Dr Taylan AkgunKartal Kosuyolu Heart and Research Hospital, Istanbul, Turkey

Dr Cemil IzgiRoyal Brompton HospitalLondon, UK

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

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

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

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

Transesophageal echocardiography

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.

Watch video

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.

1D. Hering, C. Piper and D. Horstkotte. Management of prosthetic valve thrombosis. European Heart Journal Supplements (2001) 3 (Supplement Q), Q22–Q26.

Surgery

• Pannus extending to the valve leaflet and obstructing its opening

Valve was excised and a new bileaflet mechanical prosthetic valve was implanted.

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.

Thrombus Pannus Patient Prosthesis mismatch

Clinical presentation AcuteLow INR

Generally non acuteAdequate INR

Non-acuteAdequate INR

Fluoroscopy Restriction of leaflet opening

Restriction of leaflet opening (maybe absent )

No restriction of leaflet opening

Echocardiography(TTE, TEE)

Increased gradientMass on the valve; large and soft echodensity

Increased gradientNo 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 openingMass on the valve

Restriction of leaflet opening (maybe absent )Small circular mass along the valve plane

No restriction of leaflet openingNo mass on the valve

Obstructive prosthetic heart valve dysfunction*

*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]

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