An unusual heart coping with a dysfunctional prosthetic valve (at least once in every few beats…)


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An unusual heart coping with a dysfunctional prosthetic valve (at least once in every few beats…)

  1. 1. A heart coping with a dysfunctional prosthetic valve (at least once in every few beats…) Dr Taylan Akgun Kartal Kosuyolu Heart and Research Hospital, Istanbul, Turkey Dr Cemil Izgi Royal Brompton Hospital London, UK
  2. 2. Clinical presentation • 45 years old, Female • Presented with severe dyspnea (NYHA Class III) • Mechanical mitral prosthetic valve -implanted 10 years ago -mono-leaflet tilting disc -optimum INR (3.5 at presentation) • Progressively increasing shortness of breath for the last two months • Normal sinus rhythm
  3. 3. Physical examination • Mechanical prosthetic valve sounds - decreased intensity, increasing every two/three heart beats • BP 130/90 mm Hg - dropping intermittently to 80/60 mm Hg, as seen in the arterial line - pulsus alternans • Bilateral rales up to mid zones • Pretibial edema
  4. 4. Echocardiography •Transthoracic echocardiography -increased transvalvular gradient (mean Grad. 17 mmHg) -impaired valve opening (but difficult to fully assess)  Findings highly suggestive of prosthetic valve dysfunction •Transesophageal echocardiography -Limited monoleaflet motion -opening intermittently only in every two or three beats -No obvious thrombus seen
  5. 5. Transesophageal echocardiography Watch video intermittent leaflet opening once in every two or three beats; only when the left atrial pressure increases in consecutive cycles high enough to overcome the obstruction Doppler tracing of transmitral flow with the ECG tracing. Mitral flow occurs only once in two or three beats.
  6. 6. Diagnosis • Severe prosthetic valve dysfunction with limited leaflet opening. -Pannus or Thrombus? • Factors suggesting pannus rather than thrombus1,2  No obvious obstructive thrombus but instead an echo dense, immobile structure observed on transesophageal echo  Optimum INR  No recent history of systemic embolism  Subacute development Findings were suggestive of pannus and the patient was referred for emergent surgery. D. Hering, C. Piper and D. Horstkotte. Management of prosthetic valve thrombosis. European Heart Journal Supplements (2001) 3 (Supplement Q), Q22–Q26. 1
  7. 7. Surgery • Pannus extending to the valve leaflet and obstructing its opening Valve was excised and a new bileaflet mechanical prosthetic valve was implanted.
  8. 8. Pannus • Pannus is a fibroeleastic tissue ingrowth from the valve annulus. Mostly starts from the surgical line in the annulus and is circular in the plane of the valve. Pannus formation is mostly unpredictable and there is no established risk factor for its formation. • In a large series prosthetic valve obstruction, rate of reoperation for pannus was 0.24%/patient per year and for valvular thrombosis was 0.15%/patient per year.* • Differentiation of pannus and thrombus is important as thrombolysis may be a treatment option for prosthetic heart valve thrombosis but obviously will not be effective for pannus which should be managed surgically. • In any case of suspected mechanical prosthetic valve obstructive dysfunction fluoroscopy, transesophageal echo and multislice CT provide clues on the cause of obstruction. *Rizzoli G, e al. Reoperations for acute prosthetic thrombosis and pannus: an assessment of rates, relationship and risk. Eur J Cardiothorac Surg. 1999 Jul;16(1):74-80.
  9. 9. Obstructive prosthetic heart valve dysfunction* Thrombus Pannus Patient Prosthesis mismatch Clinical presentation Acute Low INR Generally non acute Adequate INR Non-acute Adequate INR Fluoroscopy Restriction of leaflet opening Restriction of leaflet opening (maybe absent ) No restriction of leaflet opening Echocardiography (TTE, TEE) Increased gradient Mass on the valve; large and soft echodensity Increased gradient No mass identified on the valve or if present small, circular and high echogenity Increased gradient (also increased in the baseline echo and no recent increase) No mass on the valve CT Restriction of leaflet opening Mass on the valve Restriction of leaflet opening (maybe absent ) Small circular mass along the valve plane No restriction of leaflet opening No mass on the valve *Table modified from Tanis W et al. Differentiation of thrombus from pannus as the cause of acquired mechanical prosthetic heart valve obstruction by non-invasive imaging: a review of the literature. Eur Heart J Cardiovasc Imaging. 2013 Aug 2. doi:10.1093/ehjci/jet127 [Epub ahead of print]
  10. 10. Join the ESC Working Group on Valvular Heart Disease and take part in its activities ! Membership is FREE!