A Sticky Situation

DOI: 10.1111/j.1540-8175.2009.01065.x C 2010, Wiley Periodicals, Inc. IMAGE SECTION Section Editor: Ivan D’Cruz, M.D. A Sticky Situation Mark Friedman, M.D., Kartikya Ahuja, M.D., Ann J. Christian, M.D., and Cynthia C. Taub, M.D., F.A.C.C. Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York (Echocardiography 2010;27:205) Key words: mechanical valve, echocardiography A 52-year-old female with endocarditis un- derwent aortic valve replacement with a 19-mm St. Jude prosthesis. On the second post- operative day, the patient became hypotensive requiring multiple pressors for hemodynamic sup- port. An echocardiogram showed severely elevated transaortic velocities (Fig. 1A). It was unclear if the elevated transaortic velocity was contaminated from moderate mitral regurgita- tion (MR). Upon closer comparison with the MR Doppler (Fig. 1B), the onset of MR clearly occurs during the left ventricular isovolumic con- traction period, before the opening of the aortic valve (Fig. 1B arrow). As the transaortic Doppler begins distinctly after opening of the aortic valve (Fig. 1A arrow), it is clear that it accurately represents a transaortic gradient, and not contaminated by MR. A transesophageal echocardiogram was subsequently performed, but was unable to reveal the etiology of the high velocities due to reverberation artifact. There- fore, cineography was performed, which demon- strated only one moving prosthetic leaflet. The second leaflet was not visible (Fig. 1C). In- traoperative exploration showed a nonmobile mechanical aortic leaflet, stuck in the closed po- sition by a malpositioned pledget in the aortic root. A repeat aortic valve replacement was performed successfully. This case highlights the importance in distinguishing Doppler profiles of aortic stenosis and MR. The onset of MR Address for correspondence and reprint requests: Cynthia C. Taub, M.D., F.A.C.C., Assistant Professor of Medicine, Albert Einstein College of Medicine, Division of Cardiology, 1825 Eastchester Road, Room W1-120, Bronx, NY 10461. Fax: 718- 904-2573; E-mail: ctaub@montefiore.org occurs before opening of aortic valve, which can be readily detected by echocardiography. A mul- timodality noninvasive imaging approach is often necessary in making an accurate diagnosis. Figure 1. A. Continuous wave Doppler through aortic valve. B. Continuous wave Doppler through mitral valve. C. Cineog- raphy of aortic valve showing only one moving prosthetic leaflet. 205

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Transcript of A Sticky Situation

IMAGE SECTION Section Editor: Ivan D’Cruz, M.D.

A Sticky Situation

Mark Friedman, M.D., Kartikya Ahuja, M.D., Ann J. Christian, M.D.,and Cynthia C. Taub, M.D., F.A.C.C.

Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine,Bronx, New York

(Echocardiography 2010;27:205)

Key words: mechanical valve, echocardiography

A 52-year-old female with endocarditis un-derwent aortic valve replacement with a19-mm St. Jude prosthesis. On the second post-operative day, the patient became hypotensiverequiring multiple pressors for hemodynamic sup-port. An echocardiogram showed severely el-evated transaortic velocities (Fig. 1A). It wasunclear if the elevated transaortic velocity wascontaminated from moderate mitral regurgita-tion (MR). Upon closer comparison with the MRDoppler (Fig. 1B), the onset of MR clearly oc-curs during the left ventricular isovolumic con-traction period, before the opening of the aor-tic valve (Fig. 1B arrow). As the transaorticDoppler begins distinctly after opening of theaortic valve (Fig. 1A arrow), it is clear that itaccurately represents a transaortic gradient, andnot contaminated by MR. A transesophagealechocardiogram was subsequently performed,but was unable to reveal the etiology of the highvelocities due to reverberation artifact. There-fore, cineography was performed, which demon-strated only one moving prosthetic leaflet. Thesecond leaflet was not visible (Fig. 1C). In-traoperative exploration showed a nonmobilemechanical aortic leaflet, stuck in the closed po-sition by a malpositioned pledget in the aor-tic root. A repeat aortic valve replacement wasperformed successfully. This case highlights theimportance in distinguishing Doppler profilesof aortic stenosis and MR. The onset of MR

Address for correspondence and reprint requests: Cynthia C.Taub, M.D., F.A.C.C., Assistant Professor of Medicine, AlbertEinstein College of Medicine, Division of Cardiology, 1825Eastchester Road, Room W1-120, Bronx, NY 10461. Fax: 718-904-2573; E-mail: [email protected]

occurs before opening of aortic valve, which canbe readily detected by echocardiography. A mul-timodality noninvasive imaging approach is oftennecessary in making an accurate diagnosis.

Figure 1. A. Continuous wave Doppler through aortic valve.B. Continuous wave Doppler through mitral valve. C. Cineog-raphy of aortic valve showing only one moving prostheticleaflet.

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