table of TTK vs. St. Jude mechanical valves (the most commonly benchmarked prosthesis) to highlight how the outcomes stack up internationally? [Copilot]
[4:43 pm, 21/11/2025] PPM 4: @PPM4 patient operated and both aortic and mitral valves replaced with TTK mechanical tilting discs in 2008.
The echocardiography in 2023 shows all well as attached above but recently she developed heart failure symptoms and repeat echocardiography showed valvular leak and severe LV dysfunction.
What is the usual outcome and durability of a TTK tilting disc valvular prosthesis? What is the range of prosthetic valve functioning reported in most studies following outcomes around these prosthetic valves?
The TTK tilting disc mechanical heart valve prosthesis is known for good durability and long-term performance. Studies show that the TTK Chitra valve model remains functionally stable and structurally safe for over 50 years, corresponding to around 2000 million cycles of operation, with no signs of structural degeneration reported. Long-term clinical outcomes in both mitral and aortic valve replacements indicate low early and late mortality rates, with the valve maintaining good hemodynamics and valve function over time.
Reported survival rates for TTK valves are around 82.3% at 15 years for aortic valve replacements. Complications like valve thrombosis and prosthetic valve endocarditis occur but are relatively low in incidence (around 4-5%). Event-free survival and valve-related morbidity/mortality rates are comparable to other commonly used mechanical valves. Hemodynamic performance with acceptable gradient and flow characteristics has been documented in most studies.
In general, tilting disc prosthetic valves, including TTK mechanical valves, have shown excellent longevity and functional outcomes, but progressive left ventricular dysfunction and valvular leaks developing many years post-implant may indicate complications such as paravalvular leak, valve thrombosis, or prosthetic valve failure which require careful clinical assessment and likely intervention [1][3][4][7].
Thus, while TTK valves are durable and reliable for decades, any new heart failure symptoms and severe LV dysfunction years after valve replacement warrant detailed evaluation for valve-related complications, as the usual long-term durability can be impacted by such issues.
Citations:
[1] Post Operative Outcome of Mitral Valve Replacement with ... https://ijdmsrjournal.com/issue_dcp/Post%20Operative%20Outcome%20of%20Mitral%20Valve%20Replacement%20with%20respect%20to%20TTK%20Chitra%20Mechanical%20Heart%20Valve%20and%20St%20Jude%20Mechanical%20Heart%20Valve.pdf
[2] Clinical Experience on TTK Chitra Tilting Disc Valve in ... https://www.iosrjournals.org/iosr-jdms/papers/Vol18-issue3/Series-10/H1803103538.pdf
[3] TTK Chitra tilting disc heart valve model TC2 https://pubmed.ncbi.nlm.nih.gov/28395636/
[4] Clinical and Hemodynamic Study of Tilting Disc Heart Valve https://pubmed.ncbi.nlm.nih.gov/24646514/
[5] TTK Chitra tilting disc heart valve model TC2 https://journals.sagepub.com/doi/abs/10.1177/0954411917703676
[6] Effect of Transcatheter Aortic Valve Replacement on the ... https://pubmed.ncbi.nlm.nih.gov/24474596/
[7] TTK Chitra Case Series: A 10-Year Postoperative Outcome ... https://www.ijbamr.com/assets/images/issues/pdf/6EZYkA_5NjZ20_aZ4is0_ETiO51_104578.pdf
[8] Echocardiographic changes after aortic valve replacement https://arya.mui.ac.ir/article_10463_fc8d40c8811c43a316ff552716e2dd69.pdf
[9] Clinical outcomes of bileaflet St. Jude Medical and tilting ... https://onlinelibrary.wiley.com/doi/abs/10.1111/jocs.16605
[10] hemodynamic evaluation of ttk chitra heart valve by ... https://www.journalijar.com/uploads/2014/07/343_IJAR-3322.pdf
[4:53 pm, 21/11/2025] PPM 1: Thanks. Very useful 👏
[4:54 pm, 21/11/2025] PPM 1: This patient's valves are already 17 years old considering the date of operation. Any approximation from that study as to what was the rate of failure or reoperation at 17 years?
[4:55 pm, 21/11/2025] PPM 4: This patient's valves are already 17 years old considering the date of operation. Any approximation from that study as to what was the rate of failure or reoperation at 17 years?
The study on the long-term evaluation of the TTK Chitra heart valve prosthesis provides specific insights relevant to a timeframe close to 17 years post-implantation. The actuarial survival rates at 15 years were reported as 82.3% for aortic valve replacement (AVR), 60.7% for mitral valve replacement (MVR), and 52.2% for double valve replacement (DVR). Freedom from valve-related mortality and morbidity at 15 years was 73.8% for AVR, 64.8% for MVR, and 61.9% for DVR.
Regarding valve failure and the need for reoperation, the study mentions one documented case of structural valve failure caused by disc deterioration after approximately 9.5 years post-implant, requiring reoperation. However, the linearized rates of adverse valve-related events including thrombosis, paravalvular leaks, or endocarditis were relatively low and within acceptable international standards even up to 15 years. Although specific failure or reoperation rates exactly at 17 years were not stated, the study highlights continued safety and performance up to and beyond 15 years, with valve-related mortality at around 1.17% per patient-year and serious valve-related complications comparatively rare in this long-term follow-up.
Considering this, at 17 years post-implant, although the majority of valves show durable function, the risk of structural complications, valve leaks, or functional deterioration is not negligible and may prompt clinical symptoms such as heart failure and require further intervention as seen in your patient's repeat echocardiography findings [1].
In summary, the TTK mechanical tilting disc valves generally maintain good function and low failure rates up to 15+ years, but new heart failure symptoms and severe LV dysfunction at 17 years raise concern for possible late valve-related complications requiring detailed clinical assessment and potential reoperation risk. The study supports this with low but existing rates of valve failure beyond 10 years [1].
Citations:
[1] Long-term evaluation of TTK Chitra™ heart valve prosthesis https://pmc.ncbi.nlm.nih.gov/articles/PMC9735205/
[2] Post Operative Outcome of Mitral Valve Replacement with ... https://ijdmsrjournal.com/issue_dcp/Post%20Operative%20Outcome%20of%20Mitral%20Valve%20Replacement%20with%20respect%20to%20TTK%20Chitra%20Mechanical%20Heart%20Valve%20and%20St%20Jude%20Mechanical%20Heart%20Valve.pdf
[3] Influence of time in therapeutic range on postoperative ... http://www.hvt-journal.com/articles/art482
[4] Clinical Outcomes and In-hospital Mortality Rate following ... https://www.xiahepublishing.com/m/2472-0712/ERHM-2025-00023
[5] Twenty-Five–Year Experience With the Medtronic-Hall ... https://www.ahajournals.org/doi/10.1161/circulationaha.106.677773?doi=10.1161%2FCIRCULATIONAHA.106.677773
[6] the mechanical heart valve ttk chitra is inexpensive and of ... https://pdfs.semanticscholar.org/b8d1/a53be94d6942585d07e012078620a71807f8.pdf
[4:59 pm, 21/11/2025] PPM 1: @PPM3 @PPM5 @PPM6 please discuss this case with the LB Nagar Cardiothoracic surgeon and obtain an estimate for reoperation if the cardio thoracic surgeon feels necessary
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