European Journal of Echocardiography 2008 9(2):291-293; doi:10.1016/j.euje.2006.09.007
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2006. For permissions please email: journals.permissions@oxfordjournals.org
Intermittent acute aortic valve regurgitation: a case report of a prosthetic valve dysfunction
Stefanos E. Karagiannis1,*,
G. Karatasakis1,
K. Spargias1,
L. Louka2,
D. Poldermans3 and
D.V. Cokkinos1
1 First Department of Cardiology, Onassis Cardiac Surgery Centre, 356 Sygrou Avenue, 17674 Athens, Greece
2 First Department of Cardiac Surgery, Onassis Cardiac Surgery Centre, Athens, Greece
3 Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
Received 29 May 2006; accepted after revision 30 September 2006; online publish-ahead-of-print 13 November 2006.
* Corresponding author. Tel: +30 210 9493912; fax: +30 210 9493341. E-mail address: stefkarag{at}yahoo.gr (S.E. Karagiannis).
 |
Abstract
|
|---|
Complications of any mechanical prosthesis include thrombus
or pannus formation. In our case report we demonstrate that
prosthetic aortic valve regurgitation due to pannus formation
may be intermittent and non-cyclic in pattern and therefore
not obvious at the time of original clinical examination. Under
these conditions and as transesophageal echocardiography cannot
be repeated promptly, transthoracic 2-D and Doppler echocardiography
should be available at any time when symptoms occur and present
the method of choice for acute patient evaluation. Thrombolysis
seems to be the first treatment of choice in case of thrombus
formation and re-do surgery in case of pannus formation.
Keywords: Intermittent aortic regurgitation; Pannus; Echocardiography
|
Introduction
|
|---|
Complications of any mechanical prosthesis include thrombus
or pannus formation.
1 Both require prompt diagnosis and treatment
as they can be a life-threatening condition.
1 The presenting
symptoms and clinical signs of these complications are consistent
but non-specific and can include embolism, obstruction or acute
valvular regurgitation of cyclic pattern.
1,2 Echocardiography
is the diagnostic tool of choice in this acute setting.
2 In
this report we present a case of non-cyclic failure in closure
of a valvular leaflet resulting in acute massive aortic regurgitation.
|
Case study
|
|---|
A 44-year-old Turkish man was referred to the Onassis Cardiac
Surgery Center in February 2006 because of unstable angina after
non-ST elevation myocardial infarction. His medical history
revealed aortic valve replacement with a single leaflet (tilting
disc) No. 21 Medtronic Hall prosthesis in 2003 due to rheumatic
aortic stenosis. On admission he was clinically stable with
a normal electrocardiogram (EKG) (
Figure 1A) and blood
pressure of 120/80 mmHg, but with suboptimal INR value of 1.1,
and elevated troponin-I value of 1.20 ng/ ml (normal range:
0.00–0.05 ng/ml). Two hours after admission and although
on standard medical treatment for non-ST elevation myocardial
infarction, he suffered a brief episode of unstable angina followed
by severe hypotension (systolic blood pressure of 60 mmHg) and
almost loss of consciousness and concomitant cardiogenic shock.
He recovered spontaneously and a new EKG did not show any significant
abnormalities. A transthoracic echocardiogram (TTE) revealed
a normally functioning prosthetic aortic valve and almost normal
left ventricular function. Transesophageal echocardiography
(TEE) excluded the presence of thrombus or large tissue overgrowth
in the prosthetic valve. A second longer episode of chest pain
with the same clinical presentation was accompanied by remarkable
ST depression in broad leads (
Figure 1B). Coronary angiography
and cinefluoroscopy that were performed after recovery of symptoms,
showed normal coronary arteries and normally functioning aortic
prosthesis.
TTE during a third longer episode with similar clinical presentation
revealed massive acute aortic valve regurgitation (
Figure 2A, B). Luckily the patient recovered spontaneously and was urgently
transmitted to the operating theatre where he had a prosthetic
aortic valve replacement with a No. 21 Edwards Mira Ultra Finesse
mechanical valve. Abnormal pannus proliferation trapping the
right ventricular side orifice of the mechanical aortic valve
and causing intermittent acute aortic regurgitation was found.
After the operation the patient had an uncomplicated recovery
and was discharged on his 7th postoperative day.
View larger version (35K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 2 (A) Apical 4-chamber view of the patient during chest pain and acute 4/4 grade aortic regurgitation. (B) Continuous-wave Doppler showing the triangular velocity profile of the acute aortic regurgitation. In these beats the valve stays open causing free aortic regurgitation.
|
|
|
Discussion
|
|---|
We present a case of randomly repeated episodes of unstable
angina with cardiogenic shock with spontaneous recovery, due
to acute intermittent aortic regurgitation. The mechanical prosthesis
had normal function at TTE and no evidence of thrombus or tissue
at TEE during asymptomatic periods. However, pannus can cause
intermittent complaints and TTE is the imaging modality of choice
during the clinical episodes in order to detect these abnormalities.
In that scenario clinical signs and auscultation may be confusing
and unhelpful in the evaluation of the severity of valvular
dysfunction. Murmurs may be heard in normally functioning valves
whereas paravalvular regurgitation may be silent.
3,4 Artifacts
from the mechanical prosthesis may interfere with the observation
of periannular morphology
5 during TTE. It has been also shown
that when TEE fails to identify the reason of prosthetic malfunction,
it is more often a small mass, usually pannus, interfering with
the hinges of the prosthesis.
5 Treatment for these serious complications
is controversial but thrombolysis seems to be the first choice
in case of thrombus formation and re-do surgery in case of pannus
formation.
1,4
|
Conclusion
|
|---|
Even in the presence of virtually normal function of a mechanical
prosthesis, an intermittent noncyclic block that is not obvious
at the time of original clinical examination can occur due to
pannus. Under these conditions and as TEE cannot be repeated
promptly, transthoracic 2-D and Doppler echocardiography should
be available at any time when symptoms occur and is the method
of choice for acute patient evaluation.
|
References
|
|---|
- Robles P, Jimenez Nacher JJ, Rubio A, Huelmos A, Lopez L. Intermittent aortic regurgitation in a case of mechanical prosthesis dysfunction. Int J Cardiol (2005) 102:525–7.[CrossRef][Web of Science][Medline]
- Morocutti G, Bernardi G, Gelsomino S. Prosthetic valve dysfunction presenting as intermittent acute aortic regurgitation. Heart (2002) 88:3.[Free Full Text]
- Aoyagi S, Nishimi Y, Tayama E, Fukunaga S, Hayashida N, Akashi H, et al. Obstruction of St. Jude Medical valves in the aortic position: a consideration for pathogenic mechanism of prosthetic valve obstruction. Cardiovasc Surg (2002) 10:339–44.[CrossRef][Web of Science][Medline]
- Lengyel M, Vandor L. The role of thrombolysis in the management of left-sided prosthetic valve thrombosis: study of 85 cases diagnosed by transesophageal echocardiography. J Heart Valve Dis (2001) 10:636–49.[Web of Science][Medline]
- Barbetseas J, Nagueh SF, Pitsavos C, Toutouzas PK, Quinones MA, Zoghbi WA. Differentiating thrombus from pannus formation in obstructed mechanical prosthetic valves: an evaluation of clinical, transthoracic and transesophageal echocardiographic parameters. J Am Coll Cardiol (1998) 32:1410–7.[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Introduction