Table 48. Step 1: Diagnosis of severe prosthetic valve dysfunction.

	Characteristics of severe prosthetic valve dysfunction
Physical examination	Clinical signs according to the predominant type of prosthesis dysfunction
Electrocardiogram	Abnormalities according to the predominant type of prosthesis dysfunction
Chest radiography	Abnormalities according to with the predominant prosthesis dysfunction
Transthoracic echocardiogram	Evaluation the type of valve dysfunction and confirmation severity of the dysfunction –thickening of leaflets –calcification and mobility of leaflets –reduced EOA –transvalvular gradient –valve regurgitation Evaluation of ventricular systolic dysfunction Progressive evaluation of the cardiac chambers diameters
Transesophageal echocardiogram	Inadequate window for transthoracic echocardiogram Severe paravalvular regurgitation with favorable anatomy for percutaneous intervention Indicated to improve anatomical evaluation
Hemodynamic study with manometry	Cases of clinical and echocardiographic discordance
Angiotomography of the aorta triggered with EKG	Evaluation of the aorta Evaluation of bioprosthesis thrombosis and TAVI

EOA: effective orifice area; EKG: electrocardiogram; TAVI: transcatheter aortic valve implantation.